Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Neuro Critical Care Consultation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REASON FOR CONSULTATION:  Neuro critical care management.

HISTORY OF PRESENT ILLNESS:  I was asked to assist in the neuro critical care management of this (XX)-year-old male who was found at the bottom of a flight of stairs by bystanders. EMS was called, and at that time, EMS said the patient was oriented to self and was complaining of neck pain and headache. They did not report whether he was moving his arms and legs at that time, but apparently, then, he began having a seizure that lasted approximately 2 minutes. He was given Valium 5 mg. He was noted to have a right lateral gaze. His GCS was initially 7 to 8 and then dropped to 3. His blood pressure in the field was 138/86 with a pulse of 70. He was brought immediately to the emergency room. His blood pressure at that time was 162/82 with a pulse of 102. His temperature was 96.6. He was saturating at 94% and his GCS was 3. He was intubated with a rapid sequence intubation with 100 mg of lidocaine, fentanyl 50 mcg, vecuronium 1 mg, etomidate 20 mg and succinylcholine 200 mg. He was then given Versed 2 mg and another 9 mg of vecuronium thereafter. He also received Cerebyx 1 gram, Ancef 1 gram. He was taken for CT scan and MRI. He received a total of 3450 mL in the ER and 2450 mL out. His initial blood gases in the emergency room were venous 6.96/62/122. Sodium was 141, potassium was 3.8, ionized calcium was 1.15, H and H of 16.4 and 48.2.

PAST MEDICAL HISTORY:  Unknown.

MEDICATIONS AS OUTPATIENT:  Unknown.

ALLERGIES:  Unknown.

SOCIAL HISTORY:  Unknown.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 99.4 with blood pressure running between 120 to 160 over 70 to 90, cuff MAP at 88 to 110 with pulse of 72 to 84, saturating at 100% on SIMV mode, tidal volume of 700, rate of 12, pressure support of 10, PEEP of 5.
GENERAL APPEARANCE:  The patient is lying in bed unresponsive, orally intubated.
HEENT:  There is a large amount of blood coming from his head. There is a large laceration on the posterior aspect of his scalp. His sclerae are clear. He has no periorbital edema. There is no blood coming from his ear canal or his nostrils.
NECK:  The patient has a cervical collar in place.
HEART:  Regular rate and rhythm.
CHEST:  Without deformity or scars.
LUNGS:  Clear to auscultation bilaterally.
ABDOMEN:  Scaphoid, not distended. No bowel sounds present.
EXTREMITIES:  Some abrasions over the fingers, but no obvious limb deformities. Pulses are equal bilaterally and the radial DP and PT with good capillary refill. The patient has a laceration of his right knee.
NEUROLOGIC:  The patient is unresponsive to voice and pain. He does not blink to threat. His pupils are 3 mm and reactive bilaterally. Intermittently, the patient will have jerking movements of his arms and legs as though he was partially paralyzed. A train-of-four stimulation showed 1/4 stimulation with significant decrement. After waiting approximately a half hour, the patient began to move more. His left arm withdrew to pain, approximately 4-/5 strength, the right arm approximately 3-/5. The left leg withdrew, 3/5 strength in the lower extremity and the right was 2/5. His left toe was mute, the right toe was downgoing. His reflexes were 2 throughout. To deep pain, the patient had symmetric grimace.

DIAGNOSTIC AND LABORATORY DATA:  CT scan of the head shows no intracerebral hemorrhages, no extra-axial fluid collection, but bilateral encephalomalacia of the frontal lobes that appear old. An MRI of the brain also shows the same findings. No evidence of hemorrhage. The CT of the cervical spine shows a C4 on 5 subluxation with a left facet jump. The MRI shows the cord is slightly impinged, but no obvious cord hematoma or cord change in signal. Anterior to the cord is either hemorrhage or possible calcification of OPLL. Chest x-ray shows right mainstem intubation with lung fields clear. The tube has subsequently been pulled back. Chest CT shows a questionable small pneumothorax on the right. There is also question of right upper lobe collapse. Otherwise, no acute intrathoracic abnormalities. The abdominal and pelvic CT negative except for old thoracic compression fracture. Lumbar spine was clear. FAST was negative.

Repeat ABG was 7.42/39/33.5. Sodium 141 with a potassium of 3.7, chloride of 104, bicarbonate 16, BUN 13, creatinine 1.3, glucose 115, calcium 1.15, and lactic acid 18. White count 13.4 with H and H 14.8 and 44 .8. MCV is 91.8, segs 46, lymphs 38, monos 14, eosinophil 1, basophil 1 with platelet count of 396. PT is 15.2 with INR 1.2, PTT is 31.5 with a ratio of 0.8. Toxicology screen is positive for cocaine as well as alcohol, 1.03, benzodiazepines are also positive. This is likely due to the Valium in the field.

IMPRESSION:  This is a (XX)-year-old male who is status post fall down a flight of stairs, who has had an episode of seizures that lasted approximately 2 minutes. It is unclear whether this was due to his old encephalomalacia or whether he has a known seizure disorder. An EEG will be performed and the patient will be loaded with fosphenytoin and continue at 100 mg q.8 h. and recheck a level in a.m. In addition, the patient is unresponsive and this may have been the postictal state as well as receiving Valium. There is no obvious intracranial abnormality at this time. It is not clear whether the patient had any hypoxic ischemic injury as he was awake in the field. The initial ABG was a venous ABG and cannot be relied on for his oxygenation status. The patient also has a C4 on 5 subluxation and Orthopedics has been consulted for evaluation. Since the patient is moving and although he cannot be fully evaluated for strength testing, he is at least moving his lower extremities, 3/5 strength on the left and 2 on the right. His arms are also moving better on the left than the right; it was 4 and 3 respectively. The orthopedist planned for tongs with attempt to reduce the subluxation initially by closed method, otherwise, will proceed to open reduction, internal fixation tomorrow per Dr. Doe, if they are unable to reduce the patient. After tongs and weight are placed, a repeat C-spine plain film will be obtained. The patient has respiratory failure due in part to his mental status and inability to protect his airway. His full cervical spine status is not clear. We will normalize his PCO2. Blood pressure is currently adequate.

PLAN:  To admit to the neuro intensive care unit for close neuro checks. Propofol for slight sedation. We will decrease the propofol later to assess his neurologic status. We will maintain MAP greater than 80, initially with fluids, to maintain good spinal cord perfusion. Solu-Medrol protocol for potential traumatic cervical myelopathy. Protonix for stomach prophylaxis. Venodyne for DVT prophylaxis. The patient will be n.p.o. for now. Central venous catheter as well as arterial lines were placed. Blood sugars will need to be obtained and may need an insulin drip if sugars are elevated. Tetanus toxoid needs to be given. IV fluids, normal saline, with 20 of potassium at 150 mL per hour. Serial lactic acids will be obtained, p.r.n. fentanyl if the patient has significant evidence of pain and an EEG.

MT Word Help

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites