Download date of consultation: 07/18/2008

The following are samples of procedure notes pulled from an acute care setting. The last few
samples are blank ‘templates” for outpatient procedures.
DATE OF CONSULTATION: 07/18/2008
REASON FOR CONSULTATION:
Changes in bowel habits.
HISTORY: The patient is an 89-year-old woman who I met in the office on July 14, 2008, with
her daughter. She had already scheduled a colonoscopy, and this was a preprocedure visit. Over
the last year the patient reported a change in her bowel habits. She has episodes of incontinence
and feels something bulging from the rectum. She has noted slight increase in stool frequency
and has had an unintentional weight loss over the last year of at least 10 pounds. She denies
bright blood per rectum or change in stool caliber. She lives alone and admits to eating poorly.
She has occasional heartburn for which she takes an acid suppressor. She denies dysphagia and
odynophagia.
PAST MEDICAL HISTORY:
1. Acid reflux.
2. Arthritis.
3. Hypertension.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Dyazide, Fosamax, Mevacor, Protonix, and Toprol.
SOCIAL HISTORY: She is widowed and retired. She does not drink alcohol. She does not
smoke tobacco.
FAMILY HISTORY: No history of colon cancer or colon polyps.
REVIEW OF SYSTEMS: She has lost weight, as outlined above. She denies fatigue. Skin:
No rashes or jaundice. Cardiovascular Exam: She does have some peripheral edema. No chest
pain, orthopnea, palpitations. Respiratory: No cough or shortness of breath. Denies sleep apnea.
Genitourinary: No dysuria, hematuria, fecaluria. Musculoskeletal: She has some joint pain. No
back pain. Neurologic: Denies seizure, tremors, or chronic headaches.
PHYSICAL EXAMINATION: She has a blood pressure of 150/70, pulse of 64. GENERAL:
She is a pleasant woman, at times anxious. She does not appear acutely ill. CHEST: Clear to
auscultation bilaterally. CARDIOVASCULAR: Regular. ABDOMEN: Bowel sounds present.
Soft and nontender. No palpable masses. EXTREMITIES: Pedal edema. RECTAL: On exam
she does have external hemorrhoids with normal tone.
IMPRESSION: This is an 89-year-old woman who has had a change in her diet over the last
year with weight loss and a change in her bowel habits. I suspect this is the etiology of changes
in bowel habits. However, cannot totally exclude colonic pathology, specifically colon cancer or
other structural abnormalities contributing to these symptoms. In the office, the patient and her
daughter requested that colonoscopy be performed for further evaluation. I explained the risks,
benefits, and alternative of therapy, and the patient and her daughter wanted to proceed with
colonoscopy.
TITLE OF PROCEDURE: Colonoscopy, with snare polypectomy.
ANESTHESIA: Past surgical anesthesia problems: No. She has been n.p.o. for 12 hours.
ASA classification III. Sedation per CRNA with fentanyl 50 mcg and propofol 100 mg.
TECHNIQUE: The patient was placed in the left lateral decubitus position. After she was
adequately sedated, a diagnostic adult colonoscope was inserted into the patient's rectum under
direct visualization. The scope was easily advanced to the base of the cecum. The ileocecal
valve was identified and intubated. The terminal ileum was normal. Careful retrograde
examination revealed diffuse diverticular disease, primarily involving the left colon. The patient
had multiple wide-mouth diverticula present. A small polyp was identified in the left colon, and
it was removed with forceps. However, a larger polyp was identified in the rectosigmoid area,
which required removal with snare cautery. The scope was withdrawn into the patient's rectum.
Upon retroflexion, internal hemorrhoids were noted. The scope was withdrawn completely. She
tolerated the procedure well and will be sent back to the recovery area in stable condition.
POSTPROCEDURE DIAGNOSES:
1. Internal and external hemorrhoids.
2. Diverticular disease.
3. Colon polyps, status post removal.
RECOMMENDATIONS: I will call the patient next week with results of her polyps.
DATE OF PROCEDURE:
TITLE OF PROCEDURE:
1.
Carotid artery angiography.
2.
Right internal carotid angiography.
3.
Right internal carotid angioplasty.
4.
Right internal carotid stent placement secondary to recoil.
