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.

MRI of the Right Knee Sample              Abdominal MRI Sample Report

Right Elbow MRI Sample Report          MRI Medical Transcription Sample Reports    

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.

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.

MRA Circle of Willis and Head MRI Sample       Left Shoulder MRI Sample Report

Medical Transcription Word Seeker - Google Custom Search for MTs

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

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

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

General Surgery Medical Transcription Procedure Samples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Biliary colic.

POSTOPERATIVE DIAGNOSIS: Biliary colic.

OPERATION PERFORMED: Laparoscopic cholecystectomy with liver biopsy.

SURGEON: First Name Last Name, MD

ASSISTANT: First Name Last Name, MD

ANESTHESIA: General endotracheal.

ANESTHESIOLOGIST: First Name Last Name, MD

ESTIMATED BLOOD LOSS: Minimal.

DESCRIPTION OF PROCEDURE: With the patient supine on the operating table, after induction of general endotracheal anesthesia, the abdomen was prepped and draped in the usual sterile fashion. An infraumbilical incision was made. Stay sutures were placed on the fascia. The fascia was opened and abdomen was entered. Hasson cannula was placed. CO2 was insufflated into the abdominal cavity. Laparoscope was placed. A midline port was placed, a midclavicular port was placed, and an anterior axillary port was placed. The gallbladder was taken down from above with the use of the Harmonic scalpel. Cystic artery was transected with the Harmonic scalpel. Cystic duct was ligated with the #0 PDS Endoloop. A 5-mm scope was placed in the upper midline port. Laparoscopic bag was placed in the Hasson, and the gallbladder was placed in the bag and deployed. A 10-mm scope was replaced in the Hasson. A wedge liver biopsy was taken with the Harmonic scalpel. A 5-mm scope was utilized in the upper midline port. A second laparoscopic bag was placed and opened. The liver biopsy was placed in the bag, and the bag was deployed. A 10-mm scope was replaced in the Hasson and the abdomen was irrigated copiously with saline solution, suctioned dry, and noted to be hemostatic. Trocars were removed. There was no bleeding. The Hasson was removed. Both bags were removed. The fascia and the umbilical port were closed with #0 Vicryl. The skin incisions were closed with #4-0 subcuticular Vicryl. Steri-Strips were applied. Dressings were applied. Counts were reported to be correct. Estimated blood loss was minimal. The patient tolerated the procedure well and left the operating room in a stable condition.

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic abdominal pain.
2.  Increased liver function tests, unclear etiology.

POSTOPERATIVE DIAGNOSES:
1.  Elevated liver function tests.
2.  Intestinal adhesions.

OPERATION PERFORMED:  Laparoscopic liver biopsy and lysis of adhesions.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

FINDINGS:  Normal-appearing liver. There was a single adhesion band crossing over the terminal ileum, which might have indeed been causing intermittent complete bowel obstruction from a prior appendectomy. There are no other intraperitoneal abnormalities noted. There was no mesenteric lymphadenopathy.

DESCRIPTION OF PROCEDURE:  The patient was first given general endotracheal anesthetic and was then prepped and draped in the usual sterile fashion for laparoscopy and possible laparotomy. A transverse supraumbilical incision was made.  Abdomen was entered with a 5 mm Optiview trocar. A 5 mm subxiphoid trocar was then placed. Examination of the peritoneal cavity revealed normal-appearing liver, but due to increased liver function tests, multiple core biopsies were obtained and sent for permanent specimen. Additionally, exploration of the peritoneal cavity revealed a normal-appearing pelvis. There were omental adhesions crossing over the distal terminal ileum, which might have indeed been causing complete obstruction. Additionally, there were numerous adhesions in the left upper abdomen, question whether this is due to prior inflammatory bowel disease or intra-abdominal vasculitis. These adhesions were lysed. The abdomen was irrigated. The prior biopsy site was cauterized extensively. There were no other intraperitoneal abnormalities noted. The patient tolerated the procedure well and was transferred back to recovery room in stable condition.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Immunodiffusion procedure.

POSTOPERATIVE DIAGNOSIS:  Immunodiffusion procedure.

OPERATIONS PERFORMED:
1.  Laparoscopic splenectomy.
2.  Distal pancreatectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  No complications.

