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Insertion of left femoral circle-C catheter (indwelling catheter). Chronic renal failure. The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.
Surgery
Indwelling Catheter Insertion
PREOPERATIVE DIAGNOSIS: , Chronic renal failure.,POSTOPERATIVE DIAGNOSIS: ,Chronic renal failure.,PROCEDURE PERFORMED:, Insertion of left femoral circle-C catheter.,ANESTHESIA: , 1% lidocaine.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,HISTORY: , The patient is a 36-year-old African-American male present...
surgery, chronic renal failure, femoral circle-c catheter, indwelling catheter, catheter, insertion, seldinger, guidewire, indwelling, femoral, dialysis,
701
Induction of vaginal delivery of viable male, Apgars 8 and 9. Term pregnancy and oossible rupture of membranes, prolonged.
Surgery
Induction of Vaginal Delivery
DIAGNOSES,1. Term pregnancy.,2. Possible rupture of membranes, prolonged.,PROCEDURE:, Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:, The patient is a 20-year-old female, gravida 4, para 0, who presented to the office. She had small amount of leaking since last night. On exam, she ...
surgery, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars
702
Perirectal abscess. Incision and drainage (I&D) of perirectal abscess.
Surgery
I&D - Perirectal Abscess
PREOPERATIVE DIAGNOSIS:, Perirectal abscess.,POSTOPERATIVE DIAGNOSIS:, Perirectal abscess.,PROCEDURE: , Incision and drainage (I&D) of perirectal abscess.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room after obtaining an informed consent. A spinal anesthetic was given, and then the patient i...
surgery, hemorrhoids, incision and drainage, perirectal abscess, cavity, i&d, perirectal,
703
Incision and drainage (I&D) with primary wound closure of scalp lacerations. The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. The patient was taken to the operating room for an I&D of the lacerations with wound closure.
Surgery
I&D & Wound Closure - Scalp Lacerations
PREOPERATIVE DIAGNOSIS: , Scalp lacerations.,POSTOPERATIVE DIAGNOSIS: , Scalp lacerations.,OPERATION PERFORMED: , Incision and drainage (I&D) with primary wound closure of scalp lacerations.,ANESTHESIA:, GET.,EBL: , Minimal.,COMPLICATIONS: , None.,DRAINS: , None.,DISPOSITION: , Vital signs stable and taken to the reco...
surgery, drainage, incision, primary wound closure, lacerations, wound closure, scalp lacerations, scalp, i&d,
704
Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.
Surgery
I&D - ORIF Wound
TITLE OF OPERATION:,1. Irrigation and debridement of postoperative wound infection (CPT code 10180).,2. Removal of foreign body, deep (CPT code 28192).,3. Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-...
surgery, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum,
705
Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.
Surgery
I&D - Penoscrotal Abscess
PREOPERATIVE DIAGNOSIS: , Penoscrotal abscess.,POSTOPERATIVE DIAGNOSIS:, Penoscrotal abscess.,OPERATION: , Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.,BRIEF HISTORY: , The patient is a 75-year-old male presented with penoscrotal abscess. Options such as...
surgery, i&d, penoscrotal, penile biopsy, cystoscopy, urethral dilation, incision and drainage, fungating mass, penoscrotal abscess, abscess, urethral,
706
Incision and drainage of left neck abscess.
Surgery
I&D - Neck Abscess
PREOPERATIVE DIAGNOSIS: , Left neck abscess.,POSTOPERATIVE DIAGNOSIS: , Left neck abscess.,OPERATIVE PROCEDURE: , Incision and drainage of left neck abscess.,ANESTHESIA: ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to operating room and placed supine on the operating table. General inhalat...
surgery, i&d, incision and drainage, neck abscess, drainage, cavity, incision,
707
Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast.
Surgery
I&D & Open Reduction - Forearm
PREOPERATIVE DIAGNOSIS: ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1. Irrigation and debridement of skin subcutaneous...
surgery, compound fracture, mid-shaft radius, ulna, open reduction, irrigation and debridement, subcutaneous, tissues, muscle, bone, forearm, radius and ulna, forearm fracture, anatomic alignment, arm cast, puncture wound, tourniquet, i&d, fracture,
708
Incision and drainage (I&D) of gluteal abscess. Removal of pigtail catheter. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.
Surgery
I&D - Gluteal Abscess
PREOPERATIVE DIAGNOSES,1. Postoperative wound infection.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,POSTOPERATIVE DIAGNOSES,1. Postoperative wound infection. There was an intraperitoneal foreign body.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,PROCEDURES,1. Incision and dra...
surgery, intraperitoneal pigtail catheter, postoperative wound infection, foreign body, intraperitoneal, exploratory laparotomy, enterocutaneous fistula, wound infection, sinus tract, gluteal abscess, pigtail catheter, i&d, abscess, laparotomy, fascia, pigtail, catheter, gluteal, incision, foreign
709
Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.
