REASON FOR VISIT: The patient is a pleasant (XX)-year-old gentleman seen in office followup of obstructive sleep apnea syndrome.

HISTORY OF PRESENT ILLNESS: The patient has history of severe obstructive sleep apnea syndrome. He underwent a split-night sleep study that showed severe obstructive sleep apnea with apnea-hypopnea index of 52 per hour associated with oxygen desaturation with nadir oxygen desaturation of 84%. A CPAP of 13 cm water pressure resulted in improvement in sleep-disordered breathing.

The patient was subsequently seen in followup. He was prescribed CPAP at 13 cm water pressure with a full face mask. The patient started using CPAP. Initially, he was able to use it for 2-4 hours at a time and noted improvement in his daytime fatigue and sleepiness. However, after first week of starting treatment, he developed significant trouble tolerating nasal CPAP and was not able to initiate sleep.

Part of the problem was nasal mask air leak due to improper nasal mask fitting and also was waking up with complaints of high CPAP pressure. He was also seen in our CPAP clinic and ResMed Activa Mirage nasal mask was recommended with Adams circuit chin strap. He has not received his new mask or chin strap. The patient is here to discuss other options of treatment.

PAST MEDICAL HISTORY: Diabetes mellitus, hypothyroidism, history of seizure disorder, history of hypertension, stroke, and myocardial infarction.

MEDICATIONS: Insulin, levothyroxine, and Dilantin.

SOCIAL HISTORY: The patient is an ex-smoker. He does not drink alcohol.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: As noted in history of present illness. He still has significant daytime fatigue and sleepiness. He does not have complaints of sleepiness while driving. He has not had driving accidents. He has no symptoms of narcolepsy. No complaints of restless legs. No significant difficulty initiating or maintaining sleep off nasal CPAP. Weight has been stable. Of note, he has had tonsillectomy in the past. No nasal symptoms.

PHYSICAL EXAMINATION: The patient is an alert gentleman, in no distress. Vitals are stable. Blood pressure is 128/72, pulse 72, weight is 148 pounds. Oxygen saturation is 100%. Pupils are equal and reactive. Nasal mucosa is noncongested. Adequate flow, both nares. Oropharynx, slightly elongated uvula, Mallampati class II airway. Absent tonsils. No micrognathia or retrognathia. Neck without adenopathy. Trachea is midline. No thyromegaly. Lungs are clear. Heart reveals S1, S2, regular. Abdomen is unremarkable. Extremities have no edema, clubbing or calf tenderness. Neurologically alert, no deficits noted.

IMPRESSION:
1.  Severe obstructive sleep apnea/hypopnea syndrome associated with significant daytime hypersomnia.
2.  Intolerance of nasal CPAP, which is multifactorial, i.e. high CPAP pressure, mask leak and improper mask fitting.
3.  Diabetes mellitus.
4.  Hypothyroidism.
5.  Remote history of seizure disorder.

PLAN AND RECOMMENDATIONS:  We discussed pathophysiology of sleep apnea, especially in light of severe obstructive sleep apnea and associated nocturnal hyposomnia. We did discuss cardiovascular complications and discussed options of treatment, including surgical intervention such as UPPP and oral appliance therapy. Given the fact that he has severe sleep apnea, the best option is nasal CPAP therapy. We discussed surgery, which we do not recommend, possibility of oral appliance therapy, a combination of oral appliance therapy and nasal CPAP therapy.

After discussing pros and cons, our recommendations are:
1.  Trial of decreasing nasal CPAP to 11 cm of water pressure.
2.  Order a new ResMed Mirage Activa nasal mask with a chin strap.
3.  Re-evaluate in about six to eight weeks.
4.  If symptoms persist, consider CPAP therapy versus BiPAP therapy and consideration of oral appliance therapy. He has intact dentition.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR REFERRAL: Persistent cough and hoarseness.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who for the past two years has been complaining of seasonal allergies and hoarseness. She has a dry, nonproductive cough. Over the past year, she has not been able to sing due to the hoarseness. She just did not feel like she can trust her voice. She does have a lot of allergies, and she took Alavert the other day and that seemed to help her. She has also been diagnosed with GERD and has been on Aciphex for a year, recently increased the dose to twice a day. She always feels like there is something in the back of her throat and that she has to clear it constantly. She was recently diagnosed with a thyroid nodule and has seen Dr. Jane Doe for this; although, she does not recall having a direct laryngoscopy. She has no dyspnea, wheeze or cold symptoms. She is also seeing Dr. X. She has no headache. She has no effect with changes in position or food with these symptoms.