FINDINGS:  Tail of pancreas was embedded in the hilum of the spleen; therefore, distal pancreatectomy was performed en bloc with the splenectomy.  There is no sign of accessory spleen.  There are no other gross intraperitoneal abnormalities noted, except for morbid obesity.

DESCRIPTION OF PROCEDURE:  The patient was first given general endotracheal anesthetic.  He was then prepped and draped in the usual sterile fashion of laparoscopic splenectomy.  A morbid obesity lap disc was placed in the epigastrium after infiltration of 0.5% Marcaine with epinephrine.  After this was performed, 5 mm and 12 mm left upper quadrant ports were then placed.  Short gastric vessels were transected with a Harmonic scalpel.  The splenic flexure of the colon was mobilized as well.  Once this was completed, the hilum of the spleen was noted to be densely adherent to the tail of the pancreas.  Therefore, the tail of the pancreas, splenic artery, and splenic vein were all transected with an Endocutter and stapler with use of Seamguards.  Once this was completely transected, the lateral attachments of the spleen were taken down with a Harmonic scalpel.  Spleen was then brought to the lap disc in one piece.  There was no abnormality noted.  The abdomen was then irrigated and 10 mm Jackson-Pratt was placed through the lateral 12 mm port since the distal pancreas was transected.  The patient tolerated the procedure well.  The lap disc was then closed with #1 Vicryl and 4-0 Vicryl in subcuticular manner.  Drain was sutured to the skin with 2-0 nylon.

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Orthopedic Medical Transcription Operative Sample Report

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Right adhesive capsulitis of the shoulder, status post fracture dislocation.

POSTOPERATIVE DIAGNOSIS: Right adhesive capsulitis of the shoulder, status post fracture dislocation.

OPERATIONS PERFORMED: 
1. Right shoulder arthroscopy with limited glenohumeral debridement. 
2. Right shoulder manipulation under anesthesia.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: Scalene block plus LMA.

ANESTHESIOLOGIST: Jean Doe, MD

TOURNIQUET TIME: None.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

DRAINS: None.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the table in the supine position. Adequate level of LMA and scalene block anesthesia were obtained. C-arm was used prior to manipulation, and the shoulder appeared to be well healed and moved as a unit. Passive forward flexion to about 95, abduction to about 50, external rotation with her arm abducted position to 5 degrees, and internal rotation to about neutral. After manipulation, forward flexion was about 175-80, abduction to 125, external rotation to about 50 degrees, and internal rotation to 30. X-rays were then used again to verify no fracture or dislocation.

The right upper extremity was then prepped and draped in the normal sterile fashion. She was placed in the beach-chair position. Posterior incision was then made, and arthroscopy of the shoulder was performed. The blood was débrided from the joint. There was no evidence of any superior or anterior labral tears. The biceps tendon appeared to be intact. No evidence for any rotator cuff tears. Subscapularis appeared to be intact. No loose body was noted. Because of visualization difficulties and loose pieces of cartilages as well as some fraying of the superior and anterior labrum, a limited glenohumeral debridement was performed through an anterior portal.

All the instruments were then removed. Sutures were placed on the skin. A sterile dressing followed by sling was then applied. The patient was extubated and transferred to the recovery room in good stable condition. There were no complications.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right knee medial meniscus tear.

POSTOPERATIVE DIAGNOSES:
1.  Medial femoral condyle flap tear.
2.  Trochlear groove chondromalacia grade 3.
3.  Lateral femoral condyle flap tear.

OPERATION PERFORMED:
1.  Right knee arthroscopy.
2.  Debridement of flap tears, medial and lateral femoral condyles, with chondroplasty medial and lateral femoral condyles.
3.  Injection of 20 mL of 0.25% Marcaine with epinephrine and 40 mg of Kenalog.

