Sample Medical Report 1

PREOPERATIVE DIAGNOSIS: Right laryngeal lesion.

POSTOPERATIVE DIAGNOSIS: Right laryngeal lesion.

PROCEDURE: Microsuspension laryngoscopy with excision of right laryngeal

lesion.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS:

Minimal.

SPECIMENS REMOVED: Right laryngeal lesions.

COMPLICATIONS: None.

INDICATIONS FOR SURGERY:

The patient is an 84-year-old man with a history of dysphonia. He was found by an outside ENT to have a lesion overlying his right arytenoid surface. This was followed by both the outside ENT and myself and the lesion was concerning for an area of leukoplakia and therefore, intraoperative biopsy was recommended with microsuspension laryngoscopy. Risks and benefits of the procedure were discussed with the patient. He consented to surgery.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought back to the operating room, placed supine on the operating room table. A time-out was performed to identify the patient, procedure, site of surgery, OR staff, and OR equipment. General anesthesia was induced. An orotracheal tube was placed. He was then turned 90 degrees to his left. Head wrap was placed.

A dental guard was placed. A time-out was performed to identify the patient, procedure, site of surgery, OR staff, and OR equipment.

Next, a Lindholm laryngoscope was inserted into his oral cavity, oropharynx, and then used to expose his larynx. There was an approximately 3 mm smooth soft nodular lesion overlying his right arytenoid. Photodocumentation was performed. The visualization was performed using the microscope.

Next, a micro sickle knife was used to excised the lateral to this lesion. The lesion was then grasped with the microlaryngoscopy grasper and deep dissection plane was made with a microlaryngoscopy scissors. The lesion was then excised and sent as specimen. Epinephrine soaked pledget was applied to the wound and after several minutes, it was removed. There was no further bleeding.

Photodocumentation again was performed to identify the resected lesion. This marked the end of the case. The Lindholm laryngoscope was removed from the patient’s oropharynx and oral cavity. The dental guard was removed. He was turned back to anesthesia and returned to the postoperative care in stable condition.

CPT – 31541 Laryngoscopy Dir, Operative, w/Excision, Tumor/Strip Vocal Cords/Epiglottis; w/Microscope/Telescope

ICD 10- J38.7 Other diseases of larynx

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Sample Medical Report 2

PREOPERATIVE DIAGNOSIS: Spinal stenosis, right L4-L5 and L5-S1 with extruded

disk herniation to the right at L5-S1.

POSTOPERATIVE DIAGNOSIS: Spinal stenosis, right L4-L5 and L5-S1 with extruded disk herniation to the right at L5-S1 with contained extruded disk herniation, right L5-S1.

PROCEDURES PERFORMED:

1. Microlumbar hemilaminotomies and partial medial facetectomy, right L4-L5

and L5-S1, and diskectomy right L5-S1.

2. Neurophysiological monitoring.

INDICATIONS:

The patient has continued to experience chronic right lower extremity symptoms despite an appropriate course of nonoperative care including therapeutic steroid injections. She is now scheduled to undergo microdecompression right L4-L5 and L5-S1 with probable diskectomy right L5-S1.

FINDINGS:

Significant subarticular stenosis was encountered on the right at both L4-L5 and L5-S1 with ongoing compression of the right L5 and S1 nerve roots, respectively. There was also a contained extruded disk herniation that was prominent to the right at L5-S1 with ongoing residual nerve root compression which was subsequently corrected with microdiskectomy.

PROCEDURE IN DETAIL: The patient was transported to the operating room, after which general anesthesia was obtained via endotracheal intubation. She was transferred to the Jackson table and placed on a Wilson frame attachment. Great care was taken to pad all bony and soft tissue prominences in order to avoid pressure phenomena. Sequential pressure stockings and a Foley catheter were in place as was the neurophysiological monitoring system. A time-out was completed and the patient received appropriate antibiotics. The lumbosacral region was shaved, prepped and draped in usual sterile manner after which needle localization was utilized to determine the site of the posterior lumbar midline incision, which was 5 cm in length and extended from the spinous process of L4- S1. The incision was carried down the lumbar fascia and hemostasis was obtained with electrocautery. Electrocautery was then utilized to incise lumbar fascia in a longitudinal fashion on the right side of the spinous processes extending from L4-S1. A Cobb elevator was then utilized to expose the right side lamina of L4-S1 with the posterior midline structures maintained and not sacrificed. The supraspinous and intraspinous ligaments remained intact. Intraoperative fluoroscopy confirmed we were at our desired levels.

Attention was initially directed to the L5-S1 interlaminar space and the AMA drill bit was utilized to perform an inferior L5 laminotomy and partial medial facetectomy on the right side at L5-S1. The ligamentum flavum was incised and debrided both medially and laterally. The integrity of the right L5-S1 facet joint remained.