PAST MEDICAL HISTORY: Hypertension, CAD, nephroma, spontaneous pneumothorax, mother had TB with a negative PPD, thyroid nodule, meningioma and GERD.

PAST SURGICAL HISTORY: Right nephrectomy, angioplasty of the left leg and right leg, and appendectomy.

MEDICATIONS: Aciphex 20 mg twice a day, Univasc 7.5 mg daily, Norvasc 10 mg daily, aspirin, Fosamax, Alavert p.r.n., multivitamin and calcium.

ALLERGIES: NKDA.

SOCIAL HISTORY: She never smoked. She does not drink.

FAMILY HISTORY: Father deceased at 86, hypertension. Mother deceased at 76 with ALS.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative.
HEENT: She has little hoarseness, postnasal drip, otherwise negative.
GASTROINTESTINAL: Reflux.
GENITOURINARY: Negative.
CARDIOPULMONARY: As in the HPI.
MUSCULOSKELETAL: Negative.
HEMATOLOGIC: Negative.
ENDOCRINE: Negative.
PSYCHIATRIC: Negative.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is a pleasant female in no distress.
VITAL SIGNS: Weight 132, pulse 74, blood pressure 162/84, respiratory rate 18, and saturations on room air 97%.
HEENT: NC/AT. EOMI. PERRL. Conjunctivae are pink. Nares are slightly congested bilaterally with no sinus tenderness. Oral cavity has good dentition with no lesions or exudates. She has a stage II oropharynx.
NECK: She has a bounding right carotid, left has a bruit. There is no adenopathy or increased JVP.
HEART: PMI is nondisplaced. It is regular, S1/S2, with a 2/6 systolic ejection murmur in the right upper sternal border and left lower sternal border.
LUNGS: Symmetrical excursion, equal diaphragmatic descent. Clear to auscultation and percussion.
ABDOMEN: Soft, nontender with no appreciable HSM.
EXTREMITIES: No C/C/E. The patient has mild DJD.

DIAGNOSTIC DATA: Chest x-ray shows mild cardiomegaly.

IMPRESSION: The patient has hoarseness, which could be related to a lot of symptoms including but not limited to structural abnormality or chronic irritative state. She does have gastroesophageal reflux disease, which may be contributing to this. Although, we do not believe she has had what sounds like a vocal cord visualization, certainly vocal cord paralysis or structural abnormality needs to be evaluated. She has a cough, which is likely related to gastroesophageal reflux disease and/or postnasal drip with constant throat clearing. Other concerns include her thyroid nodule, valvular heart disease with her cardiac murmur, the known gastroesophageal reflux disease and her left carotid bruit.

PLAN: We recommended that she elevate the head of her bed and showed her how to do that. We will continue the Aciphex twice a day. We started her on Flonase one puff in each nostril twice a day and Zyrtec and reviewed the side effects of those medications. She needs a spirometry to evaluate her flow volume loop. She needs to have Dr. Jane Doe reevaluate her for a direct laryngoscopy, and she is seeing her in the near future. In the future, we will consider doing a 2D echocardiogram to evaluate her valvular heart disease and mild cardiomegaly and/or CT scan of her neck and/or thorax. She understands this plan and agrees, and we will see her back in about six weeks after she has tried these medications and had a spirometry.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR REFERRAL: Sleep disturbance.

HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old female who we first met in April of last year, at which time she had pulmonary embolism with chronic anticoagulation. Now, she is status post IVC filter x2. At the time of her discharge, we were very concerned that she had a sleep disturbance with excessive daytime somnolence and fatigue, and unfortunately, she never followed up. She had an overnight oximetry that showed that her saturations were 78% or less, at times, on room air. She was placed on supplemental oxygen. She does feel better with that, but she is still quite fatigued and tired during the day. In the hospital, she did have witnessed apneas. She has been sleeping in a recliner for about a year and a half. She recently had pulmonary function test that showed that she has a positive bronchodilator response at the level of small airways and was recently started on Advair, which she does seem to think has helped. She does snore. She takes a nap every day for about an hour, and other than that, she has had no other major sleep problems, except she is frequently tired and snores and had an abnormal overnight oximetry.

PAST MEDICAL HISTORY: Hypertension, DJD, asthma, hypothyroidism, arrhythmia and PE.

PAST SURGICAL HISTORY: Hysterectomy, cholecystectomy, and left cataract.

MEDICATIONS: Advair 100/50 mcg b.i.d., Prevacid 30 mg daily, Darvocet, Coumadin, trazodone 100 mg t.i.d., Xanax 0.5 mg as needed, hydrochlorothiazide, Univasc 15 mg b.i.d., Synthroid, and Ritalin in the morning.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Father is deceased, 98, with old age. Mother is deceased, 74, with a stroke.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative.
HEENT: The patient has an Epworth score of 4.
GASTROINTESTINAL: GERD.
GENITOURINARY: Negative.
CARDIOPULMONARY: As in the HPI. She has dyspnea on exertion and occasional wheezing.
HEMATOLOGIC: Negative.
ENDOCRINE: Negative.
PSYCHIATRIC: Negative.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is an obese female in no distress.
VITAL SIGNS: Weight 268, respiratory rate 18, pulse 90, blood pressure 122/74, and saturations on room air 93%.
HEENT: The patient has normal contour to her oropharynx. She has a stage IV oropharynx. She is edentulous. PERRL. Conjunctivae are pink. Nares are difficult to visualize.
NECK: Thick but supple without increased JVP, adenopathy or bruits.
HEART: PMI is not appreciated. S1, S2 without any murmurs or gallops.
ABDOMEN: Obese, soft and nontender.
EXTREMITIES: No C/C/E.

IMPRESSION: The patient has excessive daytime somnolence and fatigue, witnessed apneas and snoring and likely has some type of sleep apnea syndrome. She also has abnormal overnight oximetry. She has reactive airways disease, mild hypoxemia and shortness of breath. She has a history of pulmonary embolism, on chronic anticoagulation therapy, status post two IVC filters.

PLAN: We reviewed the pathophysiology of OSA and CSA with her. We discussed PSG testing with her, and she has agreed to do that. The patient also understands the concept of CPAP. We will send her for PSG, and we will see her back after that.

The post Sleep Disturbance Consult Sample Report appeared first on Medical Transcription Sample Reports.

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR REFERRAL:  Evaluation of slowly progressive dyspnea with exertion.

HISTORY OF PRESENT ILLNESS:  This is a pleasant (XX)-year-old gentleman who states that he has noted, since April, slight increasing shortness of breath with activity. He mostly notices this when he is exercising or trying to climb a flight of steps or so on, but he can carry out activities of daily living without any significant distress. This patient has had no pleurisy, no hemoptysis. None of his feelings have been sudden in onset. He is snoring, apparently significantly, according to him. He gets into bed between 7:30 and 8 p.m. and gets up at least three times at night. He gets up at 5 a.m. during weekdays. He has occasional wheezing. He at present limits his activity by dyspnea. His weight is a problem, presently at 350 pounds, and he may be a candidate for bariatric surgery, according to him, and he believes Dr. John Doe is working on this. There is no significant cough or phlegm production. No fevers or chills. No PND or orthopnea. He has chronic lower extremity edema. No major changes in voice, headaches, visual problems. No nausea or vomiting. No chest pain or chest pressure.