SURGEON:  John Doe, MD

DESCRIPTION OF PROCEDURE:  The patient was placed supine on the operating table after adequate general anesthesia was obtained with LMA. Then, 1 g Ancef IV was given to the patient. The patient's leg was placed in a tourniquet on the right side and well-padded leg holder. Left leg was placed in a well-leg holder. Foot of the bed was bent down. The right leg was prepped and draped in the usual sterile fashion. An infrapatellar medial portal and infrapatellar lateral portal were established. Infrapatellar lateral portal was established for introduction of the arthroscope. Examination of patellofemoral joint revealed grade 3 changes in the trochlear groove extending onto grade 4 changes over the medial femoral condyle over an area about the size of a quarter. The patient had medial and lateral gutters examined and these were free and clear of loose bodies. Examination of the medial compartment revealed a large complex flap tear involving about 50-60% depth of the cartilage surface on the medial femoral condyle. This extended onto the weightbearing surface of the medial femoral condyle. We carefully debrided back with a 4.0 shaver. The patient also was seen to have a longitudinal fissure in the medial tibial plateau that was approximately 3.5 cm x 2.5 cm down to bone. There was exposed bone in this area, and the flaps were carefully debrided with a full radius 4.0 shaver. The medial meniscus was carefully examined from front to back and was probed and was found not to have a through-and-through meniscal tear. The anterior cruciate ligament was examined and probed and found to be intact. Examination of the lateral compartment revealed a flap tear of the lateral femoral condylar cartilage involving 75-80% thickness of the cartilage in an area of weightbearing bone where the area of flap was approximately the size of a dime. This was debrided back to stable edges. We then irrigated out the knee copiously, returned to the suprapatellar pouch, instilled 20 mL of 0.25% Marcaine with epinephrine and 40 mg of Kenalog into the knee joint, closed the portals with 4-0 nylon simple suture, dry sterile dressing, and Ace wrap and EBIce. The patient was extubated in the operating room and returned to recovery room in good condition.

Orthopedic Operative Samples #1         Orthopedic Operative Samples #2

Ob-Gyn Medical Transcription Operative Samples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Menorrhagia.

POSTOPERATIVE DIAGNOSIS:  Menorrhagia with possible uterine fibroid.

OPERATION PERFORMED:  Hysteroscopy with D and C and endometrial ablation by the NovaSure technique.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD 

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Bradford Doe, MD 

OPERATIVE FINDINGS:  Bulky uterus with suggestion of left anterior uterine wall fibroid, uterine descensus with cystocele and rectocele.

DESCRIPTION OF OPERATION:  After appropriate consent, the patient was taken to the operating room and administered adequate general anesthesia. She was placed in the lithotomy position and prepped and draped. The bladder was emptied. Examination under anesthesia revealed a bulky uterus with descensus with coexisting cystocele and rectocele. There was a suggestion of right anterior cornual uterine fibroid.

A weighted speculum was inserted into the posterior vaginal fornix. The anterior cervical lip was held down with a toothed tenaculum. The uterus and the cervix were sounded and measured 11 cm. Hysteroscopy was carried out showing normal endocervical and endometrial cavity. Endocervical and endometrial curettage was carried out yielding profuse curettings which were collected and sent for pathology examination.

A NovaSure endometrial ablation procedure was then performed. The uterine cavity length was registered on the instrument panel. The array was deployed, introduced into the uterus, and the uterine cavity width was measured and entered on the instrument panel. The cavity assessment was successfully completed followed by initiation of the ablation cycle which was completed without difficulty.

All the vaginal instruments were removed. Repeat hysteroscopy showed adequate ablation of the endometrium. All the vaginal instruments were removed. The patient was returned to supine position, awake, and left the operating room in stable condition. There were no complications.

DATE OF OPERATION: XX/XX/XXXX

PREOPERATIVE DIAGNOSIS: Cervical dysplasia.

POSTOPERATIVE DIAGNOSIS: Cervical dysplasia.

OPERATION PERFORMED: Cold-knife conization and endocervical curetting.

SURGEON:  John Doe, MD

ANESTHESIA: Laryngeal mask airway.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 20 mL.

SPECIMENS: Cold-knife cone specimen and endocervical curettings.

INDICATION: This is a patient with a history of CIN 1 to CIN 3 diagnosed by colposcopy and biopsy. The patient was counseled regarding options for excisional therapy. The patient understood risks, benefits and alternatives to the procedure, and informed consent was signed for cold-knife conization. All questions were answered prior to the procedure.

