DATE OF PROCEDURE: XX/XX/XXXX
PREOPERATIVE DIAGNOSIS: Morton neuroma, left second and third metatarsal interspace.
POSTOPERATIVE DIAGNOSIS: Morton neuroma, left second and third metatarsal interspace.
PROCEDURE PERFORMED: Excision of Morton neuroma, left second and third metatarsal interspace.
SURGEON: First Last Name, DPM
ANESTHESIA: Laryngeal mask airway.
PREOPERATIVE ANTIBIOTICS: One gram of Ancef IV.
ESTIMATED BLOOD LOSS: Minimal.
MATERIALS: None.
PROCEDURE IN DETAIL: The patient was brought to the operating room and placed on the operating room table in normal supine position. At this time, a preoperative block was administered with total of 10 mL of 50:50 mixture of 0.5% Marcaine plain and 1% Xylocaine plain about the surgical site, left foot. At this time, a well-padded ankle pneumatic tourniquet was placed just proximal to the malleoli subsequent to Betadine prep. At this time, tourniquet was inflated to 250 mmHg and attention was directed to the left second metatarsal interspace where a 4 cm plantar longitudinal incision was made. Utilizing a 15 blade, the incision was carried deep with careful attention paid to clamp and Bovie all bleeders that were encountered. At this time, the neuroma was brought into the operative field and resected both proximally and distally. The wound was flushed with copious amounts of normal saline and reapproximated utilizing 4-0 Vicryl in simple interrupted fashion. Skin was closed utilizing 4-0 nylon in simple interrupted fashion. The identical procedure was carried out about the third metatarsal interspace plantarly about the left foot. Postoperative injection was administered for a total of 10 mL of 0.5% Marcaine pain. The wounds were dressed with Xeroform gauze, 4 x 4 inch gauze and 3 inch Kling. The patient tolerated the procedure and anesthesia well and left the operating room for the recovery room with vital signs stable and neurovascular status intact, bilateral lower extremities.
Pacemaker Implantation Medical Transcription Sample
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Intermittent Stokes-Adams events.
POSTOPERATIVE DIAGNOSIS:
Intermittent Stokes-Adams events.
PROCEDURES PERFORMED:
1. Chest fluoroscopy.
2. Implantation of Guidant Insignia Ultra DR pacemaker.
3. Implantation of a passive Guidant Fineline lead.
4. Implantation of a Guidant atrial Fineline lead.
INDICATION FOR PROCEDURE: Intermittent Stokes-Adams events.
PROCEDURE IN DETAIL: The patient was taken to the operating room and a single subclavian stick was performed. Because of his age, I elected to avoid multiple subclavian sticks and a single stick technique was employed, after the initial wire was placed via Seldinger technique. The pockets then were formed using a #10 blade to transect the skin. Curved Metzenbaum scissors and pickups were used to isolate the pectoralis muscle fascia. Pockets were formed with blunt dissection inferiorly, medially and laterally. A lot of time was spent on the cautery and keeping the pocket dry with the patient taking aspirin and Plavix. Eventually, over the two wires that had been introduced, the sheaths were introduced and then leads were introduced into optimal position. Initial testing was satisfactory and both leads were secured using the sleeves as provided. Final testing was then performed.
The R-wave was 25.4 millivolts. The impedance was 680 ohms. The threshold was 0.3 volts. The atrial leads have a P-wave of 2.0 millivolts. The impedance was 456 ohms. The threshold was 0.9 volts. There was no diaphragmatic pacing at 10 volts on either lead. The leads were attached to a pulse generator with a wrench provided. The pulse generator was secured to floor of the pocket. The pocket was flushed with vancomycin solution. The deep fascial layer was closed with 3-0 chromic. The skin was closed with 3-0 silk employing mattress sutures. Final fluoroscopy was performed. There was no evidence of pneumothorax. The RAO projection showed normal anterior location of the atrial lead and good position of the ventricular lead at the right ventricular apex. There was no significant blood loss. The patient was returned to his room in stable and satisfactory condition.
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Not dictated.
POSTOPERATIVE DIAGNOSIS: Not dictated.
OPERATION PERFORMED:
1. Extraction of a dual chamber pacemaker.
2. Intraoperative fluoroscopy.
3. Implant of a dual chamber pacemaker.
SURGEON: John Doe, MD
ASSISTANT: None.
INDICATION FOR OPERATION: The patient had a pacemaker malfunction. He understood possible risks and complications and agreed to proceed.
FINDINGS AND DESCRIPTION OF PROCEDURE: After informed consent was obtained, the following procedure was performed. The right prepectoral area was prepped and draped in the usual sterile fashion. Lidocaine was used for local anesthesia of the skin and subcutaneous tissue.
A skin incision was made over a pre-existing pacemaker. Blunt dissection was performed. Pacemaker was extracted. Leads were removed and connected to the analyzer. Right atrial lead revealed a T wave of 4.2 mV, impedance 530 ohms, threshold 1.1 volt at 0.5 milliseconds. Right ventricular lead with an R wave of 16.3 mV, impedance 600 ohms, and threshold 0.4 volt at 0.5 milliseconds. Lead was connected to the pacemaker, which secures to the underlying prepectoral fascia using nonabsorbable suture. The device was secured with one suture. Copious irrigation of the pocket with antibiotic saline solution was performed.
Testing of the lead threshold via the device revealed a T wave of 3.9 mV, R wave 12 mV, impedance in the atrium 410 ohms and the ventricle 526 ohms. Threshold in the atrium 0.75 volt at 0.5 milliseconds and in the ventricle 0.75 volts at 0.5 milliseconds. Device was programmed as DDD lower rate 60, upper rate 120 and AV delay extended to 300 milliseconds to allow normal conduction.
Prepectoral subcutaneous and subdermal layer was closed using interrupted and continuous Vicryl suture. Dermabond was applied to the skin. The patient left the operating room with no noted complications and the count was correct.
Electrophysiology Sample Reports Cardiac Cath Sample Report
PREOPERATIVE DIAGNOSIS:
Intermittent Stokes-Adams events.
POSTOPERATIVE DIAGNOSIS:
Intermittent Stokes-Adams events.
PROCEDURES PERFORMED:
1. Chest fluoroscopy.
2. Implantation of Guidant Insignia Ultra DR pacemaker.
3. Implantation of a passive Guidant Fineline lead.
4. Implantation of a Guidant atrial Fineline lead.
INDICATION FOR PROCEDURE: Intermittent Stokes-Adams events.
PROCEDURE IN DETAIL: The patient was taken to the operating room and a single subclavian stick was performed. Because of his age, I elected to avoid multiple subclavian sticks and a single stick technique was employed, after the initial wire was placed via Seldinger technique. The pockets then were formed using a #10 blade to transect the skin. Curved Metzenbaum scissors and pickups were used to isolate the pectoralis muscle fascia. Pockets were formed with blunt dissection inferiorly, medially and laterally. A lot of time was spent on the cautery and keeping the pocket dry with the patient taking aspirin and Plavix. Eventually, over the two wires that had been introduced, the sheaths were introduced and then leads were introduced into optimal position. Initial testing was satisfactory and both leads were secured using the sleeves as provided. Final testing was then performed.
The R-wave was 25.4 millivolts. The impedance was 680 ohms. The threshold was 0.3 volts. The atrial leads have a P-wave of 2.0 millivolts. The impedance was 456 ohms. The threshold was 0.9 volts. There was no diaphragmatic pacing at 10 volts on either lead. The leads were attached to a pulse generator with a wrench provided. The pulse generator was secured to floor of the pocket. The pocket was flushed with vancomycin solution. The deep fascial layer was closed with 3-0 chromic. The skin was closed with 3-0 silk employing mattress sutures. Final fluoroscopy was performed. There was no evidence of pneumothorax. The RAO projection showed normal anterior location of the atrial lead and good position of the ventricular lead at the right ventricular apex. There was no significant blood loss. The patient was returned to his room in stable and satisfactory condition.
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Not dictated.
POSTOPERATIVE DIAGNOSIS: Not dictated.
OPERATION PERFORMED:
1. Extraction of a dual chamber pacemaker.
2. Intraoperative fluoroscopy.
3. Implant of a dual chamber pacemaker.
SURGEON: John Doe, MD
ASSISTANT: None.
INDICATION FOR OPERATION: The patient had a pacemaker malfunction. He understood possible risks and complications and agreed to proceed.
FINDINGS AND DESCRIPTION OF PROCEDURE: After informed consent was obtained, the following procedure was performed. The right prepectoral area was prepped and draped in the usual sterile fashion. Lidocaine was used for local anesthesia of the skin and subcutaneous tissue.
A skin incision was made over a pre-existing pacemaker. Blunt dissection was performed. Pacemaker was extracted. Leads were removed and connected to the analyzer. Right atrial lead revealed a T wave of 4.2 mV, impedance 530 ohms, threshold 1.1 volt at 0.5 milliseconds. Right ventricular lead with an R wave of 16.3 mV, impedance 600 ohms, and threshold 0.4 volt at 0.5 milliseconds. Lead was connected to the pacemaker, which secures to the underlying prepectoral fascia using nonabsorbable suture. The device was secured with one suture. Copious irrigation of the pocket with antibiotic saline solution was performed.
Testing of the lead threshold via the device revealed a T wave of 3.9 mV, R wave 12 mV, impedance in the atrium 410 ohms and the ventricle 526 ohms. Threshold in the atrium 0.75 volt at 0.5 milliseconds and in the ventricle 0.75 volts at 0.5 milliseconds. Device was programmed as DDD lower rate 60, upper rate 120 and AV delay extended to 300 milliseconds to allow normal conduction.
Prepectoral subcutaneous and subdermal layer was closed using interrupted and continuous Vicryl suture. Dermabond was applied to the skin. The patient left the operating room with no noted complications and the count was correct.
Electrophysiology Sample Reports Cardiac Cath Sample Report
Upper Endoscopy Medical Transcription Sample Report
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Not given.
POSTOPERATIVE DIAGNOSES:
1. Sliding hiatal hernia plus possible short segment Barrett and mild esophagitis.
2. Antral gastritis.
3. Duodenitis.
PROCEDURE PERFORMED: Pan upper endoscopy and biopsies.
PHYSICIAN: John Doe, MD
INDICATION: Chronic heartburn with anemia, possibly iron deficiency.
PROCEDURE: Using the Olympus thin video gastroscope under IV sedation in the form of intravenous Diprivan, the patient underwent pan upper endoscopy and biopsies without apparent complications.
FINDINGS: In the esophagus, there was evidence of a sliding hiatal hernia with possible short segment Barrett and esophagitis. This was photographed and biopsies were taken of the distal esophagus. There were no ulcerations or evidence of neoplasms. Stomach showed some gastritis, particularly in the antrum, where they may have been some scar from previous ulcer disease. Biopsies were taken of the antrum as well as a CLOtest. Also showed a small hiatal hernia but no evidence of masses. Duodenal bulb showed duodenitis and it was photographed. No ulcers. The second duodenum appeared normal. A biopsy was taken of the antrum also to rule out the possibility of Helicobacter pylori and a biopsy of the gastritis site. He tolerated the procedure well.
IMPRESSION:
1. Sliding hiatal hernia, possible short segment Barrett.
2. Antral gastritis.
3. Duodenitis.
PLAN: Continue Aciphex 20 mg a day. The patient is to have an anemia workup including iron, total iron binding capacity, B12, folic acid level and hemoglobin electrophoresis because of the possibility of iron deficiency versus thalassemia minor on his labs. He is also to have an alkaline phosphatase and a GGTP.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Early satiety.
2. Weight loss.
3. Abnormal gastric folds on CT scan.
POSTOPERATIVE DIAGNOSIS:
Grade 1 esophagitis, otherwise normal upper endoscopy.
PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with biopsy.
ENDOSCOPIST: John Doe, MD
CONSENT: Risks and benefits of the procedure were discussed with the patient, including bleeding, perforation, and sedation side effects including respiratory depression. The patient verbalized understanding and wishes to proceed with the procedure.
FINDINGS: The patient was placed in the left lateral decubitus position. The Olympus video endoscope was passed under direct visualization into the esophagus. The squamocolumnar junction was located at approximately 40 cm from the incisors. The Z-line was slightly irregular. Biopsies were obtained for histology. On retroflexed viewing of the stomach, the fundus and cardia were normal. The body and antrum were normal. The duodenal bulb and second portion of the duodenum were normal. Antral biopsies were obtained for CLOtest.
SPECIMENS:
1. Antral biopsies for CLOtest.
2. Distal esophageal biopsies.
COMPLICATIONS: No immediate postprocedure complications.
IMPRESSION:
Grade 1 esophagitis, otherwise normal upper endoscopy.
DISPOSITION:
1. The patient is to call Dr. John Doe for the biopsy results.
2. We will proceed to colonoscopy.
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Upper endoscopy.
ANESTHESIA: Versed 2 mg and propofol 150 mg IV.
INDICATIONS: Heartburn and GERD.
ASA CLASSIFICATION: Class 2.
PROCEDURE IN DETAIL: After informed consent was obtained from the patient, the patient was placed in the left lateral decubitus position and connected to standard monitoring equipment for heart rate, blood pressure, and pulse oximetry. After the provision of intravenous medication, the adult flexible Olympus upper endoscope was passed per the mouth to the second portion of the duodenum and retroflexion was performed in the stomach. The second portion of the duodenum and stomach were endoscopically normal. There was a small hiatal hernia with a hiatus at 4 cm insertion of the Z line and 36 cm insertion at the Z line. The Z line was a sizable punched out white lesion ulcer, which was biopsied utilizing cold forceps and sent for histopathology. There were also two tongues of salmon-pink colored mucosa that was quite reddened, extending proximally for a short distance from the Z line, and these were biopsied utilizing cold forceps and sent for histopathology as well. There were no immediate complications.
PLAN: At this time, follow up on the results of biopsies, which may help direct subsequent management.
Colonoscopy and EGD Sample Reports
PREOPERATIVE DIAGNOSIS: Not given.
POSTOPERATIVE DIAGNOSES:
1. Sliding hiatal hernia plus possible short segment Barrett and mild esophagitis.
2. Antral gastritis.
3. Duodenitis.
PROCEDURE PERFORMED: Pan upper endoscopy and biopsies.
PHYSICIAN: John Doe, MD
INDICATION: Chronic heartburn with anemia, possibly iron deficiency.
PROCEDURE: Using the Olympus thin video gastroscope under IV sedation in the form of intravenous Diprivan, the patient underwent pan upper endoscopy and biopsies without apparent complications.
FINDINGS: In the esophagus, there was evidence of a sliding hiatal hernia with possible short segment Barrett and esophagitis. This was photographed and biopsies were taken of the distal esophagus. There were no ulcerations or evidence of neoplasms. Stomach showed some gastritis, particularly in the antrum, where they may have been some scar from previous ulcer disease. Biopsies were taken of the antrum as well as a CLOtest. Also showed a small hiatal hernia but no evidence of masses. Duodenal bulb showed duodenitis and it was photographed. No ulcers. The second duodenum appeared normal. A biopsy was taken of the antrum also to rule out the possibility of Helicobacter pylori and a biopsy of the gastritis site. He tolerated the procedure well.
IMPRESSION:
1. Sliding hiatal hernia, possible short segment Barrett.
2. Antral gastritis.
3. Duodenitis.
PLAN: Continue Aciphex 20 mg a day. The patient is to have an anemia workup including iron, total iron binding capacity, B12, folic acid level and hemoglobin electrophoresis because of the possibility of iron deficiency versus thalassemia minor on his labs. He is also to have an alkaline phosphatase and a GGTP.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Early satiety.
2. Weight loss.
3. Abnormal gastric folds on CT scan.
POSTOPERATIVE DIAGNOSIS:
Grade 1 esophagitis, otherwise normal upper endoscopy.
PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with biopsy.
ENDOSCOPIST: John Doe, MD
CONSENT: Risks and benefits of the procedure were discussed with the patient, including bleeding, perforation, and sedation side effects including respiratory depression. The patient verbalized understanding and wishes to proceed with the procedure.
FINDINGS: The patient was placed in the left lateral decubitus position. The Olympus video endoscope was passed under direct visualization into the esophagus. The squamocolumnar junction was located at approximately 40 cm from the incisors. The Z-line was slightly irregular. Biopsies were obtained for histology. On retroflexed viewing of the stomach, the fundus and cardia were normal. The body and antrum were normal. The duodenal bulb and second portion of the duodenum were normal. Antral biopsies were obtained for CLOtest.
SPECIMENS:
1. Antral biopsies for CLOtest.
2. Distal esophageal biopsies.
COMPLICATIONS: No immediate postprocedure complications.
IMPRESSION:
Grade 1 esophagitis, otherwise normal upper endoscopy.
DISPOSITION:
1. The patient is to call Dr. John Doe for the biopsy results.
2. We will proceed to colonoscopy.
PROCEDURE PERFORMED: Upper endoscopy.
ANESTHESIA: Versed 2 mg and propofol 150 mg IV.
INDICATIONS: Heartburn and GERD.
ASA CLASSIFICATION: Class 2.
PROCEDURE IN DETAIL: After informed consent was obtained from the patient, the patient was placed in the left lateral decubitus position and connected to standard monitoring equipment for heart rate, blood pressure, and pulse oximetry. After the provision of intravenous medication, the adult flexible Olympus upper endoscope was passed per the mouth to the second portion of the duodenum and retroflexion was performed in the stomach. The second portion of the duodenum and stomach were endoscopically normal. There was a small hiatal hernia with a hiatus at 4 cm insertion of the Z line and 36 cm insertion at the Z line. The Z line was a sizable punched out white lesion ulcer, which was biopsied utilizing cold forceps and sent for histopathology. There were also two tongues of salmon-pink colored mucosa that was quite reddened, extending proximally for a short distance from the Z line, and these were biopsied utilizing cold forceps and sent for histopathology as well. There were no immediate complications.
PLAN: At this time, follow up on the results of biopsies, which may help direct subsequent management.
Colonoscopy and EGD Sample Reports
Colonoscopy Medical Transcription Sample Reports
PREOPERATIVE INDICATION: History of colorectal polyps.
POSTOPERATIVE FINDINGS: Normal colonoscopy.
TYPE OF PROCEDURE: Colonoscopy to cecum.
DETAILS OF PROCEDURE: After informed consent was obtained from the patient and intravenous access was initiated, cardiopulmonary monitoring was begun and the patient was then placed in left lateral position. A visual inspection of the perianal area revealed no abnormalities. A digital rectal examination revealed no masses. An Olympus video colonoscope was inserted into the rectum and advanced without difficulty to the ileocecal area, which was identified by its landmarks, palpation and transillumination. There are no intraluminal lesions. The scope then was withdrawn from the patient, again under direct vision, and no intraluminal lesions are present. The patient agrees to followup visits with all her physicians, including me.
FINAL DIAGNOSIS: Normal colonoscopy.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Rectal ulcer.
POSTOPERATIVE DIAGNOSIS: Rectal stricture.
PROCEDURE PERFORMED:
1. Colonoscopy via stoma.
2. Flexible sigmoidoscopy.
SURGEON: John Doe, MD
ANESTHESIA: Fentanyl 100 mcg and Versed 5 mg.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who presented to this office after being referred about four months ago with severe rectal ulcerations, rectal perforation, and peritoneal sepsis. The patient underwent diverting colostomy. She now presents for a colostomy closure.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was taken to the endoscopy suite and placed in the supine position. After adequate intravenous sedation, the stoma was digitalized.
The colonoscope was then inserted into the stoma and easily advanced to the cecum. The ileocecal valve and appendiceal orifice were identified. The entire colonic mucosa was then carefully and circumferentially inspected upon slow withdrawal of the scope. The entire mucosa up to the stoma, including the cecum, ascending and transverse, descending and sigmoid colon, was normal. The patient was then placed in the left lateral decubitus position. Digital rectal exam showed a stricture at about 6-7 cm. The flexible sigmoidoscope was placed and there clearly was still a small posterior perforation in this area with a stenotic area in the mid rectum. We were able to advance the scope through the area and the colon above was totally normal.
The patient tolerated the procedure well without any complications. Postoperatively, she was transferred to the recovery room in stable condition.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Recurrent rectal bleeding.
POSTOPERATIVE DIAGNOSES:
1. Grade 2 to 3 internal hemorrhoids.
2. Diverticulosis.
PROCEDURE PERFORMED:
Total colonoscopy.
ATTENDING DOCTOR: John Doe, MD
ANESTHESIA: IV monitored anesthesia care by Anesthesiology.
DESCRIPTION OF PROCEDURE: Digital examination and inspection showed no rectal masses. The prostate showed questionably enlarged irregular right lobe. The Olympus colonoscope was introduced into the rectum and the scope was advanced without difficulty to the cecum. The ileocecal valve and the appendiceal orifice were identified. The preparation was excellent. The scope was gradually withdrawn. The colonic mucosa was inspected as we proceeded distally. There were rare right-sided diverticula. There was a moderate amount of sigmoid diverticulosis. The U-turn maneuver in the rectum showed grade 2 to 3 internal hemorrhoids. The colon was deflated. The scope was withdrawn. The patient tolerated the procedure well.
IMPRESSION:
1. Questionably enlarged prostate.
2. Internal hemorrhoids.
3. Diverticulosis.
PLAN:
1. High-fiber program, routine hemorrhoidal care.
2. PCP followup for prostate.
3. If the patient fails to respond to routine hemorrhoidal care, infrared coagulation of internal hemorrhoids might be considered.
Colonoscopy and EGD Sample Reports Colonoscopy and ERBE Argon Laser Cautery Sample
POSTOPERATIVE FINDINGS: Normal colonoscopy.
TYPE OF PROCEDURE: Colonoscopy to cecum.
DETAILS OF PROCEDURE: After informed consent was obtained from the patient and intravenous access was initiated, cardiopulmonary monitoring was begun and the patient was then placed in left lateral position. A visual inspection of the perianal area revealed no abnormalities. A digital rectal examination revealed no masses. An Olympus video colonoscope was inserted into the rectum and advanced without difficulty to the ileocecal area, which was identified by its landmarks, palpation and transillumination. There are no intraluminal lesions. The scope then was withdrawn from the patient, again under direct vision, and no intraluminal lesions are present. The patient agrees to followup visits with all her physicians, including me.
FINAL DIAGNOSIS: Normal colonoscopy.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Rectal ulcer.