PAST MEDICAL HISTORY: Positive for what appears to be renal stones. He states having some renal insufficiency. Apparently, the patient has a degree of increased protein loss in his urine, according to him. He has a history of hypertension and coronary artery disease. He had a cardiac catheterization six months ago.

FAMILY HISTORY: Father alive aged 74, has emphysema and coronary artery disease. Mother died aged 72 of myocardial infarction. He has some siblings who have coronary artery disease and diabetes.

SOCIAL HISTORY: The patient has never smoked. No alcohol. Positive exposure to smoke and dust.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed gentleman who is above his ideal body weight by a significant margin. Certainly, this may be playing a role in much of his symptomatology.
VITAL SIGNS: Height 5 feet 5 inches, pulse 98 per minute, respiratory rate 18 per minute, blood pressure 146/68, and saturations on room air 93%.
NECK: No JVD, adenopathy or tracheal deviations.
HEART: Presently regular. We did not appreciate any significant murmurs.
LUNGS: For the most part, clear.
EXTREMITIES: The patient does have peripheral edema.

DIAGNOSTIC DATA: No chest x-rays are available for review.

IMPRESSION:
1. This gentleman may have a sleep disturbance. We will go ahead and order an overnight oximetry. If this were abnormal, we would proceed to nocturnal polysomnography.
2. We would describe him as morbidly obese, and we need to work on that.
3. To assess his dyspnea, we will obtain a six-minute walk, full pulmonary function tests, and get the chest x-ray report from the outside hospital.

PLAN: The patient is to continue to follow with his usual medical team. We will try to get the results of his cardiac catheterization. We will keep you updated and further comments post reviewing the data as above. We reviewed his medications, and the patient is presently on no inhaled bronchodilators. We will comment further after review of pulmonary function tests.

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PREOPERATIVE DIAGNOSES:
1.  Respiratory failure.
2.  Possible pneumonia.

PROCEDURE PERFORMED:  Bronchoscopy with bronchoalveolar lavage.

SURGEON:  John Doe, MD

ANESTHESIA:  IV sedation.

ESTIMATED BLOOD LOSS:  Zero.

SPECIMENS:  Left and right bronchoalveolar lavage for microbiology.

COMPLICATIONS:  None.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old gentleman who has been admitted to the neurosurgical ICU with myasthenia gravis. Despite plasmapheresis and ongoing ICU care, he has continued with respiratory failure and his NIFs have remained low. The patient thus presents for tracheostomy. He has also been diagnosed with a possible pneumonia by the neurosurgical ICU team with the presence of left lower lobe infiltrate. Thus, he also presents for bronchoalveolar lavage at the same time.

DESCRIPTION OF PROCEDURE:  On the date of the procedure, the patient remained in the neurosurgical intensive care unit. He underwent bronchoscopic-assisted percutaneous tracheostomy. Once this procedure had been successfully completed, the bronchoscope was inserted through the patient’s newly placed #8 Shiley tracheostomy tube. This was advanced to the carina. We surveyed the left side first. Then, the bronchoscope was advanced into the left lower lobe and was wedged in the left lower lobe segmental orifices, segment 9. An alveolar lavage specimen was taken. It was suctioned and collected in a Lukens trap and was then passed off the table and sent to Microbiology. We then advanced the bronchoscope into the right lower lobe segmental bronchi. The bronchoscope was wedged, and an additional alveolar lavage was taken. The specimen was suctioned and was collected in a Lukens trap and was passed off the table to send to Microbiology. We then surveyed the bronchi. There was a small amount of blood that was remaining from the tracheostomy. This was suctioned free and removed. It did not reaccumulate. We surveyed the right upper lobe, right middle lobe, and right lower lobe segmental orifices, and each of these was seen to be free of mucous plugs. We then surveyed the left upper lobe, left lower lobe, and lingula. There was a moderate amount of secretions present in the left lower lobe. These were suctioned free and removed. These did not recur. There was no significant mucous plugging seen in the left lower lobe. There was general, what appeared to be, edema of the airways, but there did not appear to be severe tracheobronchitis. We did not see any endobronchial lesions. The bronchoscope was then removed, and the procedure was terminated. The patient tolerated the procedure well and remained in critical condition in the neurosurgical intensive care unit at the termination of the case.

