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801
Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy.
PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:, The patient is a 56-year-old female. She was referred for a screening colonoscopy. The patient has bowel movements every other day. There is no blood in the stool, no abdominal pain. She has hypertension, dyslipidemia, and gastroesophageal reflux disease. She has had c...
[ "cecum", "colon cancer", "colonoscopy", "diverticulosis", "malignancy", "polyps", "rectum", "screening colonoscopy", "sigmoid", "surgery" ]
1,000
802
Colonoscopy. Rectal bleeding and perirectal abscess. Normal colonoscopy to the terminal ileum. Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.
PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and ...
[ "abscess", "anal", "anal verge", "anorectal", "colonoscope", "colonoscopy", "fistulous", "ileum", "olympus", "perianal", "perianal abscess", "rectal bleeding", "rectum", "surgery", "terminal ileum", "verge" ]
1,001
803
Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos. The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.
PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Universal diverticulosis.,2. Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:, Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: ,The ...
[ "ascending colon", "cecum", "colon polyps", "colonoscopy", "descending colon", "diverticulosis", "endoscopy", "hemorrhoids", "polyps", "rectosigmoid colon", "rectum", "surgery", "total colonoscopy", "transverse colon" ]
1,002
804
History of polyps. Total colonoscopy and photography. Normal colonoscopy, left colonic diverticular disease. 3+ benign prostatic hypertrophy.
PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1. Normal colonoscopy, left colonic diverticular disease.,2. 3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of p...
[ "anorectal", "anorectal canal", "benign prostatic hypertrophy", "colonoscopy", "digital examination", "diverticular disease", "photography", "surgery" ]
1,003
805
Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.
PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of...
[ ": thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be ...
1,004
806
Screening colonoscopy. Tiny polyps. If adenomatous, repeat exam in five years.
PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:, Tiny Polyps.,PROCEDURE PERFORMED: , Colonoscopy.,PROCEDURE: , The procedure, indications, and risks were explained to the patient, who understood and agreed. He was sedated with Versed 3 mg, Demerol 25 mg during the examination. ,A digital rectal exam was ...
[ "adenomatous", "biopsy forceps", "colonoscopy", "pentax video colonoscope", "polyps", "surgery", "tiny polyps" ]
1,005
807
Colonoscopy in a patient with prior history of anemia and abdominal bloating.
PREOPERATIVE DIAGNOSES:, Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:, External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:, Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:, Digital rectal exam revealed external hemorrhoids. The colonoscope was inserted into the rectal ...
[ "abdominal", "anemia", "ascending colon", "bloating", "cecum", "colonoscope", "colonoscopy", "descending colon", "digital rectal exam", "external hemorrhoids", "hemorrhoids", "hepatic flexure", "rectal ampulla", "rectum", "scope", "splenic flexure", "surgery", "transverse colon" ]
1,006
808
Colonoscopy. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum.
MEDICATIONS:,1. Versed intravenously.,2. Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications. The Olympus video colonoscope was inserted through the anus and was advanced in retro...
[ "ascending colon", "cecum", "colonoscope", "colonoscopynote", "descending colon", "flexure", "hepatic flexure", "ileocecal", "ileocecal valve", "mucosa", "olympus", "rectum", "scope", "sigmoid colon", "splenic flexure", "surgery", "transverse colon" ]
1,007
809
Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.
INDICATION: , Iron deficiency anemia.,PROCEDURE: ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:, Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL: ,Following the preprocedure patient assessment the procedure...
[ "anemia", "colonoscopy", "endoscope", "ileocecal valve", "ileum", "iron deficiency anemia", "mucosa", "polyp", "rectum", "surgery", "terminal ileum" ]
1,008
810
Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids.
PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:, Colonic polyps.,PROCEDURE:, Colonoscopy.,ANESTHESIA:, MAC,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum ...
[ "surgery" ]
1,009
811
Colonoscopy. Change in bowel habits and rectal prolapse. Normal colonic mucosa to the cecum.
PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve a...
[ "bowel habits", "cecum", "colonic", "colonic mucosa", "colonoscope", "colonoscopy", "mucosa", "olympus", "rectal", "rectum", "surgery" ]
1,010
812
Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.
PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES: ,1. Normal operative site. ,2. Mild diverticulosis of the sigmoid colon. ,3. Hemorrhoids.,PROCEDURE: ,Total colonoscopy.,PROCEDURE IN DETAIL: ,The patient is a 60-year-old of Dr. ABC's being evaluated fo...