POSTOPERATIVE DIAGNOSIS: Rectal stricture.
PROCEDURE PERFORMED:
1. Colonoscopy via stoma.
2. Flexible sigmoidoscopy.
SURGEON: John Doe, MD
ANESTHESIA: Fentanyl 100 mcg and Versed 5 mg.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who presented to this office after being referred about four months ago with severe rectal ulcerations, rectal perforation, and peritoneal sepsis. The patient underwent diverting colostomy. She now presents for a colostomy closure.
DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was taken to the endoscopy suite and placed in the supine position. After adequate intravenous sedation, the stoma was digitalized.
The colonoscope was then inserted into the stoma and easily advanced to the cecum. The ileocecal valve and appendiceal orifice were identified. The entire colonic mucosa was then carefully and circumferentially inspected upon slow withdrawal of the scope. The entire mucosa up to the stoma, including the cecum, ascending and transverse, descending and sigmoid colon, was normal. The patient was then placed in the left lateral decubitus position. Digital rectal exam showed a stricture at about 6-7 cm. The flexible sigmoidoscope was placed and there clearly was still a small posterior perforation in this area with a stenotic area in the mid rectum. We were able to advance the scope through the area and the colon above was totally normal.
The patient tolerated the procedure well without any complications. Postoperatively, she was transferred to the recovery room in stable condition.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Recurrent rectal bleeding.
POSTOPERATIVE DIAGNOSES:
1. Grade 2 to 3 internal hemorrhoids.
2. Diverticulosis.
PROCEDURE PERFORMED:
Total colonoscopy.
ATTENDING DOCTOR: John Doe, MD
ANESTHESIA: IV monitored anesthesia care by Anesthesiology.
DESCRIPTION OF PROCEDURE: Digital examination and inspection showed no rectal masses. The prostate showed questionably enlarged irregular right lobe. The Olympus colonoscope was introduced into the rectum and the scope was advanced without difficulty to the cecum. The ileocecal valve and the appendiceal orifice were identified. The preparation was excellent. The scope was gradually withdrawn. The colonic mucosa was inspected as we proceeded distally. There were rare right-sided diverticula. There was a moderate amount of sigmoid diverticulosis. The U-turn maneuver in the rectum showed grade 2 to 3 internal hemorrhoids. The colon was deflated. The scope was withdrawn. The patient tolerated the procedure well.
IMPRESSION:
1. Questionably enlarged prostate.
2. Internal hemorrhoids.
3. Diverticulosis.
PLAN:
1. High-fiber program, routine hemorrhoidal care.
2. PCP followup for prostate.
3. If the patient fails to respond to routine hemorrhoidal care, infrared coagulation of internal hemorrhoids might be considered.
Electrophysiology Lab Procedure MT Sample Reports
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Diagnostic electrophysiology study.
SURGEON: John Doe, MD
REFERRING DOCTOR: Jane Doe, MD
INDICATIONS:
1. Recurrent, unexplained syncope.
2. Coronary artery disease.
3. Left ventricular systolic dysfunction (LVEF=15%).
SEDATION: Versed (2 mg), fentanyl (100 mcg) and propofol (250 mg).
SHEATHS: Two French 4 inch vascular sheath inserted within the right femoral vein using modified Seldinger technique.
CATHETERS: Two 5 mm interelectrode spacing, intracardiac pacer/coronary catheter advanced via the right femoral venous sheath and positioned within atrium, AV junction, right ventricular apex and right ventricular outflow tract under fluoroscopic guidance.
FINDINGS:
1. Baseline sinus rhythm with markedly prolonged HV interval in the setting of underlying interventricular conduction delay.
A. Sinus cycle length=700 milliseconds.
B. AH interval=90 milliseconds.
C. HV interval=110 milliseconds.
2. Normal sinus node function.
A. Baseline SCL=700 milliseconds.
B. Maximum CSNRT=450 milliseconds.
3. Normal AV nodal conduction.
A. Wenckebach cycle length=480 milliseconds.
B. AV nodal ERP=600/390.
4. Right atrial effective refractory=600/230.
5. Markedly abnormal His-Purkinje system conduction (baseline HV interval=110 milliseconds).
6. Right ventricular effective refractory.
A. Right ventricular apex=600/310, 400/310.
7. No inducible nonsustained or sustained ventricular tachyarrhythmias observed with right ventricular programmed electrical stimulation delivered at two RV patient sites in the setting of chronic procainamide therapy (Procan SR 500 mg q.i.d.), using:
A. One to three premature stimulations following two drive cycles (600, 400 milliseconds).
B. Rapid ventricular burst pacing (PCL=400-240 milliseconds).
8. No evidence for carotid sinus hypersensitivity with either right or left-sided carotid sinus massage.
Upon completion of the procedure, all catheters and sheaths removed and adequate hemostasis was achieved using manual compression. The patient was subsequently transferred to the stretcher and returned to the cardiac catheterization laboratory area in stable condition.
COMPLICATIONS: None.
IMPRESSION:
1. Normal sinus rhythm function.
2. Normal AV nodal conduction.
3. No evidence for carotid sinus hypersensitivity.
4. Markedly abnormal His-Purkinje system conduction (in the setting of longstanding procainamide therapy and underlying interventricular conduction delay manifested on surface ECG).
5. No inducible ventricular tachyarrhythmias with right ventricular programmed electrical stimulation (in the setting of chronic procainamide therapy).
RECOMMENDATION: Consider future pacemaker implantation +/- additional cardiac resynchronization therapy, given history of recurrent syncope in the setting of severe conduction system disease and required antiarrhythmic drug therapy, +/- additional cardiac resynchronization therapy given refractory NYHA class III CHF symptoms (despite optimized medical therapy) versus biventricular cardiac defibrillator implantation despite lack of inducible ventricular tachyarrhythmias, given possible false and negative results related to ongoing antiarrhythmic drug therapy in accordance with recent COMPANION and SCD-HeFT trial results supporting prophylactic biventricular cardiac defibrillator implantation among subjects with severe cardiomyopathy, moderate-severe cardiomyopathy (LVEF <35%), moderate-severe congestive heart failure (refractory medical therapy), and widened surface QRS (QRS duration >130 milliseconds.)
Electrophysiology Sample Reports Cardiac Cath Sample Report
PROCEDURE PERFORMED: Diagnostic electrophysiology study.
SURGEON: John Doe, MD
REFERRING DOCTOR: Jane Doe, MD
INDICATIONS:
1. Recurrent, unexplained syncope.
2. Coronary artery disease.
3. Left ventricular systolic dysfunction (LVEF=15%).
SEDATION: Versed (2 mg), fentanyl (100 mcg) and propofol (250 mg).
SHEATHS: Two French 4 inch vascular sheath inserted within the right femoral vein using modified Seldinger technique.
CATHETERS: Two 5 mm interelectrode spacing, intracardiac pacer/coronary catheter advanced via the right femoral venous sheath and positioned within atrium, AV junction, right ventricular apex and right ventricular outflow tract under fluoroscopic guidance.
FINDINGS:
1. Baseline sinus rhythm with markedly prolonged HV interval in the setting of underlying interventricular conduction delay.
A. Sinus cycle length=700 milliseconds.
B. AH interval=90 milliseconds.
C. HV interval=110 milliseconds.
2. Normal sinus node function.
A. Baseline SCL=700 milliseconds.
B. Maximum CSNRT=450 milliseconds.
3. Normal AV nodal conduction.
A. Wenckebach cycle length=480 milliseconds.
B. AV nodal ERP=600/390.
4. Right atrial effective refractory=600/230.
5. Markedly abnormal His-Purkinje system conduction (baseline HV interval=110 milliseconds).
6. Right ventricular effective refractory.
A. Right ventricular apex=600/310, 400/310.
7. No inducible nonsustained or sustained ventricular tachyarrhythmias observed with right ventricular programmed electrical stimulation delivered at two RV patient sites in the setting of chronic procainamide therapy (Procan SR 500 mg q.i.d.), using:
A. One to three premature stimulations following two drive cycles (600, 400 milliseconds).
B. Rapid ventricular burst pacing (PCL=400-240 milliseconds).
8. No evidence for carotid sinus hypersensitivity with either right or left-sided carotid sinus massage.
Upon completion of the procedure, all catheters and sheaths removed and adequate hemostasis was achieved using manual compression. The patient was subsequently transferred to the stretcher and returned to the cardiac catheterization laboratory area in stable condition.
COMPLICATIONS: None.
IMPRESSION:
1. Normal sinus rhythm function.
2. Normal AV nodal conduction.
3. No evidence for carotid sinus hypersensitivity.
4. Markedly abnormal His-Purkinje system conduction (in the setting of longstanding procainamide therapy and underlying interventricular conduction delay manifested on surface ECG).
5. No inducible ventricular tachyarrhythmias with right ventricular programmed electrical stimulation (in the setting of chronic procainamide therapy).
RECOMMENDATION: Consider future pacemaker implantation +/- additional cardiac resynchronization therapy, given history of recurrent syncope in the setting of severe conduction system disease and required antiarrhythmic drug therapy, +/- additional cardiac resynchronization therapy given refractory NYHA class III CHF symptoms (despite optimized medical therapy) versus biventricular cardiac defibrillator implantation despite lack of inducible ventricular tachyarrhythmias, given possible false and negative results related to ongoing antiarrhythmic drug therapy in accordance with recent COMPANION and SCD-HeFT trial results supporting prophylactic biventricular cardiac defibrillator implantation among subjects with severe cardiomyopathy, moderate-severe cardiomyopathy (LVEF <35%), moderate-severe congestive heart failure (refractory medical therapy), and widened surface QRS (QRS duration >130 milliseconds.)
Electrophysiology Sample Reports Cardiac Cath Sample Report
How To Search Using Google - Some Tips
We, as medical transcriptionists, use Google all the time. We use it to search for words dictated by doctors. These words can be medical words, drug names, doctor names, hospital names, lab terms, etc. As medical transcriptionists, it is vital that you find the word you are looking for quickly. The quicker you find the word you are looking for, the quicker you can complete your file and move on to the next. You can therefore increase your productivity if you are able to research words faster. If you use Google, like I do, there are a number of handy operators you can use to get to what you are looking for faster. You may know some of them, but not all. Let me briefly explain!!
A. If you just enter the words surgical fixation in the Google search box and search - Google would show all webpages containing both words, i.e. surgical and fixation but it might not show both terms together or in any particular order.
B. Now, let's see how the usage of quotes changes things. The words are the same, i.e. surgical fixation --- however you would input the words in this fashion "surgical fixation" Note, the usage of quotes. For this query, Google would show all pages that contain both words, BUT in this instance, the two words would display together and in the same order as the query.
C. Following from the above example, you can also use the * operator to search for unknown words. Take this example. "open * surgery" In this case, the words open and surgery are clear, but you know that there is a word in between that you cannot listen to clearly.
If you input the query "open * surgery" in Google using quotes as shown, Google would show you all webpages containing words open and heart and any words in between both. For instance, "open heart surgery" "open rhinoplasty surgery," etc.
D. Now, let's come to the + operator. Let's say Google is ignoring a particular term when you search for a phrase (for example). This can sometimes happen. You want results with that word included, but Google just wouldn't show you those results. With the use of the + operator, you can force Google to include that particular term in the search results. You do so by putting a '+' sign along with the word.