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PREOPERATIVE DIAGNOSIS:  Bilateral lung nodules.

OPERATION PERFORMED:  Right video-assisted thoracoscopic lung biopsy x3.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

DRAINS:  One 32 French chest tube.

OPERATIVE FINDINGS:  Frozen section was positive for metastatic adenocarcinoma.

INDICATIONS FOR OPERATION:  This is a (XX)-year-old Hispanic male with a past medical history significant for rectal cancer, status post resection three years ago, who presented for followup and was noted to have evidence of a lung nodule on x-ray. This was followed up by CAT scan of the chest that noted multiple pulmonary nodules as well as enlarged lymph nodes. All the nodules were very small and too numerous to count but not amenable to percutaneous biopsy due to their small size. The patient presents today for thoracoscopic lung biopsy.

DESCRIPTION OF OPERATION:  The patient was identified and placed on the operative table in the supine position. General endotracheal anesthesia was induced. The chest and lower extremities were prepped and draped in the normal sterile fashion. The patient was given intravenous antibiotics prior to start of the case. The patient had a dual-lumen endotracheal tube placed and was placed on independent lung ventilation utilizing just the left lung.

The patient was placed in the left lateral decubitus position, and the right lateral chest was prepped and draped in the normal sterile fashion. The patient was given intravenous antibiotics prior to start of the case. We placed three standard thoraco ports, one in the fifth interspace in the subscapular line, one in the fifth interspace in the inframammary fold, and then one in the seventh interspace in the mid axillary line. We then evaluated the chest and noted that there were several subpleural nodules that could be palpated in the upper and lower lobes near the fissure.

We then biopsied three separate positions and sent one down for frozen sectioning and the other two down for permanent sectioning. The frozen section came back as positive for adenocarcinoma. We then coated our staple lines with Tisseel. We checked for any evidence of any significant air leaks, and there was none. We then checked for any evidence of any bleeding. When we were sure that there was none, we then reinflated the lung under direct vision.

We placed a 32 French chest tube up to the apex posteriorly. We then sutured this in place. We then closed all of our thoraco ports using three layers of absorbable stitches. The wounds were all cleaned and dried, and sterile bandages were placed. All sponge, needle, and instrument counts were correct at the end of the case. The patient tolerated the procedure well and will be extubated and taken to the recovery room at the end of the case.

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PREOPERATIVE DIAGNOSES:
1.  Restrictive lung disease.
2.  Dyspnea on exertion.
3.  History of smoking.

POSTOPERATIVE DIAGNOSES:
1.  Restrictive lung disease.
2.  Dyspnea on exertion.
3.  History of smoking.

OPERATION PERFORMED:
1.  Right thoracoscopy with right upper lobe, right middle lobe, and right lower lobe wedge resection biopsies.
2.  Right sixth, seventh, and eighth intercostal space intercostal blocks with Marcaine 0.25% with epinephrine.
3.  On-Q pain catheter placement.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  25 mL.

COMPLICATIONS:  None apparent.

DISPOSITION:  To postanesthesia care unit in satisfactory condition.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old male with restrictive lung disease and progressive dyspnea on exertion. He had a prior history of smoking, having quit a year ago. Dr. Jane Doe of the pulmonary medicine service requested our assistance in obtaining lung tissue for pathologic evaluation in order to determine the etiology of his pulmonary fibrosis. The risks, benefits, and alternatives to a right thoracoscopy with wedge resection biopsies were discussed with the patient, and informed consent was obtained.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. Following the smooth induction of general anesthesia, a left-sided double lumen endotracheal tube was placed. The position was confirmed. A Foley catheter was placed. The patient was log rolled into the left lateral decubitus position. All pressure points were appropriately padded, and the right chest was prepped and draped in the usual sterile fashion. A timeout was held confirming the correct patient and the correct side for the procedure. Preoperative antibiotics and subcutaneous heparin had been administered. Compression boots and a lower body warmer were in place.