[ "colon polyps", "colonoscopy", "diverticulosis", "hemorrhoids", "partial colon resection", "polyps", "rectal vault", "sigmoid", "surgery" ]
1,011
813
Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.
PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding h...
[ "anesthesia", "closing wedge osteotomy", "internal screw fixation", "metatarsal", "metatarsal head", "osteotomy", "periosteal layer", "screw fixation", "surgery", "tailor's bunion", "wedge osteotomy" ]
1,012
814
Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.
HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicus...
[ "aorta", "aortic", "bicuspid aortic valve", "catheter was inserted", "catheterization", "coarctation", "descending aorta", "dilated cardiomyopathy", "foramen", "juxtaductal", "mmhg", "mmhg systolic", "mmhg systolic gradient", "patent foramen ovale", "surgery", "systolic gradient", "v...
1,013
815
Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.
PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1. Closed type-III supracondylar fracture, left distal humerus.,2. Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , Th...
[ "artery", "brachial", "closed reduction", "distal humeru", "elbow", "fracture", "humerus", "percutaneous pinning", "pinning", "reduction", "supracondylar", "supracondylar fracture", "surgery", "tethered brachial artery" ]
1,014
816
Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, place...
PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1. Left abdominal flap 5 x 5 cm to left forearm.,2. Debridement of skin, subcutaneous tissue, muscle, and bone.,3. Closure of wounds, simple closure approximately 8 cm.,4. Placement of VAC ...
[ "abdominal flap", "amputation", "bone", "closure", "closure of wounds", "debridement", "extremity", "flap", "muscle", "skin", "subcutaneous tissue", "surgery", "upper extremity", "vac", "vac negative", "wounds" ]
1,016
817
Iron deficiency anemia. Diverticulosis in the sigmoid.
PREOPERATIVE DIAGNOSIS:, Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:, Diverticulosis.,PROCEDURE:, Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the a...
[ "anemia", "cecum", "colonoscope", "colonoscopy", "diverticulosis", "iron deficiency anemia", "olympus", "sigmoid", "surgery" ]
1,018
818
Closure of multiple complex lacerations. Multiple complex lacerations of the periorbital area.
PREOPERATIVE DIAGNOSIS:, Multiple complex lacerations of the periorbital area.,POSTOPERATIVE DIAGNOSIS:, Multiple complex lacerations of the periorbital area.,PROCEDURE PERFORMED:, Closure of multiple complex lacerations.,ANESTHESIA: , Local 1% with epinephrine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,COMPLI...
[ "closure", "complex lacerations", "epinephrine", "lacerations", "periorbital", "surgery", "vicryl suture" ]
1,019
819
Repair of bilateral cleft of the palate with vomer flaps.
PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General ...
[ "bilateral", "bilateral cleft", "cleft", "cleft lip", "flaps", "hard palate", "mucoperiosteal", "mucoperiosteal flap", "mucosa", "nasal", "nasal mucosa", "oral mucosa", "palate", "soft palate", "surgery", "vomer flaps" ]
1,020
820
Trimalleolar ankle fracture and dislocation right ankle. A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well. Closed open reduction and internal fixation of right ankle.
PREOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA: ,Spinal with sedation.,COMPLICATIONS: ,None.,ESTIMATED B...
[ "ankle", "ankle fracture", "cancellous screws", "cortical screw", "dislocation", "fracture", "fracture site", "internal fixation", "malleolus", "open reduction", "orif", "surgery", "trimalleolar ankle fracture" ]
1,021
821
Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.
CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7...
[ ": thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be ...
1,022
822
Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted.
PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:, Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. Upon evaluation by Orthopedic Surgery team in the emergency depart...
[ "bone", "bone forearm", "closed reduction", "conscious", "conscious sedation", "department", "distal", "distal both bone forearm", "emergency", "emergency department", "forearm", "forearm fracture", "fracture", "longus", "pollicis", "pollicis longus", "reduction", "sedation", "sp...
1,023
823
Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.
PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:, Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008. Evaluation in the emer...
[ "bone", "bone forearm", "closed reduction", "conscious", "conscious sedation", "department", "displacement", "distal", "distal both bone", "distal both bone forearm", "emergency", "emergency department", "forearm", "forearm fracture", "fracture", "image", "image intensifier", "inte...
1,024
824
Bilateral open mandible fracture, open left angle and open symphysis fracture. Closed reduction of mandible fracture with MMF.
PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE: ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endotr...
[ "angle", "bilateral open mandible fracture", "closed reduction", "endotracheal", "fracture", "intubation", "mandible", "mandible fracture", "mmf", "open symphysis fracture", "pacu", "surgery", "symphysis fracture" ]
1,025
825
Newborn circumcision. The penile foreskin was removed using Gomco.
PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:, Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:, The baby was prepared and draped in a sterile manner. Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock. The penile foreskin ...
[ "circumcision", "foreskin", "gomco", "nerve block", "newborn", "newborn circumcision", "penile", "penis", "surgery" ]
1,026
826
Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear.
PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1. Repair of cleft soft palate, CPT 42200.,2. Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table. After anesthesia was adm...
[ "cleft", "ear tag", "nasal mucosa", "oral mucosa", "palate", "repair", "soft", "soft palate", "surgery", "tragus" ]
1,027
827
Circumcision and release of ventral chordee.
PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES: ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA: ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics preop.,BRIEF HISTORY: , This is a 43-...
[ "adhesions", "chordee", "circumcision", "foreskin", "penis", "phimosis", "release of ventral chordee", "surgery", "ventral chordee" ]
1,028
828
Normal penis. The foreskin was normal in appearance and measured 1.6 cm. There was no bleeding at the circumcision site.
PROCEDURE:, Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis. The foreskin was normal in appearance and measured 1.6 cm. There was no bleeding at the circumcision site.,PROCEDURE:, Patient was placed on the circumcision restraint board. EMLA had been applied approximately 90 minutes before. A time-out was com...
[ "circumcision", "emla", "foreskin", "glans penis", "mogen clamp", "penis", "surgery" ]
1,029
829
Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure.
PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA: ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents. The risks are infection, hemorrhage, and meatal stenosis. The...
[ "adhesions", "chordee", "circumcision", "dorsal slit", "epinephrine", "foreskin", "hemorrhage", "hypospadias", "infant", "lidocaine", "penis", "phallus", "surgery" ]
1,030
830
Circumcision. A dorsal slit was made, and the prepuce was dissected away from the glans penis.
PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,DETAILS OF PROCEDURE: ,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes, a...
[ ": thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be ...
1,031
831
Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus.
PROCEDURES:,1. Release of ventral chordee.,2. Circumcision.,3. Repair of partial duplication of urethral meatus.,INDICATIONS: , The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding. He is here electively for surgical c...
[ "chordee", "circumcision", "glans", "meatus", "partial duplication", "penis", "release of ventral chordee", "repair of partial duplication", "surgery", "urethral", "urethral meatus", "ventral", "ventral chordee" ]
1,032
832
Circumcision procedure in a baby
CIRCUMCISION,After informed consent was obtained the baby was placed on the circumcision tray. He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion. Then 0.2 mL of 1% lidocaine was injected at 10 and 2 o'clock. A ring block was also done using another 0.3 mL of lidocaine. Gluco...
[ "1% lidocaine", ": thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual form...
1,033
833
Circumcision in an older person
CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture is used as a stay-stitch of the glans pe...
[ ": thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be ...
1,034
834
Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.
REASON FOR CATHETERIZATION:, ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Left ventriculogram.,4. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncomplian...
[ "bare-metal stents", "cineangiography", "circumflex", "coronary system cineangiography", "infarction", "myocardial infarction", "st-elevation", "stenosis", "stents", "surgery", "ventriculogram" ]
1,036
835
Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.
PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Cineangiography of SVG to OM.,4. Cineangiography of LIMA to LAD.,5. Left ventriculogram.,6. Aortogram.,7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty...
[ "aortogram", "balloon", "balloon angioplasty", "cineangiography", "circumflex", "coronary artery", "coronary system cineangiography", "lad", "lima to lad", "obtuse marginal branch", "percutaneous intervention", "surgery", "svg to om", "ventriculogram" ]
1,037
836
Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents.
PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes, and the remainder of the...
[ ": thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be ...
1,038
837
Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis.
PREOPERATIVE DIAGNOSIS:, Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:, Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week statu...
[ "acalculous", "acalculous cholecystitis", "catheter", "cholecystitis", "cholecystostomy", "cholecystostomy tube", "surgery", "ultrasound", "under ultrasound guidance" ]
1,039
838
Circumcision procedure (neotal)
CIRCUMCISION - NEONATAL,PROCEDURE:,: The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The infant was placed on th...
[ "bell", "circumcision", "circumferentially", "external genitalia", "foreskin", "glans", "glans penis", "gomco", "gomco clamp", "infant", "infection", "meatal stenosis", "neonatal", "penile block", "penis", "preputial skin", "surgery" ]
1,040
839
The patient had spraying of urine and ballooning of the foreskin with voiding.
PREOPERATIVE DIAGNOSIS:, Phimosis.,POSTOPERATIVE DIAGNOSES:, Phimosis.,OPERATIONS:, Circumcision.,ANESTHESIA: , LMA.,EBL:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis. The patient had spraying of urine and ballooning of the foreski...
[ "ballooning", "ballooning of the foreskin", "circumcision", "foreskin", "gamco clamp", "phimosis", "spraying", "spraying of urine", "surgery", "urine" ]
1,041
840
Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially.
PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS: ,None.,OPERATIVE FINDINGS: ,...
[ "abdomen", "adhesions", "anterior abdominal wall", "cholecystectomy", "cystic duct", "gallbladder", "gallstone", "injectable", "laparoscopic", "laparoscopic cholecystectomy", "omental adhesions", "pancreatitis", "surgery", "veress needle", "video laparoscope" ]
1,042
841
Open cholecystectomy (attempted laparoscopic cholecystectomy).
PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, ...
[ "blake", "cholecystectomy", "cholecystitis", "cholelithiasis", "electrocautery", "endotracheal", "french", "gallbladder", "gallbladder fossa", "gangrenous", "hasson", "laparoscopic", "omentum", "subhepatic", "surgery" ]
1,043
842
Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.
PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesi...
[ "abdominal pain", "ampulla", "bile duct", "brush", "brush cytology", "brush cytology and biopsy", "cannulation", "cholangiogram", "cholangiopancreatography", "cholangiopancreatography with brush cytology", "common bile duct", "cytology", "endoscopic", "endoscopic retrograde cholangiopancre...
1,044
843
Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh.
PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE: ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruct...
[ "anesthesia", "chest", "chest wall", "chest wall reconstruction", "chest wall segment", "chest wall tumor", "chest wall tumor resection", "diaphragm", "electrocautery", "gore tex mesh", "left lower lobe", "lower lobe", "lung", "lung wedge resection", "mesh", "pleural cavity", "resect...
1,045
844
Laparoscopic cholecystectomy with cholangiogram.
PREOPERATIVE DIAGNOSES:,1. Cholelithiasis.,2. Acute cholecystitis.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic cholecystitis.,2. Cholelithiasis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,ANESTHESIA: , General.,INDICATIONS: , This is a 38-year-old diabetic Hispanic female patient, with ong...
[ "acute cholecystitis", "cholangiogram", "cholecystectomy", "cholelithiasis", "gallbladder", "laparoscopic", "laparoscopic cholecystectomy", "surgery" ]
1,046
845
Left pleural effusion, parapneumonic, loculated. Left chest tube placement.
PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patie...
[ "activase", "chest", "chest tube", "chest tube placement", "infiltration", "lidocaine", "loculated", "parapneumonic", "pleural", "pleural effusion", "surgery" ]
1,047
846
Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.
PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected ...
[ "chest closure", "delayed primary chest closure", "hypoplastic left heart syndrome", "norwood operation", "open chest", "stage 1 norwood operation", "surgery" ]
1,048
847
Removal of chest wall mass. The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.
PREOPERATIVE DIAGNOSIS:, Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:, Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic. The time-out pro...
[ "cartilages", "chest", "chest wall", "chest wall mass", "local anesthetic", "lower ribs", "mass", "ribs", "surgery", "wall" ]
1,049
848
Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.
PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained. This ...
[ "barometric trauma", "blunt dissection", "chest", "chest tube", "chest tube insertion", "chest wall", "chest x-ray", "insertion", "pneumonia", "pneumothorax", "respiratory failure", "sepsis", "spontaneous pneumothorax", "surgery", "thoracic cavity", "tube" ]
1,050
849
Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion.
PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:, This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. ...
[ "carcinoma", "chest tube", "hemithorax", "hemothorax", "infuse-a-port insertion", "pleur-evac device", "surgery" ]
1,051
850
Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound.
PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the ...
[ "bilateral pleural effusion", "chest", "chest tubes", "effusion", "pleural", "pleural effusion", "serous drainage", "surgery" ]
1,052
851
Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis. Term pregnancy and desires permanent sterilization.
PREOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,PROCEDURE:,1. Repeat low-transverse cesarean section.,2. Bilateral tubal ligation.,3. Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:...
[ "abdominal", "abdominal cavity", "adhesiolysis", "adhesions", "anterior", "anterior uterus", "bilateral tubal ligation", "cesarean", "cesarean section", "chromic", "chromic suture", "hemostasis", "infant", "low-transverse cesarean section", "sterilization", "surgery", "term pregnancy...
1,053
852
Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity.
PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:, Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED: ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS: ,50 ...
[]
1,054
853
Laparoscopic resection of cecal polyp. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.
PREOPERATIVE DIAGNOSIS:, Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA: ,General oral endotracheal intubation.,PROCEDURE:, After adequate general anesthesia was administered the patient's abdomen was prepped and draped asepti...
[ "anesthetic", "blunt dissection", "cecal polyp", "gia stapler", "ileocecal valve", "infiltrated", "kocher clamps", "laparoscopic resection", "peritoneal cavity", "polyp", "surgery" ]
1,056
854
Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.
PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the fr...
[]
1,057
855
Right subclavian triple lumen central line placement
PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:, Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION: ,Th...
[ "central line", "central line placement", "chronic obstructive coronary disease", "line placement", "lumen central line placement", "normal saline", "respiratory", "respiratory failure", "subclavian", "subclavian triple lumen central line placement", "subclavian vein", "surgery", "triple lum...
1,058
856
Insertion of central venous line and arterial line and transesophageal echocardiography probe.
INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including us...
[ "arterial", "arterial line", "aseptic technique", "atrial septectomy", "blood return", "catheter", "central", "central venous", "central venous line", "glenn procedure", "insertion", "open-heart surgery", "probe", "pulsatile blood", "surgery", "transesophageal echocardiography probe" ]
1,059
857
Central line insertion. Empyema thoracis and need for intravenous antibiotics.
PREOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,PROCEDURE:, Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral ar...
[ "catheter", "central line insertion", "empyema", "intravenous", "surgery", "thoracis" ]
1,060
858
Cauterization of epistaxis, left nasal septum. Fiberoptic nasal laryngoscopy. Atrophic dry nasal mucosa. Epistaxis. Atrophic laryngeal changes secondary to inhaled steroid use.
PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1. Atrophic dry nasal mucosa.,2. Epistaxis.,3. Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1. Cauterization of epistaxis, left nasal septum.,2. Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synep...
[ "atrophic", "cauterization", "dry nasal mucosa", "dysphonia", "epistaxis", "fiberoptic", "fiberoptic nasal laryngoscopy", "inhaled steroid use", "laryngeal", "laryngoscope", "lesions", "mucosa", "nasal mucosa", "supraglottic", "surgery" ]
1,061
859
Ultrasound-guided placement of multilumen central venous line, left femoral vein.
PROCEDURE PERFORMED: , Ultrasound-guided placement of multilumen central venous line, left femoral vein.,INDICATIONS:, Need for venous access in a patient on a ventilator and on multiple IV drugs.,CONSENT: , Consent obtained from patient's sister.,PREOPERATIVE MEDICATIONS: , Local anesthesia with 1% plain lidocaine.,PR...
[ "access", "catheter", "femoral", "femoral vein", "guidewire", "placement", "plain lidocaine", "surgery", "ultrasound", "vein", "venous" ]
1,062
860
Temporal cheek-neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.
PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-o...
[ "auricular", "auricular region", "cheek", "cheek neck", "cheek neck facelift", "dissection", "facelift", "incision", "lipotosis", "neck", "neck facelift", "neck skin ptosis", "post auricular", "postoperative", "pre and post auricular", "rhytides", "submental", "submental suction as...
1,063
861
Refractory priapism. Cavernosaphenous shunt. The patient presented with priapism x48 hours on this visit. The patient underwent corporal aspiration and Winter's shunt both of which failed
PREOPERATIVE DIAGNOSIS:, Refractory priapism.,POSTOPERATIVE DIAGNOSIS:, Refractory priapism.,PROCEDURE PERFORMED: , Cavernosaphenous shunt.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: ,400 cc.,FLUIDS: , IV fluids 1600 crystalloids, one liter packed red blood cells.,INDICATIONS FOR PROCEDURE: ,This is a 34-year-old Afri...
[ "aspiration", "cavernosaphenous shunt", "corpora cavernosum", "corporal", "corporal aspiration", "foley catheter", "priapism", "refractory priapism", "saphenous vein", "surgery", "winter's shunt" ]
1,064
862
Normal cataract surgery.
NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital. Topical tetracaine drops were applied. The operative eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted.,Under t...
[ ": thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. mthelpline does not certify accuracy and quality of sample reports.these transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be ...
1,065
863
Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.
PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, left eye.,PROCEDURE PERFORMED: ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction ...
[ "anterior chamber", "capsular", "cataract", "cataract extraction", "chamber", "extracapsular", "intraocular", "intraocular lens", "keratome", "limbus", "phacoemulsification", "surgery" ]
1,066
864
Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.
PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED: ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED: ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.,A...
[ "anterior chamber", "anterior vitrectomy", "cataract", "cataract extraction", "extraction", "eye", "hemodynamic", "implant", "intraocular", "intraocular lens implant", "lens", "lid speculum", "surgery", "vitrectomy", "vitreous" ]
1,067
865
Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.
PREOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1. Right carpal tunnel release.,2. Right index and middle fingers relea...
[ "carpal", "carpal tunnel", "carpal tunnel release", "carpal tunnel syndrome", "compressed median nerve", "copious irrigation", "fingers", "index", "ligament", "littler scissors", "median nerve", "middle fingers", "pulley", "stenosing tenosynovitis", "superficialis", "surgery", "tendo...
1,068
866
Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.
PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:, Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,ANE...
[ "arthroscopy", "cartilage", "cartilage loose body", "chondroplasty", "femoral", "knee", "knee arthroscopy", "loose cartilage", "medial femoral condyle", "microfracture", "orthopedic", "surgery", "tourniquet" ]
1,069
867
Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.
PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine d...
[ "anterior", "anterior capsular", "anterior chamber", "aspiration unit", "capsular", "capsular bag", "cataract", "cataract extraction", "chamber", "epinephrine", "extraction", "eye", "honan balloon", "hydrodissection", "intraocular", "intraocular lens", "irrigation and aspiration", ...
1,070
868
Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.
PROCEDURE PERFORMED:, Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequat...
[ "anterior chamber", "capsular", "capsular bag", "cataract", "cataract extraction", "eye", "knife", "lens", "lens implantation", "lid speculum", "sinskey hook", "surgery" ]
1,071
869
Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.
PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:, Left carpal tunnel release.,FINDINGS:, Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS: ,None.,FLUIDS:, 500 mL of crystalloids.,URINE OUTPUT:, N...
[ "carpal", "carpal tunnel release", "carpal tunnel syndrome", "compression", "median nerve", "surgery", "tunnel", "wrist" ]
1,072
870
Carpal tunnel syndrome. Open carpal tunnel release. A longitudinal incision was made in line with the 4th ray. The dissection was carried down to the superficial aponeurosis, which was cut. The distal edge of the transverse carpal ligament was identified with a hemostat.
PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: ,Open carpal tunnel release.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usua...
[ "carpal ligament", "carpal tunnel release", "carpal tunnel syndrome", "hemostat", "incision", "ligament", "surgery", "transverse", "transverse carpal ligament", "tunnel" ]
1,073
871
Right carpal tunnel release. Right carpal tunnel syndrome. This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.
PREOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:, Right carpal tunnel release.,ANESTHESIA:, Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than ...
[ "bier block", "carpal", "carpal ligament", "carpal tunnel release", "carpal tunnel syndrome", "median", "median nerve", "surgery", "transverse", "tunnel" ]
1,074
872
Right carpal tunnel syndrome. Right carpal tunnel release.
PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE: ,The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block usin...
[ "carpal tunnel release", "carpal tunnel syndrome", "ligament", "superficial", "superficial palmar arch", "surgery", "transverse wrist crease" ]
1,075
873
Right open carpal tunnel release and cortisone injection, left carpal tunnel.
PREOPERATIVE DIAGNOSIS: ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1. Right open carpal tunnel release.,2. Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,INDICATIONS:, This patien...
[ "4 x 4s", "adaptic", "baby metzenbaum scissors", "bilateral carpal", "bilateral carpal tunnel", "carpal", "carpal canal", "carpal ligament", "carpal tunnel", "carpal tunnel release", "carpal tunnel syndrome", "coban", "cortisone injection", "electrocautery", "esmarch", "fibrous band", ...
1,076
874
Bilateral open carpal tunnel release.
PREOPERATIVE DIAGNOSIS: ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:, General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PROCE...
[ "bilateral", "bilateral open carpal tunnel", "carpal", "carpal tunnel", "carpal tunnel release", "carpal tunnel syndrome", "release", "surgery", "tourniquet", "tunnel" ]
1,077
875
Carpal tunnel syndrome. Endoscopic carpal tunnel release. After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.
PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fash...
[ "carpal", "carpal ligament", "carpal tunnel release", "carpal tunnel syndrome", "endoscopic", "esmarch", "ligament", "surgery", "tourniquet", "transverse", "tunnel" ]
1,078
876
Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.
PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1. Left carpal tunnel release (64721).,2. Left ulnar nerve ante...
