PROCEDURE IN DETAIL: After the procedure was explained to the patient with the benefits and the complications, the patient agreed and signed the consent. After consent was obtained, with the patient in supine position under very light anesthesia, with the patient awake and able to follow commands, the scope was introduced through the mouth and the larynx and laryngeal structures were inspected. These were normal. The vocal cords were especially observed during the inspiration and expiration, and the mobility of the cords was completely normal. The scope was then introduced into the trachea, which was normal. The carina was sharp and normal. The right main bronchus and left main bronchi were normal. The scope was then directed into the upper lobe bronchus and all its subsegments were inspected; all of them were normal. Then, the left lingual segment and the left lower lobe bronchus were all inspected with their subsegments; all of them were normal. The scope was then directed into the right and in the right upper lobe bronchus, middle, and lower lobe bronchi, with their subsegments, were all inspected and normal. No evidence of structural damage was observed on the mucosa or the airways as far as the scope could see. Then, lavage was done into the right middle lobe bronchus and fluid was aspirated, about 15 mL, and sent for eosinophilic count and for Gram stain and culture.
TOTAL ABDOMINAL HYSTERECTOMY AND BILATERAL SALPINGO-OOPHORECTOMY OP SAMPLE
DESCRIPTION OF OPERATION: As soon as adequate general anesthesia was administered, with the patient in supine position, an indwelling Foley catheter was inserted. The abdomen was prepped and draped. A suprapubic Pfannenstiel incision was made. The incision was deepened into the subcutaneous fat and fascia and peritoneal cavity entered. Self-retaining retractors and wet laps were used to pack up the lower abdomen to give better visualization. Fluid was removed for cytology, and two large clamps were placed on each side of the uterus to be used as traction. The left round ligament was then taken in between two clamps, tissue cut in between clamps, and suture ligatures were placed at the distal clamp. The same procedure was done on the other side. A curvilinear incision was made on the vesicouterine peritoneal reflection, separating the bladder flap away from the lower uterine segment and pushed well below the cervix. Through the avascular space in the broad ligament, a Codman clamp was placed through this to incorporate the infundibulopelvic ligament. Two other clamps were placed in close proximity to this, tissue cut in between the first and middle clamps, and suture ligatures were placed at the distal clamp.
The left adnexa was then removed and sent for frozen section. The same procedure was done on the other side with the adnexa also sent for frozen section. They both came back as benign. The uterine vessels on each side were clamped, divided, and doubly ligated. The cardinal ligaments on either side were clamped, divided, and doubly ligated and the uterosacral ligaments clamped, divided, and doubly ligated. With the bladder pushed well below the cervix, the anterior vagina was entered. Complete amputation of the cervix from the vagina was done. Clamps were applied on the vaginal vault. Special angle sutures were placed at the angle clamps by incorporating the anterior to the posterior vault together with the stump of the uterosacral ligaments and the cardinal ligaments. Interrupted figure-of-eight suture was used to approximate the anterior to the posterior vault and closed the vault completely.
Peritonealization was done by approximating the anterior to the posterior parietal peritoneum with a continuous suture of #2-0 chromic material. Copious irrigation was done on the pelvic cavity. Proper hemostasis was observed. The appendix was localized, this was retrocecal, appeared to be very small and normal. This was left in place. No other pathology noted. As soon as sponge count and instrument counts were correct, the abdomen was closed in layers using a continuous suture of chromic #0 on the peritoneum, continuous suture of Vicryl #1 on the fascia, and continuous suture of plain catgut on the subcutaneous fat. The skin was approximated with subcuticular stitch of #4-0 Vicryl. Estimated blood loss was about 200 mL. The patient tolerated the procedure well. She was brought to the recovery room in satisfactory condition.
NEUROLOGICAL CONSULTATION TRANSCRIPTION SAMPLE
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Progressive weakness of both lower extremities.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who was referred because of progressive weakness of both lower extremities. This patient was seen in the hospital for respiratory failure and exacerbation of her asthma. The patient is diabetic and has been diabetic for two years secondary to use of steroids and she has been on steroids for many, many years. When she was initially seen, she had weakness of both proximal and lower extremity muscles. The lower extremity weakness was more profound. The left was a little bit more worse than the right, and she had distal weakness in both upper extremities, more so than the proximal weakness, and in the lower extremities, she had moderate weakness, about grade 3/5 proximally. She was telling me that she was walking with two steps, but since last week, she has noted that there is more tingling in her arms and in her feet and that she is no longer able to move her legs; she could no longer stand. She is currently still on the same dose of steroids, of 40 mg. She told me just before she was transferred, her steroid was up to 60 mg and then back down to 40 mg. During her hospitalization at the previous hospital, she did have an MRI of the cervical cord that did not show any lesion or any compressive pathology. She had a normal CPK, thyroid. She had a Foley catheter then and this has been off since her transfer. She knows when she has to go to the bathroom, but often times, she cannot make it to the bathroom because of the weakness and she leaks. She has good bowel control. Her sensory symptoms have progressed. She denies any difficulty swallowing. No visual complaints.
PAST MEDICAL HISTORY: Significant for hypothyroidism, osteomyelitis, and olecranon bursitis. She also has a history of deep vein thrombosis.
ALLERGIES: SHE IS ALLERGIC TO PENICILLIN AND PAPER TAPE.
PERSONAL AND SOCIAL HISTORY: She does not smoke nor drink and lives with her family.
PHYSICAL EXAMINATION: GENERAL: She is afebrile. NEUROLOGICAL: She is awake and alert. She is weak on the left side. She does have significant hearing deficit. The optic disks are clear. There are no visual field defects. She moves her eyes in all directions. There is no nystagmus. The speech is clear. The tongue is midline. There is no facial weakness. Motor examination revealed mild weakness of the deltoid, the biceps. The triceps is about 4/5. Distally, she has quite weak grip, about 3/5. The left is weaker than the right. In the lower extremity, all she is able to do is wiggle her toes and internally and externally rotate her hip, her legs. Sensory examination revealed decreased pinprick sensation up to just below the umbilical area. In the upper extremity, there is decreased pinprick sensation up to the mid arm level. The vibration sense is absent in the toes, diminished in the fingers. Position sense is absent as well in the toes, present in the fingers. Her reflexes are present all over, including knee jerks, except for the absent ankle jerks. She has got severe tremor in her upper extremity, both postural and with intention. She could not get up, but she was able to take her pants off independently.
DIAGNOSES:
1. Evidence of polyneuropathy, probably diabetic. I doubt that this is Guillain Barre because of the severe weakness. Her reflexes are still quite intact.
2. Steroid myopathy.
3. Diabetes, steroid induced.
4. Severe asthma, steroid dependent.
5. Tremor, probably related to weakness and asthma medication.
PLAN: I am going to go ahead and re-scan her back. She did have a cervical scan. We will scan her back to be sure that there are no compressive symptoms, compressive pathology. She will need a nerve conduction study, and I have asked Dr. Doe to do it in the hospital. She might need a muscle biopsy. If everything comes back negative, we will also do a spinal fluid analysis on her; although, clinically, she really does not have Guillain Barre because of the intact reflexes. We will also do a brain CT scan and brain MRI.
Thank you for this neurological consultation.
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PITUITARY STUDY WITH AND WITHOUT CONTRAST
This study was performed using thin sections in sagittal and coronal planes with and without contrast. Whole head images were taken using T2 weighted and contrast-enhanced imaging as well. The contents of the sella are unchanged since the previous study. The size of the pituitary itself is stable. Its enhancement pattern again is homogeneous. There is no focal area that is definitely present suggesting a new or growing mass. The optic chiasm is midline. The parasellar structures appear unremarkable. The remaining portion of the exam likewise shows no evidence of abnormal signal within the gray or white matter of the cerebral hemispheres or of the cerebellar structures. No abnormal enhancement is noted throughout these areas. Today's examination does not show any incidental note of sinusitis of significance. Only minimal ethmoid sinus mucosal change is noted. The posterior fossa structures are unremarkable. The brainstem is unremarkable.
IMPRESSION:
1. Stable appearance of pituitary gland with and without contrast when compared to the previous study. No new or growing mass is suspected.
2. No abnormal enhancement is noted on whole head images as well.
IMPRESSION:
1. Stable appearance of pituitary gland with and without contrast when compared to the previous study. No new or growing mass is suspected.
2. No abnormal enhancement is noted on whole head images as well.
MRI OF THE RIGHT KNEE TRANSCRIPTION SAMPLE
Multiplanar images were obtained. The ACL and PCL are both intact. The collateral ligaments are intact. The menisci are within normal limits. There is no meniscal tear. The patella is abnormally low in position consistent with a patella baja. This may be seen in association with Osgood-Schlatter disease, which is traumatic disturbance of the tibial tuberosity. This may also be appreciated. Patella baja may be seen post surgery. There is no evidence of Osgood-Schlatter disease. There is no irregularity of the tibial tuberosity. There is some retropatellar fluid as well as fluid anterior and lateral to the ACL. The marrow signal within the bony structures is unremarkable. There is some very minimal increased signal in the patellar tendon on the T1 weighted sequences. While some of this may be partial volume averaging, some patellar tendon degeneration is also a consideration. This could be due to injury in this area.
IMPRESSION:
1. There is an abnormally low position of the patella consistent with patella baja. This may be seen in association with Osgood-Schlatter disease or patellar realignment surgeries. The patient has not had surgery. There is no evidence of Osgood-Schlatter disease on the MRI today.
2. There is some subtle increased signal in the patellar tendon on T1 weighted sequences for which some patellar tendon degeneration is not excluded. This may be due to some trauma in this area.
3. Menisci, collateral ligaments, cruciate ligaments are all unremarkable.
LEFT ANKLE AND FOOT MRI TRANSCRIPTION SAMPLE
Numerous images are taken in different orthogonal planes using different sequences. The ankle is not done as a full separate study but was incorporated into those images of the foot due to some positioning requirements of the patient. This is felt adequate to evaluate the ankle mortise but does not evaluate the distal tibia well. The bony structures of the ankle, the hindfoot, midfoot, and forefoot show no fractures or gross destructive processes. There is, however, some high signal involving the base of the fifth metatarsal bone, which could indicate some inflammation and therefore does not rule out infection possibilities. Again, the cortex is grossly intact, and this is a mild change. The cuboid is not involved and the shaft of the fifth metatarsal bone is not involved. At this point, this only resides at the base of that fifth metatarsal bone. None of the other bony structures show any significant change to suggest that they are inflamed or infected as well.
There are some areas of soft tissue edema and thickening. This is noted particularly along the lateral aspect of the posterior talus area. This does not involve the bone. The soft tissues do appear edematous and in some cases thickened and this does go down to the fascial plane. Again, the bone is not involved. There is another area of soft tissue edema suggested again, laterally, slightly more over the midfoot region. Again, the bones do not appear involved. There is also some edema suggested directly over the forefoot dorsally. I do not know if that is due to dependent edema or inflammation, as it is not focal but generalized. Again, the underlying bony structures are not involved other than that one area already described. Also, I do not see gross tendinitis on this exam or significant synovial fluid increases to suggest synovitis.
IMPRESSION:
1. There are areas of soft tissue change and edema, particularly laterally, which do not involve the underlying bony structures and do suggest primarily focal soft tissue infection or cellulitis.
2. The only bone which does show some mild increased signal is at the base of the fifth metatarsal bone. There is no cortical disruption or growth, anatomical destruction of this area at this time. Again, this suggests some mild inflammation such that one might see with possible infection. The cuboid is not involved nor is the shaft of the fifth metatarsal bone.
3. Those images, which do include the ankle mortise, do not show osteochondral defects in that area or definite evidence of a loose joint body.
MRI OF THE BRAIN AND ORBITS WITHOUT AND WITH CONTRAST
Multiplanar images were obtained. Coronal FLAIR images were included as well.
MRI OF THE BRAIN:
The craniocervical junction is within normal limits. There is no mass, mass effect, or shift of midline structures. The ventricles are symmetric. On the FLAIR sequences, there is no abnormal area of increased signal within the brain parenchyma. In particular, there are no abnormal areas of increased signal in the periventricular white matter to suggest MS. The IACs are symmetric and unremarkable. With contrast, there is no abnormal enhancing lesion.
