POSTOPERATIVE DIAGNOSIS: Hard palate neoplasm.

PROCEDURES PERFORMED:
1. Wide local excision hard palate neoplasm.
2. Reconstruction with combination of buccal free graft and myomucosal advancement flap.

ATTENDING SURGEON: John Doe, MD

ANESTHESIA: General endotracheal tube.

ESTIMATED BLOOD LOSS: 20 mL.

FINDINGS: A 0.9 cm neoplasm of hard palate with a 1.5 cm defect following excision.

SPECIMENS: Hard palate neoplasm, sent to Pathology.

COMPLICATIONS: None.

DISPOSITION: To recovery room, stable.

INDICATIONS FOR OPERATION: A (XX)-year-old male with slowly growing hard palate neoplasm suspicious for neoplasm on clinical examination. Informed consent explaining the risks, benefits, and alternatives of the procedure was obtained from the patient.

OPERATION IN DETAIL: In the operating room under general endotracheal tube anesthesia, in the supine position, after appropriate surgical time-outs were called x2, the hard palate was injected with 0.25% Marcaine with 1:100,000 epinephrine. A McIvor gag retractor was inserted intraorally and used to reflect the tongue downwards. The hard palate neoplasm was outlined with the Colorado tip of the Bovie cautery with 3 mm margin surrounding circumferentially.

The needle tip of the electrocautery was then used to excise the hard palate neoplasm down to periosteum. Periosteum elevation was undertaken, and the neoplasm sent off to Pathology as a specimen. Incisions were made bilaterally in the soft palate and this was extensively undermined. The soft palate advancement flap was then advanced to partially close the full-thickness defect. This was sutured in place with 3 and 4-0 Vicryl.

There was a residual defect measuring approximately 1 x 1 cm. A 1 x 1 cm full-thickness buccal mucosa free graft was then taken from the right buccal mucosa taking care to spare injury to Stensen duct. This area was closed with interrupted 3-0 Vicryl deeply and mucosally. The buccal graft was then used to fill the remaining hole in the hard palate and the buccal graft was sutured in place with interrupted 4-0 Vicryl. Tisseel fibrin sealant was then used to secure the graft further. Hemostasis was found to be excellent.

The wound was copiously irrigated, made meticulously hemostatic with bipolar cautery, and hemostasis found to be excellent. Of note, prior to the incision, the mouth was sterilized with dilute Betadine solution, and the patient was given intravenous clindamycin.

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HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presented to the emergency department this evening for evaluation of injury to her left ankle, which she suffered yesterday evening.

The patient apparently suffered an inversion injury to her left ankle when she stepped awkwardly off of a step down onto pavement. She notes some pain with active range of motion of the ankle as well as with weightbearing and ambulation.

She apparently went to work today and was noted to have some difficulty with ambulation and so was instructed to present here for evaluation and treatment of her injury.

REVIEW OF SYSTEMS: The patient denies any fever, chills, nausea, vomiting or diarrhea. She denies any obvious bony deformity, ecchymosis or hematoma to the left ankle, foot or digits. She does note some soft tissue swelling to the lateral aspect of the ankle without erythema, crepitus or increased joint warmth to the same. She notes pain with active range of motion of the ankle, otherwise denies numbness, tingling or paresthesias to the same or muscle weakness.

REVIEW OF SYSTEMS: Otherwise negative as pertains to chief complaint.

Nursing notes reviewed.

PAST MEDICAL HISTORY: None.

PAST SURGICAL HISTORY: None.

CURRENT THERAPY: Vitamins.

ALLERGIES: None.

IMMUNIZATION HISTORY: Not applicable.

SOCIAL HISTORY: The patient is a nonsmoker. Denies substance/alcohol abuse.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 76, respirations 20, BP 114/72, pulse oximetry 97% on room air.
GENERAL: A well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old female.
MENTAL STATUS: The patient is alert and oriented x4.
MUSCULOSKELETAL: Focused musculoskeletal exam reveals tenderness, soft tissue swelling to the lateral malleolus of the left ankle. There is no obvious bony deformity, bruising or soft tissue swelling noted. There is no erythema, crepitus or increased joint warmth noted as well. She is ambulatory with a stable but antalgic gait, otherwise exhibits strong distal pedal pulses, brisk capillary refill in all digits of the left foot.
NEUROLOGIC: Reveals no gross motor/sensory deficits. The patient is alert, cooperative and exhibits intact distal sensation in all digits of the left foot.
INTEGUMENTARY: Without diaphoresis, rash, lesions. Skin is warm and dry to touch. Normal tone and turgor.

DIAGNOSTIC DATA: A 3-view x-ray of the patient’s left ankle revealed no evidence of fracture, dislocation or other bony abnormality as reported by radiologist.

EMERGENCY DEPARTMENT COURSE: The patient’s left ankle placed in an Ace wrap prior to the patient’s discharge. She has otherwise been stable throughout her stay in the emergency department.

MEDICAL DECISION MAKING: We discussed this patient’s case with Dr. John Doe who also evaluated the patient and agreed with the final diagnosis of a left ankle sprain and the treatment plan that follows.

CONSULTATIONS: None.

IMPRESSION: Left ankle sprain.

PLAN:
1. Rest, ice, compress, elevate.
2. Over-the-counter ibuprofen, up to 600 mg 3 times daily with food as needed for pain and swelling.
3. Follow up with primary care provider in 3 to 4 days if not improving or return to the emergency department for any worsening symptoms or new concerns.

The patient voiced agreement with this final diagnosis and treatment plan. She voiced clear understanding of the instructions.

DISPOSITION: Discharged to home in good condition.

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DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Traumatic laceration of the extensor hallucis longus tendon, left foot.

POSTOPERATIVE DIAGNOSIS: Traumatic laceration of the extensor hallucis longus tendon, left foot.

OPERATION PERFORMED: Open repair of extensor hallucis longus tendon, left foot.

SURGEON: John Doe, MD

ANESTHESIA: Local.

HEMOSTASIS: Electrocautery.

ESTIMATED BLOOD LOSS: Minimal.

DESCRIPTION OF OPERATION: The patient was placed on the operating table in the supine position. The left lower extremity was scrubbed and draped sterilely, and 10 mL of 0.5% Marcaine plain was injected for local anesthesia to the left foot.

A 5 cm linear longitudinal incision was created directly over the palpable defect of the extensor hallucis longus tendon and slightly distal and proximal to where the tendon was palpated. The defect was several centimeters proximal to the first metatarsal head. Dissection was continued into the subcutaneous layer utilizing blunt and sharp dissection, with care being taken to identify and retract all vital neurovascular structures. All bleeders were cauterized as necessary.

At this time, the tendon was identified, and an approximately 4 cm gap was noted between the tendon ends. The proximal portion of the tendon was pulled distally and noted to be able to extend toward the distal end of the tendon without excessive tension. Utilizing 4-0 PDS, a Bunnell-type suture technique was utilized to reattach the tendon ends. Simple interrupted sutures were also used to reinforce the tendon reapproximation. It must be noted that throughout the procedure the wound had been flushed with normal saline. The tendon sheath was closed utilizing 4-0 Vicryl. The subcutaneous layer was reapproximated utilizing 4-0 Vicryl and the skin was closed utilizing a horizontal mattress suture technique with 5-0 nylon.

Upon completion of the procedure, a total of 1 mL of Decadron phosphate and 3 mL 0.5% Marcaine plain were injected at the proximal aspect of the foot, away from the tendon repair. The incision was dressed with Adaptic and covered with a sterile compressive dressing consisting of gauze, Kling, Kerlix, cast padding and a posterior splint. The patient tolerated the procedure and anesthesia well and was transferred to the recovery room in apparent satisfactory condition with vital signs stable and vascular status intact.

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DATE OF PROCEDURE: MM/DD/YYYY

INDICATION FOR PROCEDURE: Cerebrovascular accident and mitral regurgitation.

PROCEDURE PERFORMED: Two-dimensional M-mode echocardiography.

PROCEDURE FINDINGS:
1.  The left ventricle is normal in size with moderate concentric left ventricular hypertrophy. Left ventricular systolic function appears grossly intact, and no regional wall motion abnormalities are appreciated. The left ventricular ejection fraction is visually estimated to be 55%.
2.  The left atrium is mildly enlarged. The aortic root is not dilated. Right-sided chambers appear to be normal in size, structure, and function. The interatrial septum seems grossly intact.
3.  The mitral valve leaflets appear minimally thickened but demonstrate adequate diastolic excursion without prolapse. Aortic valve is a trileaflet structure with normal leaflet mobility. Tricuspid valve is normal in structure and function. Pulmonic valve appears thin and pliable.
4.  There is no pericardial effusion and no intracavitary masses seen.

