My OperaMy Current Transcription practice re: Exercise 7
Friday, March 9, 2007 4:04:02 AM
EDUARD T. EBON
TRANSCRIPTION EXERCISE 7
OPERATIVE REPORT
Stevenson, Andrew
5816274
Dr. Howard
September 30, ----
PREOPERATIVE DIAGNOSES
1. Subarachnoid hemorrhage.
2. Ruptured anterior communicating artery aneurysm.
POSTOPERATIVE DIAGNOSES
1. Subarachnoid hemorrhage.
2. Ruptured anterior communicating artery aneurysm.
PROCEDURE
Right pterional craniotomy clipping of aneurysm.
Surgeon: Anderson Howard, MD.
Anesthesiologist: Colleen Page, MD.
PROCEDURE IN DETAIL
Under general endotracheal anesthesia, patient was placed in the supine position with the heads supported on the mayfill pinion headdress; and turned on the left side approximately 45 degrees. The right frontal temporal parietal scalp was shaved, prepped, and draped in the usual manner. Curvilinear incision was made starting at the right zygoma extending upper on the coronal suture and curved the anterior along the hairline near the midline. Hemostatic clips were placed on the scalp edges and the scalp flap was reflected anteriorly. Care was taken to elevate the fat pad and frontal branch with the facial nerves at scalp. The underlying and temporalis muscle was then incised along the anterior margin and along the origin with cutting current. This was reflected inferiorly. The scalp was secured with fascia retractor and the temporalis muscle was secured with 0-6 silk sutures. Four burr holes were placed to outline the standard pterional craniotomy and the bone flap was elevated with power craniotome. The underlying dural was tense to spiked administration of mannitol and a hyperventilation. The dura was opened parallel to the anterior marginal; the craniotomy was small Metzenbaum scissors. The dura was further opened over the sylvian fissure. The dural edges were the tact to the bone edges. The cortical surface showed evidence of recent subarachnoid hemorrhage with blood scattered over the cortical surface in the sylvian fissure. The intraoperative microscope was introduced into the field and then arachnoid dissection of the anterior portion of the right sylvian fissure was accomplished with bipolar cautery and microscissors. The plain of dissection was just superior to the sylvian veins which relief intact. Distal branches of the middle cerebral artery was identified in the sylvian fissure and followed back to the junction with the carotid artery. Self-retaining husker gale retractor was then used to elevate the frontal lobe. Once it was complete this separated from the temporal lobe. The arachnoid over the optic nerve was opened with the #22 blade in microscissors. The arachnoid was dissected to identify the proximal portion of the right anterior cerebral artery as it crossed over the optic chasm. There was fresh blood in the subarachnoid space in the interhemispheric fissure. During the course of dissection, opposite optic nerve and the entire chasm are identified. Because the brain was tense the lamina terminalis was opened and clear spinal floor was aspirated with suction. This result to the remark relaxation of the cortical surface. To facilitate identification of the distal branches of the anterior cerebral artery, a small portion of gyrus rectus on the right side medial to the olfactory nerves was resected. The distal branch of the right anterior cerebral artery was then identified. The aneurysm was identified arising from the anterior communicating artery and projecting to the left side and anteriorly. Continue dissection revealed the recurrent artery of Hubner; the A2 segment of the anterior cerebral artery and the A1segment of the left anterior cerebral artery. Because the aneurysm appeared to be arising from the complete anterior wall of the anterior communicating artery; and perforators were identified on the posterior wall of the anterior communicating artery. It appeared to be impossible the to clip the aneurysm with a single clip that would spare to circulation of the perforators. A straight Sunkist clip was then applied beneath the right anterior cerebral artery; and excluding the aneurysm. The A1, A2 segment to the left anterior cerebral artery. This spares the circulation to the perforators which refill from the left anterior cerebral artery. There was still filling of the aneurysm from through right anterior cerebral artery and this was occluded with small straight microclip, placed essentially at right angles to the original clip. After the clip pledge was inspected to ensure a satisfactory clip placement, a small neck was made in the dome of the aneurysm with the tuberculin syringe. There was a very slow flow of blood from the opening in the aneurysm. Bipolar cautery was then used to reduce the size of the aneurysm and contract the aneurysm wall. At the completion of the procedure, a clip appeared to exclude the aneurysm from the circulation and spared the normal vasculature, however, there was no longer free communication between the right and left anterior cerebral arteries through the anterior communicating artery.The right anterior cervical artery was observed to be in mild vasospasm and this was corrected by placement of papaverine on gel foam pledge and placed over the artery. This was resulted and returned of the artery to its normal diameter. The self-retaining retractors were then removed and additional hemostasis was attained with bipolar cautery. The dural was then closed with the running suture of 4-0 nylon. The bone flap was replaced and secured with --- titanium plate and screws. A temporalis muscles was reapproximated with interrupted sutures of 0-vicryl. A hemovac drains was placed in the subgaleal space past through the skin through a separate stab incision. This was connected to a hemovac collecting system. The scalp was closed with inverted interrupted sutures of 3-0 Vicryl and in the galea; skin staples to approximate the skin edges. A sterile headdressing was applied and the patient transferred to the intensive care unit in satisfactory condition.