A similar procedure was then performed on the right at L4-5 and again, the integrity of the right L4-L5 facet joint remained. The remainder of the operation was performed under microscopic magnification and illumination in order to permit the utilization of microsurgical techniques. Attention was maintained on the right at L4-L5 and was appreciated that residual subarticular stenosis continued to result in significant compression of the right L5 nerve root. Additional debridement of the medial aspect of the right L4-L5 facet joint was then performed using microsurgical techniques. Specifically, 4 but then 3 mm Kerrison rongeurs were utilized to debride the medial aspect of the facet joint until was flushed with the medial wall of the right L5 pedicle. We were then able to gently retract the right L5 nerve root towards the midline to examine the underlying disk which was found to be flat and without residual nerve root compression. The right L5 nerve root was subsequently deemed to be completely free and its foramen open as well when palpated with ball-tipped nerve probe. The wound was irrigated with copious amounts of antibiotic solution prior to which a Valsalva maneuver revealed no evidence of dural punctures. Liquid Gelfoam was utilized to obtain hemostasis.

Attention was then re-directed to the L5-S1 interlaminar space and again, it was appreciated that there was continued residual compression of the right S1 nerve root that appeared to not only be contributed to by subarticular and lateral recess stenosis, but also palpable disk herniation anterior to the right S1 nerve root. Using microsurgical techniques, further debridement of the medial aspect of facet joint was debrided until it was flushed with the medial wall of the right S1 nerve root which permitted exposure of the right S1 nerve root. It was then gently retracted toward the midline and underlying epidural vessels were coagulated with bipolar coagulation. We were then able to carefully examine the right side of the L5-S1 disk space and it was clear that an extruded, but contained disk herniation existed with ongoing compression of the right S1 nerve root. The extruded, but contained portion appeared to be slightly cephalad to the disk space itself and when that area was palpated with #4 Penfield, it easily popped through the thinned annulus. Multiple small fragments of disk were encountered at that site that existed between the thinned annulus and posterior longitudinal ligament and the posterior aspect of the L5 vertebral body. Using microsurgical techniques including use of micropituitary, multiple small fragments were removed from that site. The rent was then found that extended into the disk space from which additional amount of disk material was removed with micro-pituitaries, but care was taken to avoid penetration of the annulus anteriorly as well as laterally. Reinspection of the canal revealed the ongoing compression of the right S1 nerve was completely relieved and there was no residual evidence of extruded disk material. The right S1 nerve root was found to be completely free and its foramen open as well when palpated with a ball-tipped nerve probe.

The wound was then irrigated, then was re-irrigated with copious amounts of antibiotic solution. Valsalva maneuvers revealed no evidence of dural punctures. Liquid Gelfoam was again utilized to obtain hemostasis at L5-S1. The microscope was then removed from the field and we continued to re-irrigate the wound with antibiotic solution prior to which hemostasis of the soft tissue had been obtained with bipolar coagulation. No residual bleeding was appreciated, but a small Hemovac drain was placed deep to the fascia and exited through a separate stab wound. Thrombin-soaked Gelfoam was placed over the exposed neural structures on the right at both L4-L5 and L5-S1. The lumbar fascia was then reapproximated to the midline with an interrupted 0 absorbable suture and subcutaneous tissue was reapproximated with interrupted 2-0 absorbable soft suture after Exparel had been injected. The skin was reapproximated with a running subcuticular 4-0 absorbable suture, followed by Mastisol and Steri-Strips. A sterile dressing was applied after which the patient was transferred to her hospital bed, extubated, and transported to the recovery room in good condition, having tolerated the procedure well. No intraoperative complications occurred. Needle and sponge counts were reported

to be correct.

ESTIMATED BLOOD LOSS: Less than 25 cc.

SPECIMENS TO PATHOLOGY:

Consisted of the disk material from the right L5-S1 disk space. No changes occurred with regard to the neurophysiological monitoring.

CPT code: 

63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; Lumbar

63030-RT – Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

ICD 10-

M51.27   Other intervertebral disc displacement, lumbosacral region

M48.07  Spinal stenosis, lumbosacral region

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Sample Medical Report 3

PREOPERATIVE DIAGNOSIS: Left breast cancer, personal history with previous partial mastectomy defects and surgery defects and radiation.

POSTOPERATIVE DIAGNOSIS: Same

PROCEDURE: Left breast reconstruction with other technique (lipoinfiltration) and Right breast mastopexy

ASSISTANT: None.

COMPLICATIONS: None.

DRAINS: None.

