Thoracic Surgery Medical Transcription Sample Reports For Medical Transcriptionists


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:

1.  Critical right carotid artery stenosis.
2.  History of coronary artery disease, status post coronary artery bypass surgery.

POSTOPERATIVE DIAGNOSES:

1.  Critical right carotid artery stenosis.
2.  History of coronary artery disease, status post coronary artery bypass surgery.

OPERATION PERFORMED:  Right carotid endarterectomy.

SURGEON:  John Doe, MD

FIRST ASSISTANT:  Jane Doe, MD

SCRUB TECH:  Jill Doe

ANESTHESIA:  General endotracheal.

ANESTHESIOLOGIST:  Jean Doe, MD

DRAINS:  None.

CONDITION:  Stable to CVICU. 

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, placed on the table in the supine position and placed under adequate general anesthesia.  EEG monitoring was used throughout the procedure.  Once under general anesthesia, the patient was prepped and draped in the normal sterile fashion on the anterior right chest and neck.  Once positioned appropriately, an incision was made along the anterior aspect of the sternocleidomastoid muscle.  Hemostasis was maintained with electrocautery.

The dissection was carried down to the sternocleidomastoid muscle, and a retractor was inserted to gain adequate exposure, and the muscle was retracted laterally.  The dissection was then carried down to the carotid sheath, which was then opened.  The anterior facial vein was ligated and cut with #2-0 silk ties.  The carotid sheath was opened, and the common carotid artery was dissected out proximally and then we carried dissection up to the external and internal carotid artery.  The superior thyroid artery was identified going up the external carotid all the way up to the level of the hypoglossal nerve, which was identified and spared throughout the procedure.  Once these arteries were completely mobilized, vessel loops were placed around the distal internal carotid, external carotid and the proximal common carotid.  Heparin 10,000 units was administered per anesthesia.  A clamp was then placed first on the internal carotid, then the external carotid, and then the common carotid.  The common carotid artery was opened sharply with an #11 blade, and the internal carotid artery was opened up to pass the level of the stenotic lesion.

Once this was opened, an endarterectomy was performed using a Penfield dissector and forceps.  The internal carotid artery lesion was dissected out nicely, and this feathered out well and there was no plaque remaining in the internal carotid.  The plaque was completely removed.  The external carotid artery plaque was also removed without complications, and this also tapered off well.  The area was then irrigated with heparinized saline solution.  All intimal plaque was removed.  The arteriotomy was then closed with #6-0 Prolene suture, starting distally on the internal carotid and running down proximally.  A second suture was started proximally on the common carotid artery and brought out to the middle of the arteriotomy.  The internal, external and common carotid arteries were flushed to remove air or debris.

The closure was then completed.  The clamp was then taken off the external carotid and the common carotid to flush out any debris out the external, and then the internal carotid clamp was removed.  The area was irrigated with antibiotic saline solution.  Hemostasis was achieved.  The suture line looked very good without any sign of bleeding.  The right neck incision was then closed appropriately.  The wounds were dressed in a sterile manner.  Instrument counts and sponge counts were correct at the end of the procedure.  The patient tolerated it well and was sent back to recovery room in a very stable condition.

Cardiology Operative Sample Reports  

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OPERATIONS PERFORMED: 

1.  Right thoracotomy with lysis of adhesions. 

2.  Right upper lobe lobectomy. 

3.  Bronchoplasty repair right main bronchus. 

4.  Thoracic lymph node sampling. 

5.  Right fourth, fifth, and sixth intercostal space intercostal blocks. 

DESCRIPTION OF OPERATION:  The patient was brought to the operating room after placement of a thoracic epidural catheter and radial arterial line. He was placed in the supine position. Following smooth induction of general anesthesia, a left-sided double lumen endotracheal tube was placed. Position was confirmed. A Foley catheter was placed. The patent was log-rolled into the left lateral decubitus position. All pressure points were appropriately padded and the right chest was prepared and draped in the usual sterile fashion. A time-out was held confirming the correct patient, the correct side, and correct procedure. Preoperative antibiotics and heparin had been administered. Compression boots were on the lower extremities. A warming blanket was on the lower body. X-rays were on the view box. A standard right posterolateral thoracotomy incision was performed. Sharp dissection was carried down through the latissimus dorsi muscles. The serratus anterior muscles were preserved and reflected anteriorly. The right chest was entered in the fourth intercostal space just superior to the fifth rib. Intercostal block with a total of 14 mL of Marcaine was used to provide an intercostal block at the right fourth, fifth, and sixth intercostal spaces. There were dense and moderately extensive adhesions of the right upper lobe apical and anterior segments to the apex of the chest and the medial mediastinum. These were taken down sharply with Bovie cautery and Metzenbaum scissors. The phrenic nerve was identified and preserved. Dissection was assisted by the use of a 10-mm 30-degree thoracoscope placed through a separate stab wound incision in the seventh intercostal space in the posterior axillary line. 

