Please note sample reports are not formatted like spacing, headings, subheadings appropriately. Please do not refer this samples for formatting issues. These samples are intended to have understanding of common words, phrases, and headings in op reports. Lumbar epidural steroid injection. This year-old female presents with symptoms consistent with a lumbar radiculopathy, block with xylocaine and 100,000 epinephrine.
Previous epidural steroid injections have resulted in significant improvement of her pain. This is the second in a series of three of those injections. The patient was placed in the left lateral decubitus position. The L interspace was identified with deep palpation. The area was prepped and draped in the usual sterile fashion. An gauge Tuohy needle was advanced to the epidural space with the loss-of-resistance technique.
No complications were encountered and the patient was returned to the outpatient surgery department in stable condition. To repeat this procedure in two weeks. They sometimes look at ramus intermedius. And, sometimes they look at the renal arteries, too. It is interventricular septum not intra - NOT intraventricular. There was no gradient seen on pullback.
Whenever they say "by" it should be transcribed as an "x. Selective coronary angiography, right and left coronary arteries; selective renal angiography; contrast ventriculography with left heart catheterization; aortogram of the mid-abdominal aorta. Non-Q wave myocardial infarction, block with xylocaine and 100,000 epinephrine, unstable angina, block with xylocaine and 100,000 epinephrine, known history of abdominal aneurysm.
The procedure was performed from the right groin using Visipaque. Contrast was tolerated well, a total of cc. The procedure was performed from the right groin using a 5-French catheter and sheath.
Subsequently, calcium vitamin d and migraine patient was remanded to the intensive care unit. Integrilin was initiated in the cardiac catheterization laboratory. Standard angle and views were used for the right and left coronaries. Left heart catheterization was performed. Selective angiograms of the renals were performed and the right coronary and then an aortogram was performed to evaluate the abdominal aortic aneurysm.
Demonstrated the left ventricular end diastolic pressure at 20, arising to 25 post-LV gram. The contractility pattern on the left ventriculogram demonstrated a normal ejection fraction, minor apical lateral wall motion abnormality consistent with a probable obtuse marginal disease which is subsequently noted on the report.
There is a fairly significant beading and irregularity of the PDA as it becomes diffusely diseased, although the posterolateral branch is quite large. Free of disease and it branches into a nondominant left block with xylocaine and 100,000 epinephrine coronary artery. Has initial first obtuse marginal, very proximal, in the AV groove that extends two-thirds of the way to the apex where it tapers with diffuse irregularities noted within it.
A second obtuse marginal appears within 0. The circumflex coronary artery continues in the AV groove and demonstrates what appears to be a third small obtuse marginal which may well have been subtotally occluded at one time. The vessel ends at the AV groove at the inferior surface as a rapidly tapered posterobasilar branch. There are then two diagonals that arise just short of each other in the proximal one-third, block with xylocaine and 100,000 epinephrine, the first diagonal arising high and running to an obtuse marginal territory, the second one paralleling the LAD to the mid-anterior wall and then swinging laterally as a second obtuse marginal type territory branch.
This degree of stenosis would suggest the need for revascularization of the two diagonals and not simply the left anterior descending coronary artery alone. Multi-vessel block with xylocaine and 100,000 epinephrine artery disease with good targets for revascularization: Abdominal aortic aneurysm, small, probably no more than 3 cm maximum in the infrarenal area. Diffuse luminal irregularities in the aortoiliac system, block with xylocaine and 100,000 epinephrine of which appear to be critical.
The patient is a year-old cigarette smoker with a markedly positive family history of coronary artery disease who has an electrocardiogram showing an old anterior septal myocardial infarction. Nuclear study showed a fixed anterior defect.
He has had episodes of chest pain and coronary angiography has been recommended. One percent lidocaine was infiltrated over the right femoral artery. A 6-French sheath was placed in the right femoral artery. Following coronary angiography, a 6-French pigtail catheter was placed in the left ventricle where left ventriculography was performed with 36 cc of contrast injected at 12 cc per second.
At the conclusion of the procedure, the catheter and sheath were removed and Angio-Seal plug was deployed. Fentanyl mcg and Versed 2 mg. There was no aortic stenosis on left heart pullback. There was no significant obstructive coronary artery disease in this right dominant system.
The left circumflex artery is a moderate-sized vessel filling a large first obtuse marginal and diminutive second obtuse marginal and there is no significant disease. The left anterior descending coronary artery is a large vessel which extends to the apex. It fills several small diagonal branches. There are no significant stenoses.
There is a large ramus intermedius which fills the lateral wall. It, too, has no significant disease. The right coronary artery is a large dominant vessel filling a moderate-sized posterior descending artery and two larger posterolateral branches.
There are no significant obstructions in the right coronary artery. The left ventricular systolic function is normal. There are no regional wall motion abnormalities.
There is no mitral regurgitation, block with xylocaine and 100,000 epinephrine. There is no significant obstructive coronary artery disease in this right dominant system.
There is a plaque in the distal left main, but there is no significant obstruction. Left ventricular systolic function is normal. There is no evidence of previous anterior wall myocardial infarction. Coronary spasm remains in the differential diagnosis and we have encouraged him to completely discontinue smoking, which he has accomplished. He certainly can take nitroglycerin on an as-needed basis in the future.
Block with xylocaine and 100,000 epinephrine would continue aspirin indefinitely. The patient is a year-old with a long history of atrial flutter who has converted back to atrial flutter. He is on amiodarone, Coumadin, and Prinivil. His INR is between 2 and 3. The patient was sedated with Versed 80 mg and fentanyl mcg.
Cardioversion was performed with a single discharge of 50 joules from a biphasic defibrillator. This converted him from atrial flutter to sinus rhythm, block with xylocaine and 100,000 epinephrine.
There were no complications. Successful cardioversion of atrial flutter. This is a technically excellent study. Aortic diameter is 3. The left ventricular internal diameter end-diastole is 4. The left ventricular size and function is normal. There are no regional wall motion abnormalities seen. There is moderate concentric left ventricular hypertrophy. The left atrial size is normal. The aortic root appears normal. The right ventricular size and function are normal. The right atrial size is on the upper limits of normal.
There is the appearance of a pacing wire noted in the right ventricle. The mitral valve leaflet morphology and excursion is normal. On Doppler assessment there is mild mitral regurgitation, however, there is no mitral stenosis. The aortic valve is highly sclerotic. However, it appears to open normally. On Doppler assessment there is no evidence of aortic stenosis or regurgitation.
The tricuspid valve leaflet morphology and excursion is normal. On Doppler assessment there is mild to moderate tricuspid regurgitation. The pulmonic valve appears normal in morphology. On Doppler assessment there is block with xylocaine and 100,000 epinephrine pulmonic insufficiency or stenosis seen. The pericardium is normal. There is no pericardial effusion.