[ "ace bandage", "carpal", "carpal ligament", "carpal tunnel", "carpal tunnel release", "carpal tunnel syndrome", "curvilinear incision", "flexor pronator", "flexor pronator muscle", "forearm", "kerlix", "nerve", "ping-pong ball sign", "pronator", "pronator muscle", "pronator muscle mass...
1,079
877
Endoscopic release of left transverse carpal ligament.
PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia provided by surgeon. ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , Wit...
[ "agee inside job", "antebrachial", "antebrachial fascia", "carpal", "carpal ligament", "carpal tunnel", "carpal tunnel syndrome", "endoscopic", "ligament", "palmar", "release", "surgery", "synovium", "tourniquet", "transverse carpal", "transverse carpal ligament", "transverse incisio...
1,080
878
Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger.
PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1. Endoscopic release of left transverse carpal ligament.,2...
[ "agee inside job", "antebrachial fascia", "carpal", "carpal ligament", "carpal tunnel syndrome", "endoscopic", "finger", "forearm", "ligament", "middle finger", "ring ray", "stenosing tenosynovitis", "steri strips", "steroid injection", "surgery", "synovial elevator", "tenosynovitis"...
1,081
879
Left endoscopic carpal tunnel release and endotracheal fasciotomy.
PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1. Left endoscopic carpal tunnel release.,2. Endotracheal fasciotomy.,ANESTHESIA:, General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementioned d...
[ "antebrachial", "antebrachial fascia", "antebrachial fasciotomy", "carpal", "carpal ligament", "carpal tunnel", "carpal tunnel release", "carpal tunnel syndrome", "electrocautery", "endoscopic carpal tunnel release", "fasciotomy", "hamate", "ligament", "surgery", "transverse", "transve...
1,082
880
Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.
PREOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,OPERATIONS,1. Right common carotid endarterectomy.,2. Right internal carotid endarterectomy.,3. Right external carotid endarterectomy.,4. Hemashiel...
[ "angioplasty", "artery", "carotid", "carotid endarterectomy", "common carotid", "common carotid artery", "endarterectomy", "external", "external carotid artery", "hemashield", "hemashield patch", "surgery" ]
1,083
881
Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.
PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE: ,The patient was brought to the operating r...
[ "bier block", "carpal", "carpal ligament", "carpal tunnel", "carpal tunnel release", "carpal tunnel syndrome", "nerve conduction study", "surgery", "tunnel" ]
1,084
882
Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis.
PROCEDURE:, Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mm...
[ "carpal", "carpal ligament reconstruction", "carpal tunnel", "hemostat", "ligament", "superficial", "surgery", "transverse", "transverse carpal ligament", "ulnar" ]
1,085
883
Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.
PREOPERATIVE DIAGNOSES:,1. Right carotid stenosis.,2. Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1. Right carotid stenosis.,2. Prior cerebrovascular accident.,PROCEDURE PERFORMED: ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE FINDINGS: , The common and inte...
[ "carotid", "carotid endarterectomy", "carotid stenosis", "carotids", "cerebrovascular", "cerebrovascular accident", "dacron patch", "endarterectomy", "internal carotid", "platysmal", "stenosis", "surgery" ]
1,086
884
Direct-current cardioversion. This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. Successful DC cardioversion of atrial fibrillation.
PROCEDURE: ,Direct-current cardioversion.,BRIEF HISTORY: ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years. He had a wide area of circumferential ablation done on November 9th for atrial fibrillation. He did develop recurrent atrial fibrillation the day before yesterday and thi...
[ "ablation", "atrial fibrillation", "cardioversion", "circumferential ablation", "dc cardioversion", "direct current", "direct-current cardioversion", "paroxysmal atrial", "surgery" ]
1,087
885
Cardioversion. Unsuccessful direct current cardioversion with permanent atrial fibrillation.
REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of f...
[ "anterior-posterior", "atrial", "atrial fibrillation", "atrial flutter", "cardioversion", "fibrillation", "flutter/cardioversion", "surgery", "transesophageal" ]
1,088
886
Direct current cardioversion. Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.
PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL: ,The procedure was explained to the patient with risks and benefits including risk of stroke. The patient understands as well as her husband. The patient had already a transesophageal echocardiogram showing no l...
[ "atrial fibrillation", "atrium", "cardioversion", "direct current cardioversion", "echocardiogram", "rhythm", "sinus", "sinus rhythm", "surgery", "thrombus", "transesophageal" ]
1,089
887
Left carotid endarterectomy with endovascular patch angioplasty. Critical left carotid stenosis. The external carotid artery was occluded at its origin. When the endarterectomy was performed, the external carotid artery back-bled nicely. The internal carotid artery had good backflow bleeding noted.