COLOR AND DOPPLER FLOW EXAMINATION FINDINGS:
1.  Spectral Doppler interrogation of mitral inflow reveals normal inflow velocities with a reversal of E to A, compatible with decreased diastolic compliance.
2.  Forward flow velocities across the left ventricular outflow tract and aortic valve approach the upper limits of normal. Aortic insufficiency is not seen.
3.  There is trace tricuspid regurgitation with a peak velocity of 0.6 meters per second, corresponding to an estimated right ventricular systolic pressure of 20 mmHg, which is within normal limits.
4.  Trivial pulmonic insufficiency is present.
5.  No abnormal color flow pattern is identified across the interatrial septum.

SAMPLE #2

DATE OF PROCEDURE: MM/DD/YYYY

INDICATIONS FOR PROCEDURE: Precordial pain.

PROCEDURE PERFORMED: Two-dimensional M-mode echocardiography.

PROCEDURE FINDINGS:
1.  The left ventricle is normal in size with mild concentric left ventricular hypertrophy. The left ventricular systolic function appears grossly intact, and no regional wall motion abnormalities are appreciated. Left ventricular ejection fraction is visually estimated to be 55%.
2.  The left atrium is normal in size. The aortic root is not dilated. Right-sided heart chambers appear to be normal in size, structure, and function. The interatrial septum seems grossly intact.
3.  The mitral valve leaflets appear morphologically normal in structure and demonstrate adequate diastolic excursion without prolapse. The aortic valve is a trileaflet structure with normal leaflet mobility. The tricuspid valve is normal in structure and function. The pulmonic valve is not clearly visualized.
4.  There is an anterior echo-free space, which likely represents epicardial fat. No intracavitary masses seen.

COLOR AND DOPPLER FLOW EXAMINATION FINDINGS:
1.  Spectral Doppler interrogation of mitral inflow reveals normal inflow velocities, and there is no mitral stenosis. Doppler analysis of mitral annulus is consistent with diastolic dysfunction. Trace mitral regurgitation is seen.
2.  Forward flow velocities across the aortic valve approach the upper limits of normal. Aortic insufficiency is not seen.
3.  There is trivial tricuspid regurgitation with velocities that are inadequate to estimate right ventricular systolic pressure.
4.  There is no pulmonic insufficiency.
5.  No abnormal color flow patterns are identified across the interatrial septum.

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Huge retroperitoneal tumor, probable gynecological origin.
2.  Duplicated left renal collecting system.
3.  Distortion of intra-abdominal anatomy.

POSTOPERATIVE DIAGNOSES:
1.  Huge 5680 gram (26 x 25 x 16 cm) retroperitoneal fibroid tumor from the left side of the uterus.
2.  Distortion of the pelvic anatomy.
3.  Duplicated left renal collecting system.
4.  Meckel diverticulum with ectopic tissue.
5.  Normal-appearing appendix.

OPERATION PERFORMED:
1.  Exploration of the retroperitoneum and ureters.
2.  Resection of huge left retroperitoneal tumor with control of retroperitoneal bleeding.
3.  Meckel diverticulectomy with oversewing of Meckel diverticulum.
4.  Placement of left retroperitoneal drain.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  100 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was already under general anesthesia with open midline incision noted. Upon entering into the abdomen, a huge 26 x 25 x 16 cm tumor was noted to distort the entire anatomy, and this could be birthed into the incision. The cervix and uterus were distorted into the right lower quadrant. The tumor occupied the entire retroperitoneum of the left lower quadrant. No retroperitoneal stents could be noted. Gynecology stated no preoperative urethral stents were replaced. The IVP was noted to be hanging on the wall. The sigmoid colon was noted to be attached and involved within the tumor.

The sigmoid colon was followed down. It was separated, using Bovie electrocautery, from the huge tumor. A plane could be noted between the tumor and the sigmoid colon, consistent with non-bowel origin of the retroperitoneal mass. The retroperitoneum was entered and the dissection stayed against the tumor and mobilized the tumor anteriorly. The duplicate urinary system was identified throughout its entire course and remained intact.