ESTIMATED BLOOD LOSS: Minimal. SURGICAL PROCEDURE: 1. Left breast reconstruction with other techniques including fat grafting and subcision. 2. Right breast mastopexy for symmetry. HISTORY: This patient had left partial mastectomy defect with loss of tissue especially in that left upper quadrant and noted a symmetry with the left and right breast. I marked her in a sitting position, taking fat from the right and left lower abdomen, taking perhaps 400 mL total of fat and aspirate, and then after processing, this went down to about 120 mL, and I injected a total of 100 mL of purified fat. Her right breast mastopexy was performed by lifting the areola and nipple, and tracking the sizing of the areolar complex and that is the left.

PROCEDURE IN DETAIL: The patient was prepped and draped under anesthesia. Initially, I marked her and I performed liposuction into her lower abdominal area after tumescent liposuction. Then, I was able to take this processes, placed a small Penrose into both lateral aspects and dressings were used for this at the conclusion of the case, and then I took the processed fat and prepared this for injection. I used 18, 20, and 16-gauge syringes to perform subcision to undermine the tissue lift them and elevate them, and preparing them for the fat injection. Then, I used a fat injection using 5 mL in 1.4 mm ports to inject the fat in and around breast. I used 70 mL in left breast and 30 mm in the right breast to achieve symmetry. Then, the right areola was spaced with a 42 mm cutter and I went and cut the excess skin around for about a 2 cm lift to lift this and elevate it, and closed circumferentially around the areola with PDS as a circumferential stitch, then 4-0 Monocryl and 5-0 Prolene for the skin. Sterile dressings were applied and she was discharged to the recovery room in stable condition.

CPT Code

19366-LT Breast Reconstruction w/Other Technique

19316-RT Mastopexy

ICD 10

Z42.1  Encounter for breast reconstruction following mastectomy

Z85.3  Personal history of malignant neoplasm of breast

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Sample Medical Report 4

PROCEDURE PERFORMED:

1. Selective coronary angiography.

2. Ascending aortography.

3. Performed right radial artery without complication.

PREOPERATIVE DIAGNOSES:

1. Severe aortic insufficiency.

2. Bicuspid aortic valve.

3. Cardiomyopathy with systolic dysfunction.

POSTOPERATIVE DIAGNOSES:

1. Severe aortic insufficiency.

2. Bicuspid aortic valve.

3. Cardiomyopathy with systolic dysfunction.

CLINICAL HISTORY: A 53-year-old male with morbid obesity and symptomatic

valvular regurgitation with severe aortic insufficiency and cardiomyopathy with

moderate systolic dysfunction, bicuspid aortic valve, dilated aorta, presents

for preoperative cardiac catheterization, possible revascularization.

DESCRIPTION OF PROCEDURE:

The patient was brought to cardiac catheterization laboratory in fasting state after signed informed consent was obtained. The right wrist was prepped and draped in sterile fashion. Allen’s test was normal. Xylocaine 1% used for local anesthesia. A 6-French introducer sheath was placed percutaneously. Intra-arterial heparin and verapamil was administered. It was difficult reaching the aortic root from the right radial approach secondary to the patient’s morbid obesity, dilated and tortuous ascending aorta. There was also significant aortic insufficiency causing catheter _____. We were able to selectively engage the right coronary artery with a 6-French JR4 diagnostic catheter and selective right angiography performed multiple views using hand injections. We were unable to selectively engage the left main despite the use of multiple diagnostic catheters including 6-French JL3.5, 4.0, 4.5, 5.0, and 6.0 catheters. We also tried to engage the left main selectively using a 6-French EBU 4.0 and 4.5 guide and 6-French AL1 guide. Therefore, we exchanged these catheters out for an angled pigtail catheter and performed biplane ascending aortography, which did nonselectively fill the left main LAD and no obvious stenosis seen in these segments, although poorly visualized. There was no atrial reached. The left main from the right radial approach femoral access was not obtained secondary to the patient’s massive obesity and likely will be able to assess the coronary anatomy further with CT angiography.

FINDINGS:

Right coronary artery: Large vessel dominant, no significant angiographic stenosis. Left coronary system nonselectively visualized through ascending aortogram as above. There is contrast filling the LAD nonselectively. The left main circumflex and details of the LAD are not well seen on this limited injection.

Aortography: The aortic root and ascending aorta are markedly dilated. There was severe aortic insufficiency. There was no discrete aneurysm identified.

CONCLUSION: 1. Dilated ascending root and ascending aorta with severe aortic insufficiency.

2. Probably normal coronary arteries need further assessment with CT angiogram for definitive assessment.

CPT code

93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation;

93567 Injection During Cath; For Supravalvular Aortography

ICD 10

I35.1   Nonrheumatic aortic (valve) insufficiency

I42.9  Cardiomyopathy, unspecified