A 12 mm port was placed in the eighth intercostal space in the posterior axillary line after infiltration with Marcaine 0.25% with epinephrine. Under the guidance of a 10 mm 30-degree scope, a 12 mm port was placed in the sixth intercostal space anteriorly, and a 5 mm port was placed in the sixth intercostal space posteriorly. Both of these sites were infiltrated with Marcaine 0.25% with epinephrine. Additional Marcaine injection was performed in the seventh intercostal space.

The pleural space was inspected. There was no pleural effusion. There was no parietal pleural pathology. There was gross thickening and fibrotic changes of the lung, more pronounced in the middle lobe and the lower lobe than the upper lobe, but diffuse. The most grossly normal-looking lung was the apical segment of the right upper lobe of the lung. This was grasped with grasping forceps, and a wedge resection biopsy was performed with serial firings of the Echelon endoscopic stapler. The specimen was placed into a specimen bag and brought out through the anterior port site.

Next, a wedge resection of the medial segment of the right middle lobe of the lung again was performed with the Echelon stapler. The specimen was brought out through the anterior port site. The most grossly abnormal was the superior segment of the right lower lobe of the lung. This was grasped with grasping forceps, and a wedge resection biopsy was performed. The specimen was placed into a specimen bag and brought out through the anterior port site. The specimen was cut on the back table. A portion of the tissue was sent for routine fungal and mycobacterial cultures. The remaining tissue was sent for pathologic evaluation. The staple lines were then treated topically with 5 mL Tisseel fibrin sealant.

An On-Q catheter was tunneled from the costal margin to the eighth intercostal space port site and then tunneled posteriorly up to the fifth intercostal space. It was primed with 5 mL of 0.375% Marcaine. The right lung was ventilated, and with sustained positive pressures to 25 and 30 mmHg, appropriately expanded to fill the right chest. The ports were removed, and the port sites were closed in layers with absorbable suture, with the skin approximated with a 4-0 Monocryl subcuticular skin stitch. These incisions were sealed with Dermabond. A 10 French chest tube had been placed through a separate stab wound incision in the seventh intercostal space and placed posteriorly to the apex of the chest. This was secured at the skin with a #2 silk suture. It was placed to an Atrium chest drainage system. The patient awoke from general anesthesia. He was extubated and transported to the PACU in satisfactory condition.

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PREOPERATIVE DIAGNOSIS:  Left malignant pleural effusion.

POSTOPERATIVE DIAGNOSIS:  Left malignant pleural effusion.

OPERATION PERFORMED:  Left thoracoscopy with mechanical and talc pleurodesis.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  100 mL.

COMPLICATIONS:  None apparent.

FINDINGS:  Moderate right bloody pleural effusion.

DISPOSITION:  The patient was taken to the postanesthesia care unit in serious condition.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old man with recently diagnosed adenocarcinoma of the lung with a left sided malignant pleural effusion. The patient had recurrent effusion despite thoracentesis. In addition, he has suffered pulmonary emboli. After treatment of heparin for his pulmonary embolus and placement of an IVC filter, the patient was counseled on the risks, benefits, and alternatives to a left thoracoscopy with pleurodesis to help manage his malignant pleural effusion, and informed consent was obtained.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. Following smooth induction of general endotracheal anesthesia, a Foley catheter was placed. He was log rolled into the right lateral decubitus position, and all pressure points were appropriately padded, and his left chest was prepped and draped in the usual sterile fashion. A time-out was taken to confirm the correct patient and correct site for the procedure.