IMPRESSION: Unremarkable noncontrast and contrast-enhanced MRI of the brain.
MRI OF THE ORBITS:
Multiplanar images were obtained without and with contrast. The optic nerves are symmetric and unremarkable. There is no enhancement following contrast administration. The recti muscles are also symmetric. There is no intraorbital mass or abnormality adjacent to the globe. The pituitary gland is also unremarkable.
IMPRESSION: Symmetric and unremarkable optic nerves. There is no abnormal area of increased signal within the optic nerves on the FLAIR sequences.
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Wound Care Terms and Products for Medical Transcriptionists (P-Z)
Panafil
PanoGauze
PanoPlex
Petrolatum Gauze Non-Adhering Dressing
POLYDERM
PolyMem
PolyMem
PolyMem QuadraFoam cavity filler
POLYSKIN II
POLYSKIN M.R.
polyurethane film dressing
PolyWic
Primaderm wound cleanser
Primapore
Primatrix
Primatrix
Primer
Prisma
Procellera antimicrobial wound dressing
ProCyte
Profore
Profore LF
Profore Lite
Profore Wound Contact Layer
ProGuide wound contact layer
Promogran Prisma wound dressing
Prospera PRO-I
Puri-Clens
Purilon
Qoustic Wound Therapy System
Regranex
Repair Hydrogel
Repair Wound Cleanser
RepliCare
Restore
Restore
Restore
Restore
Restore CalciCare
SAF-Clens
SafeWash Saline
SAF-Gel
Sea-Clens wound cleanser
SeaSorb
SelectSilver
SeptiCare
Setopress
Shur-Clens
SignaDRESS Sterile
Silon
Silon Dual-Dress 04P Multi-Function Wound Dressing
Silon Dual-Dress 04P Multi-Function Wound Dressing
Silon Dual-Dress 20F Multi-Function Wound Dressing
Silon Dual-Dress 20F Multi-Function Wound Dressing
Silon Dual-Dress 20F Multi-Function Wound Dressing
Silon-TSR Temporary Skin Replacement
Silon-TSR Temporary Skin Replacement
SilvaGard surface engineered antimicrobial treatment
SilvaKollagen Gel
SilvaSorb
Silver Seal
SILVERCELL
SilverDerm7
Silverlon
skin substitute
Skin Tegrity
Skin Temp
Skintegrity
SOFSORB
SoloSite
SoloSite Gel Conformable
SonicOne ultrasonic wound care system
Sonoca-180 ultrasonic-assisted wound treatment
Sorbact antimicrobial wound dressing
Sorbalgon
SORBSAN
Stimulen
StrataSorb
SurePress
SureSite
Techni-Care
Tegaderm
Tegaderm HP
Tegaderm Trasparent Dressing with Absorbent Pad
Tegagel
Tegagel
Tegagen HG
Tegagen HI
Tegapore
Tegasorb
Tegasorb THIN
TELFA
TELFA AMD
TELFA CLEAR
TELFAMAX
TENDERSORB ABD
TENDERWRAP
TheraGauze sterile polymer wound care dressing
Thermazene cream
TIELLE Lite dressing
tissue engineering and growth factors
Transcyte
TRANSEAL
transparent film dressing
Tricofix
Tru-Area Determination
Ultec
undermining
UniFlex
UNNA-FLEX
Unna-Pak
V.A.C.
Various
Vashe Wound Therapy
venous stasis
VENTEX
Versajet Hydrosurgery System
Versatile 1, V1STA
viable tissue
Viasorb
Vigi-FOAM
Vigilon
wound base
wound cleanser
wound fillers
wound margin
Wound Wash Saline
WoundEaze mechanical cleansing/debriding
Woundgard Bordered Gauze Dressing
Woun'Dres
WOUN'DRESS
WoundTek's S.T.A.R. Device
XCell AM
Xelma
Ziox Ointment
Wound Care Terms and Products List Part 1 Wound Care Terms and Products Part 2
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PanoGauze
PanoPlex
Petrolatum Gauze Non-Adhering Dressing
POLYDERM
PolyMem
PolyMem
PolyMem QuadraFoam cavity filler
POLYSKIN II
POLYSKIN M.R.
polyurethane film dressing
PolyWic
Primaderm wound cleanser
Primapore
Primatrix
Primatrix
Primer
Prisma
Procellera antimicrobial wound dressing
ProCyte
Profore
Profore LF
Profore Lite
Profore Wound Contact Layer
ProGuide wound contact layer
Promogran Prisma wound dressing
Prospera PRO-I
Puri-Clens
Purilon
Qoustic Wound Therapy System
Regranex
Repair Hydrogel
Repair Wound Cleanser
RepliCare
Restore
Restore
Restore
Restore
Restore CalciCare
SAF-Clens
SafeWash Saline
SAF-Gel
Sea-Clens wound cleanser
SeaSorb
SelectSilver
SeptiCare
Setopress
Shur-Clens
SignaDRESS Sterile
Silon
Silon Dual-Dress 04P Multi-Function Wound Dressing
Silon Dual-Dress 04P Multi-Function Wound Dressing
Silon Dual-Dress 20F Multi-Function Wound Dressing
Silon Dual-Dress 20F Multi-Function Wound Dressing
Silon Dual-Dress 20F Multi-Function Wound Dressing
Silon-TSR Temporary Skin Replacement
Silon-TSR Temporary Skin Replacement
SilvaGard surface engineered antimicrobial treatment
SilvaKollagen Gel
SilvaSorb
Silver Seal
SILVERCELL
SilverDerm7
Silverlon
skin substitute
Skin Tegrity
Skin Temp
Skintegrity
SOFSORB
SoloSite
SoloSite Gel Conformable
SonicOne ultrasonic wound care system
Sonoca-180 ultrasonic-assisted wound treatment
Sorbact antimicrobial wound dressing
Sorbalgon
SORBSAN
Stimulen
StrataSorb
SurePress
SureSite
Techni-Care
Tegaderm
Tegaderm HP
Tegaderm Trasparent Dressing with Absorbent Pad
Tegagel
Tegagel
Tegagen HG
Tegagen HI
Tegapore
Tegasorb
Tegasorb THIN
TELFA
TELFA AMD
TELFA CLEAR
TELFAMAX
TENDERSORB ABD
TENDERWRAP
TheraGauze sterile polymer wound care dressing
Thermazene cream
TIELLE Lite dressing
tissue engineering and growth factors
Transcyte
TRANSEAL
transparent film dressing
Tricofix
Tru-Area Determination
Ultec
undermining
UniFlex
UNNA-FLEX
Unna-Pak
V.A.C.
Various
Vashe Wound Therapy
venous stasis
VENTEX
Versajet Hydrosurgery System
Versatile 1, V1STA
viable tissue
Viasorb
Vigi-FOAM
Vigilon
wound base
wound cleanser
wound fillers
wound margin
Wound Wash Saline
WoundEaze mechanical cleansing/debriding
Woundgard Bordered Gauze Dressing
Woun'Dres
WOUN'DRESS
WoundTek's S.T.A.R. Device
XCell AM
Xelma
Ziox Ointment
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Wound Care Terms and Products for Medical Transcriptionists (E-O)
Elta Dermal
Elta Dermal
Elta Dermal
Engenex
enzymatic debriding agent
EPIFLO - Transdermal sustained delivery of oxygen
Ethezyme 830 Papain Urea Debriding Ointment
Ethezyme Papain-Urea Debriding Ointment
Excilon AMD
ExSept Plus wound cleanser
ExuDERM
EXU-DRY
Exuviance concealing Treatment Makeup'
FIBRACOL plus Collagen
FLEXDERM
FlexiGel
FLEXZAN
foam dressing
Foam Dressing
FyBron
GammaGraft
Gelocast Unna Boot
Gentell
Gentell
Gladase
GRAFTJACKET Xpress Flowable Soft-Tissue Scaffold
GRAFTJACKET Regenerative Tissue Matrix-Ulcer Repair
Humatrix Microclysmic Gel
Hyalofil-F
Hyalofil-R
hyCURE
hyCURE Smart Gel
Hydrocol
hydrocolloid dressing
Hydrofera Blue
Hydrofera Blue
Hydrofiber dressing
hydrogel dressing
hydrogel impregnated gauze dressing
hydrogel sheet dressing
Hypergel
Hyperion Advanced Alginate Dressing
Hyperion Hydrophilic Wound Dressings
Hyperion Wound Cleanser
Iamin
Iamin
Integra
INTEGRA-GEL
Intersorb dry gauze bandage
IntraSite
Invia
IODOFLEX
IODOFLEX
IODOSORB
Jetox-ND Lavage System
KALGINATE
KALTOSTAT
Kerlix AMD
Kovia Ointment
Lyofoam
Lyofoam A
Lyofoam C
LyoFoam C
Lyofoam Extra
Lyofoam T
MatriStem wound sheet
Maxorb
Maxorb Extra Ag
Medifil
MEDIHONEY dressing
Medipore
Mefilm
Melgisorb
Mepiform
Mepilex
Mepilex Border
Mepitel
Mepore
Mepore Pro
Mesalt
MicroLattice Matrix
Mitraflex
Mitraflex Plus
MPM
MPM Antimicrobial
MPM Conductive Gel Pad
MPM GelPad
Multidex Gel or Powder
Multidex Spray
MULTIPAD
negative pressure wound therapy
Normlgel
Normlgel Impregnated Gauze
N-TERFACE
NU-DERM
NU-GEL
NU-GEL
Oasis
occlusive dressing
Odor Absorbing Dressing
Oleeva
On-Q silver dressing
OpSite
OpSite FLEXIGRID
OpSite Plus
OpSite Post-Op
Optifoam AG
Optipore Sponge
Orcel
OxyGenesys dissolved oxygen dressing
Wound Care Terms and Products List
Wound Care Terms and Products List Part 1
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Elta Dermal
Elta Dermal
Engenex
enzymatic debriding agent
EPIFLO - Transdermal sustained delivery of oxygen
Ethezyme 830 Papain Urea Debriding Ointment
Ethezyme Papain-Urea Debriding Ointment
Excilon AMD
ExSept Plus wound cleanser
ExuDERM
EXU-DRY
Exuviance concealing Treatment Makeup'
FIBRACOL plus Collagen
FLEXDERM
FlexiGel
FLEXZAN
foam dressing
Foam Dressing
FyBron
GammaGraft
Gelocast Unna Boot
Gentell
Gentell
Gladase
GRAFTJACKET Xpress Flowable Soft-Tissue Scaffold
GRAFTJACKET Regenerative Tissue Matrix-Ulcer Repair
Humatrix Microclysmic Gel
Hyalofil-F
Hyalofil-R
hyCURE
hyCURE Smart Gel
Hydrocol
hydrocolloid dressing
Hydrofera Blue
Hydrofera Blue
Hydrofiber dressing
hydrogel dressing
hydrogel impregnated gauze dressing
hydrogel sheet dressing
Hypergel
Hyperion Advanced Alginate Dressing
Hyperion Hydrophilic Wound Dressings
Hyperion Wound Cleanser
Iamin
Iamin
Integra
INTEGRA-GEL
Intersorb dry gauze bandage
IntraSite
Invia
IODOFLEX
IODOFLEX
IODOSORB
Jetox-ND Lavage System
KALGINATE
KALTOSTAT
Kerlix AMD
Kovia Ointment
Lyofoam
Lyofoam A
Lyofoam C
LyoFoam C
Lyofoam Extra
Lyofoam T
MatriStem wound sheet
Maxorb
Maxorb Extra Ag
Medifil
MEDIHONEY dressing
Medipore
Mefilm
Melgisorb
Mepiform
Mepilex
Mepilex Border
Mepitel
Mepore
Mepore Pro
Mesalt
MicroLattice Matrix
Mitraflex
Mitraflex Plus
MPM
MPM Antimicrobial
MPM Conductive Gel Pad
MPM GelPad
Multidex Gel or Powder
Multidex Spray
MULTIPAD
negative pressure wound therapy
Normlgel
Normlgel Impregnated Gauze
N-TERFACE
NU-DERM
NU-GEL
NU-GEL
Oasis
occlusive dressing
Odor Absorbing Dressing
Oleeva
On-Q silver dressing
OpSite
OpSite FLEXIGRID
OpSite Plus
OpSite Post-Op
Optifoam AG
Optipore Sponge
Orcel
OxyGenesys dissolved oxygen dressing
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Wound Care Terms and Products for Medical Transcriptionists (A-D)
3M Cavilon
3M Cavilon No Sting Barrier Film
3M Coban 2 layer
3M Tegaderm Ag Mesh
3M Tegaderm Hydrocolloid Thin Dressing
4-Layer Compression
Absorptive Border
absorptive dressing
Accuzyme
AcryDerm Strands
Acticoat 3
Acticoat 7
Acticoat Moisture Control
Actisorb
Adaptic Touch
AIRSTRIP
AlgiCell
AlgiDERM
Algidex
Algidex
alginate dressing
AlgiSite M
ALLCLENZ
Alldress
Allevyn Adhesive
Allevyn Cavity
Allevyn Compression
Allevyn Dressing
Allevyn Heel
Allevyn Island
Allevyn Sacral
Allevyn Tracheostomy