For example, +heparin (note that there is no space between the '+' sign and the word.
E. The - operator works in a similar fashion. It does the exact opposite of the + operator mentioned above. If you find that Google results are showing up a term that you don't want it to show, just precede the word with the '-' operator. For example, -heparin (again, note that there is no space between the '-' search operator and the word).
F. Next is the 'OR' operator. Say, for example, you search using the search query surgery OR hernia, you would find pages that contain the words "surgery" or "hernia" or both words, but not webpages that contain neither “surgery” nor “hernia.”
There are some other operators as well, but the ones mentioned above are the more important ones every MT should know!
For additional search operators and their functions, you can follow this link. The "define" operator mentioned there is yet another useful search operator.
http://hubpages.com/hub/Google-Search-Tips-For-More-Efficient-Searches
A. If you just enter the words surgical fixation in the Google search box and search - Google would show all webpages containing both words, i.e. surgical and fixation but it might not show both terms together or in any particular order.
B. Now, let's see how the usage of quotes changes things. The words are the same, i.e. surgical fixation --- however you would input the words in this fashion "surgical fixation" Note, the usage of quotes. For this query, Google would show all pages that contain both words, BUT in this instance, the two words would display together and in the same order as the query.
C. Following from the above example, you can also use the * operator to search for unknown words. Take this example. "open * surgery" In this case, the words open and surgery are clear, but you know that there is a word in between that you cannot listen to clearly.
If you input the query "open * surgery" in Google using quotes as shown, Google would show you all webpages containing words open and heart and any words in between both. For instance, "open heart surgery" "open rhinoplasty surgery," etc.
D. Now, let's come to the + operator. Let's say Google is ignoring a particular term when you search for a phrase (for example). This can sometimes happen. You want results with that word included, but Google just wouldn't show you those results. With the use of the + operator, you can force Google to include that particular term in the search results. You do so by putting a '+' sign along with the word.
For example, +heparin (note that there is no space between the '+' sign and the word.
E. The - operator works in a similar fashion. It does the exact opposite of the + operator mentioned above. If you find that Google results are showing up a term that you don't want it to show, just precede the word with the '-' operator. For example, -heparin (again, note that there is no space between the '-' search operator and the word).
F. Next is the 'OR' operator. Say, for example, you search using the search query surgery OR hernia, you would find pages that contain the words "surgery" or "hernia" or both words, but not webpages that contain neither “surgery” nor “hernia.”
There are some other operators as well, but the ones mentioned above are the more important ones every MT should know!
For additional search operators and their functions, you can follow this link. The "define" operator mentioned there is yet another useful search operator.
http://hubpages.com/hub/Google-Search-Tips-For-More-Efficient-Searches
Urology Medical Transcription Procedure Sample Reports
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, and irritative/obstructive urinary bladder symptoms.
POSTOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, irritative/obstructive urinary bladder symptoms, hemorrhagic cystitis, right distal ureteritis, no evidence of gross right ureteropelvic junction obstruction, right pyelocaliectasis, female urethral syndrome with subacute interstitial cystitis, mild leukoplakia, and severe trigonitis.
PROCEDURES PERFORMED: Urethral calibration, dilatation, right diagnostic ureteroscopy with transureteroscopic fulguration of all right distal ureteric bleeding points, retrograde pyelogram, hydrodistention, hydrodilation of urinary bladder, transurethral fulguration of all bleeders, especially trigone region.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female referred because of right hydronephrosis, right renal colic with hematuria plus irritative/obstructive bladder symptoms. Evaluation showed the above findings. Options were offered to the patient, of which she agrees to undergo the above-mentioned procedure. General information, alternatives and risks were explained to the patient. The patient understands and agrees to undergo the above-mentioned procedure.
PROCEDURE IN DETAIL: The patient was brought to the cystoscopy suite. General anesthesia was then given. The patient was then placed in the dorsal lithotomy position. The patient was then scrubbed, prepped and draped in the usual sterile manner. General evaluation showed grade 1 cystocele with urethral meatal stenosis, calibrated at French #10 and #12. Urethral meatal opening was progressively dilated to French #20, #22 and #24 using the female urethral sounds. Then passed a #22 French cystourethroscope instrument into the female urethra, into the bladder, showing acute female urethritis, mild leukoplakia, severe trigonitis. Classic picture of interstitial cystitis changes were observed, including ulceration, glomerulation, submucosal hemorrhages and petechia. The right ureteric orifice was found to be gaping and hemorrhagic.
At this point in time, ureteroscopic evaluation was carried out showing evidence of subacute right distal ureteritis with bleeding hemorrhagic lesions. There was no gross obstructive uropathy, no gross evidence of ureteric stricture or evidence of gross obstructive stricture formation involving the right ureteropelvic junction. There was mild pyelocaliectasis as confirmed by a right retrograde ureteropyelogram study that was performed. There were no complications during the ureteroscopic evaluation such as ureteric rupture, ureteric bleeding or evidence of urinary extravasation. From the retrograde study, we diverted our attention to the interstitial cystitis. Hydrodistention, hydrodilation of the urinary bladder was then carried out to a maximum bladder capacity of approximately 425 mL x2 cycles. During this maximum bladder filling, all bleeding points, especially in the trigone region, were electrocoagulated and fulgurated. Satisfactory hemostasis was then initiated and completed.
The procedure was terminated, bladder decompressed and the scope was then withdrawn. The patient was then transferred to the recovery room in satisfactory condition. Postoperative orders were given.
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Right extracorporeal shock-wave lithotripsy.
SURGEON: John Doe, MD
ANESTHESIA: General.
CHIEF COMPLAINT: Right renal stones.
INDICATION FOR PROCEDURE: This patient is a (XX)-year-old woman who presented with a 1 cm obstructing right ureteral stone with urosepsis. The stone was pushed back into the kidney and the kidney drained with a stent. She went on to obtain successful antibiotic therapy and now returns for definitive stone treatment.
OPERATIVE FINDINGS: Two stones, each one approximately 1 cm in the right kidney, both of which were fragmented adequately with shock-wave lithotripsy.
PROCEDURE FINDINGS AND DETAILS OF PROCEDURE: After the patient obtained adequate general anesthesia, she was placed in supine position on the lithotripsy table. Using fluoroscopic guidance, the stone in the renal pelvis, which had been the obstructing stone, was placed at the focal point of the shock waves. A total of 1500 shocks were delivered with excellent fragmentation.
The patient subsequently manipulated so that the lower pole of stone, also approximately 1 cm, was identified and placed at the focal point of the shock waves. Another 1500 shocks were delivered to this, once again with excellent fragmentation. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, and irritative/obstructive urinary bladder symptoms.
POSTOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, irritative/obstructive urinary bladder symptoms, hemorrhagic cystitis, right distal ureteritis, no evidence of gross right ureteropelvic junction obstruction, right pyelocaliectasis, female urethral syndrome with subacute interstitial cystitis, mild leukoplakia, and severe trigonitis.
PROCEDURES PERFORMED: Urethral calibration, dilatation, right diagnostic ureteroscopy with transureteroscopic fulguration of all right distal ureteric bleeding points, retrograde pyelogram, hydrodistention, hydrodilation of urinary bladder, transurethral fulguration of all bleeders, especially trigone region.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female referred because of right hydronephrosis, right renal colic with hematuria plus irritative/obstructive bladder symptoms. Evaluation showed the above findings. Options were offered to the patient, of which she agrees to undergo the above-mentioned procedure. General information, alternatives and risks were explained to the patient. The patient understands and agrees to undergo the above-mentioned procedure.
PROCEDURE IN DETAIL: The patient was brought to the cystoscopy suite. General anesthesia was then given. The patient was then placed in the dorsal lithotomy position. The patient was then scrubbed, prepped and draped in the usual sterile manner. General evaluation showed grade 1 cystocele with urethral meatal stenosis, calibrated at French #10 and #12. Urethral meatal opening was progressively dilated to French #20, #22 and #24 using the female urethral sounds. Then passed a #22 French cystourethroscope instrument into the female urethra, into the bladder, showing acute female urethritis, mild leukoplakia, severe trigonitis. Classic picture of interstitial cystitis changes were observed, including ulceration, glomerulation, submucosal hemorrhages and petechia. The right ureteric orifice was found to be gaping and hemorrhagic.
At this point in time, ureteroscopic evaluation was carried out showing evidence of subacute right distal ureteritis with bleeding hemorrhagic lesions. There was no gross obstructive uropathy, no gross evidence of ureteric stricture or evidence of gross obstructive stricture formation involving the right ureteropelvic junction. There was mild pyelocaliectasis as confirmed by a right retrograde ureteropyelogram study that was performed. There were no complications during the ureteroscopic evaluation such as ureteric rupture, ureteric bleeding or evidence of urinary extravasation. From the retrograde study, we diverted our attention to the interstitial cystitis. Hydrodistention, hydrodilation of the urinary bladder was then carried out to a maximum bladder capacity of approximately 425 mL x2 cycles. During this maximum bladder filling, all bleeding points, especially in the trigone region, were electrocoagulated and fulgurated. Satisfactory hemostasis was then initiated and completed.
The procedure was terminated, bladder decompressed and the scope was then withdrawn. The patient was then transferred to the recovery room in satisfactory condition. Postoperative orders were given.
DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Right extracorporeal shock-wave lithotripsy.
SURGEON: John Doe, MD
ANESTHESIA: General.
CHIEF COMPLAINT: Right renal stones.
INDICATION FOR PROCEDURE: This patient is a (XX)-year-old woman who presented with a 1 cm obstructing right ureteral stone with urosepsis. The stone was pushed back into the kidney and the kidney drained with a stent. She went on to obtain successful antibiotic therapy and now returns for definitive stone treatment.
OPERATIVE FINDINGS: Two stones, each one approximately 1 cm in the right kidney, both of which were fragmented adequately with shock-wave lithotripsy.
PROCEDURE FINDINGS AND DETAILS OF PROCEDURE: After the patient obtained adequate general anesthesia, she was placed in supine position on the lithotripsy table. Using fluoroscopic guidance, the stone in the renal pelvis, which had been the obstructing stone, was placed at the focal point of the shock waves. A total of 1500 shocks were delivered with excellent fragmentation.
The patient subsequently manipulated so that the lower pole of stone, also approximately 1 cm, was identified and placed at the focal point of the shock waves. Another 1500 shocks were delivered to this, once again with excellent fragmentation. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.
MRA Carotid Arteries and MRI Head MT Sample Report
MRA OF THE CAROTID ARTERIES
CLINICAL HISTORY: Headache, neck pain and jaw pain.
TECHNIQUE AND FINDINGS: Multiple time-of-flight images were obtained through both carotid arteries. Images through the right side show wide patency. No indication of any stenosis. No findings to suggest dissection. Images through the left side bifurcation also show wide patency, again without evidence of stenosis or dissection. The vertebral arteries show relatively symmetric appearance with no particular dominance.
IMPRESSION: Unremarkable examination of each carotid artery without findings of any specific stenosis or dissection. Normal appearance through the vertebral arteries as well without particular dominance.
MRI SCAN OF THE HEAD WITHOUT CONTRAST
TECHNIQUE AND FINDINGS: Multiplanar sagittal and axial images were obtained through the brain without contrast administration. Sagittal images show normal level of the craniocervical junction. The ventricles and sulci are normal in appearance. No clear indication of any specific midline shift. No mass effect demonstrated. Basal cisterns are still well visualized. Structures of the posterior fossa are unremarkable.
IMPRESSION: Unremarkable intracranial examination. No findings of any contained mass or midline shift. Normal appearance of the ventricles and sulci. Structures of the posterior fossa are unremarkable as well.
MRA OF THE CAROTID ARTERIES WITH CONTRAST:
INDICATION FOR STUDY: Status post CVA.
TECHNIQUE AND FINDINGS: Raw data and composite images were available. A 2D time-of-flight study was performed. The left vertebral artery is much larger than that of the right and clearly dominant. There is some narrowing of the right vertebral artery compared to the left. The left internal carotid artery is slightly narrowed compared with that of the right suggestive of some mild to moderate stenosis. There is no severe stenosis. There is no alteration. The left ICA/ECA complex is slightly splayed compared with that of the right. There is no obvious mass seen on the raw data. This may be congenital anomaly or some tortuosity.
IMPRESSION:
1. The left vertebral artery is dominant compared with that of the right, as the right is more narrowed.
2. The internal carotid arteries are minimally narrowed more in the left than the right. This is suggestive of some mild to moderate stenosis. There is no severe narrowing. There is no alteration.
3. The left internal carotid artery/external carotid artery complex is slightly splayed compared with that on the right. We do not see a discrete mass on the raw data. This may be some atherosclerosis, some tortuosity, or congenital asymmetry.
4. If clinically warranted, carotid Doppler ultrasound could be obtained to confirm the mild to moderate stenosis in the carotid artery system, more in the left than the right.
MRI OF THE HEAD WITH CONTRAST ONLY:
This is a followup from the MRI of the head without contrast dated MM/DD/YYYY.
INDICATION FOR STUDY: Questionable neurofibromatosis.
TECHNIQUE AND FINDINGS: Images were taken in the coronal and axial planes through the posterior fossa and the orbital regions following contrast administration.
There is no evidence of an acoustic neuroma or other pathology in the IAC or CP angle regions.
In the orbital areas, we see no evidence of asymmetric uptake within the optic nerves to indicate a glioma or other pathology. There is no abnormal uptake seen with contrast throughout this study.
IMPRESSION: No abnormal findings with contrast to indicate neurofibromatosis or associated tumors in the area of the orbital regions or the posterior fossa. Also, images taken through the entire head without any contrast administration showed no remarkable pathology as well.
MRI OF THE HEAD WITHOUT CONTRAST:
Multiplanar images were obtained without contrast. The ventricles are symmetric. There is no mass, mass effect, or shift of midline structures. The region of the pituitary gland is unremarkable. The IACs are symmetric. The recti muscles are symmetric and unremarkable. Optic nerves are unremarkable. There is some incidental right maxillary mucosal thickening versus polyp versus mucus retention cyst. Craniocervical junction is within normal limits.
IMPRESSION:
1. Incidental ovoid area of high signal in the right maxillary sinus on T2 weighted sequences. This could be a mucus retention cyst, polyp, focal mucosal thickening.
2. No other focal lesion is identified. There is no mass or mass effect. The recti muscles are symmetric and unremarkable.
CLINICAL HISTORY: Headache, neck pain and jaw pain.
TECHNIQUE AND FINDINGS: Multiple time-of-flight images were obtained through both carotid arteries. Images through the right side show wide patency. No indication of any stenosis. No findings to suggest dissection. Images through the left side bifurcation also show wide patency, again without evidence of stenosis or dissection. The vertebral arteries show relatively symmetric appearance with no particular dominance.
IMPRESSION: Unremarkable examination of each carotid artery without findings of any specific stenosis or dissection. Normal appearance through the vertebral arteries as well without particular dominance.
MRI SCAN OF THE HEAD WITHOUT CONTRAST
TECHNIQUE AND FINDINGS: Multiplanar sagittal and axial images were obtained through the brain without contrast administration. Sagittal images show normal level of the craniocervical junction. The ventricles and sulci are normal in appearance. No clear indication of any specific midline shift. No mass effect demonstrated. Basal cisterns are still well visualized. Structures of the posterior fossa are unremarkable.
IMPRESSION: Unremarkable intracranial examination. No findings of any contained mass or midline shift. Normal appearance of the ventricles and sulci. Structures of the posterior fossa are unremarkable as well.
MRA OF THE CAROTID ARTERIES WITH CONTRAST:
INDICATION FOR STUDY: Status post CVA.
TECHNIQUE AND FINDINGS: Raw data and composite images were available. A 2D time-of-flight study was performed. The left vertebral artery is much larger than that of the right and clearly dominant. There is some narrowing of the right vertebral artery compared to the left. The left internal carotid artery is slightly narrowed compared with that of the right suggestive of some mild to moderate stenosis. There is no severe stenosis. There is no alteration. The left ICA/ECA complex is slightly splayed compared with that of the right. There is no obvious mass seen on the raw data. This may be congenital anomaly or some tortuosity.
IMPRESSION:
1. The left vertebral artery is dominant compared with that of the right, as the right is more narrowed.
2. The internal carotid arteries are minimally narrowed more in the left than the right. This is suggestive of some mild to moderate stenosis. There is no severe narrowing. There is no alteration.
3. The left internal carotid artery/external carotid artery complex is slightly splayed compared with that on the right. We do not see a discrete mass on the raw data. This may be some atherosclerosis, some tortuosity, or congenital asymmetry.
4. If clinically warranted, carotid Doppler ultrasound could be obtained to confirm the mild to moderate stenosis in the carotid artery system, more in the left than the right.
MRI OF THE HEAD WITH CONTRAST ONLY:
This is a followup from the MRI of the head without contrast dated MM/DD/YYYY.
INDICATION FOR STUDY: Questionable neurofibromatosis.
TECHNIQUE AND FINDINGS: Images were taken in the coronal and axial planes through the posterior fossa and the orbital regions following contrast administration.
There is no evidence of an acoustic neuroma or other pathology in the IAC or CP angle regions.
In the orbital areas, we see no evidence of asymmetric uptake within the optic nerves to indicate a glioma or other pathology. There is no abnormal uptake seen with contrast throughout this study.
IMPRESSION: No abnormal findings with contrast to indicate neurofibromatosis or associated tumors in the area of the orbital regions or the posterior fossa. Also, images taken through the entire head without any contrast administration showed no remarkable pathology as well.
MRI OF THE HEAD WITHOUT CONTRAST:
Multiplanar images were obtained without contrast. The ventricles are symmetric. There is no mass, mass effect, or shift of midline structures. The region of the pituitary gland is unremarkable. The IACs are symmetric. The recti muscles are symmetric and unremarkable. Optic nerves are unremarkable. There is some incidental right maxillary mucosal thickening versus polyp versus mucus retention cyst. Craniocervical junction is within normal limits.
IMPRESSION:
1. Incidental ovoid area of high signal in the right maxillary sinus on T2 weighted sequences. This could be a mucus retention cyst, polyp, focal mucosal thickening.
2. No other focal lesion is identified. There is no mass or mass effect. The recti muscles are symmetric and unremarkable.
MRI Medical Transcription Dictation Sample Report
LUMBAR SPINE MRI WITHOUT CONTRAST
CLINICAL HISTORY: History of back pain. No history of prior surgery.
TECHNIQUE AND FINDINGS: Multiplanar sagittal and axial images were obtained through the lumbar spine without contrast administration. Sagittal images indicate what appears to be congenital, blocked fusion involving the L1-L2 and L3-L4 levels. Cord terminates appropriately at the L1 level.
L5-S1: Desiccation and some disc space narrowing. Cross-sectional images indicate severe stenosis due to the facet arthropathy, ligamentum flavum hypertrophy and diffuse disc bulge. Small triangular configuration of the remaining thecal sac again indicating significant stenosis.
L4-L5: Significant disc space narrowing and endplate changes. This is no doubt compounded by what appears to be the congenital fusion, in which the adjacent endplates show advanced degenerative changes. Cross-sectional images again show significant severe stenosis in part due to the diffuse disc bulge, flavum hypertrophy and facet arthropathy. Very small residual remaining thecal sac noted.
L3-L4: No indication of any significant stenosis. Again, this level is probably congenitally fused.
L2-L3: Significant disc space narrowing with moderate diffuse disc bulge. Some flavum hypertrophy and facet arthropathy. This gives rise to a moderate stenosis.
L1-L2: Again, congenital fusion most likely. No significant stenosis at this level.
IMPRESSION: Probable congenital fusion with blocked vertebrae involving L1-L2 and L3-L4. As a result, the adjacent disc spaces show advanced degenerative changes. L5-S1 shows severe stenosis as a result of the combination of epidural diffuse disc bulge, facet arthropathy and flavum hypertrophy. Severe stenosis involving L4-L5 as well. Moderate stenosis involving L2-L3.
THORACIC SPINE MRI:
The thoracic spine shows the vertebral bodies to be grossly intact. They are of normal height and contour. There is no lytic or blastic disease or evidence of partial or complete fracture or contusion seen. The sagittal images show the pedicles to be intact as well.
There is no evidence of significant focal disc disease. No evidence of a disc herniation or large extra-axial mass, which is compressing the cord on this exam.
Some axial images were taken from T6 through T9 and do not show focal disc or neural foraminal disease.
The cord is intact throughout the thoracic spine.
IMPRESSION: No bone contusion or fractures noted. No cord or neural foraminal compromise is seen. No significant focal disc disease is noted.
CLINICAL HISTORY: History of back pain. No history of prior surgery.
TECHNIQUE AND FINDINGS: Multiplanar sagittal and axial images were obtained through the lumbar spine without contrast administration. Sagittal images indicate what appears to be congenital, blocked fusion involving the L1-L2 and L3-L4 levels. Cord terminates appropriately at the L1 level.
L5-S1: Desiccation and some disc space narrowing. Cross-sectional images indicate severe stenosis due to the facet arthropathy, ligamentum flavum hypertrophy and diffuse disc bulge. Small triangular configuration of the remaining thecal sac again indicating significant stenosis.
L4-L5: Significant disc space narrowing and endplate changes. This is no doubt compounded by what appears to be the congenital fusion, in which the adjacent endplates show advanced degenerative changes. Cross-sectional images again show significant severe stenosis in part due to the diffuse disc bulge, flavum hypertrophy and facet arthropathy. Very small residual remaining thecal sac noted.
L3-L4: No indication of any significant stenosis. Again, this level is probably congenitally fused.
L2-L3: Significant disc space narrowing with moderate diffuse disc bulge. Some flavum hypertrophy and facet arthropathy. This gives rise to a moderate stenosis.
L1-L2: Again, congenital fusion most likely. No significant stenosis at this level.
IMPRESSION: Probable congenital fusion with blocked vertebrae involving L1-L2 and L3-L4. As a result, the adjacent disc spaces show advanced degenerative changes. L5-S1 shows severe stenosis as a result of the combination of epidural diffuse disc bulge, facet arthropathy and flavum hypertrophy. Severe stenosis involving L4-L5 as well. Moderate stenosis involving L2-L3.
THORACIC SPINE MRI:
The thoracic spine shows the vertebral bodies to be grossly intact. They are of normal height and contour. There is no lytic or blastic disease or evidence of partial or complete fracture or contusion seen. The sagittal images show the pedicles to be intact as well.
There is no evidence of significant focal disc disease. No evidence of a disc herniation or large extra-axial mass, which is compressing the cord on this exam.
Some axial images were taken from T6 through T9 and do not show focal disc or neural foraminal disease.
The cord is intact throughout the thoracic spine.
IMPRESSION: No bone contusion or fractures noted. No cord or neural foraminal compromise is seen. No significant focal disc disease is noted.
MRI OF THE RIGHT KNEE:
HISTORY: Possible meniscal tear. Lateral pain.
Multiplanar images were obtained. The ACL and PCL are both intact. The collateral ligaments are intact. The marrow signal within the bony structures is unremarkable. There is some suprapatellar joint fluid, more lateral than medial. There is some fluid anterior and lateral to the ACL and minimally posteriorly to the PCL. The menisci are intact. There is some globular increased signal in the posterior horn of the medial meniscus suggestive of degenerative type change. There is no discrete linear area of signal that touches upon the articular surface to suggest an acute tear.
IMPRESSION:
1. Collateral ligaments, cruciate ligaments, the menisci are all intact.
2. There is a suprapatellar joint effusion as well as some fluid anterior and lateral to the anterior cruciate ligament as well as posterior to the posterior cruciate ligament.
3. No other focal abnormality is appreciated.
MRI OF THE BRAIN WITHOUT CONTRAST:
HISTORY: Right neck and right parietal pain. Recent episode of amnesia.
Routine images of the brain show, on the FLAIR images, small foci of high signal indicating some probable white matter demyelination just lateral to the mid section of the right lateral ventricle, in the area of the anterior parietal region. T2 weighted imaging show no significant edema in this area. No effacement of any of the sulci. There is no mass effect or midline shift. These three to four small white matter areas of change may represent demyelination from ischemic insult. There is one or two very small, approximately 2 mm areas of abnormal high signal just lateral to the left anterior lateral ventricle region in the posterior frontal lobe area.
There is no evidence of a mass or mass effect on this examination. No abnormal extra-axial fluid collections are seen.
The brain stem is intact. Craniocervical junction is within normal limits.
IMPRESSION:
1. Several small white matter lesions are seen involving the right anterior parietal region just lateral to the lateral ventricle and two small white matter lesions just lateral to the left anterior lateral ventricle. These reside in the posterior frontal lobe area. There is no significant edema around any of these at this time. No effacement of the sulci is present. These are mostly likely the sequela of vascular insult.
2. No other significant findings are present.
Google for MTs and Other Useful MT Search Engines
Customized search engines are search engines that cater to the specific needs of certain individuals or groups. We, as medical transcriptionists, basically research words via a search engine such as Google. However, since Google searches all available websites on the web, the search results you get from a general search engine might not be relevant to your query. Hence, the need for a custom search engine that searches primarily across medical sites (in the case of a medical transcriptionist).
One such search engine is called "Medical Transcription Word Seeker." It is also known to medical transcriptionists as "MT Google" or "Google MT" or "Google for MTs" or "Google search for MTs."
This is a Google custom search engine just for medical transcriptionists. It searches only websites that focus on medical and medical transcription data. Here's the direct link to this custom search engine for MTs.
Google search for MTs
Another custom search engine is "Doctor Finder Search Engine." This custom search engine, as the name suggests, searches across just doc finder / hospital finder websites to get you doc / hospital names that you may be searching for. You can use search quotes and wildcards to find docs. A typical search query might look like,
"* Smith, MD * OH" - if you are looking for a "Dr. Smith" in Ohio, but aren't sure of his/her first name
If you have additional information like the department the doc is from, you can add that to the query and it may now look like this,
"* Smith, MD * OH" Cardiology
If you don't know the name of the doc at all, or can't spell out the name, you may search using a query like this,
"*, MD * OH" cardiology - this search would return results with all doctors who are cardiologists from Ohio
You can switch from using "MD" to "DO" as your credentials - if you don't find any results with "MD"
This custom search engine can be found here,
Doc Finder Custom Search Engine
There are other similar custom search engines created just for MTs. You may find some more custom-made Google search engines on this site,
MT Word Help
One such search engine is called "Medical Transcription Word Seeker." It is also known to medical transcriptionists as "MT Google" or "Google MT" or "Google for MTs" or "Google search for MTs."
This is a Google custom search engine just for medical transcriptionists. It searches only websites that focus on medical and medical transcription data. Here's the direct link to this custom search engine for MTs.
Google search for MTs
Another custom search engine is "Doctor Finder Search Engine." This custom search engine, as the name suggests, searches across just doc finder / hospital finder websites to get you doc / hospital names that you may be searching for. You can use search quotes and wildcards to find docs. A typical search query might look like,
"* Smith, MD * OH" - if you are looking for a "Dr. Smith" in Ohio, but aren't sure of his/her first name
If you have additional information like the department the doc is from, you can add that to the query and it may now look like this,
"* Smith, MD * OH" Cardiology
If you don't know the name of the doc at all, or can't spell out the name, you may search using a query like this,
"*, MD * OH" cardiology - this search would return results with all doctors who are cardiologists from Ohio
You can switch from using "MD" to "DO" as your credentials - if you don't find any results with "MD"
This custom search engine can be found here,
Doc Finder Custom Search Engine
There are other similar custom search engines created just for MTs. You may find some more custom-made Google search engines on this site,
MT Word Help
Discharge Summary Dictation MT Sample Report
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING PHYSICIAN: John Doe, MD
DISCHARGING PHYSICIAN: Jane Doe, MD
ADMITTING DIAGNOSES:
1. Angina.
2. Diabetes mellitus.
3. Hypertension.
4. Hyperlipidemia.
5. Obstructive sleep apnea.
DISCHARGE DIAGNOSES:
1. Chest pain, myocardial infarction ruled out.
2. Hypertension.
3. Diabetes mellitus.
4. Hyperlipidemia.
5. Morbid obesity with obstructive sleep apnea.
6. Depression.
7. Hyperkalemia.
CONSULTANT: Jack Doe, MD
OPERATIONS AND PROCEDURES: Attempted left heart catheterization, left ventriculography and selective coronary angiography.
LABORATORIES AND X-RAYS: HEMGPD, WBC 9.7, hemoglobin 13.4, hematocrit 39.4, platelet count 246,000, neutrophils 70 and bands 0. Prothrombin time 10.2, INR 1.36, aPTT 26.4, D-Dimer less than 0.21. HEMGPD, sodium 135, potassium 5.1, chloride 98, CO2 of 22, glucose 145, BUN 32, creatinine 1.1, calcium 11.2, total protein 7.7, total bilirubin 0.2, alkaline phosphate 47, ALT 46, AST 32, magnesium 2, CK 70, CK-MB 3.3, and troponin I less than 0.3. HDL 32, LDL 83, VLDL 58, triglycerides 291, and cholesterol 173. Chest x-ray, only moderately well inflated lung fields without evidence of alveolar filling.
BRIEF HISTORY AND PHYSICAL: The patient is a (XX)-year-old male who complained of having chest pain, which was relieved with rest, poorly localized and provoked by stress.
PHYSICAL EXAMINATION: On admission, temperature 98.9 degrees Fahrenheit, pulse rate 90 per minute, respirations 24 per minute, and blood pressure 137/68. Constitutional: The patient is morbidly obese. Respiratory: Decreased breath sounds. Cardiovascular: S1, S2 distant. Abdomen: Nontender, morbidly obese.
HOSPITAL COURSE:
1. Chest pain, rule out MI. On (mm dd, yyyy), the patient was admitted to a monitored bed and chest pain protocol was started. Serial cardiac enzymes were done, which were all negative. Cardiology, Dr. Doe, was consulted who saw the patient and planned to do cardiac catheterization due to recurrence of atypical chest pain. The patient signed the consent after the procedures and alternatives were discussed with him by the cardiologist. However, in the catheterization lab, the patient was belligerent, abusive and uncooperative with the staff and eventually he requested that the procedure be terminated. Thus, the cardiac catheterization procedure was never done. On (mm dd, yyyy), the patient was not complaining of any chest pain and no shortness of breath. He was transferred to a skilled nursing facility. Vital signs stable on discharge.
2. Hypertension. During this hospital stay, the patient's blood pressure was well controlled with antihypertensive medications with only one occasion of having a blood pressure of 147/81. On discharge, the patient's blood pressure was 131/64.
3. Diabetes mellitus. Accu-Cheks and sliding scale with NovoLog insulin subcutaneously were ordered. The patient also self-injected his insulin with Novolin N 100 units subcutaneously t.i.d. and Novolin R 100 units subcutaneously t.i.d. The patient was initially placed on metformin 500 mg p.o. t.i.d. on (mm dd, yyyy), and this was discontinued on (mm dd, yyyy), since the patient is going for the cardiac catheterization and creatinine level increased to 1.8 from the initial 1.1. The patient was given Mucomyst 600 mg p.o. prior to the scheduled cardiac catheterization.
4. Hyperlipidemia. The patient was placed on Lipitor as well as Lopid.
5. Morbid obesity with obstructive sleep apnea. The patient uses his own BiPAP. O2 saturation was adequate during this hospital stay.
6. Depression. The patient was given Prozac p.o.
7. Hyperkalemia. The patient's potassium was monitored and was noted to have normal as well as abnormal levels. On admission, his potassium was 5.1. However, this was noted to increase slightly, and on (mm dd, yyyy), the patient's potassium was 5.3.
EKG was checked, which was within normal limits.
DISCHARGE DISPOSITION: The patient is to be transferred to a skilled nursing facility on discharge.
DISCHARGE CONDITION: Fair.
DISCHARGE MEDICATIONS:
1. Nitroglycerin patch 0.4 mg TD daily.
2. Isosorbide dinitrate 40 mg p.o. b.i.d.
3. Protonix 40 mg p.o. b.i.d.
4. Lopressor 50 mg p.o. b.i.d.
5. Lipitor 20 mg p.o. every night.
6. Prozac 20 mg p.o. daily.
7. Novolin R 100 units t.i.d., Novolin N 100 units t.i.d.
8. Gemfibrozil 600 mg p.o. b.i.d. with meals.
Pediatric Discharge Summary Samples #1 Discharge Summary Sample Reports #2
History and Physical (H and P) Medical Transcription Sample
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old white female who was in her usual state of health until yesterday morning when she began noticing shortness of breath with cough productive of clear phlegm and wheezing. She used her albuterol inhaler, but it did not improve. She had a neighbor bring her to the emergency room. She has been treated aggressively here in the emergency room and is feeling somewhat better. She reports no fever. No nasal congestion or sore throat. No nausea, vomiting or diarrhea. She does report some tightness at the base of the neck, which was unrelieved by nitroglycerin but was relieved by the respiratory treatments. The patient has a long-standing history of asthma. Usually uses Flovent and Serevent inhalers routinely, as well as Singulair.
PAST MEDICAL HISTORY:
1. Minimal atherosclerotic heart disease. She was admitted 8 years ago with an episode of atypical chest pain. Heart catheterization showed a 15-25% mid diffuse left anterior descending obstruction. The patient had a renal artery, on the left side, with greater than 90% stenosis. This was treated with angioplasty and stent by Dr. Doe that same month. He wanted to redo the stent indicating that there is probably some recurrent disease. She has not yet consented to this.
