Medical Transcription

DESCRIPTION OF PROCEDURE: Reasons, risks, possible complications, and alternative procedures were explained to the patient, and the permit was signed .   After sedation per Anesthesiology, the Olympus colonoscope was inserted in the rectum and advanced without difficulty to the cecum, which was identified by the ileocecal valve and appendiceal orifice .   The colon was well cleansed .   The scope was withdrawn, examining the entire lumen in circumferential fashion .   The mucosal and vascular patterns were normal throughout and no intraluminal mass, lesions, or polyps were identified .   Retrograde examination of the rectum and anoscopy were normal .   She tolerated the procedure well and was transferred to Recovery .

DIAGNOSIS Tracheal stenosis . PROCEDURE Direct microlaryngoscopy, rigid bronchoscopy, and balloon dilatation of tracheal stenosis . INDICATION Patient has a history of tracheal stenosis and is status post two balloon dilatations in the past . PROCEDURE IN DETAIL Patient was brought to the operating room and placed on the table in supine position .   After an adequate level of general anesthesia, patient was prepped and draped in the usual sterile fashion .    Laryngoscope was inserted into the oral cavity and   advanced down to the level of larynx .   It was suspended in position and using microscopic visualization, a balloon catheter was placed through the laryngoscope into the stenotic area of the trachea and inflated to 12 atmospheres of pressure .   A #16-French dilator was used and was completely inflated. Th...

PREOPERATIVE DIAGNOSIS Left hip degenerative joint disease. POSTOPERATIVE DIAGNOSIS Left hip degenerative joint disease. PROCEDURE Left anterior total hip arthroplasty. ANESTHESIA Spinal. INDICATION FOR PROCEDURE This patient is a female with a longstanding history of severe left hip pain.  She had failed conservative treatment including cane use, oral anti-inflammatories, cortisone injections, physical therapy.  Decision made to proceed forward with treatment. DESCRIPTION OF PROCEDURE The patient was met in preoperative area.  Operative extremity identified and marked.  Informed consent discussed and signed including the risks of, but not limited to, pain, infection, bleeding, weakness, stiffness, numbness, tingling, need for further surgery, leg-length discrepancy, dislocation, loss of limb or life.  The patient is aware of this, consented.  The patient is taken to the operative theater.  Spinal anesthesia given.  The patient wa...

PREOPERATIVE DIAGNOSIS Left olecranon fracture. POSTOPERATIVE DIAGNOSIS Left displaced olecranon fracture with intra-articular extension. PROCEDURES Open reduction and internal fixation of left olecranon. ANESTHESIA General. INDICATION FOR PROCEDURE This patient is an elderly male who sustained a widely displaced olecranon fracture.  Because of the likelihood of disability with nonsurgical treatment, decision was made to proceed forward with treatment. DESCRIPTION OF PROCEDURE The patient was met in preoperative area.  Operative extremity identified and marked.  Informed consent discussed and signed including the risks of, but not limited to, pain, infection, bleeding, weakness, stiffness, numbness, tingling, need for further surgery.  Malunion, nonunion, arthritis, loss of limb or life.  Patient consented.  The patient was taken to the operative theater, general anesthesia given.  The patient's sterilely prepped, anesthetized in late...

PREOPERATIVE DIAGNOSIS Left rotator cuff repair. POSTOPERATIVE DIAGNOSIS Left rotator cuff repair. PROCEDURE Left revision rotator cuff repair. Left extensive debridement arthroscopic. ANESTHESIA General with scalene block. INDICATION FOR PROCEDURE This patient is an elderly female, that had previously had rotator cuff repair.  She developed a tear next to the suturing of her prior rotator cuff repair.  She had pain, inability to progress with rehab.  She had failed conservative treatment.  Because of this, decision was made to proceed forward with operative treatment. DESCRIPTION OF PROCEDURE The patient was met in preoperative area.  Operative extremity identified and marked.  Informed consent discussed and signed including the risks of not limited to, pain, infection, bleeding, weakness, stiffness, numbness, tingling, re-tear, need for further surgery, loss of limb or life.  The patient was aware of this and consented for the proc...

