Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Stenting

Description: Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending.
(Medical Transcription Sample Report)

NAME OF PROCEDURE: Successful stenting of the left anterior descending.

DESCRIPTION OF PROCEDURE: Angina pectoris, tight lesion in left anterior descending.

TECHNIQUE OF PROCEDURE: Standard Judkins, right groin.

CATHETERS USED: 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.

ANTICOAGULATION: The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.

COMPLICATIONS: None.

INFORMED CONSENT: I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.

HEMODYNAMIC DATA: The aortic pressure was in the physiologic range.

ANGIOGRAPHIC DATA: Left coronary artery: The left main coronary artery showed insignificant disease. The left anterior descending showed fairly extensive calcification. There was 90% stenosis in the proximal to midportion of the vessel. Insignificant disease in the circumflex.

SUCCESSFUL STENTING: A wire crossed the lesion. We first predilated with a balloon, then advanced, deployed and post dilated the stent. Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.

PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30. He is saturating at 96% on 4 L nonrebreather.
GENERAL: The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3. The patient cannot speak and communicates through writing.
HEENT: Very small moles on face. However, pupils equal, round and regular and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is moist.
NECK: Supple. Tracheostomy site is clean without blood or discharge.
HEART: Regular rate and rhythm. No gallop, murmur or rub.
CHEST: Respirations congested. Mild crackles in the left lower quadrant and left lower base.
ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves II-XII grossly intact. No focal deficit.
GENITALIA: The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.

CONCLUSIONS
1. Successful stenting of the left anterior descending. Initially, there was 90% stenosis. After stenting with a drug-eluting stent, there was 0% residual.
2. Insignificant disease in the other coronaries.

PLAN: The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins. I have discussed this with him, and I have answered his questions.

Keywords: surgery, tight lesion, standard judkins, balloon for predilatation, angina pectoris, coronary artery, stenting, anterior, respirations, descending,
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