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: Dual Chamber Generator Replacement

Description: Dual chamber generator replacement. The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.
(Medical Transcription Sample Report)

REFERRAL INDICATIONS
1. Pacemaker at ERI.
2. History AV block.

PROCEDURES PLANNED AND PERFORMED: Dual chamber generator replacement.

FLUOROSCOPY TIME: 0 minutes.

MEDICATION AT THE TIME OF STUDY
1. Ancef 1 g.
2. Versed 2 mg.
3. Fentanyl 50 mcg.

CLINICAL HISTORY: The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.

RISKS AND BENEFITS: Risks, benefits, and alternatives to generator replacement have been discussed with the patient. Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient. The patient agreed both verbally and via written consent.

DESCRIPTION OF OPERATION: The patient was transported to the cardiac catheterization laboratory in a fasting state. The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner. Lidocaine 1% (20 mL) was administered to the area of the previous incision. A transverse incision was made through the skin and subcutaneous tissue. Hemostasis was achieved with electrocautery. Using blunt dissection, pacemaker, and leads were removed from the pocket. Leads were disconnected from the pulse generator and interrogated. The pocket was washed with antibiotic impregnated saline. The new pulse generator was obtained and connected securely to the leads and placed back in the pocket. The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch. Sponge and needle counts were correct at the end of the procedure. No acute complications were noted.

DEVICE DATA
1. Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.
2. New pulse generator Medronic, product # ADDR01, serial # ABCD1234.
3. Right atrial lead, product # 4068, serial # ABCD1234.
4. Right atrial lead, product # 4068, serial # ABCD1234.

MEASURED INTRAOPERATIVE DATA
1. Right atrial lead impedance 572 ohms. P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.
2. Right ventricular lead impedance 365 ohms. No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.

CONCLUSIONS
1. Successful dual chamber generator replacement.
2. No acute complications.

PLAN
1. She will be monitored for 3 hours and then dismissed home.
2. Resume all medications. Ex-home dismissal instructions.
3. Doxycycline 100 mg one p.o. twice daily for 7 days.
4. Wound check in 7-10 days.
5. Continue followup in device clinic.

Keywords: surgery, pacemaker, av block, atrial lead, dual chamber generator replacement, dual chamber, pulse generator, medronic, impedance, pocket, pulse,
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