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General Surgery Consultation Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION:  Evaluation of ileostomy protrusion above the level of the skin.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who came to the hospital with complaint of left-sided pain, left-sided upper extremity and chest pain, and weakness.  This patient underwent emergency operation of the abdomen a couple of months back.  The patient had presented with small bowel obstruction and upon exploration was found to have tumor involving the right colon, causing intestinal obstruction.  Upon reviewing the record, it appeared that the patient had right hemicolectomy with ileostomy.  Pathology report of the tumor was consistent with grade 2 adenocarcinoma of the colon.  Four lymph nodes were identified and were found to be free of tumor.  Surgical evaluation of this patient was called because family has noted that ileostomy protrudes above the level of the skin and comes out several inches beyond the level of the skin.  The patient currently has symptom of nausea but denies any vomiting.  No abdominal distention or abdominal cramps.

PAST MEDICAL HISTORY:  Significant for gastroesophageal reflux disease and colon cancer.

PAST SURGICAL HISTORY:  Significant for exploratory laparotomy and right hemicolectomy.

MEDICATIONS:  Zantac, Nexium, Paxil and Xanax.

ALLERGIES:  PENICILLIN.

SOCIAL HISTORY:  No history of substance abuse.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6 degrees, pulse 88, respirations 22, O2 saturation 98% on room air and blood pressure 122/64.
ABDOMEN:  Abdomen was completely soft, nontender and nondistended.  Right lower quadrant region of the abdomen was found to contain ileostomy, which was pink and viable.  There was no evidence of parastomal hernia or abnormal protrusion of the mucosa.  There was significant amount of air and stool in the colostomy bag.  No evidence of obstruction.

LABORATORY DATA:  CBC showed white cell count of 4.7, hemoglobin of 9.8, hematocrit of 29.4 and platelet count of 248,000.  BMP showed sodium 142, potassium 3.6, chloride 111, CO2 of 22, glucose 102, BUN 14, creatinine 0.7 and calcium 8.9.  Urinalysis showed 0 to 4 red cells, 0 to 4 white cells, 0 to 4 squamous cells and 1+ bacteria.

RADIOLOGICAL DATA:  CT of the brain showed a subtle area of low attenuation, right parietal lobe, probably consistent with volume averaging.  The possibility of edema or ischemia cannot be excluded.  Portable chest x-ray showed that the heart is at the upper limit of normal in size with bilateral apical pleural thickening and some degenerative changes of the thoracic spine, bilateral shoulders.  Two views of the shoulder were obtained on the left side and showed degenerative changes involving the left shoulder with elevation of the left humeral head that could be consistent with rotator cuff injury.  Lung scan performed showed low probability of air trapping.  MR angiography of the neck was done and showed no evidence of carotid bifurcation disease or stenosis, patent left and right vertebral arteries, poorly visualized left vertebral artery origin stenosis cannot be completely excluded.  MR angiography of the head performed showed a 2.5 mm left posterior communicating artery infundibulum.  MR of the brain performed showed age-appropriate involutional changes, scattered nonspecific foci of increased signal throughout the white matter of both cerebral hemispheres and the posterior pons.  Given the patient's age, finding likely represents the sequelae of chronic microvascular ischemic disease.  No acute infarct demonstrated and minimal sphenoid sinus disease.

ASSESSMENT AND PLAN:
1.  This is a (XX)-year-old female with history of colon cancer who does not have any evidence of intestinal obstruction, parastomal hernia or stomal necrosis.  Based on the history, this patient has not had detailed workup done for her colonic cancer.  The patient needs to be evaluated by a hematologist/oncologist.
2.  CEA level should be obtained.
3.  A CT scan of the abdomen and pelvis should be performed to rule out the possibility of metastatic disease and consultation with GI should be obtained.  I see that Dr. John Doe from GI has already been involved.  Besides, this patient is extremely weak and weighs only about 70 pounds.  Her nutritional status requires aggressive support.  The patient may get benefit with milkshakes of Ensure if her oral intake is not good.

Family has discussed the possibility of reversal of colostomy.  I have counseled the patient and the family to focus on evaluation of the patient by an oncologist first and perform detailed cancer workup and support her nutritional status so that the patient can gain weight first.  Once the patient's clinical condition improves and she gains more weight, then possibility of ileostomy reversal can be considered.  At this point, there is no acute surgical emergency that requires me to offer immediate surgical intervention.

Thank you, Dr. Doe, for allowing me to participate in the care of this patient.

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