Alloderm
Altrazeal Transforming Powder Dressing
Amerigel Topical Ointment
AmeriGel wound dressing
Anasept
antimicrobial dressing
Apligraf
Apligraf
AQUACEL
Aquacel Ag
Aquacel Hydrofiber
Aquacel Ribbon
AQUASORB
Arglase
ArtAssist
Artiflex
Askina Sorg
AutoloGel System
Bard Absorption Dressing
Bard Vigilon Primary Wound Dressing
BGC Matrix
BGC Matrix
BIAFINE
Biobrane
BIOCLUSIVE
BIOCLUSIVE MVP
Biolex
Biolex
BIOPATCH
Biostep
Biostep Ag
Blisterfilm
CarboFlex
CarraFilm
CarraGauze
CarraGinate with Acemannan gel
CarraSorb
CarraSorb H
Carrasyn
CellerateRx
Centurion SorbaView
Cica-Care
Circulator Boot
CIRCULON
Clean 'N Moist
ClearSite
ClearSite
Clinical Care
ClinsWound wound cleanser
ColActive Ag
ColActive Ag
collage dressing
Collagen/AG
Collagenase
Collagenase Santyl Ointment
CombiDERM
Comfeel
Comfortell composite wound dressing
composite dressing
compressive dressing
compressive wrap
Comprilan
Conformant 2 Wound Veil
Constant-Clens dermal wound cleanser
Contreet
COVADERM
Coverlet
Coverlet
CovRSite Plus Composite Dressing
CURAFIL
CURAFIL
CURAFOAM
CURAGEL
Curasalt Sodium Chloride Dressing
CURASOL
CURASOL
Curasorb calcium alginate dressing
CURITY ABD
Curity AMD
Cuticell sterile ointment dressing
Cutifilm
Cutinova Cavity
Cutinova Hydro
Cutinova Thin
DEBRISAN
Dermabond
Dermacea
DermaClose RC
DermaFilm HD
DermaFilm Thin
DermaGauze
Derma-Gel
DermaGinate
DermaGinate AG
Dermagraft
Dermagraft
Dermagran
Dermagran
Dermagran
DermaKlenz
DERMANET
DermAssist
DermAssist
DermaSyn
DermaView
DeRoyal Xeroform gauze dressing
DIAB GEL
Di-Dak-Sol wound irrigant or cleanser
DP Woundcare Dressing
DuoDERM
DuoDERM
DuoDERM CGF
DuoDERM SCB
DYNA-FLEX
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3M Cavilon No Sting Barrier Film
3M Coban 2 layer
3M Tegaderm Ag Mesh
3M Tegaderm Hydrocolloid Thin Dressing
4-Layer Compression
Absorptive Border
absorptive dressing
Accuzyme
AcryDerm Strands
Acticoat 3
Acticoat 7
Acticoat Moisture Control
Actisorb
Adaptic Touch
AIRSTRIP
AlgiCell
AlgiDERM
Algidex
Algidex
alginate dressing
AlgiSite M
ALLCLENZ
Alldress
Allevyn Adhesive
Allevyn Cavity
Allevyn Compression
Allevyn Dressing
Allevyn Heel
Allevyn Island
Allevyn Sacral
Allevyn Tracheostomy
Alloderm
Altrazeal Transforming Powder Dressing
Amerigel Topical Ointment
AmeriGel wound dressing
Anasept
antimicrobial dressing
Apligraf
Apligraf
AQUACEL
Aquacel Ag
Aquacel Hydrofiber
Aquacel Ribbon
AQUASORB
Arglase
ArtAssist
Artiflex
Askina Sorg
AutoloGel System
Bard Absorption Dressing
Bard Vigilon Primary Wound Dressing
BGC Matrix
BGC Matrix
BIAFINE
Biobrane
BIOCLUSIVE
BIOCLUSIVE MVP
Biolex
Biolex
BIOPATCH
Biostep
Biostep Ag
Blisterfilm
CarboFlex
CarraFilm
CarraGauze
CarraGinate with Acemannan gel
CarraSorb
CarraSorb H
Carrasyn
CellerateRx
Centurion SorbaView
Cica-Care
Circulator Boot
CIRCULON
Clean 'N Moist
ClearSite
ClearSite
Clinical Care
ClinsWound wound cleanser
ColActive Ag
ColActive Ag
collage dressing
Collagen/AG
Collagenase
Collagenase Santyl Ointment
CombiDERM
Comfeel
Comfortell composite wound dressing
composite dressing
compressive dressing
compressive wrap
Comprilan
Conformant 2 Wound Veil
Constant-Clens dermal wound cleanser
Contreet
COVADERM
Coverlet
Coverlet
CovRSite Plus Composite Dressing
CURAFIL
CURAFIL
CURAFOAM
CURAGEL
Curasalt Sodium Chloride Dressing
CURASOL
CURASOL
Curasorb calcium alginate dressing
CURITY ABD
Curity AMD
Cuticell sterile ointment dressing
Cutifilm
Cutinova Cavity
Cutinova Hydro
Cutinova Thin
DEBRISAN
Dermabond
Dermacea
DermaClose RC
DermaFilm HD
DermaFilm Thin
DermaGauze
Derma-Gel
DermaGinate
DermaGinate AG
Dermagraft
Dermagraft
Dermagran
Dermagran
Dermagran
DermaKlenz
DERMANET
DermAssist
DermAssist
DermaSyn
DermaView
DeRoyal Xeroform gauze dressing
DIAB GEL
Di-Dak-Sol wound irrigant or cleanser
DP Woundcare Dressing
DuoDERM
DuoDERM
DuoDERM CGF
DuoDERM SCB
DYNA-FLEX
Wound Care Terms and Products List Wound Care Terms and Products Part 2
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DISCHARGE SUMMARY MEDICAL TRANSCRIPTION SAMPLE
ADMITTING DIAGNOSES:
1. Right-sided chest pain and shortness of breath, musculoskeletal versus postcardiotomy syndrome.
2. Diabetes.
3. History of hypothyroidism.
4. Hyperlipidemia.
5. History of redo coronary artery bypass grafting.
6. Prior history of obesity.
7. History of degenerative joint disease, status post previous spinal fusion.
8. History of dysfunctional uterine bleeding, status post dilatation and curettage.
DISCHARGE DIAGNOSES:
1. Right-sided chest pain and shortness of breath, musculoskeletal versus postcardiotomy syndrome.
2. Diabetes.
3. History of hypothyroidism.
4. Hyperlipidemia.
5. History of redo coronary artery bypass grafting.
6. Prior history of obesity.
7. History of degenerative joint disease, status post previous spinal fusion.
8. History of dysfunctional uterine bleeding, status post dilatation and curettage.
9. Uncontrolled blood glucose secondary to steroids.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: This pleasant (XX)-year-old patient, recently discharged after a CABG, presented to the hospital after the visiting nurse found her to have some chest pain and shortness of breath. She was brought to the ER. She was started on steroids. She was ruled out for another MI. A CT chest was done to rule out PE. She was ruled out for all that and did well on steroids. She had uncontrolled blood glucose secondary to steroids. Her medications were increased. Oral hypoglycemics were increased with improvement in her glucose control.
LABORATORIES AND CT: CT chest shows no evidence of pulmonary embolism, bibasilar infiltrate, bilateral effusions, aortopulmonary window adenopathy, atherosclerotic disease of the aorta. She had a white count of 12.5, hemoglobin of 10.4, and platelet count of 366,000. PT/INR was within normal range, and her BMP with sodium 133, potassium 5.2, chloride 94, CO2 of 26, glucose 303, BUN 26, creatinine 0.7, and calcium 9.2.
DISCHARGE DIRECTIONS: She was discharged to an extended care facility on tapering dose of steroids and her home medications. She would follow up with Cardiology in 1 to 2 weeks and follow up with Pulmonary in 1 to 2 weeks.
1. Right-sided chest pain and shortness of breath, musculoskeletal versus postcardiotomy syndrome.
2. Diabetes.
3. History of hypothyroidism.
4. Hyperlipidemia.
5. History of redo coronary artery bypass grafting.
6. Prior history of obesity.
7. History of degenerative joint disease, status post previous spinal fusion.
8. History of dysfunctional uterine bleeding, status post dilatation and curettage.
DISCHARGE DIAGNOSES:
1. Right-sided chest pain and shortness of breath, musculoskeletal versus postcardiotomy syndrome.
2. Diabetes.
3. History of hypothyroidism.
4. Hyperlipidemia.
5. History of redo coronary artery bypass grafting.
6. Prior history of obesity.
7. History of degenerative joint disease, status post previous spinal fusion.
8. History of dysfunctional uterine bleeding, status post dilatation and curettage.
9. Uncontrolled blood glucose secondary to steroids.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: This pleasant (XX)-year-old patient, recently discharged after a CABG, presented to the hospital after the visiting nurse found her to have some chest pain and shortness of breath. She was brought to the ER. She was started on steroids. She was ruled out for another MI. A CT chest was done to rule out PE. She was ruled out for all that and did well on steroids. She had uncontrolled blood glucose secondary to steroids. Her medications were increased. Oral hypoglycemics were increased with improvement in her glucose control.
LABORATORIES AND CT: CT chest shows no evidence of pulmonary embolism, bibasilar infiltrate, bilateral effusions, aortopulmonary window adenopathy, atherosclerotic disease of the aorta. She had a white count of 12.5, hemoglobin of 10.4, and platelet count of 366,000. PT/INR was within normal range, and her BMP with sodium 133, potassium 5.2, chloride 94, CO2 of 26, glucose 303, BUN 26, creatinine 0.7, and calcium 9.2.
DISCHARGE DIRECTIONS: She was discharged to an extended care facility on tapering dose of steroids and her home medications. She would follow up with Cardiology in 1 to 2 weeks and follow up with Pulmonary in 1 to 2 weeks.
MRI OF THE BRAIN/PITUITARY/ORBITS WITHOUT AND WITH CONTRAST TRANSCRIBED EXAMPLE
Multiplanar images were obtained without and with contrast. The craniocervical junction is within normal limits. There is a pituitary mass predominantly along the right and centrally, measuring 2.3 cm CC x 2.4 cm AP x 1.6 cm transverse. The mass has an ovoid configuration with a superior convex border. The mass does deviate the stalk to the left. The mass enhances with contrast and does extend along the superior and inferior surface of the right carotid artery. The mass is fairly homogeneous on T1 pre- and post-contrast images and again enhances homogeneously. The ventricles are symmetric. There are no other masses, mass effects or shift of midline structures. There is some mild high signal on the T2 weighted axial images in the right mastoid air cell suggestive of some mild infectious, inflammatory-type process. The IACs are symmetric. There is no evidence of an intraorbital mass. The globes are symmetric. The recti muscles are symmetric. Optic nerves are unremarkable as well. There are postsurgical changes in the sphenoid sinus.
IMPRESSION: Large mass involving the pituitary gland that is more right sided, measuring approximately 2.3 x 2.4 x 1.6 cm and causes deviation of the stalk to the left. This is suggestive of a recurrent macroadenoma. The mass does extend along the superior and inferior aspect of the right carotid artery.