Surgery
I&D & Foreign Body Removal
PREOPERATIVE DIAGNOSIS:, Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1. Incision and drainage, right foot.,2. Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off h...
surgery, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, orthopedic, metatarsal, i&d, incision, drainage, foot
710
Incision and drainage of right buccal space abscess and teeth extraction.
Surgery
I&D - Buccal Space Abscess
PREOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1. Right buccal space abscess/cellulitis.,2. Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1. Incision and drainage of right buccal space abscess.,2. Extraction of teet...
surgery, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal,
711
Placement of right external iliac artery catheter via left femoral approach, arteriography of the right iliac arteries, primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon, open stent placement in the right external iliac artery for inadequate angiographic result...
Surgery
Iliac Artery Catheter & Stent Placement, Arteriography, Angioplasty
PREOPERATIVE DIAGNOSIS: , External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,POSTOPERATIVE DIAGNOSIS:, External iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,PROCEDU...
surgery, external iliac artery catheter, catheter via left femoral, external iliac artery stenosis, impaired renal function, common iliac artery, iliac artery catheter, external iliac artery, iliac artery, femoral approach, iliac arteries, transplanted kidney, renovascular hypertension, widely patent, residual stenosis...
712
Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid. Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.
Surgery
Hysteroscopy & Laproscopy with Salpingooophorectomy
PREOPERATIVE DIAGNOSES:,1. Thickened endometrium and tamoxifen therapy.,2. Adnexal cyst.,POSTOPERATIVE DIAGNOSES:,1. Thickened endometrium and tamoxifen therapy.,2. Adnexal cyst.,3. Endometrial polyp.,4. Right ovarian cyst.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Hysteroscopy.,3. Laparoscopy w...
surgery, adnexal cyst, endometrial, ovarian cyst, dilation and curettage, d&c, hysteroscopy, laparoscopy, salpingooophorectomy, aspiration of cyst fluid, thickened endometrium, tamoxifen therapy, abdominal wall, cyst, ovarian, endometrium,
713
Incision and drainage (I&D) of buttock abscess.
Surgery
I&D - Buttock Abscess
PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:, Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE: ,Under general anesthesia, skin was prepped and draped in usual fashion. Two incisions were made along the right buttock approximately 5 mm diamet...
surgery, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage
714
Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.
Surgery
Hysterectomy & Salpingoophorectomy
PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL ...
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715
Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.
Surgery
Hysteroscopy & Endometrial Ablation
PREOPERATIVE DX:,1. Menorrhagia,2. Desires permanent sterilization.,POSTOPERATIVE DX:,1. Menorrhagia,2. Desires permanent sterilization.,OPERATIVE PROCEDURE:, Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.,ANESTHESIA: , General with paracervical block.,ESTIMATED BLOOD LOSS: , Minimal...
surgery, menorrhagia, essure, hysteroscopy, thermachoice, uterine cavity, endometrial ablation, endometrium, fibroids, fluffy, lactated ringer, nulliparous, paracervical block, permanent sterilization, polyps, tubal occlusion, tubal ostia, lactated ringer's, ablation, uterine,
716
Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.
Surgery
I&D - Auricular Hematoma
PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:, Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephr...
surgery, bolster dressing placement, antihelix fold, incision and drainage, bolster dressing, auricular hematoma, auricular, hematoma, incision, drainage
717
Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).
Surgery
Hypospadias Repair & Chordee Release - 1
PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:, Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RE...
surgery, coronal hypospadias with chordee, coronal hypospadias, tissue flap relocation, nesbit tuck, hypospadias with chordee, horizontal mattress sutures, chordee release, zaontz catheter, coronal cuff, hypospadias repair, penile shaft, zaontz, glans, urethral, repair, coronal, hypospadias, penis, chordee,
718
Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.
Surgery
Hysterectomy (TAH - BSO)
PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:, Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:, Genera...
surgery, tah, bso, lymphadenectomy, endometrial, total abdominal hysterectomy, bilateral salpingo oophorectomy, tubes and ovaries, salpingo oophorectomy, lymph nodes, endometrial cancer, abdominal, hysterectomy, oophorectomy, hemostasis, retractors, washings, laparotomy, ligated, pelvic, uterus, nodes,
719
Pelvic tumor, cystocele, rectocele, and uterine fibroid. Total abdominal hysterectomy, bilateral salpingooophorectomy, repair of bladder laceration, appendectomy, Marshall-Marchetti-Krantz cystourethropexy, and posterior colpoperineoplasty. She had a recent D&C and laparoscopy, and enlarged mass was noted and could n...
Surgery
Hysterectomy, BSO, & Appendectomy.
1. Pelvic tumor.,2. Cystocele.,3. Rectocele.,POSTOPERATIVE DIAGNOSES:,1. Degenerated joint.,2. Uterine fibroid.,3. Cystocele.,4. Rectocele.,PROCEDURE PERFORMED: ,1. Total abdominal hysterectomy.,2. Bilateral salpingooophorectomy.,3. Repair of bladder laceration.,4. Appendectomy.,5. Marshall-Marchetti-Krant...
surgery, marshall-marchetti-krantz cystourethropexy, pelvic tumor, cystocele, rectocele, uterine fibroid, hysterectomy, salpingooophorectomy, bladder laceration, appendectomy, colpoperineoplasty, marshall marchetti krantz cystourethropexy, bard parker blade knife, vicryl suture, vaginal mucosa, uterus, vaginal, uterine...
720
Laparoscopic supracervical hysterectomy. Menorrhagia and dysmenorrhea.
Surgery
Hysterectomy - Laparoscopic Supracervical
PREOPERATIVE DIAGNOSES:, Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simpl...
surgery, supracervical hysterectomy, incision, uterine, uteroovarian, hysterectomy, supracervical, menorrhagia, dysmenorrhea, cervical, laparoscopic, laparoscope, cervix, ligaments, trocar
721
Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.
Surgery
Hypergranulation - Consult
CHIEF COMPLAINT:, Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted...
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722
Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.
Surgery
Hypospadias Repair & Chordee Release
PREOPERATIVE DIAGNOSIS:, Penoscrotal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Penoscrotal hypospadias with chordee.,PROCEDURE:, Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,ANESTHESIA: , General inhalation anesthetic with a caudal block.,FLUIDS RECEIVED: , 300 mL of...
surgery, tissue flap relocation, penoscrotal hypospadias, urethra, nesbit tuck chordee release, horizontal mattress sutures, hypospadias repair, chordee release, zaontz catheter, urethral plate, glans, hypospadias, penis, chordee,
723
Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.
Surgery
Hydrocelectomy - 1
PREOPERATIVE DIAGNOSES:, Bladder cancer and left hydrocele.,POSTOPERATIVE DIAGNOSES: , Bladder cancer and left hydrocele.,OPERATION: ,Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,ANESTHESIA:, Spinal.,ESTIMATED BLOOD LOSS: ,Minimal.,FLUIDS:, Crystalloid.,BRIEF HISTORY: ,The ...
surgery, hydrocele, fulguration, bladder biopsy, hydrocelectomy, cystopyelogram, cystopyelogram bladder, bladder cancer, bladder,
724
Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.
Surgery
Hydrocelectomy
PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose...
surgery, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,
725
Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.
Surgery
Hypospadias Repair
PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring...
surgery, tissue flap relocation, urethroplasty plate incision, penile shaft skin, chordee release, zaontz catheter, penile shaft, hypospadias repair, flap relocation, coronal cuff, urethral plate, tissue flap, hypospadias, flap, chordee,
726
Wide Local Excision of the Vulva. Radical anterior hemivulvectomy. Posterior skinning vulvectomy.
Surgery
Hemivulvectomy
PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy. Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a h...
surgery, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning,
727
Laparoscopic left inguinal hernia repair.
Surgery
Hernia Repair
PREOPERATIVE DIAGNOSIS:, Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Left inguinal hernia.,ANESTHESIA:, General; 0.25% Marcaine at trocar sites.,NAME OF OPERATION:, Laparoscopic left inguinal hernia repair.,PROCEDURE: , A skin incision was placed at the umbilicus where the left rectus fascia was incised anterio...
surgery, rectus fascia, hernia, laparoscopic left inguinal hernia, inguinal hernia repair, hernia repair, laparoscopic, rectus, fascia, repair, balloon, inguinal,
728
Placement of a subclavian single-lumen tunneled Hickman central venous catheter. Surgeon-interpreted fluoroscopy.
Surgery
Hickman Central Venous Catheter Placement
PROCEDURE PERFORMED,1. Placement of a subclavian single-lumen tunneled Hickman central venous catheter.,2. Surgeon-interpreted fluoroscopy.,OPERATION IN DETAIL:, After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient ...
surgery, j wire, distal tip, stab incision, tunneled, hickman central venous catheter, subclavian, venous, fluoroscopy, hickman, catheterNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and qua...
729
Inguinal hernia hydrocele repair.