CARDIOLOGIST:
PROCEDURE NOTE: Patient was consented prior to the procedure. She was told the risks and
benefits involved. She is agreeable. She was brought to the catheterization laboratory where left
and right groin was prepped. Patient was draped in a sterile manner. My initial attention was
turned toward the right groin where approximately 10-15 mL of 2% lidocaine was used to local
anesthetize the area above the right femoral artery and vein. Using an 18-gauge cook hollow
needle and modified Seldinger technique, I was able to instrument a 6-French arterial sheath. I
took up a 6-French JV2 catheter using angled glide wire and glide catheter. I was able to get the
glide catheter to the common carotid artery where selective angiographic views were done for a
mapping shot. I used the glide wire to advance the glide catheter to the external carotid artery,
then I was able to use a SuperCore wire to bring a 6 x 90-cm Terumo sheath. I then was able to
wire the lesion using a 6.5-mm filter which was an Accunet filter and then I did an angioplasty
using a 4-mm coronary balloon and then I stented it using a 7 x 10 tapered by 40 mm in length
Abbott Expert self-expanding Acculink stent and then I postdilated using a 5-mm Viatrak
balloon. We then were able to retrieve the filter. There was no neurological compromise. The
residual was 0%. I then did cerebral angiography to make sure there was no evidence of
significant emboli or dissection. Results are as follows: The right internal carotid artery went
from 80% to a residual of 0%. I was able to stent it using a 7 x 10 tapered by 40 mm in length
Abbott Acculink self-expanding stent.
DATE OF PROCEDURE: 07/18/08
TITLE OF PROCEDURE: Endoscopic retrograde cholangiopancreatography (ERCP) with
sphincterotomy and 11.5 mm balloon sweep.
REFERRING PHYSICIAN:
OPERATOR:
ASSISTANT:
PREPROCEDURE DIAGNOSIS: Gallstone pancreatitis.
POSTPROCEDURE DIAGNOSIS:
1. Normal cholangiogram status post sphincterotomy and balloon sweep. No stones seen,
only debris was able to be cleared in the bile duct.
2. Papillotomy performed.
3. Unremarkable esophagus.
4. Unremarkable stomach.
HISTORY OF STATED PROCEDURE NEED: The patient is a 27-year-old Latin American
female who is two months postpartum, presented with acute onset of epigastric pain, nausea and
vomiting, with abnormal liver function tests, which include a total bilirubin of 8, ALT of 600 and
AST of 300 and alkaline phosphatase of 300s with ultrasound consistent with a common bile
duct of 11 mm and lipase greater than 6,000, concerning for biliary pancreatitis. ERCP for bile
duct clearance was recommended.
EQUIPMENT USED: Olympus duodenoscope, GJ140L. We also used an Ultratome XL
sphincterotome, a 0.035 Jag wire and an 11.5 mm balloon ERCP catheter.
ANESTHESIA: Provided by CRNA, total of 2 mg of Versed, 75 micrograms of fentanyl, 280
mg of propofol, 0.75 mg of Glucagon, 100 mg of lidocaine and 20 mg of ketamine.
ASA SCORE: II.
DESCRIPTION OF PROCEDURE: After careful review, patient history and physical
examination was performed revealing no contraindications for the procedure. Laboratory was
then analyzed, showing no contraindications for the procedure. Risks (bleeding, perforation,
aspiration, infection, breathing problems and pancreatitis), benefits and alternatives were
discussed with the patient, the patient’s husband and the patient’s aunt, who voiced
understanding and agreed to proceed.
The patient was brought to the GI lab for an urgent ERCP. Anesthesia was provided by CRNA.
Oxygen supplementation was provided to the patient. Vital signs were monitored closely
throughout the procedure. The patient was placed in a prone position. After adequate sedation
was verified, the Olympus duodenoscope was introduced under direct visualization over the
patient's tongue into the esophagus. The esophagus was intubated with minimal resistance. The
limited view of the esophagus showed an unremarkable esophagus. In the stomach, there was
bile, which was aspirated before we proceeded. After all bile was aspirated, we were able to
advance the duodenoscope to the antrum. The pylorus was then intubated revealing a normal
duodenal bulb. We then advanced the instrument to the second portion of the duodenum, where
reduction maneuver was performed revealing normal major papilla. We then used the Ultratome
XL sphincterotome to cannulate the papilla. After cannulation was confirmed, we then used a
0.035” Jag wire to confirm biliary cannulation. On the first two attempts, we cannulated the
pancreatic duct. We did not inject any dye in the pancreatic duct. We then removed the catheter
and allowed for the pancreatic duct to drain and we attempted cannulation. At this time, Dr.
Hakert took the instrument from me and through manipulation was able to cannulate the
common bile duct. Photodocumentation was obtained of the cannulation. The sphincterotome
was introduced into the bile duct to the bifurcation and cholangiogram was performed. The
cholangiogram revealed a normal bile duct, measuring approximately 6 mm with no filling
defect. At this time, we then performed a sphincterotomy with excellent flow of bile and no
bleeding. Photodocumentation was again taken of the sphincterotomy. We then performed an
exchange, removing the sphincterotome and inserting the 11.5 mm balloon catheter. The balloon
catheter was then advanced with the assistance of the guidewire to the bifurcation of the left and
right hepatic duct. The balloon was then inflated and a balloon sweep was performed of the bile
tree, revealing only debris, but no stones retrieved. The balloon was completely passed easily
through the sphincterotomy site with no bleeding. Residual air, fluid and contrast were
aspirated. The balloon catheter was removed. The Jag wire was removed and the patient
tolerated the procedure well without immediate complications.