BRAIN MRI WITH AND WITHOUT GADOLINIUM AND INTERNAL AUDITORY CANAL STUDY TRANSCRIBED SAMPLE
Images through the head were taken both with and without contrast in the normal fashion. No evidence of abnormal enhancement is seen on the thin section coronal and axial images through the internal auditory canal or cerebellopontine angle regions. The cerebral and cerebellar hemispheres also reveal no focal abnormal enhancement to suggest a mass in any of these areas. The venous drainage pattern does suggest a slight irregularity in the left sigmoid sinus, in the posterior fossa. It was persistent on several images. It is unclear whether this could represent some mixed drainage flow or perhaps a very small thrombus. If this would correspond to any symptoms of the patient, one may want to proceed to an MRV. FLAIR images do not show evidence of white matter lesions to indicate demyelination and ischemic or other disease. Development of gray and white matter is within normal limits. No sellar or parasellar changes are indicated. The brain stem is intact. No significant sinus disease is indicated. This includes the mastoid air cell sinuses as well.
IMPRESSION:
1. No internal auditory canal acoustic neuroma or other tumors are indicated in the cerebellopontine angle of internal auditory canal region. No abnormal enhancement throughout the study and no abnormalities to gray or white matter is seen.
2. Slight irregularity noted in the left sigmoid sinus may be due to different venous drainage patterns or perhaps indicate a very small thrombus in that region. If this would correlate to the patient’s symptoms, then MRV may be helpful.
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Mental Status Examination Samples / Examples Part 2
MENTAL STATUS EXAMINATION: Upon admission showed a medium-built male with good eye contact. Affect was flat. Oriented x2. There was some partial insight into his condition. Judgment appeared to be poor. Behavior was passively cooperative during examination. Denied any current suicidal or homicidal ideation. Claims to have auditory and visual hallucinations, which on retrospect seems somewhat suspect. Memory appeared to be intact. Cognitive functioning was judged to be impaired. Speech was unremarkable. Trend of thoughts, the patient claims visual hallucinations at bedtime only. Mood appeared to be depressed. Intelligence was average or lower. Reality testing was grossly intact.
MENTAL STATUS EXAMINATION: He is a (XX)-year-old male who is fairly well groomed. He appeared his stated age. There was clinical evidence of psychomotor agitation. He has difficulty maintaining eye contact. His speech is somewhat coherent, spontaneous, appropriate with normal rate, volume and rhythm. He described his mood as depressed. Objectively, his mood was dysphoric. His affect was restricted, sad, despondent and he was unable to display spontaneous emotional reactivity. There were clinical features suggestive of severe depression. His behavior, however, is appropriate. His memory is intact for recent and remote events. He is well oriented to place, time and person. His concentration and attention appeared to be impaired. His general level of intelligence and fund of knowledge appeared to be within normal limits. His level of personal hygiene was fairly good. He was able to communicate clearly and he was able to achieve goal directed ideas. At the time of the evaluation, he denied any suicidal or homicidal ideation. His level of abstract reasoning is within normal limits. He was able to maintain adequate rapport with me throughout the interview, and he was able to follow directions. He denied any ideation of worthlessness or hopelessness. He denied any auditory or visual hallucinations. He has good insight into the nature of his mental illness.
MENTAL STATUS EXAMINATION: He is a (XX)-year-old male who is well groomed and appeared his stated age. During the interview, he was pleasant and cooperative and displayed a positive attitude. He went into details, the circumstances surrounding his admission. He was able to maintain adequate eye contact. His speech was coherent, spontaneous and appropriate with normal rate, volume and rhythm. He described his mood as depressed. Objectively, his mood was euthymic. His affect is somewhat restricted but he was able to display spontaneous emotional reactivity. At the time of the clinical evaluation, I could not elicit any clinical features of affective or psychotic illness. His behavior was appropriate. His memory was intact for recent and remote events. He was well oriented to place, time and person. His concentration and attention were both adequate. He was able to do serial 7s. His general level of intelligence and fund of general knowledge are adequate and appropriate for his age. His level of personal hygiene was fairly good. He was able to communicate clearly and he was able to achieve goal directed ideas without any difficulty. He denied any suicidal or homicidal ideation. His level of abstract reasoning was intact. I was able to establish adequate rapport with him throughout the interview and he was able to follow directions. He denied any ideation of worthlessness or hopelessness. He denied any auditory or visual hallucinations. He denied any preoccupation, illusions or phobia. He has a fair amount of insight into the nature of his depression.
MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old male who is fairly well groomed and appeared his stated age. During the interview, there was no clinical evidence of psychomotor disturbance. He was able to maintain adequate eye contact. His speech was coherent, spontaneous and appropriate with normal rate, volume and rhythm. He described his mood as normal. Objectively, his mood was euthymic. His affect was full range and appropriate with spontaneous emotional reactivity. There were no clinical features of affective or psychotic illness. His behavior was appropriate. His memory was intact for recent and remote events. He was well oriented to place, time and person. His concentration and attention were both adequate. He was able to do serial 7s and able to subtract and add without difficulty. His general level of intelligence is average. His fund of general knowledge is adequate. His level of personal hygiene is good. He was able to communicate clearly and his use of language was quite sophisticated. He was able to achieve goal directed ideas without any significant difficulty. He denied any suicidal or homicidal ideation. His level of abstract reasoning was intact. I was able to maintain adequate rapport with him throughout the interview and he was able to follow directions. He denied any ideation of worthlessness or hopelessness. He denied any hallucinatory experiences. He denied any preoccupation, illusions or phobia. He has very poor insight into the nature of his dysfunctional behavior. His judgment is impaired.
MENTAL STATUS EXAMINATION: The patient presents as a (XX)-year-old male who appears to be about his stated age. He is neatly and appropriately dressed. He is a pleasant but somewhat subdued conversationalist. He does show appropriate affective response throughout the interview. He is able to give a lucid, coherent and generally consistent history. He presents considerable insight into the effects of drugs on his life. The patient currently denies lowered mood or anhedonia and presents no suicidal ideation and is in fact very much hopeful and future oriented. He presents no pressured speech, flight of ideas or delusional grandiosity. He presents no irritability or pugnaciousness. He does not appear to be particularly distressed or anxious. I assessed him to be of approximately average intelligence by his vocabulary, usage and fund of general information. He presents no delusional system, disorganization, paranoia, extreme affect flattening or withdrawal consistent with formal thought disorder.
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Physical Examination Medical Transcription Words / Sample MT Reference
PHYSICAL EXAMINATION: Vital Signs: The patient's temperature is 97.8 degrees, pulse is 74, respirations 19 and blood pressure is 154/96. General: This is an obese female who is in no apparent distress. Neurologic: The patient is alert and oriented to person, place and time. Her speech is fluent. Language is intact. Both short-term and long-term memory adequate. Cranial Nerve Examination: Pupils are equal and reactive at 3 mm and brisk. Extraocular movements are intact. Visual fields are intact. Accommodation is intact. Corneal reflex is intact. Hearing is intact to finger rub. There is no facial asymmetry. Tongue is midline with good palate elevation. Motor examination reveals the patient to have full strength, 5/5, in all four extremities. There is no pronator drift, fasciculations or atrophy. Deep tendon reflexes are physiologic and symmetric in all four extremities. The patient's fine motor coordination is intact with finger-to-nose and heel-to-shin testing performed bilaterally. The patient's Romberg is negative. Tandem gait is steady. Wide-based gait is steady. The patient is walking around in the room with no apparent distress. Sensory Examination: There is no asymmetry of either body half or face to primary modalities. Cardiovascular: S1, S2, regular. Respiratory: Lungs are clear.
PHYSICAL EXAMINATION: Afebrile, blood pressure 132/90, heart rate 74, and respirations 14. In general, an elderly Hispanic female in no acute distress. HEENT: Normocephalic and atraumatic. Neck: Supple. No jugular venous distention or carotid artery bruits. Lungs: Clear. Respirations unlabored. Heart: Regular rate and rhythm. S1 and S2. No extra heart sounds or murmurs. PMI nondisplaced. Abdomen: Soft and nontender. Bowel sounds are present. Extremities: Demonstrate no peripheral edema. Neurologic: Alert, oriented, and grossly nonfocal.
PHYSICAL EXAMINATION: Vital Signs: Temperature is 98.4 degrees, pulse 78, respiratory rate 15 and blood pressure 132/82. General: He is a well-developed male, sedated, arouses, moves all four extremities, attempts to follow simple commands. HEENT: Male pattern alopecia. Pupils are conjugate. Oral endotracheal tube is in good position. Neck: Reveals no jugular venous distention, bruits, adenopathy, use of accessory muscles. Lungs: Lung fields reveal bibasilar crackles. Heart: No gallop or murmur. Abdomen: Distended, protuberant, hypoactive bowel sounds; otherwise, benign without organomegaly. The umbilical incision is clean and dressed. Genitourinary: Foley catheter is in place. Extremities: Reveals no clubbing, cyanosis or edema. Negative Homans sign. No palpable cords. Neurologic: He is sedated, otherwise nonfocal.
PHYSICAL EXAMINATION: Afebrile, blood pressure 132/90, heart rate 74, and respirations 14. In general, an elderly Hispanic female in no acute distress. HEENT: Normocephalic and atraumatic. Neck: Supple. No jugular venous distention or carotid artery bruits. Lungs: Clear. Respirations unlabored. Heart: Regular rate and rhythm. S1 and S2. No extra heart sounds or murmurs. PMI nondisplaced. Abdomen: Soft and nontender. Bowel sounds are present. Extremities: Demonstrate no peripheral edema. Neurologic: Alert, oriented, and grossly nonfocal.
PHYSICAL EXAMINATION: Vital Signs: Temperature is 98.4 degrees, pulse 78, respiratory rate 15 and blood pressure 132/82. General: He is a well-developed male, sedated, arouses, moves all four extremities, attempts to follow simple commands. HEENT: Male pattern alopecia. Pupils are conjugate. Oral endotracheal tube is in good position. Neck: Reveals no jugular venous distention, bruits, adenopathy, use of accessory muscles. Lungs: Lung fields reveal bibasilar crackles. Heart: No gallop or murmur. Abdomen: Distended, protuberant, hypoactive bowel sounds; otherwise, benign without organomegaly. The umbilical incision is clean and dressed. Genitourinary: Foley catheter is in place. Extremities: Reveals no clubbing, cyanosis or edema. Negative Homans sign. No palpable cords. Neurologic: He is sedated, otherwise nonfocal.
PHYSICAL EXAMINATION: General: The patient is a pleasant female who appears to be in no apparent distress. Vital Signs: Currently, blood pressure 123/48, heart rate 76, and pulse oximetry is 98% on 2 liters of oxygen by nasal cannula. HEENT: Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Neck: Supple. No jugular vein distention noted. No carotid bruits noted. Lungs: Clear to auscultation bilaterally. No wheezes, rubs or rhonchi. Heart: Regular rate and rhythm. Normal S1, S2. A 2/6 to 3/6 systolic ejection murmur at the right upper sternal border. PMI is nondisplaced. Abdomen: Notable for laparoscopy surgical wound. Positive bowel sounds. Extremities: No cyanosis, clubbing or edema. Peripheral pulses are palpable and symmetrical. Neurologic: The patient is alert and oriented x3. No focal neurologic deficits noted.
PHYSICAL EXAMINATION: On initial physical exam, temperature 97.8, respirations 16, blood pressure 102/58, pulse 82 and regular. In general, the patient is a well-developed, well-nourished female, in no acute distress at the time of presentation. HEENT exam is significant for pupils constricted and nonreactive. Mucous membranes moist with no oral lesions. Neck is supple with no thyromegaly. Respiratory exam reveals bilaterally equal air entry with no wheezes or rhonchi. Cardiovascular exam reveals PMI not palpable, regular rate and rhythm. S1, S2, with no murmur. Pedal pulses are present and there is no pedal edema. GI exam reveals abdomen to be soft, nontender, nondistended with positive bowel sounds and no masses. Musculoskeletal exam reveals strength 5/5 in bilateral upper and lower extremities. Skin exam reveals no suspicious-looking lesions and no pressure ulcers. Neurologic exam reveals cranial nerves II through XII to be grossly intact with intact sensation bilaterally. Psychiatric exam reveals the patient to be alert and oriented x3 with appropriate mood and affect, slightly anxious.