Surgery
Hydrocele Repair
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surgery, inguinal hernia, external oblique, hernia sac, hydrocele, hydrocele repair, ilioinguinal nerve, inguinal skin crease, oblique aponeurosis, scrotum, spermatic cord, testicle appendix, transverse inguinal skin crease incision, hernia, anesthesia, inguinalNOTE,: Thesetranscribed medical transcription sample repor...
730
Left hydrocelectomy. This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocelectomy. Physical exam confirmed obvious hydrocele, left scrotum.
Surgery
Hydrocelectomy.
PREOPERATIVE DIAGNOSIS: , Left hydrocele.,OPERATION: , Left hydrocelectomy.,POSTOPERATIVE DIAGNOSIS: , Left hydrocele.,ANESTHESIA: , General,INDICATIONS AND STUDIES: , This is a 67-year-old male with pain, left scrotum. He has had an elevated PSA and also has erectile dysfunction. He comes in now for a left hydrocele...
surgery, hydrocele, erectile dysfunction, spermatic cord, tunica vaginalis, vicryl sutures, dartos fascia, hydrocelectomy, psa, testicle, scrotum, scrotal,
731
Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.
Surgery
Hemilaminotomy & Foraminotomy
PRE AND POSTOPERATIVE DIAGNOSIS:, Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, T...
surgery, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminot...
732
Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. End-stage renal disease with failing AV dialysis fistula.
Surgery
Hemodialysis Fistula Construction
PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF ...
surgery, end-stage renal disease, av dialysis fistula, brachial vein, upper arm hemodialysis fistula, fistula, vein, hemodialysis, av, dialysis, anastomosis, brachial,
733
Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.
Surgery
Hemicraniectomy
TITLE OF OPERATION:, Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: , The patient is a patient well known to my service. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. I took her t...
surgery, large hemicraniectomy, intracranial pressure, multiple fractures, skull, traumatic brain injury, mayfield headholder, injury, hemicraniectomyNOTE
734
Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.
Surgery
Hemangioma Debulking & Rhinoplasty
PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:, Hemangioma, nasal tip.,PROCEDURE PERFORMED: ,1. Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2. Rhinoplasty.,ESTIMATED BLOOD LOSS: ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columel...
surgery, rhinoplasty approach, debulking of hemangioma, nasal domes, lower lateral cartilages, nasal tip, columella, hemangioma, debulking, cartilages, rhinoplasty, nasal,
735
Left heart catheterization, coronary angiography, and left ventriculogram. No angiographic evidence of coronary artery disease. Normal left ventricular systolic function. Normal left ventricular end diastolic pressure.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 8
PROCEDURES,1. Left heart catheterization.,2. Coronary angiography.,3. Left ventriculogram.,PREPROCEDURE DIAGNOSIS:, Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure....
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736
Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture.
Surgery
Hemiarthroplasty - Austin-Moore Bipolar
PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA: ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,HISTORY: ,The patient is an 86-year-old female ...
surgery, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral,
737
Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.
Surgery
Hematoma Evacuation
PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1. Right temporal lobe intracerebral hemorrhage.,2. Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1. Emergency right side craniotomy fo...
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738
Left heart catheterization, coronary angiography, left ventriculography. Severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 7
PROCEDURE: , Left heart catheterization, coronary angiography, left ventriculography.,COMPLICATIONS: , None.,PROCEDURE DETAIL: , The right femoral area was draped and prepped in the usual fashion after Xylocaine infiltration. A 6-French arterial sheath was placed in the usual fashion. Left and right coronary angiogra...
surgery, heart catheterization, coronary angiography, left ventriculography, arterial sheath, coronary artery, obtuse marginal branch, angiography, catheterization,
739
Left heart catheterization, left ventriculography, selective coronary angiography.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 9
PROCEDURE:, Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the righ...
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740
Exploratory laparotomy, lysis of adhesions, and right hemicolectomy. Right colon cancer, ascites, and adhesions.
Surgery
Hemicolectomy
PREOPERATIVE DIAGNOSIS: , Right colon tumor.,POSTOPERATIVE DIAGNOSES:,1. Right colon cancer.,2. Ascites.,3. Adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions.,3. Right hemicolectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,URINE OUTPUT...
surgery, colon tumor, ascites, adhesions, lysis of adhesions, exploratory laparotomy, colon cancer, transverse colon, hemicolectomy, laparotomy,
741
Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus.