Then, we performed a careful endoscopic examination of the ampulla, which was clean and dry
with no bleeding. The duodenal bulb was unremarkable. Retroflexion in the stomach reveals a
normal stomach with normal gastroesophageal junction. We then aspirated residual air and fluid.
The instruments were removed and the patient tolerated the procedure well without immediate
complications.
Total fluoroscopy time was three minutes and twelve seconds.
COMPLICATIONS: None.
IMPRESSION:
1. Cholangiogram revealing normal common bile duct of 6 mm with no filling defects, no
stones, with only debris on the balloon sweep consistent with a history of probable passed
stones.
2. Normal stomach.
3. Normal esophagus.
4. Status post biliary sphincterotomy.
RECOMMENDATIONS:
1. Admit the patient for hydration, pain management and cholecystectomy as you are doing.
2. Aggressive fluid hydration in the setting of pancreatitis with lactated Ringer’s.
3. Cholecystectomy per Dr. Kirby.
4. We will check LFTs and lipase and hematocrit in the morning, those have been ordered.
DATE OF PROCEDURE:
07/18/2008
PREPROCEDURE DIAGNOSES:
1. Abdominal pain.
2. Chest pain.
3. Dysphagia.
POSTPROCEDURE DIAGNOSES:
1. Antral deformity with some mild pyloric stenosis.
2. Dysphagia.
PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with biopsy of the esophagus as well
as pyloric channel biopsy.
ENDOSCOPIST:
ASSISTANT:
INSTRUMENT USED: GIF-180
MEDICATIONS: Propofol 250 mg IV given in incremental doses
ANESTHESIOLOGIST:
COMPLICATIONS: None
PROCEDURE NOTE: The patient was placed in the left lateral
decubitus position after informed, witnessed consent was
obtained. The risks, benefits, and alternatives to the procedure
and sedation were reviewed previously with the patient who
wished to proceed.
A lubricated endoscope was advanced into the esophagus under
direct vision. The gastroesophageal junction was slightly
irregular and was biopsied to rule out Barrett’s esophagus. The
esophagus was dilated due to her complaints of dysphagia with a
52 French Maloney dilator with some resistance met at 25 cm, but
no heme was noted.
The stomach had some antral deformity, likely secondary to
scarring from her peptic ulcer disease and the pylorus was
somewhat narrowed. It was dilated with a 12-13.5 to 3-4.5
atmospheres in one minute increments with resistance noted at
13.5 mm with no blood seen. The duodenal bulb, second and third
portions of the duodenum appeared normal.
IMPRESSION:
1. Antral deformity with scarring.
2. Pyloric stenosis.
3. Dysphagia.
PLAN:
1. Await pathology.
2. Follow symptoms.
CHIEF COMPLAINT: This 87-year-old male is seen today for a chronic sacral decubitus
wound as well as intermittent wounds of his ankles, and today, he complains of a left first toe
with drainage. He has history of having had all his toenails removed by a podiatrist in the past
for onychomycosis or nail infection.
PAST MEDICAL HISTORY: Significant for:
1.
Alzheimer dementia.
2.
Osteoarthritis.
3.
Diabetes.
4.
Coronary artery disease.
5.
History of superior vena cava blood clot.
REVIEW OF SYSTEMS: Drainage from the sacral wound has been light to moderate.
Constitutional: No fever or chills. GI: The daughter reports that although he requires total
assistance in all care and total assistance in being fed, he is eating well.
PHYSICAL EXAMINATION: He is a stiff white male who is aphasic. The sacral wound is a
chronic Stage IV wound, full-thickness into a cavity about the size of a grape with poor quality
fibrinous-type lining but there is no cellulitis. There is slight undermining but only superiorly.
On vascular exam, he did have a palpable left dorsalis pedis pulse. The left great toenail was
thickened and very onychomycotic and had infection around the base of the nail consistent with
an ingrown toenail.
IMPRESSION:
1.
Infected ingrown toenail. Plan will be to do a digital block and then remove the left
great nail.
2.
For the sacral wound, will continue the treatment with Aquacel and a foam dressing.
3.
Both ankle areas are now healed where he has previously had ulcers but for the right
ankle wound which was the worse in the past, will continue a dry dressing.
PROCEDURE NOTE: The left great toe underwent a digital block with 1% lidocaine by
injecting both the medial and lateral nerve bundles. I then used a Hemostat and avulsed the left
great toenail, and we applied a pressure dressing. He will put an antibiotic ointment on the
toenail bed daily with a Band-Aid or 4 x 4's.
PLAN: Will be to see him back in a month.
TITLE OF PROCEDURE:
1.
Digital block of left great toenail.
2.
Avulsion of left great toenail.
DATE OF PROCEDURE:
07/18/08
CARDIOLOGIST:
NAME OF PROCEDURE: Peripheral vascular intervention.
HISTORY: The patient returns with right superficial femoral artery stenosis.
PROCEDURE: After informed consent was obtained, the patient was given anesthesia per
CRNA. Please refer to their notes for this portion of the dictation. We obtained access after
local anesthetic with lidocaine. We placed a 6-French femoral arterial sheath in the left common
femoral artery and then used a RIM catheter, glidewire and glide catheter combination to obtain
contralateral access. We then used a glidewire to take serial angiographic pictures. After this we
placed a 7 x 45 cm Terumo sheath contralaterally and then performed serial atherectomy with a
CSI solid crown 70 grit atherectomy device with several passes initially starting at 90,000
rotations per minute, then 120,000 rotations per minute for two passes on the stenosis of the
proximal edge of the previously placed Viabahn stent. The lesion went from 95% to
approximately 30% with good cutting but there is some significant residual stenosis. Therefore
we used a 7 x 4 SMART stent and we deployed this and then postdilated with a 6 x 4 Powerflex
balloon. The lesion again went from 95% previously to 0 after the stent was finally deployed.
After this, below the knee, there was a 70% tibioperoneal stenosis. There was some aneurysmal
ectasia to the vessel as well. We passed the ViperWire down through this and we were able to
use the 2.25 same solid crown with the same grit (70 micron) to polish this area as well times
two passes with 90,000 and 120,000. The lesion went from 70% to 25%. There was excellent
runoff and the procedure was completed.
Also please note peri-procedurally the patient received 9,000 units of unfractionated heparin.
After the procedure was completed, we exchanged the sheath for a short 7-French sheath and the
patient was taken to the recovery room with anesthesia for recovery.
IMPRESSION:
1. Successful atherectomy and stenting of the right mid superficial femoral artery from 95%
to 0%.
2. Successful CSI atherectomy of the tibioperoneal trunk from 70% to 25% with good
runoff.
3. Continue medical therapy for peripheral vascular disease and follow-up with Dr. Charles
Levin in 2-4 weeks.
(ambulatory care setting for steroid injection)
PATIENT NAME:
XXRPN
TYPE OF REPORT:
PROCEDURE NOTE
DATE OF VISIT:
XXLSD
SUBJECTIVE:
“”
PRE-OP DIAGNOSIS:
1.
2.
POST-OP DIAGNOSIS:
OPERATIONS:
1.
ELBOW STEROID JOINT INJECTION # UNDER
FLUOROSCOPIC GUIDANCE USING AN OEC 9800
SUPER C-ARM FLUOROSCOPE.
2.
ELBOW
JOINT
FLUOROSCOPY.
ARTHROGRAM
UNDER
PROCEDURE NOTE:
The risks and benefits were explained to the patient. The patient
agreed to the injections. The consent form was signed. The patient was placed in the seated
position. The forearm was placed on the x-ray table with the dorsal side up. The elbow was
flexed at 90 degrees. A skin wheal was made over the elbow joint line. Using the fluoroscope,
the elbow was pre-anesthetized with 1 cc of lidocaine 1%. The elbow area was cleansed with a
Betadine solution. A sterile, fenestrated drape was placed over the injection site. A 25-gauge,
1-inch needle was directed toward the elbow joint space with AP visualization with the
fluoroscope. Then, 0.5 cc of Omnipaque 300 contrast was injected demonstrating a elbow
arthrogram and good needle placement. Next, 30 mg of Depo-Medrol and 0.5 cc of lidocaine
1% were injected. Sterile technique was used.
POST PROCEDURE ASSESSMENT:
The patient tolerated the procedure well and was
released to the observation and recovery area for monitoring of any possible adverse affects of
the injection procedure. Followup visit is to determine the outcome.
(sample template from an ambulatory surgical center)
PATIENT NAME:
xxpnm
MRN:
xxmrn
DATE OF BIRTH:
xxdsc
DATE OF PROCEDURE: xxdos
SURGEON:
{}
PREOPERATIVE DIAGNOSIS(ES)
1.
{}
POSTOPERATIVE DIAGNOSIS(ES)
1.
{}
OPERATION(S) PERFORMED:
1.
{}
ANESTHESIA: {}
DESCRIPTION OF PROCEDURE: {}