PHYSICAL EXAMINATION ON ADMISSION: General: Well-developed, well-nourished, white female in mild distress. HEENT: Head is normocephalic. She does have an abrasion on her left forehead and there is a left anterior/superior skull abrasion. Pupils equal, round, and reactive to light. Extraocular movements intact. No pain at TMJ. Neck: Cervical C-collar in place. No pain on palpation. Cardiovascular: Regular rate and rhythm. Clear S1, S2. Respiratory: Lungs clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Musculoskeletal: Right lower extremity: The patient resting with right hip flexed but not significantly rotated. No active range of motion of the right hip secondary to pain. Pain with all passive range of motion of the right hip as well. Mild tenderness to palpation at the right lateral knee. Right knee active range of motion limited by hip pain. The patient tolerates passive range of motion of the right knee well. Mild AP instability noted at the right knee while the patient was under conscious sedation for reduction of her right hip, which was posteriorly dislocated at the time of admission but well reduced under conscious sedation. Bilateral upper extremities and left lower extremity reveal no deformity, no tenderness to palpation. Full pain-free active range of motion in all joints with 5/5 strength in all major muscle groups and sensation intact to light touch throughout with no gross instability and brisk distal capillary refill. It should also be noted that the patient never displayed any neuro deficits in her right lower extremity with sensation intact to light touch throughout the right lower extremity and 5/5 strength in her tibialis anterior, extensor hallucis longus and gastroc-soleus musculature.
PHYSICAL EXAMINATION: Vital Signs: Temperature 100.2, respiratory rate 28, blood pressure 122/88, pulse rate 96, and 98% oxygen saturation on 2 liters nasal cannula. General Appearance: No acute distress. Eyes: PERRLA. EOMI. ENT: Normal nasal mucosa. Oral mucosa is moist without evidence of exudates or lesions. Neck: No adenopathy or masses were appreciated. Thyroid was normal. Respiratory: Increased respiratory effort was appreciated. Decreased air entry bilaterally. Crackles at the left base. Cardiovascular: Regular rate and rhythm. Normal S1, S2. No S3, S4, murmurs, rubs or clicks were appreciated. No JVD, no pedal edema, 2+ pedal pulses. Abdomen: Soft, nontender, nondistended, positive bowel sounds throughout. No organomegaly. No abdominal bruits were appreciated. GU: Normal testes and penis. Lymphatics: No neck or axillary adenopathy was appreciated. Musculoskeletal: The patient did have 4/5 strength in the upper and lower extremities bilaterally. The patient appeared to have normal muscle tone throughout. Skin: The patient had no rashes or lesions. However, did have dry, scaly skin on the lower extremities bilaterally. Neurologic: Cranial nerves II through XII are grossly intact bilaterally. DTRs were normal at the level of the patellar and Achilles tendons. No focal motor or sensory deficits were appreciated. Psychiatric: Normal judgment and insight. The patient was alert and oriented x3. Recent and remote memory intact. Mood and affect were normal.
PHYSICAL EXAMINATION: General: Emaciated male, appearing older than stated age with very poor hygiene. Vital Signs: At the time that he came into the ER, temperature 97.4, pulse 72, respiratory rate 18, blood pressure 189/101. Denied any pain. At the time of examination, the patient's blood pressure was 176/87 with a heart rate of 94. Skin: Turgor is fair. No rashes, bruises or open areas noted. However, there was one area on the outer part of his right ankle, approximately the size of a nickel, that was scabbed over. HEENT: Normocephalic, atraumatic. PERRL. No conjunctival injection. Sclerae anicteric. EOMs intact. Visual fields are within normal limits. Ears are free of tenderness or discharge. Tympanic membranes are clearly visible in the right ear, pearly gray with landmarks clearly visible. Left ear unable to visualize due to cerumen. Nares patent. Free of redness, inflammation or discharge. Mouth, the patient has no upper teeth. Denies having dentures. He has one to two teeth on the bottom. Mucous membranes are moist and pink. Throat is free of erythema, exudate or tonsillar enlargement. Neck: Supple. No masses. No tracheal deviation. No thyromegaly. Heart: Regular rate and rhythm. A notable systolic ejection murmur, grade 3/6, best heard over left upper sternal border. No gallops or rubs noted. Lungs: Clear to auscultation bilaterally with symmetrical chest rise upon inspiration. Abdomen: Soft, nontender, nondistended. No organomegaly and no masses with deep palpation. No CVA tenderness. GU: No bladder distention noted with palpation. No tenderness. No penile discharge noted. No ulcers. Rectal: Deferred. Musculoskeletal: Has 4/5 strength in all four extremities. No redness or swelling of joints. Vascular: Systolic ejection murmur radiates to both right and left neck. No carotid bruits noted. No JVD. The patient has trace to +1 edema in both ankles and feet. Distal pulses are 2+ in all four extremities. Neurologic: The patient is alert and oriented to self. Able to follow commands. Cranial nerves II through XII grossly intact. Strength as stated above, and reflexes are 1+ in all four extremities.
PHYSICAL EXAMINATION: Vital Signs: Blood pressure 192/78, pulse 64, respirations 18 and saturation of 98% on room air. General Appearance: Comfortable, lean, pleasant man. HEENT: Eyes, conjunctivae normal. Pupils PERRLA. EOMI. Neck: No masses. Trachea central. No thyromegaly. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Irregular rhythm. Carotid arteries bilateral, brisk pulses, atherosclerosed. Pedal pulses, unable to do. No pedal edema though. Abdomen: Soft, nontender, nondistended. Bowel sounds positive. For FOBT, unable to obtain specimen. GU: Prostate, hypertrophic prostate, smooth margin. Musculoskeletal: Upper and lower limbs bilaterally normal. Skin: Normal
PHYSICAL EXAMINATION ON ADMISSION: General: Well-developed, well-nourished, white female in mild distress. HEENT: Head is normocephalic. She does have an abrasion on her left forehead and there is a left anterior/superior skull abrasion. Pupils equal, round, and reactive to light. Extraocular movements intact. No pain at TMJ. Neck: Cervical C-collar in place. No pain on palpation. Cardiovascular: Regular rate and rhythm. Clear S1, S2. Respiratory: Lungs clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Musculoskeletal: Right lower extremity: The patient resting with right hip flexed but not significantly rotated. No active range of motion of the right hip secondary to pain. Pain with all passive range of motion of the right hip as well. Mild tenderness to palpation at the right lateral knee. Right knee active range of motion limited by hip pain. The patient tolerates passive range of motion of the right knee well. Mild AP instability noted at the right knee while the patient was under conscious sedation for reduction of her right hip, which was posteriorly dislocated at the time of admission but well reduced under conscious sedation. Bilateral upper extremities and left lower extremity reveal no deformity, no tenderness to palpation. Full pain-free active range of motion in all joints with 5/5 strength in all major muscle groups and sensation intact to light touch throughout with no gross instability and brisk distal capillary refill. It should also be noted that the patient never displayed any neuro deficits in her right lower extremity with sensation intact to light touch throughout the right lower extremity and 5/5 strength in her tibialis anterior, extensor hallucis longus and gastroc-soleus musculature.
PHYSICAL EXAMINATION: Vital Signs: Temperature 100.2, respiratory rate 28, blood pressure 122/88, pulse rate 96, and 98% oxygen saturation on 2 liters nasal cannula. General Appearance: No acute distress. Eyes: PERRLA. EOMI. ENT: Normal nasal mucosa. Oral mucosa is moist without evidence of exudates or lesions. Neck: No adenopathy or masses were appreciated. Thyroid was normal. Respiratory: Increased respiratory effort was appreciated. Decreased air entry bilaterally. Crackles at the left base. Cardiovascular: Regular rate and rhythm. Normal S1, S2. No S3, S4, murmurs, rubs or clicks were appreciated. No JVD, no pedal edema, 2+ pedal pulses. Abdomen: Soft, nontender, nondistended, positive bowel sounds throughout. No organomegaly. No abdominal bruits were appreciated. GU: Normal testes and penis. Lymphatics: No neck or axillary adenopathy was appreciated. Musculoskeletal: The patient did have 4/5 strength in the upper and lower extremities bilaterally. The patient appeared to have normal muscle tone throughout. Skin: The patient had no rashes or lesions. However, did have dry, scaly skin on the lower extremities bilaterally. Neurologic: Cranial nerves II through XII are grossly intact bilaterally. DTRs were normal at the level of the patellar and Achilles tendons. No focal motor or sensory deficits were appreciated. Psychiatric: Normal judgment and insight. The patient was alert and oriented x3. Recent and remote memory intact. Mood and affect were normal.
PHYSICAL EXAMINATION: Vital Signs: Blood pressure 108/64. Heart rate upon coming in was 146; at this time, it is down in the low 100s. Respiratory rate is 18. He is afebrile. Telemetry is irregular rhythm, atrial fibrillation. HEENT: Normocephalic and atraumatic. Neck: Supple. No JVD. Cardiovascular: Irregularly regular, S1 and S2. No murmurs, rubs, gallops or clicks. Pulmonary: Clear to auscultation; however, decreased breath sounds at bases, left more than right. Abdomen: Soft, nontender and nondistended with active bowel sounds. It is obese. Extremities: No clubbing, cyanosis or edema. Neurologic: Nonfocal. He does have a sternotomy scar on his chest.
PHYSICAL EXAMINATION: Vital Signs: Temperature is 98.6 degrees, pulse 76, respirations 22, and blood pressure 92/57. She is saturating at 2 liters on 97% room air. General: This is a female who appears to be in no acute distress. She is alert, awake, and oriented x3. Cardiac: She has a regular rate and rhythm. Lungs: Clear to auscultation. Abdomen: No evidence of any Murphy sign elicited. She has some mild epigastric discomfort, otherwise obese, soft, no rebound, no guarding. Unable to palpate the liver and spleen. Extremities: No cyanosis, clubbing or edema.
PHYSICAL EXAMINATION: Reveals an (XX)-year-old female patient who is well built, fairly well nourished, in no acute cardiorespiratory distress. Vital signs are normal. Exam of the head, eyes, ears, nose and throat are unremarkable. Neck veins are not enlarged. Thyroid is not enlarged. There is no cervical lymphadenopathy. No clubbing of the fingers. No pedal edema. The abdomen is soft and nontender. No organomegaly. No masses felt. Normal bowel sounds. Lungs clear. Heart sounds normal. No gallop is appreciated. Neurologically, she has some weakness on the right side but difficult to do the detailed neurological examination. The musculoskeletal examination is unremarkable, except for the scars on both knees from her surgeries.
PHYSICAL EXAMINATION: The vital signs are temperature 99.8 degrees, blood pressure 122/64, pulse 96 and respiratory rate 18. The patient is noted to have a decubitus of the sacrum, which appears to be clean without any evidence of necrosis, purulence or odor. There is no conjunctivitis or rhinorrhea. There is no sinus tenderness, oral thrush, or other intraoral lesions. There is no facial rash or otorrhea. The patient has no nuchal rigidity, JVD or neck lymphadenopathy. There is no palpable neck mass. There is no gallop, rub or murmur. The breath sounds are clear bilaterally. There is no abdominal distention or tenderness. There is no palpable organomegaly. The bowel sounds are positive. There is no suprapubic or costovertebral tenderness. There is a Foley intact. There are no cellulitis changes of the lower extremities. There is no joint tenderness or palpable subcutaneous nodules. There is no clubbing or edema. The neurologic exam is grossly intact without any new neurologic deficit.
PHYSICAL EXAMINATION: His blood pressure is 120/74. He is afebrile with stable vital signs. He is a middle-aged Hispanic gentleman, who appears comfortable sitting in a chair. Alert and oriented to person, place and time. His head and neck exam is unremarkable. The patient wears corrective glasses. Funduscopic exam reveals somewhat tortuous arteries without any evidence of hemorrhage or papilledema. His ear exam is unremarkable. Tympanic membranes are gray with good cone of light bilaterally. Ear tunnels are patent. Nasal passages are patent. No evidence of erythema. Oral cavity is without evidence of exudate in pharynx. No swallowing problem is observed. He has a long uvula. No orthodontic work. He has significant caries with fillings. No evidence of infection in the mouth. Gag reflex is positive. No evidence of lymphadenopathy in neck. No JVD. Chest of normal configuration with some muscle wasting. He does not appear cachectic, but is skinny. His lungs are clear to auscultation bilaterally. Heart reveals a regular rate and rhythm. S1 and S2 present. No murmurs, rubs or gallops identified. Abdomen: Slightly distended, not obese, with positive bowel sounds and negative Murphy sign. Abdomen is nontender to palpation throughout. Neurologic: Reveals muscle strength 3/5 in left lower extremity, mostly in the proximal thigh. No footdrop. The rest of neurological exam is unremarkable. Cranial nerves II through XII grossly intact. Skin without rashes or cyanosis.