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EDUARD T. EBON
TRANSCRIPTION EXERCISE 7
History and physical and discharged summary
Gerald Tout
9284306
Dr. Wallace
History and Physical: May 15, ----
Short stay
History of present of illness
The patient is 44-year-old black male with sickle cell nephropathy and end stage renal function has sustained the--- this past Tuesday. He was seen at the emergency room at South General Hospital angle was begun on rabies vaccination. He was subsequently seen at Bucket General hospital and given an antibiotic. He on the went chronic maintenance hemodialysis today and following the dialysis he developed the temperature to 104 degrees. He was referred by Dr. Quinton Jones, dialysis supervisor to the undersign for further evaluation and was admitted for further assessment. He had no chill, cold, or fever. He had no access tenderness; the. . . biopsied has heal without any pain or discomfort.
Past history
Sickle cell disease, surgical-vascular access procedures
Family history
Non-contributory
Social history
He is married and on the going dialysis at the Buckey hemodialysis unit. He is on the chronic renal failure regime.
Allergies: NONE
Review of systems
HEENT: Non-contributory.
Cardiorespiratory: Non-contributory.
Gastrointestinal: Non-contributory.
Genital urinary: Non-contributory.
Neurologic: Non-contributory.
Physical examination
General: The patient is a pleasant, middle-age, black male in no acute distress; his temperature was 102.8 degrees Fahrenheit, pulse 80 per minute, respirations 18 per minute, blood pressure 140/70 mmHg. HEENT: pupils were equal and reactive. The fundi unremarkable. Tympanic membranes were intact. The teeth were in fair repair. Neck supple no masses. Otharomegally or adenopathy. Chest symmetrical. Lungs were clear to percussion and auscultation. Heart regular rhythm with no S2 –S4 murmur or rub. Abdomen soft, no masses, tenderness, or organomegaly. GU unremarkable. Rectal had not done. Extremities he had a evidence of an animal bite to the left middle finger which was heal, there was no tenderness, wound, purulence, he had a diastac, gothics, AV fistul in his right upper extremity which was none tende. Skin no oblations, pulse 2+ of equal. Neurological intact.
Impression
1. Fever of no origin.
2. Con bit left middle finger.
3. Sickle cell nephropathy.
4. Sickle cell anemia.
5. Anemia of chronic illness.
6. Hyperthyrodism secondary to end stage renal disease.
Plan
1. Cultures
2. Empiric antibiotic therapy.
3. Obsultation
4. Renal failure regimen.
Discharge summary
Admitted: May 16, ----
Discharged: May 17, ----
History of present illness
The patient is 40-year-old black male with sickle cell nephropathy who sustained the condition bite one week prior to this admission. He was admitted because of a afebrile episode following his dialysis treatment. His access was non-tender and not inflamed. No other source of infliction could be ---.