Next, dissection began in the junction between the minor and major fissure between the right middle lobe and right upper lobe. We were able to identify the pulmonary artery and dissect out an interlobar lymph node. This was sent for frozen section. This was negative for malignancy. A plane was developed anterior to the pulmonary artery and then coming out in the anterior hilum between the pulmonary vein branch to the middle and upper lobe. The fissure between the right middle lobe and right upper lobe was then completed with serial firings of an endoscopic GIA stapler. Next, the posterior pulmonary artery branch to the right upper lobe of the lung was identified, encircled, and doubly ligated proximally and distally and transected. The fissure between the right lower lobe and right upper lobe was completed with a single firing of a 60 mm endoscopic GIA stapler. A posterior level II lymph node was dissected off the upper aspect of the bronchus intermedius and sent for frozen section. This was negative for malignancy. An anterior pulmonary branch was then identified, encircled, doubly ligated proximally and distally and transected. The truncus anterior to the right upper lobe of the lung was identified. The superior pulmonary vein branch draining the right upper lobe was identified and divided with the 35 mm vascular GIA stapler. Next, the truncus anterior was dissected out and divided with a 35 mm endoscopic vascular GIA stapler. The large mass had been palpated and was left intact. It was separate from the main pulmonary artery and the pulmonary artery continuation in the major fissure.

We then took a U-incision of the right main stem bronchus beginning at the origin and approximated this up to the proximal right main, thus taking a small portion of the right main stem bronchus with the right upper lobe bronchus. The specimen was sent to pathology and frozen section of the bronchial margin was negative for malignancy. A more longitudinal opening in the airway was then closed transversely with interrupted horizontal mattress 4-0 PDS sutures. This gave us good closure of the bronchus without any evidence of extrinsic narrowing. The bronchial repair line was tested under water to 25 cm of pressure and was airtight. The azygos vein was divided at the junction with the superior vena cava with a 35 mm vascular GIA stapler. The divided azygos vein stump was then tacked over the bronchoplasty repair site with interrupted sutures. This provided avascularized tissue pedicle between the bronchial anastomosis and the pulmonary artery. The right middle lobe was tacked to the right lower lobe to prevent torsion of the right middle lobe because of near complete nature of the major fissure between the right middle lobe and right lower lobe. The staple lines were then treated topically with Tisseel fibrin sealant. Four drill holes were placed in the fifth rib, and through these drill holes, #5 Ethibond intercostal sutures were placed. A 24 French chest tube was placed through the seventh intercostal space port tract and advanced to posterior apex of the chest. The chest tube was secured to the skin with a silk suture. The chest tube was placed to Atrium chest drainage system. The right middle lobe and right lower lobe were ventilated and appropriately expanded to fill the right chest.

The wound was then closed in layers with absorbable suture, with the skin approximated with a 4-0 Monocryl subcuticular skin stitch. The incision was sealed with Dermabond. The patient was returned to the supine position. The double lumen endotracheal tube was exchanged for a single lumen 8.5 endotracheal tube. Position was confirmed. Next, flexible bronchoscopy was performed and bloody secretions blocking the right main bronchus were aspirated clear. The right bronchus intermedius was then irrigated and aspirated dry. A small amount of secretions in the left lower lobe of the bronchus were aspirated clear. The anastomosis was visualized and was intact. There was no evidence of narrowing of the bronchus intermedius. Photos were taken to document the patency of the airway and intact repair. The patient then awoken from general anesthesia without difficulty, extubated, and transported to the postanesthesia care unit in satisfactory condition.

Cardiology Consultation Samples    

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Symptomatic multivessel coronary artery disease.

POSTOPERATIVE DIAGNOSIS:  Symptomatic multivessel coronary artery disease.

OPERATION PERFORMED:  Coronary artery bypass grafting x3 with left internal mammary to left anterior descending, free right internal mammary to major diagonal, and reverse saphenous vein to obtuse marginal.