PREOPERATIVE DIAGNOSIS Right knee degenerative joint disease. POSTOPERATIVE DIAGNOSIS Right knee degenerative joint disease. PROCEDURE Right total knee arthroplasty. ANESTHESIA General with femoral block. INDICATIONS FOR THE PROCEDURE This patient is a female with a longstanding history of severe right knee pain.  She had failed conservative treatment including cortisone injections, oral anti-inflammatories, physical therapy, and bracing.  Because of this, decision was made to proceed forward with surgery. DESCRIPTION OF PROCEDURE Patient was met in the preoperative area.  The operative extremity was identified and marked.  Informed consent was discussed and signed.  The patient was then taken to the operative theater, general anesthesia was given.  The patient was sterilely prepped and anesthetized.  Time-out was performed with all personnel.  Tourniquet was not inflated.  First, an anterior incision was created.  A med...

PREOPERATIVE DIAGNOSIS Umbilical hernia. POSTOPERATIVE DIAGNOSIS Umbilical hernia. PROCEDURES Umbilical hernia repair. ANESTHESIA General. ESTIMATED BLOOD LOSS Minimal. COMPLICATIONS None. SPECIMENS Hernia sac. DISPOSITION To the PACU in stable condition. OPERATIVE NOTE The patient was brought to the operative suite, placed supine on the operating room table.  After adequate general anesthesia had been achieved, the abdomen was prepped and draped in the usual sterile fashion.  Then, using a #15 blade, an infraumbilical curvilinear incision was made and then the cautery was used for hemostasis.  Then, the hernia defect was dissected free in the subcutaneous space and then a clamp was placed posteriorly to the hernia defect and then the hernia sac was opened and the umbilical skin overlying the defect was detached using cautery.  Then, the hernia sac was identified and opened.  There was no bowel within the hernia sac, only preperitoneal ...

PREOPERATIVE DIAGNOSIS Ventral hernia. POSTOPERATIVE DIAGNOSIS Ventral hernia. PROCEDURE Laparoscopic ventral hernia repair with mesh. ANESTHESIA General. ESTIMATED BLOOD LOSS Minimal. COMPLICATIONS None. DISPOSITION To the PACU in stable condition. OPERATIVE NOTE The patient was brought to the operative suite, placed supine on operating table.  After adequate general anesthesia had been achieved, the abdomen is prepped and draped in usual sterile fashion.  Then, using a #15 blade, a mid abdominal incision was made and a Veress needle was inserted.  The abdomen was then insufflated with CO2 to create a pneumoperitoneum and then a 5 mm bladeless trocar was inserted to the abdomen using the laparoscope in the right upper quadrant.  With laparoscope inserted, four additional trocars were inserted to the abdomen under direct visualization, two in left upper quadrant, one in the right lower quadrant and one 12 mm trocar in the right mid abdomen late...

PREOPERATIVE DIAGNOSIS Right breast sebaceous cyst. POSTOPERATIVE DIAGNOSIS Right breast sebaceous cyst. PROCEDURE Excision of right breast sebaceous cyst. ANESTHESIA General. ESTIMATED BLOOD LOSS Minimal. COMPLICATIONS None. SPECIMEN Right breast sebaceous cyst. DISPOSITION To PACU in stable condition. PROCEDURE IN DETAIL This patient was brought to the operative suite, placed supine on the operating table.  After adequate general anesthesia had been achieved, the right breast was prepped and draped in usual sterile fashion.  Then, using a #15 blade, an elliptical incision was made around the sebaceous cyst.  The incision measured approximately 3 x 5 cm.  Once this was completed, the cyst was excised using cautery and then the wound was inspected for any bleeding and any points of bleeding were coagulated with the Bovie.  Then, the skin incision was then closed with 3-0 nylon suture in an interrupted vertical mattress fashion.  St...

PREOPERATIVE DIAGNOSIS Biliary dyskinesia. POSTOPERATIVE DIAGNOSIS Biliary dyskinesia. PROCEDURE Robotic-assisted laparoscopic cholecystectomy. ANESTHESIA General. ESTIMATED BLOOD LOSS Minimal. COMPLICATIONS None. SPECIMEN Gallbladder. DISPOSITION To PACU in stable condition. DESCRIPTION OF PROCEDURE This patient was brought to the operative suite, placed supine on the operating table.  After adequate general anesthesia had been achieved, the abdomen was prepped and draped in the usual sterile fashion.  Then, using a #15 blade, an infraumbilical curvilinear incision was made.  The incision was extended down to underlying subcutaneous tissue and cautery was used for hemostasis.  A Veress needle was inserted and the abdomen was then insufflated with CO2 to create a pneumoperitoneum.  Then, a bladeless trocar was inserted in the abdomen and the laparoscope was inserted.  The abdomen was examined and there was no evidence of any bowel ...