A 12 mm port was placed in the sixth intercostal space in the anterior axillary line after infiltrating with Marcaine 0.25% with epinephrine. There were some loose adhesions, which were taken down using the 5 mm scope and a laparoscopic Kitner to break up the adhesions. Under the guidance of a 10 mm 30-degree scope, an 11 mm port was placed in the eighth intercostal space in the mid axillary line. Again, this site was infiltrated with Marcaine 0.25% with epinephrine. Approximately 1 liter of bloody fluid was aspirated from the right breast. Mechanical abrasion of the entire parietal pleura was performed using a piece of Bovie scratch pad on laparoscopic ring forceps.

Next, a total of 3 g of sterile talc powder was insufflated with attention paid to applying it to the posterior and diaphragmatic surfaces of the pleura. Prior to the talc insufflation, portions of the parietal pleura were sent for permanent pathology evaluation. A 24 French Blake channel drain was then placed through the eighth intercostal space port site and advanced posteriorly to the apex of the chest in a dependent fashion. It was secured to the skin with interrupted 2-0 silk suture.

The port sites were closed in layers with absorbable suture with the skin approximated with a 4-0 Monocryl subcuticular stitch. The incisions were sealed with Dermabond. The patient awoke from general anesthesia. He was extubated and transported to the postanesthesia care unit in serious condition.

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PREOPERATIVE DIAGNOSIS:  Right chest postpneumonic empyema and fluid collection with entrapment of right lower lobe.

POSTOPERATIVE DIAGNOSIS:  Right chest postpneumonic empyema and fluid collection with entrapment of right lower lobe.

OPERATION PERFORMED:  Right mini thoracotomy x2 with drainage of empyema contents and decortication of right lower and portion of right upper lobe, intercostal nerve blocks x5.

SURGEON:  John Doe, MD

ANESTHESIA:  Double-lumen general endotracheal.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old woman who had originally been admitted with pneumonia. Subsequent to this, she developed a reactive fluid collection in the chest that has been resistant to less invasive maneuvers and drainage. She has been brought to the operating room today on elective basis for right lung decortication and removal of the products of the empyema process.

OPERATIVE FINDINGS:  The right lung was fairly densely adherent to the chest cavity in general from inflammatory adhesions. The anterior aspects of the lung were easily mobilized. Along the diaphragm and posterior along the back and near the spine, the adhesions were fairly dense and firm. With time and care, ultimately the lung was able to be fully mobilized circumferentially. The most intense area of the inflammatory reaction and also the largest collection of fibrinous material was posteriorly near the spine. The surface of the lung was also removed of all fibrinous contents. At the conclusion of the procedure, all above three lobes of the right lung were discrete and able to inflate fully.

DESCRIPTION OF OPERATION:  After obtaining adequate double-lumen general endotracheal anesthesia, the patient was placed in the left lateral decubitus position with all appropriate pressure points padded. An axillary roll was put in place. A beanbag device with a gel pad was used to hold her in position. The patient’s right chest was prepped and draped in a sterile manner. Initially, a small incision was made at about the tenth intercostal space. We placed this incision over the point of what appeared to be maximal fluid collection. In entering the chest cavity, there was a bunch of gelatinous material that was removed both digitally and with a suction device. At this level, the lung was intensely welded to the diaphragm along the posterolateral edge of the lung. We did not try to mobilize this more than once or twice, as the lung would yield before anything else wound. Once we did everything we could from this incision, it was clear that we needed to move above that.

We made another small incision two interspaces higher. This proved to be all that was necessary to fully mobilize the lung. We were able to mobilize the upper, then middle, then lower lobes anteriorly completely. Ultimately, with a little bit more time and patience, the entirety of the lung was able to be mobilized posteriorly as well. We broke into a couple of loculations posteriorly back near the spine. These were filled with fibrinous material as well that was quietly densely organized. Various adhesions were present that were all taken down.

We were able to define the fissure between the lower and middle lobe first. This was readily separated. The fissure between the upper and middle lobe was a bit more densely adherent, but nonetheless, it readily separated. In working forward and inferiorly, we were able to get between the lung and the diaphragm anteriorly and laterally. We were able then to carry this dissection plane posteriorly all the way and ultimately free the lung off the diaphragm entirely.