PREOPERATIVE DIAGNOSIS:, Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:, Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:, Cervical block.,GROSS FINDINGS: ,The patient is a 57-year-old black female with chronic renal failure. S...
[ "angioplasty", "artery", "carotid", "carotid artery", "carotid endarterectomy", "carotid stenosis", "cervical block", "common carotid", "common carotid artery", "endarterectomy", "endovascular", "endovascular patch", "endovascular patch angioplasty", "external carotid", "external carotid...
1,090
888
Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.
HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first eme...
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1,091
889
Left heart cardiac catheterization.
PROCEDURE PERFORMED:,1. Right femoral artery access.,2. Selective right and left coronary angiogram.,3. Left heart catheterization.,4. Left ventriculogram.,INDICATIONS FOR PROCEDURE:, A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents ...
[ "anterior descending", "anterior descending artery", "artery", "cardiac catheterization", "catheterization", "circumflex coronary", "circumflex coronary artery", "coronary", "coronary angiogram", "coronary artery", "descending", "distal left anterior descending", "femoral artery", "femoral...
1,092
890
Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth.
PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 1...
[ "carious", "carious teeth", "forceps extraction", "intraoral procedure", "partial bony impacted tooth", "periodontal", "periodontal disease", "surgery", "teeth extraction" ]
1,093
891
Right carpal tunnel release.
PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:, There were no complications during the procedure.,SPECIMEN: ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct ...
[ "ace wrap", "bulky dressing", "carpal", "carpal ligament", "carpal tunnel", "carpal tunnel release", "carpal tunnel syndrome", "emg", "freer elevator", "kerlix", "lidocaine with epinephrine", "ligament", "palmar fascia", "subcutaneous fat", "surgery", "transverse carpal ligament", "t...
1,094
892
Cardioversion. An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation
HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion...
[ "aortic valve", "atrial", "atrial fibrillation", "cardioversion", "cpap", "fibrillation", "normal sinus rhythm", "paroxysmal", "sinus rhythm", "surgery" ]
1,095
893
Cardiac catheterization and coronary intervention report.
EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1. Left heart catheterization, coronary angiography, left ventriculography.,2. PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1. IV Valium.,2. IV Benadry...
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1,096
894
Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.
PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-a...
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1,097
895
White male with onset of chest pain, with history of on and off chest discomfort over the past several days.
INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual short...
[ "artery", "branch", "cardiac", "catheterization", "circumflex", "coronary", "coronary artery", "cpk", "diagonal branch", "ejection fraction", "elevation", "french angio-seal", "pigtail catheter", "posterior descending", "q wave", "rca", "st", "st elevation", "st segment", "sten...
1,098
896
Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.
PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known...
[ "angio-seal", "angiogram", "angiography", "artery", "atherosclerotic", "bifurcation", "catheterization", "closure device", "coronary", "coronary artery", "coronary atherosclerotic heart disease", "pda", "saphenous", "saphenous vein", "saphenous vein graft", "surgery", "vein graft", ...
1,099
897
Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.
INDICATIONS FOR PROCEDURE:, The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.,C...
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1,100
898
Cardiac catheterization. Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.
PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% li...
[ "abdominal", "aorta", "artery", "calcification", "cardiac", "cardiac catheterization", "catheterization", "coronary", "coronary arteries", "coronary artery", "coronary artery disease", "descending artery", "intimal", "intimal calcification", "mid", "mid abdominal aorta", "proximal", ...
1,101
899
Left Heart Catheterization. Chest pain, coronary artery disease, prior bypass surgery. Left coronary artery disease native. Patent vein graft with obtuse marginal vessel and also LIMA to LAD. Native right coronary artery is patent, mild disease.
EXAM: , Left Heart Catheterization,REASON FOR EXAM:, Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained. The patient was brought to the cath lab. The right groin was draped in the usual ster...
[ "artery", "bypass", "bypass surgery", "catheterization", "chest pain", "coronary", "coronary artery", "coronary artery disease", "graft", "heart catheterization", "lad", "lima", "marginal", "marginal vessel", "obtuse", "obtuse marginal", "obtuse marginal vessel", "surgery", "vein...
1,102
900
Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.
EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:, None.,DE...
[ "angiography", "aortic valve", "artery", "cardiac catheterization", "catheterization", "cineangiography", "coronary", "coronary artery", "diffuse luminal irregularities", "heart catheterization", "luminal irregularities", "regurgitation", "selective coronary angiography", "surgery", "the...
1,103