Hospital course treatment
The patient was placed on the--- floor, cultures were obtained. CBC revealed the white count of 6400, hemoglobin 8.7, hematocrit 24%, platelet count 173000. chemistries reveal the BUN of 41, sodium 138, potassium 4.6, glucose 87, creatinine 10.3, calcium 8.9, phosphorous 3.8, magnesium 1.4. The urinalysis revealed the small amount of bilirubin trace ketones, large amount of blood and protein urea,
TRANSCRIPTION EXERCISE 7
OPERATIVE REPORT
Stevenson, Andrew
5816274
Dr. Howard
September 30, ----
PREOPERATIVE DIAGNOSES
1. Subarachnoid hemorrhage.
2. Ruptured anterior communicating artery aneurysm.
POSTOPERATIVE DIAGNOSES
1. Subarachnoid hemorrhage.
2. Ruptured anterior communicating artery aneurysm.
PROCEDURE
Right pterional craniotomy clipping of aneurysm.
Surgeon: Anderson Howard, MD.
Anesthesiologist: Colleen Page, MD.
PROCEDURE IN DETAIL
Under general endotracheal anesthesia, patient was placed in the supine position with the heads supported on the mayfill pinion headdress; and turned on the left side approximately 45 degrees. The right frontal temporal parietal scalp was shaved, prepped, and draped in the usual manner. Curvilinear incision was made starting at the right zygoma extending upper on the coronal suture and curved the anterior along the hairline near the midline. Hemostatic clips were placed on the scalp edges and the scalp flap was reflected anteriorly. Care was taken to elevate the fat pad and frontal branch with the facial nerves at scalp. The underlying and temporalis muscle was then incised along the anterior margin and along the origin with cutting current. This was reflected inferiorly. The scalp was secured with fascia retractor and the temporalis muscle was secured with 0-6 silk sutures. Four burr holes were placed to outline the standard pterional craniotomy and the bone flap was elevated with power craniotome. The underlying dural was tense to spiked administration of mannitol and a hyperventilation. The dura was opened parallel to the anterior marginal; the craniotomy was small Metzenbaum scissors. The dura was further opened over the sylvian fissure. The dural edges were the tact to the bone edges. The cortical surface showed evidence of recent subarachnoid hemorrhage with blood scattered over the cortical surface in the sylvian fissure. The intraoperative microscope was introduced into the field and then arachnoid dissection of the anterior portion of the right sylvian fissure was accomplished with bipolar cautery and microscissors. The plain of dissection was just superior to the sylvian veins which relief intact. Distal branches of the middle cerebral artery was identified in the sylvian fissure and followed back to the junction with the carotid artery. Self-retaining husker gale retractor was then used to elevate the frontal lobe. Once it was complete this separated from the temporal lobe. The arachnoid over the optic nerve was opened with the #22 blade in microscissors. The arachnoid was dissected to identify the proximal portion of the right anterior cerebral artery as it crossed over the optic chasm. There was fresh blood in the subarachnoid space in the interhemispheric fissure. During the course of dissection, opposite optic nerve and the entire chasm are identified. Because the brain was tense the lamina terminalis was opened and clear spinal floor was aspirated with suction. This result to the remark relaxation of the cortical surface. To facilitate identification of the distal branches of the anterior cerebral artery, a small portion of gyrus rectus on the right side medial to the olfactory nerves was resected. The distal branch of the right anterior cerebral artery was then identified. The aneurysm was identified arising from the anterior communicating artery and projecting to the left side and anteriorly. Continue dissection revealed the recurrent artery of Hubner; the A2 segment of the anterior cerebral artery and the A1segment of the left anterior cerebral artery. Because the aneurysm appeared to be arising from the complete anterior wall of the anterior communicating artery; and perforators were identified on the posterior wall of the anterior communicating artery. It appeared to be impossible the to clip the aneurysm with a single clip that would spare to circulation of the perforators. A straight Sunkist clip was then applied beneath the right anterior cerebral artery; and excluding the aneurysm. The A1, A2 segment to the left anterior cerebral artery. This spares the circulation to the perforators which refill from the left anterior cerebral artery. There was still filling of the aneurysm from through right anterior cerebral artery and this was occluded with small straight microclip, placed essentially at right angles to the original clip. After the clip pledge was inspected to ensure a satisfactory clip placement, a small neck was made in the dome of the aneurysm with the tuberculin syringe. There was a very slow flow of blood from the opening in the aneurysm. Bipolar cautery was then used to reduce the size of the aneurysm and contract the aneurysm wall. At the completion of the procedure, a clip appeared to exclude the aneurysm from the circulation and spared the normal vasculature, however, there was no longer free communication between the right and left anterior cerebral arteries through the anterior communicating artery.The right anterior cervical artery was observed to be in mild vasospasm and this was corrected by placement of papaverine on gel foam pledge and placed over the artery. This was resulted and returned of the artery to its normal diameter. The self-retaining retractors were then removed and additional hemostasis was attained with bipolar cautery. The dural was then closed with the running suture of 4-0 nylon. The bone flap was replaced and secured with --- titanium plate and screws. A temporalis muscles was reapproximated with interrupted sutures of 0-vicryl. A hemovac drains was placed in the subgaleal space past through the skin through a separate stab incision. This was connected to a hemovac collecting system. The scalp was closed with inverted interrupted sutures of 3-0 Vicryl and in the galea; skin staples to approximate the skin edges. A sterile headdressing was applied and the patient transferred to the intensive care unit in satisfactory condition.