The peritoneum was incised circumferentially around the tumor. The right ovarian pedicle and ovary were transected by Gynecology. The tumor was birthed into the incision and separated from the retroperitoneum. Retroperitoneal bleeding sites were controlled using 0-Vicryl suture ties, and the tumor was removed and en bloc and sent to pathology as a specimen including the left ovary, tube, and part of the left uterus. Pathology revealed a 5680 gram tumor, 26 x 25 x 16 cm in size, involving the left retroperitoneum.

Meticulous hemostasis of the left retroperitoneum was ensured. Copious irrigation of the abdomen was performed. All bleeding points were controlled. A J-VAC was placed into the left pelvis, exiting the left lower quadrant, sewn to the skin using 2-0 nylon. The drain was attached to bulb suction. During cleansing of the abdomen, a large mass was noted to be on the small bowel. This was noted to be a huge diverticulum, approximately 5 inches in length, with an abnormal mass at its tip consistent with ectopic tissue. The Meckel diverticulum was transected using a GIA 55 stapler. The suture line was oversewn using 3-0 silk ties in an interrupted fashion. It was sent to pathology as a specimen.

Meticulous hemostasis was assured of all bleeding points, and the ureters were once again inspected and found to be intact throughout their entire course on both sides. Gynecology closed the abdomen.

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DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Acute on chronic calculous cholecystitis.

POSTOPERATIVE DIAGNOSIS: Acute on chronic calculous cholecystitis.

PROCEDURE PERFORMED: Laparoscopic cholecystectomy.

SURGEON: John Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Less than 10 mL.

INDICATIONS FOR PROCEDURE: This is a (XX)-year-old male admitted to the emergency room last night with chest pain radiating into his back. Cardiac workup was performed and found to be negative. CT scan demonstrated large gallstone with gallbladder wall thickening and pericholecystic fluid. Followup ultrasound confirmed the diagnosis.

The patient was seen and found to have clinical symptoms and signs consistent with cholecystitis. We consented him for laparoscopic cholecystectomy. We discussed in detail technical aspects of the procedure as well as possible complications, the risks and benefits of the procedure as well as outcomes without the surgical procedure. The patient wished to proceed, consented, and requested that we proceed.

DESCRIPTION OF PROCEDURE: The patient was brought to the OR. He received IV antibiotics preoperatively. SCDs were applied to his lower extremities. A general anesthetic was administered. He was endotracheally intubated. A Foley catheter was placed in the urinary bladder. The abdomen was prepped and draped in the usual sterile fashion.

A 1 cm incision was made in the umbilicus after instillation of local was carried down to the level of the fascia. The fascia was incised, and a blunt-tip trocar was introduced into the abdominal cavity followed by inflation of the abdominal cavity with 15 mmHg. Camera was introduced through the trocar. Intra-abdominal contents were inspected. There was no evidence of injuries at the entry site. The gallbladder was found under the right lobe of the liver, covered with omental adhesions.

Additional trocars were placed at the subxiphoid and lateral positions. Omental adhesions were taken down with combination of blunt and electrocautery dissection, and the fundus of the gallbladder was grasped and elevated. The omental adhesions were taken off the body and off the infundibulum. The infundibulum was found to have large impacted stone. It was grasped with forceps and splayed laterally. The porta hepatis was dissected exposing the gallbladder-cystic duct junction as well as cystic artery.

The cystic duct was divided by placing a clip at the gallbladder-cystic duct junction. Then, additional clips were placed on the mid cystic duct with care taken to avoid injury to the common bile duct. The cystic duct was then divided between clips. The cystic artery was divided in a similar fashion. The gallbladder was then dissected away from the liver using electrocautery. There was no spillage of bile or stones. Gallbladder was then placed in the Endobag and removed from the abdominal cavity without spillage of bile or stones.

The liver and gallbladder fossa were irrigated with a copious amount of saline, was closely inspected, and was found to be completely hemostatic. Cystic duct remnant and cystic artery remnant were inspected closely for evidence of bleeding or bile leak. None was identified. The area was irrigated once again, aspirated dry, and then reinspected. There was no evidence of any bile leak or bleeding from the liver.

All instruments were removed. The abdomen was deflated. All wounds were closed in layers using interrupted 0 Vicryl for the fascia and Monocryl for skin. Sterile bandages were applied. The patient was awakened and extubated in the operating room, moved to recovery room in satisfactory condition. All sponge and instrument counts were reported correct. There were no complications and only minimal bleeding.