PHYSICAL EXAMINATION: Today, visual acuity is 20/40 in both eyes. Intraocular pressures are 18 in both eyes. Slit-lamp examination is remarkable for a very mild cataract in both eyes. Dilated funduscopic examination in the right eye reveals mild drusen in the posterior pole. In the far superior nasal periphery, there is a flat, pigmented lesion. This lesion could be either a choroidal nevus or congenital hypertrophy of the retinal pigment epithelium. Dilated funduscopic examination in the left eye revealed a small, flat, choroidal nevus just superior to the fovea and drusen within the posterior pole.
PHYSICAL EXAMINATION: On physical exam, the patient has an exquisite pain with internal rotation of the right hip to about 5 degrees of internal rotation. Her external rotation is about 20 degrees and she has pronounced pain, greater than with anterior impingement. She has a positive posterior impingement sign. Her left hip, she has about 5 degrees of internal rotation and 25 to 30 degrees of external rotation, but this is not painful. She has 5/5 iliopsoas, quad, and hamstring strength. She has 5/5 EHL, AT, gastrocnemius-soleus and peroneal strength bilaterally. She has 2+ pulses. Bilaterally sensation is intact to light touch of both lower extremities. On her right side, she has about 15 cm distance between the table and her knee during a fabere test, which is positive as well and this is significantly different than the left side, which she can get down to about 5 inches; this is also known as Patrick's test. She has no pain with log roll with either side, and when she lies flat with her leg externally rotated, she does note an ache in the posterior part of her buttocks, which may or may not correlate with posterior impingement sign.
PHYSICAL EXAMINATION: On physical examination, he has no tenderness on the medial collateral. No tenderness on the lateral compartment of the left knee. Minimal effusion is noted. He does have full extension and he can flex to over 100 degrees, left knee flexion. He has a negative Lachman test. He has no excursion with varus-valgus stress and no pain. He has no pain or sign of chondromalacia with compression of the patella in the patellofemoral joint. No laxity of his patella. Anterior drawer test is negative. Positive endpoint.
PHYSICAL EXAMINATION: Blood pressure 136/72 and pulse 72. In general, this is a pleasant female in no acute distress. Alert and oriented x3. HEENT: Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. No cervical lymphadenopathy is noted. No mucosal lesions. Neck: No cervical lymphadenopathy. Neck is supple. Cardiovascular: S1, S2, regular rate and rhythm. No murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. No wheezes or crackles. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities: There is some evidence of mild lower extremity edema with the left greater than the right. The extremities are warm to touch with positive palpable DP pulses. There is some evidence of actinic skin damage diffusely on her extremities. Skin: Over the medial aspect of her calves bilaterally, there is a petechial, violaceous, nonraised, nonblanching rash that is visible on both calves bilaterally. There are small, dark red 1 to 2 mm violaceous lesions, which are nonpalpable. This area extends approximately 5 to 6 inches x 2 inches on either leg. Area is warm to touch. There is no pain to palpation over the calves bilaterally. There is also no evidence of trauma over the lower extremities.
PHYSICAL EXAMINATION: Today shows that his blood pressure is 126/80, pulse is 66 and regular, respiratory rate is 14. Heart is normal. There is no evidence of ocular or cervical bruits. There is no evidence of temporal tenderness. His concentration seems to be somewhat diminished, but otherwise, his language structure is normal, naming is normal, multi-step commands that require conceptualization were done fairly well, although with some delay and with repeated attempts. His pupils were equal and reactive to light. The fundi showed sharp disk margins, no retinal emboli. The visual fields were full. Extraocular eye movements were intact; although, he seems to have diminished pursuit over to the left side and gaze nystagmus to the left more than the right and at one point seemed to close the right eye and perhaps has mild skew deviation, but he denied any diplopia. Upgaze seemed within normal for age. Convergence is normal. There is mild dysarthria, which is corroborated by the family. His lingual movements are somewhat slowed and inarticulate. There is some asymmetry with flattening of the right nasolabial fold. The tongue is normal. Motor examination as to the tone, bulk, strength is normal; seems to have slightly decreased fine motor movements in the right hand than the left, but feels that the hand is unchanged from his baseline. Deep tendon reflexes are 1+ at the knees and at the ankles, +1 in the upper extremities. The toes are downgoing. There may be some vibratory loss. He walks with a slightly wide base, but is steady. There is no limb dysmetria or gait ataxia. There is some decreased arm swing on the right side as compared to the left.
PHYSICAL EXAMINATION: Height 5 feet 4 inches, weight 132 pounds, blood pressure 110/72, pain score 0. Her abdomen is soft, nontender. No masses. No ascites. Pelvic: Vulva: No lesions seen. There is a 3 cm mobile Bartholin's gland cyst on the left, which is deep and nontender. Vagina: No discharge. Cervix: Nulliparous. Uterus is retroverted, slightly irregular, but normal size. Adnexa: Nontender and nonpalpable. A Pap smear was obtained.
PHYSICAL EXAMINATION: Well-developed, well-nourished male in no acute distress. Blood pressure in the left arm with a large adult cuff is 166/106. Blood pressure in the right arm with a large adult cuff is 160/104. Cardiac: S1, S2, regular rate and rhythm. No murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally. Neck is supple without lymphadenopathy or thyromegaly. Bilateral TMs are dull and slightly erythematous. Oropharynx: Pink with erythematous cobblestoning. No tonsillar enlargement or exudate.
PHYSICAL EXAMINATION: Height 4 feet 10 inches, weight 166 pounds, blood pressure 136/86, pain score 0. External Genitalia: Atrophic. The vagina reveals no discharge. Microscopic exam negative for hyphae, negative for clue cells, negative for whiff, negative Trichomonas. No signs of red blood cells. Cervix is clean, closed, nontender. Uterus and adnexa reveal no masses.
PHYSICAL EXAMINATION: His blood pressure is 120/74. He is afebrile with stable vital signs. He is a middle-aged Hispanic gentleman, who appears comfortable sitting in a chair. Alert and oriented to person, place and time. His head and neck exam is unremarkable. The patient wears corrective glasses. Funduscopic exam reveals somewhat tortuous arteries without any evidence of hemorrhage or papilledema. His ear exam is unremarkable. Tympanic membranes are gray with good cone of light bilaterally. Ear tunnels are patent. Nasal passages are patent. No evidence of erythema. Oral cavity is without evidence of exudate in pharynx. No swallowing problem is observed. He has a long uvula. No orthodontic work. He has significant caries with fillings. No evidence of infection in the mouth. Gag reflex is positive. No evidence of lymphadenopathy in neck. No JVD. Chest of normal configuration with some muscle wasting. He does not appear cachectic, but is skinny. His lungs are clear to auscultation bilaterally. Heart reveals a regular rate and rhythm. S1 and S2 present. No murmurs, rubs or gallops identified. Abdomen: Slightly distended, not obese, with positive bowel sounds and negative Murphy sign. Abdomen is nontender to palpation throughout. Neurologic: Reveals muscle strength 3/5 in left lower extremity, mostly in the proximal thigh. No footdrop. The rest of neurological exam is unremarkable. Cranial nerves II through XII grossly intact. Skin without rashes or cyanosis.
PHYSICAL EXAMINATION: Today, visual acuity is 20/40 in both eyes. Intraocular pressures are 18 in both eyes. Slit-lamp examination is remarkable for a very mild cataract in both eyes. Dilated funduscopic examination in the right eye reveals mild drusen in the posterior pole. In the far superior nasal periphery, there is a flat, pigmented lesion. This lesion could be either a choroidal nevus or congenital hypertrophy of the retinal pigment epithelium. Dilated funduscopic examination in the left eye revealed a small, flat, choroidal nevus just superior to the fovea and drusen within the posterior pole.
PHYSICAL EXAMINATION: On physical exam, the patient has an exquisite pain with internal rotation of the right hip to about 5 degrees of internal rotation. Her external rotation is about 20 degrees and she has pronounced pain, greater than with anterior impingement. She has a positive posterior impingement sign. Her left hip, she has about 5 degrees of internal rotation and 25 to 30 degrees of external rotation, but this is not painful. She has 5/5 iliopsoas, quad, and hamstring strength. She has 5/5 EHL, AT, gastrocnemius-soleus and peroneal strength bilaterally. She has 2+ pulses. Bilaterally sensation is intact to light touch of both lower extremities. On her right side, she has about 15 cm distance between the table and her knee during a fabere test, which is positive as well and this is significantly different than the left side, which she can get down to about 5 inches; this is also known as Patrick's test. She has no pain with log roll with either side, and when she lies flat with her leg externally rotated, she does note an ache in the posterior part of her buttocks, which may or may not correlate with posterior impingement sign.
PHYSICAL EXAMINATION: On physical examination, he has no tenderness on the medial collateral. No tenderness on the lateral compartment of the left knee. Minimal effusion is noted. He does have full extension and he can flex to over 100 degrees, left knee flexion. He has a negative Lachman test. He has no excursion with varus-valgus stress and no pain. He has no pain or sign of chondromalacia with compression of the patella in the patellofemoral joint. No laxity of his patella. Anterior drawer test is negative. Positive endpoint.
PHYSICAL EXAMINATION: Blood pressure 136/72 and pulse 72. In general, this is a pleasant female in no acute distress. Alert and oriented x3. HEENT: Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. No cervical lymphadenopathy is noted. No mucosal lesions. Neck: No cervical lymphadenopathy. Neck is supple. Cardiovascular: S1, S2, regular rate and rhythm. No murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. No wheezes or crackles. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities: There is some evidence of mild lower extremity edema with the left greater than the right. The extremities are warm to touch with positive palpable DP pulses. There is some evidence of actinic skin damage diffusely on her extremities. Skin: Over the medial aspect of her calves bilaterally, there is a petechial, violaceous, nonraised, nonblanching rash that is visible on both calves bilaterally. There are small, dark red 1 to 2 mm violaceous lesions, which are nonpalpable. This area extends approximately 5 to 6 inches x 2 inches on either leg. Area is warm to touch. There is no pain to palpation over the calves bilaterally. There is also no evidence of trauma over the lower extremities.
PHYSICAL EXAMINATION: Today shows that his blood pressure is 126/80, pulse is 66 and regular, respiratory rate is 14. Heart is normal. There is no evidence of ocular or cervical bruits. There is no evidence of temporal tenderness. His concentration seems to be somewhat diminished, but otherwise, his language structure is normal, naming is normal, multi-step commands that require conceptualization were done fairly well, although with some delay and with repeated attempts. His pupils were equal and reactive to light. The fundi showed sharp disk margins, no retinal emboli. The visual fields were full. Extraocular eye movements were intact; although, he seems to have diminished pursuit over to the left side and gaze nystagmus to the left more than the right and at one point seemed to close the right eye and perhaps has mild skew deviation, but he denied any diplopia. Upgaze seemed within normal for age. Convergence is normal. There is mild dysarthria, which is corroborated by the family. His lingual movements are somewhat slowed and inarticulate. There is some asymmetry with flattening of the right nasolabial fold. The tongue is normal. Motor examination as to the tone, bulk, strength is normal; seems to have slightly decreased fine motor movements in the right hand than the left, but feels that the hand is unchanged from his baseline. Deep tendon reflexes are 1+ at the knees and at the ankles, +1 in the upper extremities. The toes are downgoing. There may be some vibratory loss. He walks with a slightly wide base, but is steady. There is no limb dysmetria or gait ataxia. There is some decreased arm swing on the right side as compared to the left.