DESCRIPTION OF OPERATION: The patient was taken to the operating room, where LMA anesthesia was obtained without difficulty. The patient was prepped and draped in the normal sterile fashion in the dorsal lithotomy position using candy cane stirrups. Attention was then turned to the patient's vagina where the weighted speculum was placed into the posterior fornix and a curved Deaver was placed into the anterior fornix. Two sutures of 0 Vicryl were used to ligate the cervical branches of the cervical artery at the 3 and 9 o'clock positions in a figure-of-eight suture. Then, the cervix was injected with 10 in 200 of Pitressin. Lugol solution was applied to the cervix to see any abnormalities. Cold-knife cone specimen was then obtained. This was handed off for pathologic review. Stitch was placed at the 12 o'clock position. Next, endocervical curetting was performed of the canal. This was handed off also for pathologic review. The base of the cervical cone specimen was then cauterized using Bovie cautery. The margins of the cone specimen were also cauterized in a similar manner. The cone site was noted to be hemostatic. Avitene was then placed into the cervical cone site, the sutures were cut and all the instruments removed from the patient's vagina. All sponge, lap and needle counts were correct x2. The patient tolerated the procedure well, was awakened and transferred to the recovery room.

LEEP Procedure Sample Report               Delivery Note Transcribed Sample Report

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Neurosurgery Medical Transcription Operative Samples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES: 
1. Cervical disk herniation, C5-6, C6-7.
2. Cervical instability, C5-6, C6-7. 

POSTOPERATIVE DIAGNOSES: 
1. Cervical disk herniation, C5-6, C6-7.
2. Cervical instability, C5-6, C6-7. 

OPERATIONS PERFORMED: 
1. Anterior cervical strut graft arthrodesis C5-6, C6-7.
2. Anterior cervical osteophytectomy, C5-6, C6-7.
3. Anterior cervical decompressive foraminotomies bilateral, C5-6 and bilateral C6-7.
4. Anterior cervical plating, C5 to C7.
5. Microscope used for nerve root microdissection.

SURGEON:  John Doe, MD 

ANESTHESIA: General. 

ESTIMATED BLOOD LOSS: 20 mL. 

DESCRIPTION OF OPERATION: The patient was brought to the operating room after receiving IV antibiotics in the holding area. He was induced and intubated without difficulty. A roll was placed under his shoulder blade and SSEP monitoring was brought online. The right side of his neck was scrubbed with Betadine scrub brush and washed with alcohol. The C-arm fluoroscopy was used to mark out a right parasagittal transverse incision. This 4-cm incision was prepped and draped in sterile fashion. It was infiltrated with 1% Xylocaine with epinephrine and opened with a #10 blade. Sharp dissection to the platysma down to the anterior border of the sternocleidomastoid. Sharp and blunt dissection medial to this structure led into the paravertebral space. A handheld Cloward was used to retract the midline structures. The spinal needle was then placed in the C5-6 disk spacing, and this was confirmed with C-arm fluoroscopy. At this point, Bovie cautery was used to dissect the anterior longitudinal ligament of the inferior aspect of C5, the body of C6, and the superior aspect of C7. Medial and lateral rainbow retractors were placed in the field, posteriorly drilled into the bodies of C5 and C7. Axial distraction was applied. At this point, the microscope was brought in. Under microscopic guidance, the disk spaces were entered with a series of pituitaries. This was easy at C6-7, but difficult due to osteophytic disease and disk collapse at C5-6. 

Concentrating first on C6-7, curettes were used to remove disk material down to the posterior osteophytic disease. A #2 Kerrison was then used to remove these bone spurs. Decompressive foraminotomies were performed bilaterally at C6-7. Next, a nerve hook was used to fish out large fragments of disk material from behind the posterior longitudinal ligament. Once 5 or 6 of these fragments were removed, the thecal sac obviously was slackened. Copious irrigation at this point was followed with sizing of the defect. An 8-mm titanium strut graft packed with Osteofil was selected and tapped into place under fluoroscopic guidance. Attention was redirected towards C5-6, where the endplates were drilled down to the posterior osteophytes. These were removed with #2 Kerrison. Decompressive foraminotomies were performed bilaterally with the same #2 Kerrison. Again an 8-mm titanium strut graft packed with Osteofil was sized. This was tapped into place at C5-6. Next, the posts were removed and posts holes were waxed. A 42-mm anterior cervical titanium plate was chosen. This was secured to the bodies of C5, C6, and C7 with 12-mm variable screws and locking screws were tightened. Further irrigation was followed with closure.