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PREOPERATIVE DIAGNOSIS:  Multiple scalp abscesses.

POSTOPERATIVE DIAGNOSIS:  Multiple scalp abscesses.

PROCEDURE PERFORMED:  Incision and drainage of multiple scalp abscesses.

SURGEON:  John Doe, MD

ANESTHESIA:  MAC.

ESTIMATED BLOOD LOSS:  15 mL.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old male with about a two-week history of what was thought to initially be a fungal infection of his scalp but became progressively purulent. He was admitted with leukocytosis and multiple abscesses of the scalp. He has also multiple areas that are denuded of hair. There are multiple tender fluctuant areas as well as multiple small pustules.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and sedation was provided. Local anesthetic used was 0.5% Marcaine with epinephrine. A total of 10 mL was used. Blunt pressure was used to penetrate these follicular pores, which had a white purulent discharge, and this was done with small hemostats and probed.

First, the largest one at the upper portion of his scalp, anterior midline, had approximately 3 cm area of fluctuance and denuded of hair. This area had multiple white draining sinuses. One of these sinuses was probed, and the area widened bluntly with a hemostat, and there was no extension noted to the deeper scalp tissue or galea.

The clamp was then probed laterally subcutaneously, and it was noted that these pustular pockets were primarily in the dermal layer. Small sample was excised using Metzenbaum scissors and sent to pathology.

Once this larger area was probed and drained, then multiple small areas were probed and also drained in a similar fashion; that is by first probing the draining sinus and then widening the opening, allowing the deeper purulent material to drain. The material in all these areas was similar, that is white in nature. Prior to this, the scalp was prepped with Betadine and also the scalp was washed with ChloraPrep scrub. The scalp thus was progressively inspected, and all major palpable small abscesses were drained using this method.

The scalp was then cleansed once again with saline, dried, and then a dry sterile dressing was applied. The patient tolerated the procedure well without complications. He was then transferred to the recovery room in stable condition.

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PRESENTING COMPLAINT: Syncope.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who was brought to the emergency room by paramedics after an episode of syncope. At present, the patient seems to be slightly confused. She is unable to provide accurate information. According to the ER records, she fell at home, and her friend called the ambulance and brought her to the emergency room, but the patient does not have any recollection that she came to the emergency room by ambulance. She thinks that her friend brought her over.

The patient says she was having elevated blood pressure. She has been taking her medicine, and for last three days, she has been having increasing headache and she attributed that to her elevated blood pressure, but the patient was also having nausea and vomiting at home.

At present, at the time of interview, the patient says she is not having any headache, and she feels better and back to normal. No syncope since that time.

PAST MEDICAL HISTORY: Hypertension, CVA, hypercholesterolemia, and depression.

PAST SURGICAL HISTORY: Appendectomy and hysterectomy.

ALLERGIES: No known drug allergies.

CURRENT MEDICATIONS: Clonidine 0.3 mg three times daily, Prozac 40 mg p.o. daily, aspirin 325 mg p.o. daily, and Prilosec 20 mg p.o. daily.

SOCIAL HISTORY: The patient lives with her elderly mother. The patient cannot remember the name of her primary care provider. The patient says she does not smoke and does not drink alcohol.

FAMILY HISTORY: Mother has a history of CAD and diabetes. The patient’s father also has diabetes. The patient has one brother, who has diabetes.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies any dizziness or weakness. Denies any blurred vision.
HEENT: No nasal congestion, rhinorrhea or epistaxis.
CARDIOVASCULAR: Denies any palpitations, chest pain, dyspnea, orthopnea or PND.
RESPIRATORY: Denies any shortness of breath. No cough or hemoptysis.
GASTROINTESTINAL: Denies any abdominal pain, nausea or vomiting, diarrhea or constipation.
GENITOURINARY: No dysuria, frequency or urgency or hematuria.
MUSCULOSKELETAL: Denies any back pain, neck pain or calf pain.
DERMATOLOGY: Denies any rash or discoloration.
NEUROLOGICAL: The patient is complaining of syncopal episode at home. Denies any paresthesias or weakness. The patient was also having headache at home, which has resolved now.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented, sitting up in the bed comfortably, not in any acute distress.
VITAL SIGNS: Maximum temperature since admission 96.4, pulse 50, respirations 20, blood pressure 126/52, and admission weight 72 kg.
HEENT: Moist mucous membranes, anicteric sclerae.
NECK: Supple. No jugular venous distension or carotid bruits noted.
HEART: S1, S2 audible.
LUNGS: Clear breath sounds bilaterally. No wheezing or rales.
ABDOMEN: Soft and nondistended. No mass, no guarding.
GENITOURINARY: Deferred.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGICAL: The patient is having preference of her gaze to the right, and the patient’s vision is blurred, but the patient denies any blurry vision. While talking to the patient, interviewing her, asked the patient to close one eye and tell the pictures on the TV, which is approximately 6 feet away from her, and the patient is unable to recognize the picture. The patient says she can see a shadow on the TV. When asked to write something on the paper, she is preferring the right visual field. Pupils are round and reactive, and extraocular movements are intact. No gross sensory or motor deficit is noticed. GCS is 15.

INITIAL DIAGNOSTIC AND LABORATORY DATA: In the emergency room, the patient had a CT of the head without contrast, which was read by Radiology as acute cortical infarct in the occipital region.

A 12-lead EKG showed sinus bradycardia with a heart rate of 50, short PR interval. No acute ST segment elevation or depression.

Echocardiogram was ordered this morning, which shows normal ejection fraction of 50-60%, mild to moderate tricuspid regurgitation, and the patient’s left atrium is mildly dilated on the echocardiogram.

MRA of the brain shows complete or near complete occlusion of the right posterior cerebral artery, mild atheromatous irregularity of the left posterior cerebral artery, small aneurysm approximately 2 mm at the right posterior cerebral artery.

MRI of the brain shows moderate to large size acute cortical infarct in the right posterior cerebral artery distribution. Multiple additional small foci of acute ischemia are noted involving the white matter of the left cerebral hemisphere. Findings suggestive of embolic disease.

CPK 244, CK-MB 3.42, troponin 0.41.

Sodium 134, potassium 3.2, chloride 96, CO2 of 26, glucose 192. BUN 52, creatinine 1.3. Alkaline phosphatase 58, total bilirubin 1.3. AST 42, ALT 28.

Urinalysis normal. Urine drug screen negative. WBC count 11.6, hemoglobin 13.6, hematocrit 39.8, platelets 298. TSH 1.03. Repeat CPK is 188, CK-MB 2.82, and troponin 0.392.

Total cholesterol 210, triglycerides 300, HDL 40, LDL 112. Repeat electrolytes this morning show potassium down to 2.7.

CLINICAL IMPRESSION:
1.  Non-ST myocardial infarction.
2.  Occipital ischemic infarct.
3.  Renal insufficiency.
4.  Bradycardia.
5.  Hyperlipidemia.

RECOMMENDATIONS:
1.  The patient was evaluated in the emergency room and admitted to the ICU. Considering the large area of infarct, the patient is receiving aspirin 325 mg p.o. daily. Plavix and Lovenox are not given because of the risk of conversion of the stroke to a hemorrhagic stroke. Neurology consult is obtained. Most of the workup for her stroke is completed. At present, the patient will benefit from TEE. The service is not available.
2.  We have discussed the patient’s CT and MRI findings and physical findings with Dr. John Doe, and considering the bed situation, Dr. John Doe has advised to transfer this patient to the regular medical floor where she can be managed by hospitalist instead of transferring the patient to the ICU since hemodynamically and neurologically the patient is stable.
3.  That recommendation was followed by a call to on-call hospitalist. Case was discussed with Dr. Jane Doe at this time, and according to Dr. Jane Doe, normally they do not take any transfers after 3 p.m. and we should try to transfer her during the daytime when there is more help available to accept the transfer.
4.  At present, the patient will be transferred out from the ICU to the telemetry floor.
5.  We will continue to monitor her closely. Continue on aspirin. Start the patient on simvastatin 40 mg p.o. daily.
6.  Continue to monitor cardiac enzymes. Continue to monitor the patient’s blood pressure. Repeat cardiac enzymes and EKG in the morning.
7.  We will discuss with on-call hospitalist in the morning for possible transfer and further cardiology evaluation as well since these services are not available. The patient will also need TEE, which is not available during the weekends here.