************************************************************************************************
EDUARD T. EBON
TRANSCRIPTION EXERCISE 7
History and physical and discharged summary
Gerald Tout
9284306
Dr. Wallace
History and Physical: May 15, ----
Short stay
History of present of illness
The patient is 44-year-old black male with sickle cell nephropathy and end stage renal function has sustained the--- this past Tuesday. He was seen at the emergency room at South General Hospital angle was begun on rabies vaccination. He was subsequently seen at Bucket General hospital and given an antibiotic. He on the went chronic maintenance hemodialysis today and following the dialysis he developed the temperature to 104 degrees. He was referred by Dr. Quinton Jones, dialysis supervisor to the undersign for further evaluation and was admitted for further assessment. He had no chill, cold, or fever. He had no access tenderness; the. . . biopsied has heal without any pain or discomfort.
Past history
Sickle cell disease, surgical-vascular access procedures
Family history
Non-contributory
Social history
He is married and on the going dialysis at the Buckey hemodialysis unit. He is on the chronic renal failure regime.
Allergies: NONE
Review of systems
HEENT: Non-contributory.
Cardiorespiratory: Non-contributory.
Gastrointestinal: Non-contributory.
Genital urinary: Non-contributory.
Neurologic: Non-contributory.
Physical examination
General: The patient is a pleasant, middle-age, black male in no acute distress; his temperature was 102.8 degrees Fahrenheit, pulse 80 per minute, respirations 18 per minute, blood pressure 140/70 mmHg. HEENT: pupils were equal and reactive. The fundi unremarkable. Tympanic membranes were intact. The teeth were in fair repair. Neck supple no masses. Otharomegally or adenopathy. Chest symmetrical. Lungs were clear to percussion and auscultation. Heart regular rhythm with no S2 –S4 murmur or rub. Abdomen soft, no masses, tenderness, or organomegaly. GU unremarkable. Rectal had not done. Extremities he had a evidence of an animal bite to the left middle finger which was heal, there was no tenderness, wound, purulence, he had a diastac, gothics, AV fistul in his right upper extremity which was none tende. Skin no oblations, pulse 2+ of equal. Neurological intact.
Impression
1. Fever of no origin.
2. Con bit left middle finger.
3. Sickle cell nephropathy.
4. Sickle cell anemia.
5. Anemia of chronic illness.
6. Hyperthyrodism secondary to end stage renal disease.
Plan
1. Cultures
2. Empiric antibiotic therapy.
3. Obsultation
4. Renal failure regimen.
Discharge summary
Admitted: May 16, ----
Discharged: May 17, ----
History of present illness
The patient is 40-year-old black male with sickle cell nephropathy who sustained the condition bite one week prior to this admission. He was admitted because of a afebrile episode following his dialysis treatment. His access was non-tender and not inflamed. No other source of infliction could be ---.
Hospital course treatment
The patient was placed on the--- floor, cultures were obtained. CBC revealed the white count of 6400, hemoglobin 8.7, hematocrit 24%, platelet count 173000. chemistries reveal the BUN of 41, sodium 138, potassium 4.6, glucose 87, creatinine 10.3, calcium 8.9, phosphorous 3.8, magnesium 1.4. The urinalysis revealed the small amount of bilirubin trace ketones, large amount of blood and protein urea,