Bleeding sites were cauterized. The platysma was closed with interrupted #3-0 Vicryl sutures after FloSeal was in the dissection area. The skin was closed with #4-0 subcuticular stitch. Steri-Strips were applied and dressing was placed on the patient’s neck. He awoke in good neurological condition and was taken to recovery room.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:  Lumbosacral instability, L4-5; spinal stenosis, L4-5.

POSTOPERATIVE DIAGNOSES:  Lumbosacral instability, L4-5; spinal stenosis, L4-5.

OPERATIONS PERFORMED:  Segmental arthrodesis with bony autograft, L4-5; pedicle instrumented fusion, bilateral L4-5; posterior lumbar interbody fusion with cage placement, L4-5; decompressive laminectomy, L4; and decompressive foraminotomies, bilateral L4-5.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  250 mL.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, induced and intubated without difficulty.  She was rolled on a Wilson frame table, and the lumbosacral region of her spine was scrubbed with a Betadine scrub brush and washed with alcohol.  She had received IV antibiotics in the operating room.  A C-arm fluoroscopy unit was used to aid marking of the midline lumbar incision.  This area was prepped and draped in sterile fashion.  It was infiltrated with 1% Xylocaine with epinephrine and opened with a #10 blade.  Bovie cautery through superficial fascial layers led down to the lumbodorsal fascia.  Subperiosteal dissection of the spinous processes and lamina of L3, L4, and L5 ensued.  The dissection was carried out over the L3-4 and L4-5 facet.  The transverse processes of L4 and L5 on either side were freed out.  Deep retractors were placed in the wound at this point.  The C-arm fluoroscopy unit was again used to confirm the correct operative location.  A Leksell was used to remove the spinous process of L4 and thinned the lamina of L4.  It was clear that there was a pars defect at this level.  Curettes were used along the underside of L4 and a decompressive laminectomy was performed.  Large fragments of the superior facet at this level were likewise able to be removed en bloc and #4 Kerrison was used to perform decompressive foraminotomies bilaterally at L4-5.  A dental tool was used to ensure that these were freed up.  Once decompression was complete, the thecal sac was retracted medially from the right-hand side exposing the left L4-5 disk area.  Epidural veins were cauterized and covered with micro scissors, and the 11 blade was used to incise the disk space.  This material was removed with series of pituitaries and curettes.  After sizing, a 7 mm boomerang graft was selected.  This was tapped into the disk space under fluoroscopic guidance.  Bone had been packed in the boomerang prior to placement with the interbody device countersunk.  Attention was directed towards pedicle screw placement in standard fashion.  The inferior facet junction and transverse process at L4 was identified.  A Midas Rex was used to drill through the cortex in this area.  A pedicle sound was used at L4 under fluoroscopy guidance and direct palpation medially of the pedicle.  Once this had been done to a depth 50 mm, a thin probe was used to palpate the area.  A 5.0 tap was used to widen the hole.  Palpation again was followed with placement of a 6.0, 50 mm screw.  The transverse processes of L4 and L5 have been roughed up prior to the screw placement.  In similar fashion at L5, a drill was used to begin the pedicle screw hole.  A tap was used under fluoroscopic guidance.  Palpation of the hole was followed with use of a 5.0 tap.  Palpation again was followed with placement of a 6.0, 50 mm screw.  Attention was directed towards the right-hand side where identical screws were placed at L4 and L5.  A pulse jet irrigator was used to irrigate out the entire wound at this point.  Rods were cut and contoured.  Top-loading caps were applied.  These were provisionally tightened and finally tightened.  Bone morphogenic protein sponges packed with Mastergraft and laminectomized bone were laid along the transverse processes of L4 and L5 on either side.  At this point, FloSeal was placed in the lateral gutters.  A drain was brought out through a separate stab incision.  Closure then began.  The lumbodorsal fascia was closed with interrupted 0 Vicryl sutures.  The superficial facial layers were closed with interrupted 2-0 Vicryl sutures.  The skin was closed with a 4-0 subcuticular stitch.  Steri-Strips were applied.  A dressing was placed on the patient's back.  She awoke in good neurologic condition and was taken to the recovery room.