PHYSICAL EXAMINATION: Height 5 feet 4 inches, weight 132 pounds, blood pressure 110/72, pain score 0. Her abdomen is soft, nontender. No masses. No ascites. Pelvic: Vulva: No lesions seen. There is a 3 cm mobile Bartholin's gland cyst on the left, which is deep and nontender. Vagina: No discharge. Cervix: Nulliparous. Uterus is retroverted, slightly irregular, but normal size. Adnexa: Nontender and nonpalpable. A Pap smear was obtained.
PHYSICAL EXAMINATION: Well-developed, well-nourished male in no acute distress. Blood pressure in the left arm with a large adult cuff is 166/106. Blood pressure in the right arm with a large adult cuff is 160/104. Cardiac: S1, S2, regular rate and rhythm. No murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally. Neck is supple without lymphadenopathy or thyromegaly. Bilateral TMs are dull and slightly erythematous. Oropharynx: Pink with erythematous cobblestoning. No tonsillar enlargement or exudate.
PHYSICAL EXAMINATION: Height 4 feet 10 inches, weight 166 pounds, blood pressure 136/86, pain score 0. External Genitalia: Atrophic. The vagina reveals no discharge. Microscopic exam negative for hyphae, negative for clue cells, negative for whiff, negative Trichomonas. No signs of red blood cells. Cervix is clean, closed, nontender. Uterus and adnexa reveal no masses.
PHYSICAL EXAMINATION: Height 5 feet 4 inches. Weight 196 pounds. Blood pressure 142/86. Pain score 0. Breast exam shows no masses. External genitalia and vagina are normal female. The cervix is clean, closed, nontender. Uterus is anteverted, about 14 weeks in size. Adnexa reveal no masses and the rectovaginal exam confirms this.
OBJECTIVE: On examination of the right upper extremity, the skin is circumferentially intact. There is deformity of the right wrist. There is resolving ecchymosis. The hand is warm and well perfused with brisk capillary refill. Sensation is intact to light touch in the distribution of the radial, ulnar, and median nerves. She is able to actively flex and extend the fingers and thumb at the MP and IP joints. She is able to flex and extend the wrist without any pain. There is minimal tenderness to palpation over the distal radius. There is no tenderness to palpation of the distal ulna. On examination of the right hip, the surgical skin incisions are healed with no local signs of infection. The foot is warm and well perfused with brisk capillary refill. Sensation is intact to light touch in the distribution of the sural, saphenous, superficial peroneal, deep peroneal, and tibial nerves. She is able to actively dorsiflex and plantarflex the foot and toes against gravity. There is no calf pain, swelling or tenderness to palpation. There is no pain with gentle passive range of motion of the right hip. She is able to extend the knee from a flexed position.
PHYSICAL EXAMINATION: Blood pressure 124/78, pulse 72, and respiratory rate 18. Weight 142 pounds. Head: Normocephalic and atraumatic. Sclerae were white and pupils equal and briskly reactive. Disk margins were sharp bilaterally. Nose and throat were unremarkable. Carotids without bruit and heart sounds are regular. She had good distal pulses. On neurological examination, she had normal mental status. She was alert, attentive, and oriented. She had normal speech without sign of dysarthria or aphasia. On cranial nerve testing, visual acuity corrected with eyeglasses was 20/30-1, both eyes, on the Jaeger card. She had full visual fields and ocular motility. She had very slight torsional nystagmus in a counterclockwise direction with gaze to the right. She had normal facial sensation and strength. Hearing was symmetric bilaterally. Palate elevated well. Sternocleidomastoid and trapezius strength were full and tongue protruded midline. On motor exam, she had no pronator drift. She had full strength throughout. She was tremulous on finger-to-nose bilaterally. She had no rest tremor. She had good amplitude and rhythmicity of rapid alternating movements. She had stable stance and gait both with and without use of cane. She could take steps on heels and on toes. Tandem was fairly steady. Sensory exam was significant for decreased pinprick in both lower extremities. Vibration was present at feet and extinguished slightly early. Position was intact. Reflexes were normoactive and toes were downgoing.
OBJECTIVE: Weight 172, height 5 feet 4 inches, blood pressure 126/78, pulse 88 and regular. Neck: Supple. No increased adenopathy. Thyroid not enlarged. Chest: Clear to P and A. No rales, rhonchi or wheezes. Heart: Normal sinus rhythm without murmurs. Breasts: Without masses or tenderness. Abdomen: Soft and nontender. LKKS nonpalpable. Bowel sounds good. Pelvic: BUS clear. Vagina clean. Cervix clean. Uterus: Small, freely movable and nontender. Adnexa clear. Extremities: Full range of motion. Pulses 2+ bilaterally. DTRs 2+ bilaterally.
PHYSICAL EXAMINATION: Height 5 feet 6 inches. Weight 122 pounds. Stands with level pelvis, is decompensated, perhaps 10 cm anterior and perhaps another 10 cm to the right. She has a significant kyphoscoliosis. However, she has no trigger point tenderness or point tenderness over any of the spinous processes. She is minimally correctable. Her gait is reciprocal. Her strength exam shows no isolated deficits. Her reflexes at the knees and ankles were quite benign. Sharp, dull sensation is intact. She did not exhibit any root tension signs.
OBJECTIVE: On examination of the right upper extremity, the skin is circumferentially intact. There is deformity of the right wrist. There is resolving ecchymosis. The hand is warm and well perfused with brisk capillary refill. Sensation is intact to light touch in the distribution of the radial, ulnar, and median nerves. She is able to actively flex and extend the fingers and thumb at the MP and IP joints. She is able to flex and extend the wrist without any pain. There is minimal tenderness to palpation over the distal radius. There is no tenderness to palpation of the distal ulna. On examination of the right hip, the surgical skin incisions are healed with no local signs of infection. The foot is warm and well perfused with brisk capillary refill. Sensation is intact to light touch in the distribution of the sural, saphenous, superficial peroneal, deep peroneal, and tibial nerves. She is able to actively dorsiflex and plantarflex the foot and toes against gravity. There is no calf pain, swelling or tenderness to palpation. There is no pain with gentle passive range of motion of the right hip. She is able to extend the knee from a flexed position.
PHYSICAL EXAMINATION: Blood pressure 124/78, pulse 72, and respiratory rate 18. Weight 142 pounds. Head: Normocephalic and atraumatic. Sclerae were white and pupils equal and briskly reactive. Disk margins were sharp bilaterally. Nose and throat were unremarkable. Carotids without bruit and heart sounds are regular. She had good distal pulses. On neurological examination, she had normal mental status. She was alert, attentive, and oriented. She had normal speech without sign of dysarthria or aphasia. On cranial nerve testing, visual acuity corrected with eyeglasses was 20/30-1, both eyes, on the Jaeger card. She had full visual fields and ocular motility. She had very slight torsional nystagmus in a counterclockwise direction with gaze to the right. She had normal facial sensation and strength. Hearing was symmetric bilaterally. Palate elevated well. Sternocleidomastoid and trapezius strength were full and tongue protruded midline. On motor exam, she had no pronator drift. She had full strength throughout. She was tremulous on finger-to-nose bilaterally. She had no rest tremor. She had good amplitude and rhythmicity of rapid alternating movements. She had stable stance and gait both with and without use of cane. She could take steps on heels and on toes. Tandem was fairly steady. Sensory exam was significant for decreased pinprick in both lower extremities. Vibration was present at feet and extinguished slightly early. Position was intact. Reflexes were normoactive and toes were downgoing.
OBJECTIVE: Weight 172, height 5 feet 4 inches, blood pressure 126/78, pulse 88 and regular. Neck: Supple. No increased adenopathy. Thyroid not enlarged. Chest: Clear to P and A. No rales, rhonchi or wheezes. Heart: Normal sinus rhythm without murmurs. Breasts: Without masses or tenderness. Abdomen: Soft and nontender. LKKS nonpalpable. Bowel sounds good. Pelvic: BUS clear. Vagina clean. Cervix clean. Uterus: Small, freely movable and nontender. Adnexa clear. Extremities: Full range of motion. Pulses 2+ bilaterally. DTRs 2+ bilaterally.
PHYSICAL EXAMINATION: Height 5 feet 6 inches. Weight 122 pounds. Stands with level pelvis, is decompensated, perhaps 10 cm anterior and perhaps another 10 cm to the right. She has a significant kyphoscoliosis. However, she has no trigger point tenderness or point tenderness over any of the spinous processes. She is minimally correctable. Her gait is reciprocal. Her strength exam shows no isolated deficits. Her reflexes at the knees and ankles were quite benign. Sharp, dull sensation is intact. She did not exhibit any root tension signs.
PHYSICAL EXAMINATION: General: The patient is awake, alert, in no acute distress. Pleasant and interactive. HEENT: Normocephalic skull. He has a large laceration to his right temple that is scabbed, not bleeding. He has ecchymosis around his right eye. He has a large bruise to the bridge of his nose. His right eye is swollen shut; he is able to open it. No subconjunctival hemorrhages. Pupils equal, round, reactive to light and accommodation. Sclerae and conjunctivae with no subconjunctival hemorrhages. Nasal mucosa, turbinates and septum intact with no bleeding or rhinorrhea. Bilateral tympanic membranes not examined. Oral mucosa pink, moist and intact. Small laceration to right upper lip, on the inside. He does have braces in place. His teeth appear intact. Neck: Supple with no adenopathy. Lungs: Clear to auscultation without wheezing, rales or retractions. Heart: Regular rate and rhythm. Normally split S1 and S2. No murmur, rub or gallop. Pulses equal and symmetric in upper and lower extremities. Abdomen: Soft, nontender and nondistended with no hepatosplenomegaly. Bowel sounds are normoactive. Extremities: Full active range of motion to left shoulder and left leg. Full active range of motion of right shoulder; however, he does have some pain with movement/full active range of motion to right knee. Mother states right knee was swollen yesterday, but today, it does not appear swollen. Neurologic: Intact and nonfocal. Skin: See HEENT. Also has large, scabbed abrasion to right calf and ecchymosis to the right shoulder and ecchymosis to the right knee. Lymphatics: No cervical, supraclavicular or axillary adenopathy.
PHYSICAL EXAMINATION: Reveals a well-built, well-nourished male who looks in good health for his age. His left eye is sunken due to previous laser surgery on the left eye. Temperature 97.5 degrees, blood pressure 112/74, pulse 64. Head and ENT examination are otherwise unremarkable. JVP is not raised. Both heart sounds are audible. He has a grade 2/6 ejection systolic murmur. Lungs are clear. Abdomen is soft and nontender. Liver and spleen not enlarged or palpable. The extremities have no pedal edema of the feet. Neurological examination is normal.
PHYSICAL EXAMINATION: Temperature 98.3 degrees, pulse 94, respiratory rate 22 and mildly labored, blood pressure 125/77, oxygen saturation 95% on 6 liters. He is a well-developed male, very conversant, mildly dyspneic at rest. HEENT examination shows male pattern alopecia. Nasal prongs in place. Oropharynx is clear, redundant. Neck is short with no jugular venous distention, bruits or adenopathy. Moderate use of accessory muscles. Lung fields have poor excursions with few basilar rhonchi on the left. Cardiac examination shows no gallop or murmur. Sternotomy incision is intact. Abdomen is obese, protuberant, normoactive bowel sounds. Otherwise, benign without organomegaly. Genitourinary shows normal external male. Extremities reveal clean vein graft sites, trace edema. Negative Homans sign. No palpable cords. No clubbing or cyanosis. Neurologic is nonfocal.