Surgery
Hemiarthroplasty - Shoulder
PREOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head...
surgery, dislocation, proximal humerus, comminuted fracture, rotator interval, tuberosity portion, hemiarthroplasty, fracture, wound, proximal, deltoid, rotator, stem, humeral, humerus, tuberosity, cemented,
742
Left heart catheterization with left ventriculography and selective coronary angiography. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function. Frequent PVCs. Metabolic syndrome.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 6
PREOPERATIVE DIAGNOSES,1. Dyspnea on exertion with abnormal stress echocardiography.,2. Frequent PVCs.,3. Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1. A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2. Frequent PVCs.,3. Metabolic syndrome.,PROCEDURES...
surgery, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization,
743
Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 5
PREOPERATIVE DIAGNOSES,1. Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2. Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3. Primary malignant ventricular arrhythmia...
surgery, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, a...
744
Left heart catheterization with left ventriculography and selective coronary angiography. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 4
NAME OF PROCEDURE,1. Left heart catheterization with left ventriculography and selective coronary angiography.,2. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort. The patient had elevat...
surgery, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography
745
Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.
Surgery
Heart Catheterization, Ventriculography, & Angiography
PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Saphenous vein graft angiography.,4. Left internal mammary artery angiography.,5. Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease...
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746
Selective coronary angiography, left heart catheterization, and left ventriculography. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 11
NAME OF PROCEDURES,1. Selective coronary angiography.,2. Left heart catheterization.,3. Left ventriculography.,PROCEDURE IN DETAIL: ,The right groin was sterilely prepped and draped in the usual fashion. The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed. Con...
surgery, coronary angiography, catheterization, ventriculography, heart catheterization, coronary artery, stenosis, artery, angiography
747
Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 1
PROCEDURE:, Left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery. This gentleman has had a non-Q-wave, troponin-positive myocardial infarction, complicated by ventricular f...
surgery, heart catheterization, ventriculography, coronary angiography, stenting, distal circumflex, coronary artery, coronary, lesion, catheterization, cardiac, angiography, heart, rca, artery, circumflex,
748
Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 12
PROCEDURE: , Cardiac catheterization by:,a. Left heart catheterization.,b. Left ventriculography.,c. Selective coronary angiography.,d. Right femoral artery approach.,COMPLICATIONS:, None.,MEDICATIONS,1. IV Versed.,2. IV fentanyl.,3. Intravenous fluid administration.,4. Heparin 3000 units IV.,INDICATIONS: , Th...
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749
Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 10
PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL: ,The patient was brought to the Catheterization Laboratory. After informed consent, he was medicated with Versed and fentanyl. The ...
surgery, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography
750
Left heart catheterization with ventriculography, selective coronary angiography. Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 3
NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin. Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4. ,ANTICOAGULATION: ,The patient was on heparin at ...
surgery, standard judkins, french pigtail, selective coronary angiography, heart catheterization, ventriculography, catheterization, angiography,
751
Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test.
Surgery
Heart Catheterization & Angiography - 1
CLINICAL INDICATION: ,Normal stress test.,PROCEDURES PERFORMED:,1. Left heart cath.,2. Selective coronary angiography.,3. LV gram.,4. Right femoral arteriogram.,5. Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure. The patient ...
surgery, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography,
752
Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography. The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a par...
Surgery
Heart Catheterization & Ventriculogram
PROCEDURE PERFORMED:,1. Right heart catheterization.,2. Left heart catheterization.,3. Left ventriculogram.,4. Aortogram.,5. Bilateral selective coronary angiography.,ANESTHESIA:, 1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:, The patient is a 48-year-old female with severe mitral stenosis diag...
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753
Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.
Surgery
Heart Catheterization & Angiography - 2
PROCEDURES PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,3. Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consen...
surgery, non-st elevation, coronary angiography, ventriculogram, heart catheterization, bypass grafting, catheterization, coronary, artery, angiography, luminal, branch, descending, circumflex, vessel, guidewire,
754
Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.
Surgery
Heart Catheterization, Ventriculography, & Angiography - 2
NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:, Recurrent angina. History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:, 6-French pigtail,...
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755
Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo.
Surgery
Heart Catheterization & Angiography
INDICATION:, Coronary artery disease, severe aortic stenosis by echo.,PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Right heart catheterization.,3. Selective coronary angiography.,PROCEDURE: , The patient was explained about all the risks, benefits and alternatives to the procedure. The patient agreed to ...
surgery, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary
756
Right heart catheterization. Refractory CHF to maximum medical therapy.
Surgery
Heart Catheterization - 2
PROCEDURE PERFORMED:, Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing....
surgery, chf, cardiac, catheterization, swan-ganz, heart catheterization, internal jugular, pulmonary artery, heart, jugular, cannulate, vascular, needle, pulmonary, therapy
757
Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.
Surgery
Hardware Removal - Metatarsal
TITLE OF OPERATION:,1. Removal of painful hardware, first left metatarsal.,2. Excision of nonunion, first left metatarsal.,3. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left...
surgery, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation...
