Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Nephrology
Sample Name: AV Fistula - 5

Description: Left forearm arteriovenous fistula between cephalic vein and radial artery.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES
1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.
2. Ischemic cardiomyopathy, ejection fraction 20%.

POSTOPERATIVE DIAGNOSES
1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.
2. Ischemic cardiomyopathy, ejection fraction 20%.

OPERATION
Left forearm arteriovenous fistula between cephalic vein and radial artery.

INDICATION FOR SURGERY
This is a patient referred by Dr. Michael Campbell. He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy. This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula. All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.

ANESTHESIA
Monitored anesthesia care.

DESCRIPTION OF PROCEDURE
The patient was identified, brought to the operating room, placed supine, and IV sedation given. This was done under monitored anesthesia care. He was prepped and draped in the usual sterile fashion. He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.

Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery. Incision was deepened down through the subcutaneous fascia. The vein was identified, dissected for a good length, and then the artery was identified and dissected. Heparin 5000 units was given. The artery clamped proximally and distally, opened up in the middle. It was found to have Monckeberg's arteriosclerosis of a moderate intensity. The vein was of good caliber and size.

The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down. Thrill was immediately felt and heard.

The incision was closed in two layers and sterile dressing applied.

Keywords: nephrology, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples