Sample Medical Transcription Report

OPERATIVE NOTES: Every student translates only 1 of them! Operative Note DIAGNOSIS: Acute perforated appendicitis. SUMMARY: The patient was brought into the operating room and prepped and draped in the usual sterile fashion. A 10 mm trocar was placed through a curvilinear incision in the supraumbilical region through the umbilical hernia defect. Next, a 12 mm trocar was placed in the left lower quadrant under direct visualization after insufflation of the pneumoperitoneum. A 5 mm trocar was placed in the suprapubic region. Upon inspection, the appendix was seen adherent to the right lateral pelvic wall. It was seen to be perforated on the inferior margin with pus present. This was irrigated. The appendix was then dissected free from the lateral abdominal wall. Once the appendix was free from the abdominal wall, the appendix and mesoappendix were dissected free from the base of the colon to allow adequate transection. Next, the window was established through the base of the mesoappendix and the mesoappendix was then divided with a vascular load on the endovascular stapler. During further dissection, there was a small amount of bleeding that was encountered from the mesoappendix. This was controlled with a 1 cm hemoclip. After this was done, the appendix was then taken using a blue load on a 45 endovascular stapler. After the appendix was transected, it was placed in an endobag and brought out through the left lateral incision. Once this was done, the abdomen was irrigated copiously with 3 liters of sterile saline. After copious irrigation and clear return of fluid, the trocars were removed and the pneumoperitoneum was evacuated along with the fluid and the midline supraumbilical fascia was reapproximated with a figure-of-eight Vicryl sutures. Once this was done, all skin sites were closed with interrupted Vicryl subcuticular sutures. Sterile dressing was applied, the patient was awakened, and extubated and taken to post-anesthesia care unit in stable condition. Lap and needle counts were correct X2 as reported to me.

Operative Note PROCEDURE: Meniscus repair. SUMMARY: The patient was brought to the operating room and placed supine on the operating table and given a spinal anesthetic and a tourniquet about the thigh. The extremity was prepped and draped in the usual manner. The limb was elevated, exsanguinated, and tourniquet was inflated to 300 mm/Hg for approximately 35 minutes. The scope was introduced anterolaterally, outflow superolaterally, and operating portal anteromedially. The findings were that the anterior cruciate ligament was intact, having been reconstructed with hamstring tendon. There was a displaced medial meniscal tear and this was resected with a portion excised and submitted to pathology. The remainder was arthroscopically removed with the rotary meniscotome, which was initially a 5 mm resector and then a 3.5 mm resector. Photos were taken intraoperatively. Once the medial meniscus was complete, attention was paid to lateral meniscus where a complex tear, posterolateral meniscus was present, anterior to the popliteal tendon. This was arthroscopically smoothed out and the tear resected using an up-biter vascular forceps and the 3.5 mm meniscal resector. The knee was inspected. The articular surface of the femoral condyle was healthy. There were no loose bodies present in the knee. The knee was copiously irrigated at the conclusion. The portal site was closed with interrupted 4- 0 nylon and the knee injected with 20 cc 0.25% Marcaine and 0.5% Marcaine plain wrapped with Kerlix and Ace wrap. The patient tolerated the procedure well. No complications were sustained. He was in good condition at the conclusion of the procedure. Operative Note PROCEDURE: Above-the-knee amputation. SUMMARY: After satisfactory prepping and draping of the area the sterile tourniquet was placed at the higher end of the thigh. It was inflated to 300 mmHg. The skin flaps were then raised in a fishmouth fashion with proposed bone transection at upper 1/3rd of the thigh and the skin incision extending up to the middle 1/3rd of the thigh. The skin, subcutaneous tissue, and fascia were then incised along the line of incision. All the muscles were individually transected and visible bleeders were cauterized. The femoral artery, femoral vein, and sciatic nerve were also identified and they were all doubly ligated and transected. The bone was cut with a Gigli power saw and then the rest of the muscles in the posterior compartment were also transected. The tourniquet was released and all the minor bleeding that came from the muscular vessels were also tied. The patient did have open femoral artery and a good blood supply to all the muscles. So there was quite a bit of muscular blood vessels that we had to tie, but it was systematically done and satisfactory hemostasis was secured. The fascia was closed with 2-0 Dexon. The skin was approximated with skin staples. Pressure dressing was applied. The patient was sent to recovery room in good condition.

Operative Note PROCEDURE: Bilateral vasectomy. SUMMARY: Under adequate IV sedation, the patient was put in supine position and genitalia prepped and draped in the usual sterile manner. First, the right vas deferens was separated from surrounding cord structures by palpation and then held firmly against the stretched scrotal skin over it. About 3 cc of 1% lidocaine was injected and then skin tissue incision was made about 2 cm long and the vas deferens was grasped with hemostat and brought out of the incision. Following that, surrounding tissue from the vas was dissected off sharply. Hemostasis was achieved with broad cauterization. About a 2 cm long segment of vas deferens was excised. The cord ends were cauterized, tied with 3-0 chromic ties, and then suture ligated and folded over with suture ligature of 3-0 chromic material. Hemostasis was confirmed. The vas deferens was dropped back into the scrotum, scrotal incision closed with interrupted mattress suture of 3-0 chromic. Similar procedure was carried out on the left vas deferens. Following the procedure, sterile dressings are applied. The patient was transferred to recovery in satisfactory condition. Sample Medical Transcription Report

PATIENT NAME: Hardy, Jack

MEDICAL RECORD#: 12345

DATE OF ADMISSION: 01/02/06

ATTENDING PHYSICIAN: Max Morgan, M.D.

CHIEF COMPLAINT: Anaemia, constipation, no diarrhoea or hematochezia, no pyrosis, anorexia. Weight loss for several weeks. The patient has microcytic anaemia. Bilateral BKA.

MEDICATIONS: Monopril 10 mg q.d, aspirin b.i.d., ferrous sulphate.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Diabetes mellitus, arteriosclerotic heart disease.

SOCIAL HISTORY: Denies using tobacco or alcohol. Does not use non-steroidal anti-inflammatories or recreational drugs.

PHYSICAL EXAMINATION:

Vital Signs: Blood pressure is 112/70. Pulse is 46. Respirations 18. Afebrile. HEENT: Within normal limits. Neck: Supple, no asymmetry, no masses, no thyromegaly or bruits. Chest: No wheezes, rales, rhonchi. Percussion dullness. Heart: S1, S2 diminished. Regular rhythm. Soft systolic murmur at the left sternal border. Abdomen: Soft, non-distended, non-tender. There is no guarding, rebound, masses, hepatosplenomegaly, hernias, or ascites. Lymphatics: Negative, post amputation. Genitalia: Normal. Rectal: Positive stool.

PLAN: The patient will need colonoscopy and gastroscopy in view of his cardiopulmonary status and amputation status. He will need a 24 hour admit on IV fluids and careful observation.

Max Morgan, M.D. D: 01/02/06 T: 01/03/06 MM/ms