ATTENDING SURGEON:  John Doe, MD

ASSISTANT SURGEON:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

INDICATIONS:  The patient is a (XX)-year-old male admitted with symptomatic coronary disease and cardiac catheterization, which showed some mild to moderate noncritical stenoses in the right, severe stenosis in the proximal LAD, severe stenosis in the diagonal and multiple moderate to severe stenoses in the circumflex feeding a good-sized obtuse marginal.  LV function was minimally to mildly decreased.  Coronary artery bypass grafting was indicated.  I discussed the risks and benefits of the procedure in detail with the patient and his family preoperatively.  The risks we discussed included, but were not limited to, bleeding, infection, stroke, myocardial infarction, early and late graft failure and death.  They understood and agreed to proceed.

DESCRIPTION OF OPERATION:  After induction of anesthesia, the patient was prepped and draped.  Saphenous vein was harvested from the leg using an endoscopic technique, while simultaneously both internal mammaries were taken down with a Harmonic scalpel in a skeletonized fashion.  The right was taken as a free graft and preserved in a blood papaverine solution.  The patient was heparinized.  The distal mammary was divided.  The ascending aorta was palpated and free of gross disease.  Guidant stabilizing system was utilized.  There was good exposure.  The LAD was incised distal to the palpable disease, and over a 1.75 mm shunt was grafted to the left internal mammary with a running 7-0 Prolene.  There was a good biphasic signal in the graft.  The heart was rotated medially and the diagonal was incised, and over a 2 mm shunt, the free right internal mammary was anastomosed here end-to-side with a 7-0 Prolene.  This flushed easily.  Heart was further rotated over and the marginal was dissected out before it bifurcated, and over a 2 mm shunt, reverse saphenous vein was anastomosed here end-to-side with a 7-0 Prolene.  This likewise flushed easily.  A side-biting clamp was placed in the ascending aorta.  The two proximals were completed and de-aired.  The distals were inspected and free of bleeding.  Temporary atrial and ventricular pacing wires were placed.  The patient was apaced at 80 after full protamine reversal.  The graft to the LAD had a mean flow of 21 with a PI of 2.6.  The graft to the obtuse marginal had a mean flow of 57 with a PI of 3.1, and the graft to the diagonal had a mean flow of 34 with a PI of 1.4.  After ensuring adequate hemostasis, chest tubes were placed in mediastinum and the pleural spaces.  Sternal edges were irrigated with antibiotics and covered with platelet gel.  The wound was irrigated in layers and closed in layers.  All counts were correct at the end of the procedure.  There were no known complications.

DATE OF OPERATION:  MM/DD/YYYY

 
PREOPERATIVE DIAGNOSES:
1.  Respiratory failure.
2.  Renal failure.
3.  Status post coronary artery bypass surgery.
 
POSTOPERATIVE DIAGNOSES:
1.  Respiratory failure.
2.  Renal failure.
3.  Status post coronary artery bypass surgery.
 
OPERATIONS PERFORMED:
1.  Tracheostomy.
2.  Hickman dialysis catheter insertion.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Jane Doe, MD
 
ANESTHESIA:  General endotracheal.
 
ANESTHESIOLOGIST:  Jill Doe, MD
 
COMPLICATIONS:  None.
 
CONDITION:  Stable to CVICU.
 
DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed on the table in a supine position.  First, under adequate general anesthesia, he was prepped and draped in the normal sterile fashion from the chin to the xiphoid.  First, using fluoroscopy and Seldinger technique, a guidewire was inserted in the right subclavian vein down to the atriocaval junction.  An introducer sheath was then placed over this, a #9.5 French introducer sheath, placed over the guidewire.  A Hickman catheter was then inserted through a separate stab wound in the right infraclavicular region.  The tip of the catheter was then brought out through the insertion site of the introducer.  A cup was placed subcutaneously.  The sheath was then removed from the introducer and the Hickman catheter was inserted through the sheath, again using fluoroscopic guidance.  The sheath was removed and the catheter was in good position by fluoroscopy.  The Hickman catheter was then secured to the skin with a large silk suture and was flushed with heparinized saline.  This area was then dressed in the appropriate fashion.
 
The second procedure was a tracheostomy.  An incision was made in transverse fashion above the sternal notch.  Blunt dissection was carried down to the pretracheal fascia, which was open.  The strap muscles were retracted laterally.  The trachea was then opened at approximately the second and third tracheal ring and a #8 Shiley tracheostomy tube was inserted without complications.  Was inflated and connected to the ventilator.  The patient ventilated and oxygenated well.  The tracheostomy was then secured to the skin with large silk sutures and the trach tie.  The patient tolerated both procedures well and was sent to the CVICU in stable condition.  
 




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