758
Left distal medial hamstring release.
Surgery
Hamstring Release
PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia. Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTI...
surgery, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring,
759
Right and left heart catheterization, coronary angiography, left ventriculography.
Surgery
Heart Catheterization
PROCEDURES:,1. Right and left heart catheterization.,2. Coronary angiography.,3. Left ventriculography.,PROCEDURE IN DETAIL:, After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory. Patient was prepped and draped in sterile fashion. Via modified Seldinger technique, t...
surgery, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions
760
Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.
Surgery
Hallux Infected Bone Resection
PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after ...
surgery, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,
761
Hardware removal in the left elbow.
Surgery
Hardware Removal - Elbow
PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:, Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia. The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET: ,There is no ...
surgery, retained hardware, hardware removal, tourniquet, elbow, hardware,
762
Hardware removal, right ulnar
Surgery
Hardware Removal - Ulnar
PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:, The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: ,...
surgery, both-bone forearm fracture, retained hardware, hardware removal, hardware, forearm, ulnar,
763
Chest pain and non-Q-wave MI with elevation of troponin I only. Left heart catheterization, left ventriculography, and left and right coronary arteriography.
Surgery
Heart Catheterization - 1
PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE: ,The patient was brought to the procedure room in satisfactory condition. The right groin was prepped and draped in rout...
surgery, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms
764
Left heart catheterization and bilateral selective coronary angiography. The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that w...
Surgery
Heart Cath & Coronary Angiography
PROCEDURE PERFORMED:,1. Left heart catheterization.,2. Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent out...
surgery, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire,
765
Pyogenic granuloma, left lateral thigh. Excision of recurrent pyogenic granuloma.
Surgery
Granuloma Excision
PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:, General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation o...
surgery, trochanter, granuloma, pyogenic granuloma, vascular malformation, pyogenic, vascular, malformation, thigh,
766
Surgery
G-tube placement
PREOPERATIVE DIAGNOSIS:, Neurologic devastation secondary to nonaccidental trauma.,POSTOPERATIVE DIAGNOSES: , Neurologic devastation secondary to nonaccidental trauma.,PROCEDURE: , Laparoscopic G-tube placement (14-French 1.2-cm MIC-Key).,INDICATIONS FOR PROCEDURE: , This patient is a 5-month-old baby boy who presente...
surgery, neurologic devastation, g-tube placement, mic-key, laparoscopic g-tube placement, babcock, g-tube site, gastrotomy, mic key, abdominal wall, gastrotomy site, nonaccidental trauma, tube, stomach,
767
Gastroscopy. A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.
Surgery
Gastroscopy - 3
PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:, Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum. Th...
surgery, olympus, gastroscope, barrett, gastroesophageal reflux disease, transverse duodenum, barrett esophagus, hiatal hernia, gastroscopy, endoscopy, hiatal, duodenum, esophagus, hernia,
768
Gangrene osteomyelitis, right second toe. The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection requiring first ray resection.
Surgery
Gangrene Surgery
PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT: ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infecti...
surgery, dorsally, toe, ulcerations, foot infection, ray resection, metatarsophalangeal joint, ace bandage, gangrene osteomyelitis, foot, infection, gangrene, digital,
769
Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.
Surgery
Gastroscopy
PREOPERATIVE DIAGNOSES: , Dysphagia and esophageal spasm.,POSTOPERATIVE DIAGNOSES: , Esophagitis and esophageal stricture.,PROCEDURE:, Gastroscopy.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenu...
surgery, duodenum, esophagus, gastroscope, stomach, upper endoscopy, transverse duodenum, gastroesophageal junction, hiatal hernia, gastroscopy, endoscopy, esophagitis, gastroesophageal, hiatal, esophageal, hernia
770
Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.
Surgery
Gastrostomy
PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to C...
surgery, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy
771
Full mouth dental rehabilitation in the operative room under general anesthesia.
Surgery
Full Mouth Dental Rehabilitation - 2
OPERATION PERFORMED:, Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1. Severe dental caries.,2. Non-restorable teeth.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,...
surgery, full mouth dental rehabilitation, dental rehabilitation, full mouth, dental caries, non-restorable teeth, dental extractions, throat pack, oral cavity, restorative phase, primary teeth, dental, anesthesia, mouth, rehabilitation, prophylaxis, oral, amalgam, tooth,
772
Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.
Surgery
Ganglion Excision
PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table. A tourniquet appl...
surgery, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion
773
Full mouth dental rehabilitation in the operating room under general anesthesia.