2. Dysrhythmia. Dr. Jane Doe, her prior cardiologist, had recommended pacemaker and AICD. I do not believe she ever had an electrophysiologic study. She has not been noted to have any arrhythmia problems in the last year or two.
3. Stroke with diplopia in the late 1980s. CT scan apparently showed an abnormality in the brain stem. She had a carotid Doppler done in September 1991, which did not show any significant stenoses.
4. Hypothyroidism. Followed by Dr. Jack Doe. She had Graves disease. Unsure how it was treated.
5. Recent episode of what sounds like vertigo. She did come to the emergency room about a week ago for this. She was treated in the emergency room, improved, went home, and has had no further problems.
PAST SURGICAL HISTORY:
1. Hysterectomy.
2. Left breast biopsy x3.
MEDICATIONS: Flovent 110 mcg 2 puffs b.i.d., Serevent 1 puff b.i.d., albuterol p.r.n., and Singulair 10 mg daily. She has used Rhinocort in the past. Levoxyl 137 mcg half tablet daily.
ALLERGIES: PENICILLIN CAUSED A RASH, CODEINE CAUSED CNS SYMPTOMS, NOVOCAIN AND XYLOCAINE ASSOCIATED WITH SYNCOPE, ACCUPRIL CAUSED A COUGH. SHE HAD A TAPE REACTION WITH CATHETERIZATION.
FAMILY HISTORY: Mother died in childbirth. Father died of heart disease. Sisters have breast cancer, diabetes, atrial fibrillation and hypertension. A brother had prostate cancer.
SOCIAL HISTORY: The patient is widowed. She has no family in town. She lives alone. She does not smoke or drink. She follows no special diet.
REVIEW OF SYSTEMS: The patient has some proptosis. An MRI scan showed this secondary to retroorbital fat. She has an ANA, which is slightly positive at 1:160 nucleolar with a sedimentation rate of only 16. No other rheumatologic symptoms. The patient did have hypertension secondary to her left renal stenosis. She is not on any medication at this time.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is currently afebrile with normal vital signs. Blood pressure was 135/78. O2 saturation is 97% on oxygen.
HEENT: ENT examination is unremarkable.
NECK: Supple without nodes or enlarged thyroid. Carotids are 2+ with a right carotid bruit.
LUNGS: Clear at this time with some slightly diminished breath sounds throughout.
HEART: Regular with a grade 1-2/6 systolic murmur at the right upper sternal border.
BREASTS: Without masses.
ABDOMEN: Soft and nontender. Bowel sounds are normal without organomegaly.
EXTREMITIES: Without edema. Pedal pulses are 2+.
NEUROLOGICAL: Nonfocal.
SKIN: Unremarkable.
LABORATORY DATA: Potassium 3.5, BUN 21, creatinine 1.2, and glucose 84. The rest of the profile, including liver enzymes, is normal. The CPK is 234 but the MB CPK is 3.5. Troponin is normal. EKG shows no significant ischemic changes. There is an inverted T wave in V3 and V4. INR is 0.92, PTT 28.6, hemoglobin 13.8, white blood cell count 3600, normal differential, and platelets are 155,000.
IMPRESSION:
1. Exacerbation of underlying asthma.
2. Minimal atherosclerotic heart disease.
3. Renovascular hypertension.
a. Status post left renal artery angioplasty and stent.
b. Normotensive post procedure.
4. History of dysrhythmia.
5. Stroke, late 1980s, with resolution.
6. Hypothyroidism.
7. Right carotid bruit.
PLAN: The patient is admitted to the hospital to continue pulmonary toilet with intravenous steroids. Singulair will be continued, as will her Flovent and Serevent. Carotid sonogram will be done.
Fracture Rehab H&P Sample Report H&P Transcribed MT Sample Report
CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old white female who was in her usual state of health until yesterday morning when she began noticing shortness of breath with cough productive of clear phlegm and wheezing. She used her albuterol inhaler, but it did not improve. She had a neighbor bring her to the emergency room. She has been treated aggressively here in the emergency room and is feeling somewhat better. She reports no fever. No nasal congestion or sore throat. No nausea, vomiting or diarrhea. She does report some tightness at the base of the neck, which was unrelieved by nitroglycerin but was relieved by the respiratory treatments. The patient has a long-standing history of asthma. Usually uses Flovent and Serevent inhalers routinely, as well as Singulair.
PAST MEDICAL HISTORY:
1. Minimal atherosclerotic heart disease. She was admitted 8 years ago with an episode of atypical chest pain. Heart catheterization showed a 15-25% mid diffuse left anterior descending obstruction. The patient had a renal artery, on the left side, with greater than 90% stenosis. This was treated with angioplasty and stent by Dr. Doe that same month. He wanted to redo the stent indicating that there is probably some recurrent disease. She has not yet consented to this.
2. Dysrhythmia. Dr. Jane Doe, her prior cardiologist, had recommended pacemaker and AICD. I do not believe she ever had an electrophysiologic study. She has not been noted to have any arrhythmia problems in the last year or two.
3. Stroke with diplopia in the late 1980s. CT scan apparently showed an abnormality in the brain stem. She had a carotid Doppler done in September 1991, which did not show any significant stenoses.
4. Hypothyroidism. Followed by Dr. Jack Doe. She had Graves disease. Unsure how it was treated.
5. Recent episode of what sounds like vertigo. She did come to the emergency room about a week ago for this. She was treated in the emergency room, improved, went home, and has had no further problems.
PAST SURGICAL HISTORY:
1. Hysterectomy.
2. Left breast biopsy x3.
MEDICATIONS: Flovent 110 mcg 2 puffs b.i.d., Serevent 1 puff b.i.d., albuterol p.r.n., and Singulair 10 mg daily. She has used Rhinocort in the past. Levoxyl 137 mcg half tablet daily.
ALLERGIES: PENICILLIN CAUSED A RASH, CODEINE CAUSED CNS SYMPTOMS, NOVOCAIN AND XYLOCAINE ASSOCIATED WITH SYNCOPE, ACCUPRIL CAUSED A COUGH. SHE HAD A TAPE REACTION WITH CATHETERIZATION.
FAMILY HISTORY: Mother died in childbirth. Father died of heart disease. Sisters have breast cancer, diabetes, atrial fibrillation and hypertension. A brother had prostate cancer.
SOCIAL HISTORY: The patient is widowed. She has no family in town. She lives alone. She does not smoke or drink. She follows no special diet.
REVIEW OF SYSTEMS: The patient has some proptosis. An MRI scan showed this secondary to retroorbital fat. She has an ANA, which is slightly positive at 1:160 nucleolar with a sedimentation rate of only 16. No other rheumatologic symptoms. The patient did have hypertension secondary to her left renal stenosis. She is not on any medication at this time.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is currently afebrile with normal vital signs. Blood pressure was 135/78. O2 saturation is 97% on oxygen.
HEENT: ENT examination is unremarkable.
NECK: Supple without nodes or enlarged thyroid. Carotids are 2+ with a right carotid bruit.
LUNGS: Clear at this time with some slightly diminished breath sounds throughout.
HEART: Regular with a grade 1-2/6 systolic murmur at the right upper sternal border.
BREASTS: Without masses.
ABDOMEN: Soft and nontender. Bowel sounds are normal without organomegaly.
EXTREMITIES: Without edema. Pedal pulses are 2+.
NEUROLOGICAL: Nonfocal.
SKIN: Unremarkable.
LABORATORY DATA: Potassium 3.5, BUN 21, creatinine 1.2, and glucose 84. The rest of the profile, including liver enzymes, is normal. The CPK is 234 but the MB CPK is 3.5. Troponin is normal. EKG shows no significant ischemic changes. There is an inverted T wave in V3 and V4. INR is 0.92, PTT 28.6, hemoglobin 13.8, white blood cell count 3600, normal differential, and platelets are 155,000.
IMPRESSION:
1. Exacerbation of underlying asthma.
2. Minimal atherosclerotic heart disease.
3. Renovascular hypertension.
a. Status post left renal artery angioplasty and stent.
b. Normotensive post procedure.
4. History of dysrhythmia.
5. Stroke, late 1980s, with resolution.
6. Hypothyroidism.
7. Right carotid bruit.
PLAN: The patient is admitted to the hospital to continue pulmonary toilet with intravenous steroids. Singulair will be continued, as will her Flovent and Serevent. Carotid sonogram will be done.
Fracture Rehab H&P Sample Report H&P Transcribed MT Sample Report
Consultation Medical Transcription Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abdominal pain and abnormal ultrasound.
HISTORY OF PRESENT ILLNESS: The patient is a delightful (XX)-year-old white female who was admitted to the hospital after experiencing syncopal symptoms. She was admitted on to a telemetry floor and has ongoing cardiology consultation and followup. She was noted to have complaints of abdominal pain, of midepigastric and substernal location. She states that she has onset of these symptoms approximately weekly, and due to concern of her cardiac ischemia with a history of coronary artery disease, cardiac consultation was requested. She currently describes no symptoms of abdominal or chest pain. She states that she was having significant postprandial reflux complaints, and she manages with p.r.n. Nexium therapy. She states that food occasionally will feel stuck in her lower chest area, approximately once or twice a week, and she states that this happens on an intermittent basis and is not associated with any typical food intake such as dry breads or meat products. She states that sometimes she merely gets a sensation of tightness in her lower chest and a fullness sensation. This is consistent with a globus sensation of the esophagus.
She has a significant past GI history, of approximately 4 years, having evaluation by my partner, Dr. John Doe, for reflux and esophageal spasm. She had an EGD and an empiric dilation of lower esophagus performed with short-term relief of symptoms. Subsequently, she has been noted, on this hospitalization, to have right-sided abdominal pain. She describes the pain as subacute in nature, not of recent onset, and involving the right lower quadrant and at previous surgical site. She states that her bowels are generally hard and require stool softeners regularly. She states that she will often get the sensation of fullness or pain about the right lower quadrant that she relates to a hernia that she localizes to that area. She has several surgical scars and states that in the past she has been told she has postsurgical adhesions, which affect her bowel regularity. She has not had a colonoscopy in the last 5 years. She has not had an EGD in the last 3 years.
PAST MEDICAL HISTORY: She has no diabetes. She has positive coronary artery disease. She has positive hypercholesterolemia, and she has current evaluation for symptomatic bradycardia.
PAST SURGICAL HISTORY: She had a hysterectomy, she had an appendectomy, and she had an exploratory laparotomy performed in the distant past.
ALLERGIES: SHE HAS DRUG ALLERGIES TO PENICILLIN AND QUESTIONABLE IODINE SENSITIVITY WITH RADIOPHARMACEUTICAL DYE.
MEDICATIONS: As an outpatient, Nexium taken on a p.r.n. basis. She takes also Dyazide, Xanax half a tablet a day, baby aspirin a day, and Atacand daily.
FAMILY HISTORY: Negative for colon cancer, negative for gastric cancer, positive for a female family member with pancreatic disease of unclear etiology. She has 2 female family members who are status post cholecystectomy for symptomatic gallstones. She herself has not had prior hospitalization for cholelithiasis or cholecystitis.
REVIEW OF SYSTEMS: On comprehensive review of systems, she has positive cardiac complaints, positive pulmonary complaints, positive GI complaints, positive constitutional complaints, negative endocrine, negative skin, negative neurologic, and negative GYN or urologic complaints.