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PREOPERATIVE DIAGNOSES:
1.  Right breast cancer.
2.  Inadequate peripheral venous access for chemotherapy.

POSTOPERATIVE DIAGNOSES:
1.  Right breast cancer.
2.  Inadequate peripheral venous access for chemotherapy.

PROCEDURE PERFORMED:  Mediport insertion with fluoroscopy and right lumpectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  Intravenous sedation.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  30 mL.

INDICATIONS FOR PROCEDURE:  The patient underwent lumpectomy and node dissection for a stage II carcinoma of the right breast. She has inferior margin involvement. She will require chemotherapy. A request was made for central venous access, so the patient returns for clearance of the inferior margin.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in a supine position. After induction of adequate intravenous sedation, she was prepped with Betadine and draped in appropriate fashion. In the Trendelenburg position, the left subclavicular area was anesthetized with Xylocaine and Marcaine with epinephrine. The left subclavian vein was entered, and the guidewire was passed without resistance. It was seen on fluoroscopy to be in a central venous circulation.

A transverse incision was made inferior to the puncture site and deep into the chest wall where a pocket was created and a port was anchored in place with 2-0 Prolene sutures. The catheter was cut to the appropriate length and tunneled to the puncture site. A venous dilator was passed over the guidewire and the dilator was removed. The dilator and peel-away sheath were passed together with a guidewire, and the guidewire and dilator were then removed. The catheter was passed with a peel-away sheath and the sheath was removed. There was good blood return from the catheter and the catheter flushed easily. Fluoroscopy showed the tip to be in the proximal superior vena cava.

The wounds were then closed with interrupted 3-0 Vicryl for the deep tissue followed by subcuticular 4-0 Monocryl for the skin. The patient was then put in the supine semi upright sitting position, and the previous right lumpectomy incision was reopened. This was deep into the subcutaneous tissue and the previous deep closure was undone. The inferior margin tissue was grasped with Allis clamps and tissue was excised for a thickness of approximately 1 to 1.5 cm down to the chest wall. This was marked with the suture on the side of the new inferior margin.

Hemostasis was assured with pressure and cautery. The wound was irrigated and closure was performed with a running 2-0 Vicryl for the deep tissue followed by running subcuticular 4-0 Monocryl for the skin. Benzoin and Steri-Strips were applied. Dressings were applied. The patient tolerated the procedure well and had no complications. Blood loss was 30 mL, and the patient was taken to the recovery room in stable condition.

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DATE OF PROCEDURE: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

PREOPERATIVE DIAGNOSIS: History of adenomatous colon polyps, last removed five years ago.

POSTOPERATIVE DIAGNOSES:
1. Recurrent polyp of sigmoid colon.
2. Small to moderate-sized internal hemorrhoids.

PROCEDURE PERFORMED:  Colonoscopy with forceps polypectomy.

SURGEON:  Jane Doe, MD

MEDICATIONS:  Demerol 125 mg IV and Versed 5 mg IV.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained after explanation of the risks, benefits, and alternatives of the procedure. Specific risks discussed with the patient included, but were not limited to, risk of bleeding, infection, perforation, missed polyps, and sedation.

The patient was premedicated in order to obtain conscious sedation. Rectal examination was unremarkable. The prostate gland was mildly enlarged consistent with the patient’s age. Next, a video colonoscope was inserted into the rectum and gently advanced to cecum under direct visualization without difficulty.

Preparation was very good. Cecum was identified by the appendiceal orifice and ileocecal valve. The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal. The mid sigmoid colon had a 4-5 mm sessile polyp. It was removed in a couple of bites using forceps polypectomy technique.

There was excellent hemostasis. The polyps were retrieved and sent to pathology. The rectum had small to moderate-sized internal hemorrhoids seen on the frontal and retroflexion view. The patient tolerated the procedure well and was returned to the recovery unit in stable condition. The previously seen mild proctitis on his colonoscopy five years ago had completely resolved. Greater than 10 minutes were spent examining the mucosa between the cecum and the rectum.

IMPRESSION:
1.  Recurrent colon polyps, status post removal.
2.  Small to moderate-sized internal hemorrhoids.

PLAN:
1.  Check results of colon polyp pathology. If there are no ominous changes, we will repeat colonoscopy in five years.
2.  Call office for biopsy results in one week.
3.  Follow up with Dr. John Doe as regularly scheduled.

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