Surgery
Full Mouth Dental Rehabilitation - 1
OPERATION PERFORMED:, Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,POSTOPERATIVE DIAGNOSES: ,1. Severe dental caries.,2. Hemophilia.,3. Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal...
774
Dysphagia, possible stricture. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.
Surgery
Gastroscopy - 1
PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was ...
surgery
775
Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms.
Surgery
Gastroscopy - 2
PROCEDURE:, Gastroscopy.,PREOPERATIVE DIAGNOSIS:, Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosi...
surgery, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation
776
Cystoscopy and removal of foreign objects from the urethra.
Surgery
Foreign Object Removal - Urethra
PREOPERATIVE DIAGNOSIS: , Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATION: , Cystoscopy and removal of foreign objects from the urethra.,BRACHYTHERAPY:, Iodine 125.,ANESTHESIA: , General endotracheal. The patient was given Levaquin 500 mg IV preoperatively.,Total seeds were 59. Activity of 0.4...
surgery, foreign objects, foley catheter, transrectal ultrasound, prostate cancer, cystoscopy, ultrasound, urethra, endotracheal, prostate
777
Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma. Acute subdural hematoma, right, with herniation syndrome.
Surgery
Frontotemporoparietal Craniotomy
PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED: ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: ...
surgery, subdural hematoma, craniotomy, herniation, subdural, temporalis, frontotemporoparietal, hematoma,
778
Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.
Surgery
Foot Lesions
S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first me...
surgery, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful
779
Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a w...
Surgery
Foreign Body Removal - Foot
PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n....
surgery, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound,
780
Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.
Surgery
Foreign Body Removal - Foot - 1
PREOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,PROCEDURE PERFORMED:,1. Irrigation debridement.,2. Removal of foreign body of right foot.,ANESTHESIA:, S...
surgery, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent,
781
Microscopic hematuria with lateral lobe obstruction, mild.
Surgery
Flexible Cystoscopy - BPH
PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:, Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in th...
surgery, benign prostatic hyperplasia, urethra, lateral lobe obstruction, flexible cystoscopy, microscopic hematuria, cystoscopy, hematuria, obstruction,
782
Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy. Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post b...
Surgery
Flexible Fiberoptic Bronchoscopy
PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1. Severe tracheobronchitis.,2. Mild venous engorgement with question varicosities associated pulmonary hypertension.,3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a. ...
surgery, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, sub...
783
Removal of foreign body of right thigh. Foreign body of the right thigh, sewing needle.
Surgery
Foreign Body Removal - Thigh
PREPROCEDURE DIAGNOSIS:, Foreign body of the right thigh.,POSTOPERATIVE DIAGNOSIS: , Foreign body of the right thigh, sewing needle.,PROCEDURE: ,Removal of foreign body of right thigh.,HISTORY: ,This is a 71-year-old lady who has been referred because there is a mass in the right thigh. The patient comes with an ul...
surgery, removal of foreign body, sewing needle, foreign body
784
Flexor carpi radialis and palmaris longus repair. Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.
Surgery
Flexor Carpi Radialis & Palmaris Longus Repair
PREOPERATIVE DIAGNOSIS:, Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:, Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceratio...
surgery, kessler stitch, flexor carpi radialis, palmaris longus, radialis, laceration, fiberwire, flexor, carpi, palmaris, longus, repair
785
Flexible nasal laryngoscopy. Foreign body, left vallecula at the base of the tongue. Airway is patent and stable.
Surgery
Flexible Nasal Laryngoscopy
PREOPERATIVE DIAGNOSIS: ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1. Foreign body, left vallecula at the base of the tongue.,2. Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:, ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year...
surgery, oropharyngeal foreign body, flexible nasal laryngoscopy, nasal spray, foreign body, tongue, laryngoscopy, erythema, epiglottis, nasal, oropharyngeal
786
CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.
Surgery
Frameless Stereotactic Radiosurgery
PREOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident w...
surgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,
787
Fogarty thrombectomy, left forearm arteriovenous Gore-Tex bridge fistula and revision of distal anastomosis with 7 mm interposition Gore-Tex graft. Chronic renal failure and thrombosed left forearm arteriovenous Gore-Tex bridge fistula.
Surgery
Fogarty Thrombectomy
PREOPERATIVE DIAGNOSES:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,POSTOPERATIVE DIAGNOSIS:,1. Chronic renal failure.,2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula.,PROCEDURE PERFORMED:,1. Fogarty thrombectomy, left forearm arteriovenous Gore-Tex ...
surgery, chronic renal failure, thrombosed, gore-tex bridge fistula, arteriovenous, fogarty, thrombectomy, anastomosis, gore tex bridge, fogarty thrombectomy, prolene suture, renal failure, distal anastomosis, bridge fistula, interposition, renal, prolene
788
Flexible fiberoptic bronchoscopy diagnostic with right middle and upper lobe lavage and lower lobe transbronchial biopsies. Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.