PHYSICAL EXAMINATION: Vital Signs: Temperature is 97.2 degrees, heart rate is 52, she has a respiratory rate of 16, and blood pressure of 139/51. She is saturating 98% on room air at this time. General: She is taking her afternoon meal with no abdominal complaints, and she has been eating a general diet for the last 24-48 hours. HEENT: On examination, she has anicteric sclerae. She has a normocephalic and atraumatic head examination. Oropharyngeal examination is intact. Mucous membranes are moist. Neck: Supple. No lymphadenopathy. No goiter. No thyromegaly. Cardiac: Bradycardia. Normal S1 and S2. No murmur. Chest: Clear to auscultation bilaterally. Abdomen: She has 3 healed surgical incisions. She has positive bowel sounds. She has a soft and nontender abdomen. She is tender to manipulation of the right lower quadrant in the region of the appendectomy. She has an incisional hernia present. She has an apparent incisional hernia along the midline, and she has no right upper quadrant tenderness. No Murphy sign. No rebound. No guarding. The remainder of the abdomen is soft and benign. She has a nonincarcerated hernia of the right lower quadrant. Extremities: She has no edema, no skin and joint finding. Neurologic: Examination is intact.
LABORATORY STUDIES: She has a WBC count of 3200, hemoglobin 10.3, and platelet count 214,000. She has sodium of 140, creatinine 0.6, and magnesium 2.3. She has a normal GGT. She has a normal AST and normal ALT. She has a normal total bilirubin. Her alkaline phosphatase is elevated at 190. The remainder of her serum chemistries are normal.
RADIOLOGY IMAGING: Right upper quadrant ultrasound reveals no intrahepatic ductal dilatation, reveals a small single 2 mm stone within the gallbladder, reveals a normal-appearing gallbladder wall, no wall thickening, no edema, no pericholecystic fluid. Her common bile duct is diffusely at the upper limit of normal at 8-9 mm. There is some dilation to approximately 9 mm at the most proximal extent near the common hepatic duct. There are no other abnormalities noted on ultrasound.
IMPRESSION: The patient is a pleasant (XX)-year-old white female who was admitted to the hospital with syncopal symptoms and has symptomatic bradycardia. She is experiencing some midepigastric and mid chest discomfort, and these symptoms could be consistent with esophageal spasm or stricture as her past gastrointestinal history would suggest. She is status post esophageal dilation with some relief of her symptoms. These are consistent with noncardiac chest pain-type symptoms. Additionally, she has some right lower quadrant tenderness at the site of a postsurgical site incisional hernia. She has a benign right upper quadrant. She additionally has symptoms and history of gastroesophageal reflux disease and constipation.
The patient is feeling well, as she has no right upper quadrant symptoms, as she has a normal GGT and liver function tests, which all correlate with an essentially normal right upper quadrant ultrasound with the exception of a small stone present in the gallbladder. The diameter of her common bile duct is not alone impressive with lack of AST/ALT elevation and right upper quadrant symptoms. I have personally reviewed the ultrasound findings with the radiologist.
SUGGESTIONS: My suggestions at this time include:
1. Twice daily Nexium therapy to be taken before meals, directed at control of her GERD symptoms, which have been more significant recently.
2. Continued pacemaker evaluation, which should be useful provided her symptomatic bradycardia.
3. It is important that she follows up with me in the office in 1-2 weeks, for most likely she will need an EGD with esophageal dilation and I will at that time complete repeat liver function testing and examination of the right upper quadrant to verify my impression as above.
I have suggested noninvasive MRI of the biliary tree; however, she attempted to have an MRI during this admission and she experienced significant anxiety related to potential claustrophobia. Should she be able to complete the study, this would be useful for definite evaluation of the anatomy of her biliary tree; however, in the setting of tolerance of her diet and no right upper quadrant symptoms with normal liver function tests, which do not suggest gallstone in the common bile duct, I feel that it would be reasonable for her to have close outpatient followup with me. I have explained to her that should right upper quadrant symptoms recur, should temperature elevate or should she experience nausea or any change in symptoms, she needs to tell her primary physician or call my office for further management.
Thank you for allowing me to participate in this patient's care. If you have any further questions or concerns, please do not hesitate to contact me.
Gastroenterology Consultation MT Sample Report Neuro Critical Care Consultation Sample Report
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abdominal pain and abnormal ultrasound.
HISTORY OF PRESENT ILLNESS: The patient is a delightful (XX)-year-old white female who was admitted to the hospital after experiencing syncopal symptoms. She was admitted on to a telemetry floor and has ongoing cardiology consultation and followup. She was noted to have complaints of abdominal pain, of midepigastric and substernal location. She states that she has onset of these symptoms approximately weekly, and due to concern of her cardiac ischemia with a history of coronary artery disease, cardiac consultation was requested. She currently describes no symptoms of abdominal or chest pain. She states that she was having significant postprandial reflux complaints, and she manages with p.r.n. Nexium therapy. She states that food occasionally will feel stuck in her lower chest area, approximately once or twice a week, and she states that this happens on an intermittent basis and is not associated with any typical food intake such as dry breads or meat products. She states that sometimes she merely gets a sensation of tightness in her lower chest and a fullness sensation. This is consistent with a globus sensation of the esophagus.
She has a significant past GI history, of approximately 4 years, having evaluation by my partner, Dr. John Doe, for reflux and esophageal spasm. She had an EGD and an empiric dilation of lower esophagus performed with short-term relief of symptoms. Subsequently, she has been noted, on this hospitalization, to have right-sided abdominal pain. She describes the pain as subacute in nature, not of recent onset, and involving the right lower quadrant and at previous surgical site. She states that her bowels are generally hard and require stool softeners regularly. She states that she will often get the sensation of fullness or pain about the right lower quadrant that she relates to a hernia that she localizes to that area. She has several surgical scars and states that in the past she has been told she has postsurgical adhesions, which affect her bowel regularity. She has not had a colonoscopy in the last 5 years. She has not had an EGD in the last 3 years.
PAST MEDICAL HISTORY: She has no diabetes. She has positive coronary artery disease. She has positive hypercholesterolemia, and she has current evaluation for symptomatic bradycardia.
PAST SURGICAL HISTORY: She had a hysterectomy, she had an appendectomy, and she had an exploratory laparotomy performed in the distant past.
ALLERGIES: SHE HAS DRUG ALLERGIES TO PENICILLIN AND QUESTIONABLE IODINE SENSITIVITY WITH RADIOPHARMACEUTICAL DYE.
MEDICATIONS: As an outpatient, Nexium taken on a p.r.n. basis. She takes also Dyazide, Xanax half a tablet a day, baby aspirin a day, and Atacand daily.
FAMILY HISTORY: Negative for colon cancer, negative for gastric cancer, positive for a female family member with pancreatic disease of unclear etiology. She has 2 female family members who are status post cholecystectomy for symptomatic gallstones. She herself has not had prior hospitalization for cholelithiasis or cholecystitis.
REVIEW OF SYSTEMS: On comprehensive review of systems, she has positive cardiac complaints, positive pulmonary complaints, positive GI complaints, positive constitutional complaints, negative endocrine, negative skin, negative neurologic, and negative GYN or urologic complaints.
PHYSICAL EXAMINATION: Vital Signs: Temperature is 97.2 degrees, heart rate is 52, she has a respiratory rate of 16, and blood pressure of 139/51. She is saturating 98% on room air at this time. General: She is taking her afternoon meal with no abdominal complaints, and she has been eating a general diet for the last 24-48 hours. HEENT: On examination, she has anicteric sclerae. She has a normocephalic and atraumatic head examination. Oropharyngeal examination is intact. Mucous membranes are moist. Neck: Supple. No lymphadenopathy. No goiter. No thyromegaly. Cardiac: Bradycardia. Normal S1 and S2. No murmur. Chest: Clear to auscultation bilaterally. Abdomen: She has 3 healed surgical incisions. She has positive bowel sounds. She has a soft and nontender abdomen. She is tender to manipulation of the right lower quadrant in the region of the appendectomy. She has an incisional hernia present. She has an apparent incisional hernia along the midline, and she has no right upper quadrant tenderness. No Murphy sign. No rebound. No guarding. The remainder of the abdomen is soft and benign. She has a nonincarcerated hernia of the right lower quadrant. Extremities: She has no edema, no skin and joint finding. Neurologic: Examination is intact.
LABORATORY STUDIES: She has a WBC count of 3200, hemoglobin 10.3, and platelet count 214,000. She has sodium of 140, creatinine 0.6, and magnesium 2.3. She has a normal GGT. She has a normal AST and normal ALT. She has a normal total bilirubin. Her alkaline phosphatase is elevated at 190. The remainder of her serum chemistries are normal.
RADIOLOGY IMAGING: Right upper quadrant ultrasound reveals no intrahepatic ductal dilatation, reveals a small single 2 mm stone within the gallbladder, reveals a normal-appearing gallbladder wall, no wall thickening, no edema, no pericholecystic fluid. Her common bile duct is diffusely at the upper limit of normal at 8-9 mm. There is some dilation to approximately 9 mm at the most proximal extent near the common hepatic duct. There are no other abnormalities noted on ultrasound.
IMPRESSION: The patient is a pleasant (XX)-year-old white female who was admitted to the hospital with syncopal symptoms and has symptomatic bradycardia. She is experiencing some midepigastric and mid chest discomfort, and these symptoms could be consistent with esophageal spasm or stricture as her past gastrointestinal history would suggest. She is status post esophageal dilation with some relief of her symptoms. These are consistent with noncardiac chest pain-type symptoms. Additionally, she has some right lower quadrant tenderness at the site of a postsurgical site incisional hernia. She has a benign right upper quadrant. She additionally has symptoms and history of gastroesophageal reflux disease and constipation.
The patient is feeling well, as she has no right upper quadrant symptoms, as she has a normal GGT and liver function tests, which all correlate with an essentially normal right upper quadrant ultrasound with the exception of a small stone present in the gallbladder. The diameter of her common bile duct is not alone impressive with lack of AST/ALT elevation and right upper quadrant symptoms. I have personally reviewed the ultrasound findings with the radiologist.
SUGGESTIONS: My suggestions at this time include:
1. Twice daily Nexium therapy to be taken before meals, directed at control of her GERD symptoms, which have been more significant recently.
2. Continued pacemaker evaluation, which should be useful provided her symptomatic bradycardia.
3. It is important that she follows up with me in the office in 1-2 weeks, for most likely she will need an EGD with esophageal dilation and I will at that time complete repeat liver function testing and examination of the right upper quadrant to verify my impression as above.
I have suggested noninvasive MRI of the biliary tree; however, she attempted to have an MRI during this admission and she experienced significant anxiety related to potential claustrophobia. Should she be able to complete the study, this would be useful for definite evaluation of the anatomy of her biliary tree; however, in the setting of tolerance of her diet and no right upper quadrant symptoms with normal liver function tests, which do not suggest gallstone in the common bile duct, I feel that it would be reasonable for her to have close outpatient followup with me. I have explained to her that should right upper quadrant symptoms recur, should temperature elevate or should she experience nausea or any change in symptoms, she needs to tell her primary physician or call my office for further management.
Thank you for allowing me to participate in this patient's care. If you have any further questions or concerns, please do not hesitate to contact me.
Gastroenterology Consultation MT Sample Report Neuro Critical Care Consultation Sample Report
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