Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF CATHETERIZATION:  MM/DD/YYYY

PROCEDURES PERFORMED:  Left heart catheterization, left ventriculography.

REASON FOR PROCEDURE:  Unstable angina and abnormal stress test.

FINDINGS:

1.  The left main coronary artery was short and patent.
2.  The left anterior descending coronary artery had total occlusion in the proximal and mid portion.
3.  The circumflex coronary artery had 95% lesion in the proximal portion.
4.  The right coronary artery had 90% proximal and 100% total occlusion in the mid.

GRAFTS:  The left internal mammary artery graft to the left anterior descending coronary artery was patent.  The saphenous vein graft to the diagonal vessel was also patent.  The saphenous vein graft to the obtuse marginal was not located and was not selectively engaged.

COLLATERALS:  There were collaterals noted from the left anterior descending, septal and obtuse marginal to the right side.

Left ventriculography revealed an overall ejection fraction of around 40% with inferobasal akinesis and mid anterior and septal hypokinesis.  End-diastolic pressure was normal at 13 mmHg.  There was no gradient across aortic valve on pullback.

At the end of the procedure, the decision to proceed with angioplasty and stent placement of the critical circumflex lesion was made.

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Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF PROCEDURE:  MM/DD/YYYY

PREPROCEDURE DIAGNOSES:1.  Nonsustained ventricular tachycardia.
2.  Normal left ventricular ejection fraction.
3.  History of coronary disease.  Status post coronary artery bypass graft with patent bypass grafts on cardia cath.
PROCEDURE:  Electrophysiology study.
DETAILS OF PROCEDURE:  The patient was brought to the electrophysiology lab where ECG and vital signs were continuously monitored.  The right groin was meticulously prepared with Betadine solution and was draped in the usual sterile fashion.  Lidocaine 1% was administered subcutaneously for local anesthetic.  Using modified Seldinger technique, two #6 French introducer sheaths were inserted into the right femoral vein.  Two quadripolar EP catheters were inserted into the sheaths and advanced under fluoroscopic guidance.  One was positioned in the area of the high right atrium and one in the area of the His bundle.  The high right atrial catheter was later moved to the RV apex for ventricular stimulation.  Endocardial potentials were recorded and baseline measurements were performed.  The sinus cycle length was 1195 milliseconds.  The AH interval was 115 milliseconds.  The HV interval was 45 milliseconds with a pacing cycle length of 800 milliseconds.  The sinus node recovery time was 1430 milliseconds with the pacing cycle length of 700 milliseconds.  The sinus node recovery time was 1465 milliseconds with a pacing cycle length of 600 milliseconds.  The sinus node recovery time was 1570 milliseconds.  AV Wenckebach recorded an atrial pacing cycle length of 450 milliseconds.  The AV node effective refractory period was 320 milliseconds with the pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 600 milliseconds.  The pacing threshold from the right ventricular apex was 0.5 milliamps, 1:1 VA conduction was present at a ventricular pacing cycle length of 600 milliseconds.  The ventricular effective refractory period was 240 milliseconds with a pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 400 milliseconds.  After single, double and triple extrastimuli were performed at two pacing cycle lengths from the RV apex, Isuprel was started at 2 mcg per minute.  This was gradually increased to 4 mcg per minute in order to achieve a good heart rate response.  The ventricular effective refractory period was 220 milliseconds with the pacing cycle length of 400 milliseconds.  All ventricular pacing was performed from the RV apex.  After completion of programmed electrical stimulation, catheters were removed.  Good hemostasis was achieved using manual compression.  The patient was then transferred to the recovery room in good condition.
IMPRESSION:
1.  Mildly abnormal sinus node function.
2.  Normal atrioventricular node function without evidence of dual atrioventricular node physiology.
3.  Normal His-Purkinje function without evidence of infra-His block.
4.  Frequent nonsustained ventricular tachycardia with single, double and triple ventricular extrastimuli from the right ventricular apex.  The morphology of the nonsustained ventricular tachycardia varied between left bundle, left axis and left bundle right axis morphology.  Nonsustained ventricular tachycardia or prolonged nonsustained ventricular tachycardia was induced.

RECOMMENDATIONS:  The patient will be continued on beta blocker, which should be increased as tolerated.  If the patient has recurrent symptoms, despite medications, an ablation procedure may be considered.  However, given the differing morphologies of the nonsustained VT, this may make ablation difficult.

 

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PREOPERATIVE DIAGNOSIS
By-lateral subdural hematomas.

POST OPERATIVE DIAGNOSIS
By-lateral subdural hematomas.

PROCEDURES:
By-lateral burr holes frontal and parietal for drainage of subdural hematomas.

ANESTHESIA
General Endotracheal.

ANESTHESIOLOGIST 

X, M.D.


PROCEDURE IN DETAIL
The patient was brought into the operating room and after induction of general endotracheal anesthesia. The head was completely shaved, prepped and draped in the usual manner. An incision was made over the frontal areas approximately 3.0 cm from the midline on both sides. The incision was carried down through the scalp, rainy clips where applied for homeostasis, self retaining retractor were placed, burr holes has been made with common perforator. Bleeding from bone was then controlled with bone wax. The left flexed of bone where taken out with a curette and the dura underneath was coagulated in a cruciate fashion. The dura was open widely and copuis amount of all the crankcase colored blood should form. This was irrigated copiously on both side and blake 7millimitter drain where advance under the scalp and into this hole and to this subdural space. Both wounds where close then with zero vicruse who close the gailio layer and 30 nylon to close the skin. Zero form dressing where applied and both drain where secured with 20 silk The patient was recovered from anesthesia and taken to the recovery room in satisfactory condition.