Surgery
Flexible Fiberoptic Bronchoscopy -1
POSTOPERATIVE DIAGNOSIS:, Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:, Flexible fiberoptic bronchoscopy diagnostic with:,a. Right middle lobe bronchoalveolar lavage.,b. Right upper lobe bronchoalveolar lavage.,c. Right lower lobe transbro...
surgery, bronchoalveolar, lavage, lobe, tracheobronchitis, granulomatous, miliary tb, tb, flexible fiberoptic bronchoscopy, bronchoscope, flexible, fiberoptic, transbronchial, biopsies, bronchoscopy, oropharynx,
789
Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA. Normal cystoscopy with atrophic vaginitis.
Surgery
Flexible Cystoscopy - Atrophic Vaginitis
PREOPERATIVE DIAGNOSIS:, Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:, Atrophic vaginitis.,PROCEDURE: ,The patient was brought in to the procedu...
surgery, urge incontinence, frequency, overactive bladder, vesicare, flexible cystoscopy, bladder infections, atrophic vaginitis, incontinence, cystoscopy, vaginitis,
790
Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.
Surgery
Flap revision
PREOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0....
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791
Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.
Surgery
Flex Sig - 2
PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. Withdrawal notes an otherwise normal descendin...
surgery, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: 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...
792
Flexible bronchoscopy to evaluate the airway (chronic wheezing).
Surgery
Flexible Bronchoscopy
PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used...
surgery, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe,
793
Flexible sigmoidoscopy due to rectal bleeding.
Surgery
Flex Sig - 1
INDICATION: , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE: ,
surgery, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal
794
Fiberoptic flexible bronchoscopy with lavage, brushings, and endobronchial mucosal biopsies of the right bronchus intermedius/right lower lobe. Right hyoid mass, rule out carcinomatosis. Chronic obstructive pulmonary disease. Changes consistent with acute and chronic bronchitis.
Surgery
Fiberoptic Flexible Bronchoscopy
PREOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Right hyoid mass, rule out carcinomatosis.,2. Weight loss.,3. Chronic obstructive pulmonary disease.,4. Changes consistent with acute and chronic bronchitis....
surgery, carcinomatosis, chronic obstructive pulmonary disease, fiberoptic flexible bronchoscopy, lavage, brushings, endobronchial mucosal biopsies, mucosal, bronchoscope, atrovent, topical, fiberoptic, hemoptysis, bronchoscopy, endobronchial, oropharynx
795
Left arm fistulogram. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. Ultrasound-guided access of left upper arm brachiocephalic fistula.
Surgery
Fistulogram & Angioplasty
PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1. Left arm fistulogram.,2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3. Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:, ...
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796
Fiberoptic nasolaryngoscopy. Dysphagia with no signs of piriform sinus pooling or aspiration. Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.
Surgery
Fiberoptic Nasolaryngoscopy
PREOPERATIVE DIAGNOSES:,1. Dysphagia.,2. Right parapharyngeal hemorrhagic lesion.,POSTOPERATIVE DIAGNOSES:,1. Dysphagia with no signs of piriform sinus pooling or aspiration.,2. No parapharyngeal hemorrhagic lesion noted.,3. Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,PROCEDURE PERFORMED...
surgery, parapharyngeal, dysphagia, sinus pooling, piriform, nasolaryngoscopy, fiberoptic, laryngoscope, nasopharynx, oropharynx, fiberoptic nasolaryngoscopy, hemorrhagic lesion, aspiration, cartilage, hypopharynx, lesion,
797
Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.
Surgery
Flex Sig - 3
PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:, Rectal bleeding.,POSTOPERATIVE DIAGNOSIS: ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal de...
surgery, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon
798
Flexible Sigmoidoscopy.
Surgery
Flex Sig
MEDICATIONS:, None.,DESCRIPTION OF THE PROCEDURE:, After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then sl...
surgery, flexible sigmoidoscopy, flex sig, olympus video colonoscope, colonoscopeNOTE,: 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 transcr...
799
Emergent fiberoptic bronchoscopy with lavage. Status post multiple trauma/motor vehicle accident. Acute respiratory failure. Acute respiratory distress/ventilator asynchrony. Hypoxemia. Complete atelectasis of left lung. Clots partially obstructing the endotracheal tube and completely obstructing the entire lef...
Surgery
Fiberoptic Bronchoscopy with Lavage
PREOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respirator...
surgery, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, r...