Medical Transcription

PREOPERATIVE DIAGNOSIS: Bilateral inguinal hernias. POSTOPERATIVE DIAGNOSIS: Bilateral inguinal hernias. OPERATION PERFORMED: Laparoscopic repair of bilateral inguinal hernias. ESTIMATED BLOOD LOSS: Minimal. COMPLICATIONS: None. ANESTHESIA: General. SPECIMEN SENT: None. OPERATIVE FINDINGS: There was a large hernia on the right side, indirect in nature, with a fairly substantial lipoma of the cord and properitoneal fat within the internal ring as well as a fairly scarred in hernia sac. On the right side, there was a patulous ring with properitoneal fat sitting unreduced within the internal ring and minimal sac exiting through the internal ring. OPERATION: The patient was brought to the operating room, placed supine on the operating room table. General anesthesia was induced. A Foley catheter was inserted aseptically. The abdomen was prepped and draped sterilely below the umbilicus. Just below the umbilicus, a small midline incision was carried down through ...

PREOPERATIVE DIAGNOSES: 2 cm left proximal ureteral stone, 6 mm left lower pole renal stone. POSTOPERATIVE DIAGNOSES: 2 cm left proximal ureteral stone, 6 mm left lower pole renal stone. OPERATION PERFORMED: Robotic-assisted laparoscopic ureterolithotomy, intraoperative ureteroscopy with basketing of renal stone. ANESTHESIA: General endotracheal. FLUIDS: 2000 mL of crystalloid. ESTIMATED BLOOD LOSS: 50 mL. URINE OUTPUT: Not measurable. COMPLICATIONS: None. SPECIMENS: Stone sent for metabolic evaluation. DRAINS: • 16-French urethral catheter. • 15-French round Blake drain. DISPOSITION: Patient was taken to the recovery room in stable condition. OPERATION: Patient was brought to the operating room. The patient was identified by myself. The patient was intubated in the supine position. The patient was then placed in the left flank up position. The patient was prepped and draped in the standard sterile fashion. A surgical time-out was performed. The films were...

PREOPERATIVE DIAGNOSIS: Displaced left ankle distal tibial plafond fracture, intra-articular. POSTOPERATIVE DIAGNOSIS: Displaced left ankle distal tibial plafond fracture, intra-articular. OPERATION PERFORMED: ORIF of distal tibia plafond intra-articular fracture. ANESTHESIA: General. OPERATION: Patient taken to the main operating theatre with anesthesia general. Ancef was given. A time-out was done. Sterile prep and drape was utilized. The tourniquet was set at 250 on the left leg and a bump was placed under the left hip. After elevation, exsanguination, the tourniquet was set, sterile prep and drape was done and fluoro imager was used to guide the skin incision, and an anterior 1-inch incision was made over the distal tibia at the articular surface of the ankle joint, adjacent to the fibula dissection was taken down to the subcutaneous tissues, they were divided. Extensor tendons were retracted. Dissection was taken through the capsule and the hematoma from the fract...

PREOPERATIVE DIAGNOSIS: Idiopathic Lenke 3 scoliosis. POSTOPERATIVE DIAGNOSIS: Idiopathic Lenke 3 scoliosis. OPERATION PERFORMED • Posterior lumbar instrumentation T2-L4. • Posterior lumbar fusion T2-L4. • Posterior type 1 swab osteotomies from T2-T5 and from T11-L3 and posterior type 2 swab osteotomies from T6-T10 for the purpose of a posterior release. • Allograft. • Local bone graft. ANESTHESIA: General endotracheal anesthesia. ESTIMATED BLOOD LOSS: 1800 mL. IV FLUIDS: 4000 mL of crystalloid, 4 units of packed RBC's, 4 units of FFP, and 260 mL of Cell Saver. OPERATION: The patient was intubated in supine position with full ASA monitoring. SCD's were applied. Foley's catheter was placed. Neuromonitoring leads were applied. Patient was placed prone on the Jackson operating table. Pressure points were well padded. The back was adequately scrubbed, painted, and draped in usual sterile fashion. An adequate time-out was performed. A skin incision of ...