All fibrinous debris was then removed from the surface of the lung and also from the lateral chest wall. Once all this had been completed, the chest was copiously irrigated with a warm antibiotic-containing saline solution. A single 36-French chest tube was placed posteriorly and inferiorly in the chest through a small separate stab wound through the eleventh intercostal space. Each of the mini thoracotomy was closed in usual fashion with absorbable sutures. Prior to closing the incisions, a five-level intercostal block with 100% plain Marcaine was done to aid in postoperative analgesia. Additionally, each wound was injected with 1.5% plain Marcaine to help keep her comfortable postoperatively.

Dry sterile dressings were applied to each closed incision. The patient was awakened and extubated and transferred to the postanesthesia care unit in stable condition from my care.

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PREOPERATIVE DIAGNOSES:
1.  Right upper lobe lung mass.
2.  Right hilar adenopathy.
3.  History of colon cancer.

POSTOPERATIVE DIAGNOSES:
1.  Right upper lobe lung mass.
2.  Right hilar adenopathy.
3.  History of colon cancer.

PROCEDURES PERFORMED:
1.  Flexible bronchoscopy with right upper lobe lavage, brushing, and transbronchial biopsy.
2.  Cervical mediastinoscopy with biopsy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  20 mL.

COMPLICATIONS:  None apparent.

FINDINGS:  Friable mass in the anterior segment of the right upper lobe of the lung. Negative mediastinal lymph nodes on frozen section.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. Following smooth induction of general endotracheal anesthesia, an 8.0 endotracheal tube was placed and position was confirmed. Flexible bronchoscopy was performed. The trachea, right and left mainstem bronchi, left upper lobe, left lower lobe, right middle lobe, and right lower lobe bronchi were all normal. There appeared to be some distortion of the posterior segmental bronchus. Lavage, brushings, and biopsies were performed with transbronchial biopsy of this site and sent to pathology. Neck was then extended in the midline. The anterior neck, chest, and shoulders were prepared in the sterile fashion. A time-out was taken to confirm correct patient, correct side, and correct procedure. Preoperative antibiotics had been administered. Subcutaneous heparin had been administered. Compression boots were on the lower extremities.

A 3 cm transverse low collar incision was performed after infiltration with Marcaine 0.25% with epinephrine. Sharp dissection was carried down to the strap muscles. The strap muscles were separated in the midline. The pretracheal fascia was identified and incised. The mediastinum was explored. There were soft anthracotic lymph nodes in the subcarinal, right tracheobronchial angle, and right paratracheal region. Biopsies were taken from level 7, level 10R, and level 2R, and sent to pathology. Frozen sections at level 7, 10, and 4 were all negative for malignancy. Final pathology is pending. The mediastinum was packed with a gauze sponge. Five minutes was allowed for tamponade. The mediastinum was explored. There was good hemostasis. Gauze packing had been removed. The mediastinum was explored. There was good hemostasis. Additional Marcaine 0.25% with epinephrine was used for local block. A total of 15 mL was administered. The strap muscles were reapproximated with 2-0 Vicryl sutures. The subcutaneous layer was closed with interrupted 2-0 Vicryl sutures. The skin was approximated with a 4-0 Monocryl subcuticular skin stitch. The incision was sealed with Dermabond.

The initial transbronchial biopsies showed no evidence of malignancy. Mediastinal lymph nodes were negative on frozen section. Sponge and needle counts were correct. Repeat flexible bronchoscopy was performed. Through the anterior segmental bronchus out beyond in the subsegmental bronchi, we could just make out what appeared to be whitish tissue in a segmental bronchus. Transbronchial biopsies were taken of this tissue. There was some mild amount of bleeding with biopsy, which was controlled with dilute 1:100,000 epinephrine saline solution. Four separate biopsies were taken, placed in a specimen bag, and sent to pathology for routine pathologic evaluation. The airways were aspirated clear. There was good hemostasis. The bronchoscope was removed. The patient awoke from general anesthesia without difficulty. The patient was extubated and transported to the postanesthesia care unit in satisfactory condition.

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