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OR Report (Laparoscopic cholecystectomy)

PREOPERATIVE DIAGNOSIS:  Stage III gastric carcinoma requiring long-term intravenous access for chemotherapy treatment.

POSTOPERATIVE DIAGNOSIS:  Stage III gastric carcinoma requiring long-term intravenous access for chemotherapy treatment with poor peripheral venous access.

OPERATION PERFORMED:  Insertion of a 7.8 French pre-assembled Deltec ProPort via right subclavian.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  Local 0.25% Marcaine with MAC.

ANESTHESIOLOGIST:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Minimal.

BLOOD TRANSFUSED:  None.

DRAINS:  None.

SPECIMENS:  None. 

INDICATIONS:  The patient is a very pleasant (XX)-year-old female who is now one month status post subtotal gastrectomy for a stage III gastric carcinoma.  She was found to have positive node that is localized for which Dr. Doe has requested that we place a port for adjuvant chemotherapy.  The procedure risks, complications including but not limited to bleeding, infection, pneumothorax and underlying pneumothorax were explained to the patient and her daughter, who was present, and agreed to proceed.

DESCRIPTION OF OPERATION:  With the patient in the main operating room under adequate IV sedation and carefully monitored by anesthesia, Kefzol was given at the time of induction.  A small towel was placed in the intrascapular area.  Both arms were tucked at the side and adequately padded.  The entire upper chest, on both sides, including the neck and shoulder area were prepped with iodoform and draped in the usual sterile fashion.  The patient was placed in Trendelenburg position.  Attention was first directed to the left infraclavicular region.  This was anesthetized using 0.25 % Marcaine.  Here, using a standard percutaneous Seldinger technique, I was unable to identify the subclavian vein, and I opted to go on the right side. 

At this point, the right infraclavicular region was anesthetized using 0.25% Marcaine.  Here, using a standard percutaneous Seldinger technique, I was able to identify the right subclavian vein with no difficulty.  Blood was aspirated.  The guidewire was then placed through the needle, guided along the subclavian vein, superior vena cava at the atrium as confirmed by fluoroscopy.  Next, a small pocket was then fashioned just below the entrance of the guidewire.  Hemostasis was then obtained within this pocket where a 7.8 French pre-assembled Deltec ProPort was then placed within the pocket and secured.  A catheter was then tunneled up to the entrance of the guidewire.  The catheter was then cut to appropriate length and flushed using heparin saline.

At this point, a dilator with a peel-away sheath was placed over the guidewire.  The guidewire along with the dilator was subsequently removed.  The catheter tube was then placed with the peel-away sheath.  As the catheter was then guided down, the subclavian vein, superior vena cava-right atrial junction was confirmed by fluoroscopy.  Blood was aspirated from this catheter with no difficulty and this was then also flushed with heparin saline with no difficulty.  At this point, hemostasis was then obtained. 

The small incisions were approximated using #3-0 Vicryl.  The skin was approximated using running subcuticular #4-0 Monocryl.  Steri-Strips were applied to the wound.  Before placing the dressing, the catheter was accessed one more time with absolutely no difficulty, flushed again using heparin saline and sterile dressing was applied to the wound. 

The estimated blood loss was minimal and none was transfused.  No drains were placed.  Sponge and instrument counts were correct x2 at the end of the case.  The patient subsequently tolerated the procedure well and was then returned to her room in stable condition.

OPERATION PERFORMED:  Laparoscopic cholecystectomy.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. Following induction of general anesthesia, the abdomen was prepped with Betadine and draped sterilely. This patient had received Zosyn preoperatively. A 1.5 cm incision was made at the lower border of the umbilicus, dissection carried down through the skin and subcutaneous tissue. The umbilical raphe was visualized and placed on upward traction. A transverse incision was then made at the base of the raphe and the abdomen thus directly entered. A Hasson trocar was introduced and the abdomen insufflated with carbon dioxide to about 12 to 13 mmHg pressure. The 0-degree laparoscope was then introduced and the gallbladder inspected. It was very distended and thick-walled with obvious acute cholecystitis changes about it. Additional trocars were then placed into position in the right lateral, the right subcostal, and the epigastric area. The gallbladder was unable to be grasped due to its distention; therefore, it was decompressed with a needle through the right subcostal port. Following this, the grasper in the right lateral port was used to close the opening where the aspiration had been performed and to place the gallbladder on upward traction. The infundibulum was then placed on outward traction and the edematous tissue about the tapering of the infundibulum was clearly teased away to identify the cystic duct. There appeared to be several stones impacted in the neck. The cystic duct was cleaned free of surrounding tissue and then triply clipped with the endoclips applier and divided. Likewise, the cystic artery which ran adjacent to this was triply clipped and divided. The gallbladder was then removed from the liver bed with the cautery device and blunt dissection. Once removed, it was placed in an EndoCatch bag and then retrieved and removed through the umbilical port under direct vision. Inspection of the operative area was then carried out again, and since there was some mild oozing in the gallbladder fossa, it was felt best to drain this area postoperatively. Therefore, a #10 Jackson-Pratt was placed into the abdomen in Morison pouch and brought out through the right lateral trocar site. All irrigant was removed and returns were clear. The patient was then placed back in the flat supine position instead of the head upward position and all returns were further aspirated from the irrigant. Carbon dioxide was evacuated and the ports removed under direct vision, with no evidence of any oozing. The fascia at the umbilical and epigastric areas was then closed with interrupted 2-0 Vicryl and all skin incisions with 5-0 subcuticular Monocryl and Steri-Strips. Sterile bandage was applied and the patient then awakened and returned to recovery in good condition.

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