PREOPERATIVE DIAGNOSIS Acute appendicitis. POSTOPERATIVE DIAGNOSIS Acute appendicitis. PROCEDURE Laparoscopic appendectomy. ANESTHESIA General. ESTIMATED BLOOD LOSS Minimal. COMPLICATIONS None. SPECIMEN Appendix. FINDINGS Nonperforated appendicitis. DISPOSITION To PACU in stable condition. DESCRIPTION OF PROCEDURE The patient was brought to the operative suite, placed supine on the operating room table.  After adequate general anesthesia had been achieved, the abdomen was prepped and draped in the usual sterile fashion.  Then, using a #15 blade, an infraumbilical curvilinear incision was made.  The incision was extended down to underlying subcutaneous tissue and cautery was used for hemostasis.  Then, the fascia was incised.  The Hasson trocar was inserted to the abdomen.  The abdomen was then insufflated with CO2 to create a pneumoperitoneum, and two additional 5 mm trocars were inserted to the abdomen under direct visualizati...

PREOPERATIVE DIAGNOSIS Acute appendicitis. POSTOPERATIVE DIAGNOSIS Acute appendicitis. PROCEDURE Laparoscopic appendectomy. ANESTHESIA General. ESTIMATED BLOOD LOSS 5 mL. COMPLICATIONS None. SPECIMEN Appendix. DISPOSITION To PACU in stable condition. OPERATIVE NOTE The patient was brought to the operative suite, placed supine on the operating room table.  After adequate general anesthesia had been achieved, the abdomen was prepped and draped in usual sterile fashion.  Then, using 15 blade, an infraumbilical curvilinear incision was made.  The fascia was incised.  The Hasson trocar was inserted to the abdomen.  The abdomen was then insufflated with CO2 to create a pneumoperitoneum and two additional 5 mm trocars were inserted to the abdomen under direct visualization, one in the suprapubic region, one in left lower quadrant.  As this was completed, the appendix was visualized and noted to be markedly inflamed and edematous and stuc...

PREOPERATIVE DIAGNOSIS Perforated viscus. POSTOPERATIVE DIAGNOSIS Perforated pre-pyloric ulcer. PROCEDURE Exploratory laparotomy with omental patch repair of perforated pre-pyloric ulcer. ANESTHESIA General. ESTIMATED BLOOD LOSS 3 mL. COMPLICATIONS None. FINDINGS Perforated pre-pyloric ulcer measuring approximately 1.5-2.0 cm in diameter with no other intra-abdominal abnormalities and the previous colorectal anastomosis was intact. OPERATIVE NOTE The patient was brought to the operative suite, placed supine on operating table.  After adequate general anesthesia had been achieved, the abdomen was prepped and draped in usual sterile fashion.  Then, the patient's previous abdominal incision was opened and the previously placed PDS sutures were removed.  The patient's mesh from her recent hernia repair was removed and then upon entering the abdominal cavity there was a large amount of fluid noted in the upper abdomen, which was purulent.  This was ...

PART I PROCEDURE Cardiac catheterization. INDICATIONS Coronary artery disease. Positive cardiovascular stress test. PROCEDURE PERFORMED Selective coronary angiogram. Left heart catheterization. COMPLICATIONS None. DESCRIPTION OF THE PROCEDURE Prior to the test, risk, benefit and alternatives were discussed with the patient and informed consent were obtained.  Patient brought to the cath laboratory in stable condition.  He was prepped and draped in the usual sterile fashion.  We used Versed and fentanyl for conscious sedation and lidocaine for local anesthesia.  We accessed the right radial artery and 5-French sheath was placed and we advanced 5-French JL3.5 catheter over the wire and engaged the left main, images obtained.  Then, we advanced 5-French JR5 over the wire and engaged to the RCA, images obtained.  With the JR catheter we brought the aortic valve and pressure obtained and the gradient across the valve obtained with pullback...