Far-Lateral Microdiskectomy and Lateral Facetectomy Operative Sample
DESCRIPTION OF OPERATION: The patient was brought to the operating room, induced, and intubated without difficulty. The patient received IV antibiotics in the holding area. He was given 10 mg of Decadron IV. He was rolled prone on the Williams frame table, and the lumbosacral region of his spine was scrubbed with a Betadine scrub brush and washed with alcohol. With the aid of the C-arm fluoroscopy unit, a 6 cm parasagittal incision was marked out in the L4-5 region. This area was prepped and draped in sterile fashion. It was infiltrated with 1% Xylocaine with epinephrine and opened with a 10 blade, dissecting down to the fascia, opening the fascia in blunt dissection through the lumbar musculature to the facet at L4-5. The L5 facet was confirmed with the C-arm fluoroscopy unit. Further dissection down identified the transverse process of L5. Dissection rostrally continued to the inferior edge of the L4 transverse process. A deep McCullough retractor was placed in the field and the microscope was brought in at this point. The Midas Rex and AM-8 drill bit were used to drill away portions of the lateral facet. The intertransverse musculature was carefully cauterized and cut with microscissors. Blunt dissection down through fat led to identification of the passing L4 nerve root; this was retracted laterally. Bipolar cautery was used to cauterize the vascular structures and the disk space was identified. A micro Jannetta dissector was placed into the disk space and the C-arm fluoroscopy unit again confirmed this correct location. A micropituitary was then used to remove lateral disk fragments. Once these disk fragments were removed from the lateral aspect of the disk, more room was freed up. Probing slightly rostral to the disk space, a few lumps of disk material were seen just rostral to the disk space, as expected. These were pulled out with the micropituitary. Copious irrigation at this point was followed with inspection of the L4 nerve root; it appeared freed up at this point. Further irrigation was followed with placement of FloSeal in the area. Bony edges were waxed. Closure then began. The lumbodorsal fascia was closed with interrupted 0 Vicryl sutures. Superficial fascial layers were closed with interrupted 2-0 Vicryl sutures. The skin was closed with a 4-0 subcuticular stitch. Steri-Strips were applied and a dressing was placed on the patient's back. The patient awoke in good neurologic condition and was taken to the recovery room.
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Laparoscopic Cholecystectomy with Intraoperative Cholangiogram Operative Sample
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. After adequate general endotracheal anesthesia, the abdomen was shaved, prepped and draped in sterile fashion. The patient was already on preoperative antibiotics. Next, two towel clamps were placed on either side of the umbilicus.
An incision was made and the Veress needle was introduced without any difficulty. The water-drop test was positive. The needle was then attached to the CO2 insufflator and insufflated to a pressure of 15 mm. Next, the needle was removed and a 10 mm trocar was slowly and carefully introduced without any difficulty. The camera was placed in the introducer and the abdomen was scanned. Three accessory ports were placed under direct visualization; one was placed in the subxiphoid region, one in the midclavicular line, and one in the midaxillary line.
Next, we were able to elevate the liver. The gallbladder was near gangrenous, and once we manipulated the fundus of the gallbladder, there was a large stone which actually came out and we placed this in the right upper quadrant while we were doing the procedure. This was all considerably difficult just to maneuver and the gallbladder was tearing throughout the procedure. We were able to dissect down on the gallbladder down to the cystic duct, which was easily identified at its junction of the common bile duct. We also identified the cystic artery. The clip was placed distally on the cystic duct.
A small enterotomy was made in the cystic duct. There was good bile flow back. We placed the Cholangiocath without any difficulty and there was good flow without any leak. We then placed the patient back in supine position, shot a series of cholangiograms with the possibility of distal common bile duct stones noted, but good flow into the duodenum. The rest of the ductal system was intact without any defects. At this point, we placed the patient back into position. After I discussed this with the radiologist, the clip was removed and the catheter was removed. Two clips were placed proximally on the cystic duct. The duct was divided from the tube. The cystic artery had two clips placed proximally, one distally and was divided. The gallbladder, which was near gangrenous and intrahepatic was then taken off of liver bed using blunt dissection and cautery.
When we had it removed, there was no active bleeding or bile leak noted. The gallbladder and the stone, which were separate, were then placed in the Ethicon pouch and brought out the umbilicus after opening the fascia further. We then irrigated the right upper quadrant and suctioned it dry. There was no purulent material, bleeding or bile leak noted. We then removed each of the ports under direct visualization and de-insufflated the abdomen. The fascia at the umbilicus was closed with 0-Vicryl sutures. Each skin incision was closed with 4-0 Vicryl subcuticular sutures and each of the sites was locally anesthetized with 0.5% Marcaine with epinephrine for a total of 24 mL. The patient tolerated the procedure well and was sent to the recovery room in a satisfactory condition.
More Laparoscopic Cholecystectomy Sample Reports
An incision was made and the Veress needle was introduced without any difficulty. The water-drop test was positive. The needle was then attached to the CO2 insufflator and insufflated to a pressure of 15 mm. Next, the needle was removed and a 10 mm trocar was slowly and carefully introduced without any difficulty. The camera was placed in the introducer and the abdomen was scanned. Three accessory ports were placed under direct visualization; one was placed in the subxiphoid region, one in the midclavicular line, and one in the midaxillary line.
Next, we were able to elevate the liver. The gallbladder was near gangrenous, and once we manipulated the fundus of the gallbladder, there was a large stone which actually came out and we placed this in the right upper quadrant while we were doing the procedure. This was all considerably difficult just to maneuver and the gallbladder was tearing throughout the procedure. We were able to dissect down on the gallbladder down to the cystic duct, which was easily identified at its junction of the common bile duct. We also identified the cystic artery. The clip was placed distally on the cystic duct.
A small enterotomy was made in the cystic duct. There was good bile flow back. We placed the Cholangiocath without any difficulty and there was good flow without any leak. We then placed the patient back in supine position, shot a series of cholangiograms with the possibility of distal common bile duct stones noted, but good flow into the duodenum. The rest of the ductal system was intact without any defects. At this point, we placed the patient back into position. After I discussed this with the radiologist, the clip was removed and the catheter was removed. Two clips were placed proximally on the cystic duct. The duct was divided from the tube. The cystic artery had two clips placed proximally, one distally and was divided. The gallbladder, which was near gangrenous and intrahepatic was then taken off of liver bed using blunt dissection and cautery.
When we had it removed, there was no active bleeding or bile leak noted. The gallbladder and the stone, which were separate, were then placed in the Ethicon pouch and brought out the umbilicus after opening the fascia further. We then irrigated the right upper quadrant and suctioned it dry. There was no purulent material, bleeding or bile leak noted. We then removed each of the ports under direct visualization and de-insufflated the abdomen. The fascia at the umbilicus was closed with 0-Vicryl sutures. Each skin incision was closed with 4-0 Vicryl subcuticular sutures and each of the sites was locally anesthetized with 0.5% Marcaine with epinephrine for a total of 24 mL. The patient tolerated the procedure well and was sent to the recovery room in a satisfactory condition.
More Laparoscopic Cholecystectomy Sample Reports
Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy Operative Sample
DESCRIPTION OF OPERATION: The patient was taken to the operating room, and after adequate level of general anesthesia was achieved, the patient was placed in the Trendelenburg position, prepped and draped in the usual sterile fashion. Subsequently, a Pfannenstiel incision was made and the incision was taken down to the fascia. The fascia was opened up sharply. The fascia was extended to the length of the incision using the Mayo scissors. At this time, the rectus muscles were dissected from the fascia superiorly and inferiorly to the symphysis pubis. The midline rectus muscles were opened sharply and extended superiorly and inferiorly. The peritoneum was visualized, grasped, opened sharply, and extended superiorly and inferiorly towards the bladder. The abdominal contents were packed superiorly away from the operative site using the lap packs. At this time, the pelvic organs were noted. The inferior and superior blades were placed in place on the Balfour self-retaining retractor. Bowel was packed away from the operative site. The fundus of the uterus was then grasped with a triple-tooth tenaculum and retracted out of the pelvic cavity into the abdominal site. At this point, Kelly clamps were placed in both right and left adnexal regions. Subsequently, using the LigaSure cautery unit, the round ligaments were grasped, cauterized, and dissected. The bladder flap was then formed and the bladder flap was pushed away down anteriorly over the lower uterine segment, pushed away from the operative site on both the right and left sides. Subsequently, the posterior leaf of the broad ligament was opened sharply and the LigaSure instrument was then placed below the level of the ovary in both the right and left side, care being taken not to damage bowel or uterus and the infundibulopelvic ligament was then grasped, cauterized, and again dissected. Further dissection of the broad ligament was carried down posteriorly towards the uterine vessels. The bladder was pushed inferiorly down towards the vagina. Subsequently, the uterine vessels were then grasped again with the LigaSure machine, cauterized, and dissected. The cardinal ligaments were further grasped, dissected, and suture ligated, again with the LigaSure machine. At that point, the LigaSure machine instrument was stopped and straight Zeppelin clamps were used on the cardinal ligaments down towards the uterosacral ligaments. The cardinal ligaments were grasped, dissected with a scalpel and then ligated with transfixion sutures with #1 Vicryl suture down to the uterosacral ligaments. The uterosacral ligaments were grasped, dissected, and suture ligated again with #1 Vicryl suture and transfixion sutures. At that time, the bladder had been pushed over the vagina and at this time right-angle Zeppelin clamps were placed on the vagina at the level of the cervix, and using the Jorgenson scissors, the cervix was dissected away from the vagina. At this time, the vaginal cuff was then closed using interrupted sutures of #1 Vicryl suture from the midline to each lateral corner. After the good hemostasis had been achieved in the vaginal cuff, both the right and left adnexa was visualized and no more bleeding was noted. The cuff was intact with no bleeding noted. The bladder was visualized and no bleeding was noted. Seprafilm was then placed over the vaginal cuff. The Balfour self-retaining retractor was removed as well as the anterior and inferior blades. The lap packs were removed, and at this time, general closure of the abdomen was carried out. The peritoneum was closed with a 2-0 Vicryl suture and continuous running suture. The fascia was closed using a #1 Vicryl suture from each corner to the midline. Subcutaneous tissue was cauterized. No bleeding was noted. The subcutaneous tissue was then reapproximated using plain sutures and interrupted sutures, and the skin was closed using 4-0 Vicryl suture in a Keith needle. The patient tolerated the procedure well and was transferred to the recovery room in excellent condition. The patient returned to the floor for recovery.
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Left Total Hip Replacement Operative Sample
DESCRIPTION OF OPERATION: The patient was placed on the operating table in the supine position. After establishment of adequate spinal anesthesia, Foley catheter was placed. Confirmed prophylactic antibiotics were previously given intravenously. The patient was placed in the lateral position. All bony prominences were well padded and an axillary roll placed. Pelvis was secured with Montreal Universal Hip Positioner. This was somewhat difficult due to the patient's exogenous obesity. Firm stabilization was achieved and good placement of axillary roll was achieved. Under ultraviolet lights, the lateral aspect of the hip and thigh were shaved, then sterilely prepped and draped in the usual sterile fashion. The patient was brought into the enclosed environment laminar flow suite with all personnel utilizing body exhaust suits, and an additional sterile draping was carried out. The site of skin incision was isolated with Betadine-impregnated Vi-Drape. The skin was incised parallel with the proximal femur curving gently posteriorly, proximally, and deepened to the level of the fascia of the thigh, which was divided along its fibers. The gluteus maximus was carefully split proximally. Piriformis was identified, released. Remaining rotators left attached to the capsule, which was reflected posteriorly, protecting the sciatic nerve. The hip was then dislocated without difficulty. The femoral neck was transected along a line determined on preoperative templating and acetabulum exposed circumferentially. Acetabulum was sequentially reamed until excellent circumferential contact was achieved at 57 mm of reaming. This was noted to be larger than the preoperative templated size. The acetabulum had some flare and did not provide rim fit until it was reamed to 57 mm. A 58 mm trial provided excellent rigid fit. Significant bone remains in anterior and posterior columns. Fovea was cleared free of soft tissues. Cysts were curetted free of soft tissue and were filled with bone graft harvested from the resected femoral head. Graft compacted with reamer run in reverse. A 58 mm shell was impacted into position and excellent fit achieved. Attention was then turned to the femur. Axial line of the femur was determined with the starting reamer and then broached up through including a #7 broach; this provided rigid fit. The patient had extremely dense cancellous bone and it was felt the #8 rasp likely could not be seated. Trial reduction was carried out and excellent stability achieved to a zero length 32 mm head and neck. Hip was reduced and excellent motion achieved. Hip could be forward flexed to 90 degrees, internally rotated to 90 degrees at mid flexion position, 80 degrees at full 90 degrees of flexion, could be forward flexed 110 degrees. The hip could be externally rotated and extended and abducted without impingement, subluxation or dislocation with either extreme of motion. The trial components were removed. A hole eliminator placed in the acetabulum, permanent liner locked into position after irrigating and drying the acetabular shell. A #7 HA stem was impacted on the femur with firm fit and rigid fit achieved. A zero length head was then impacted on the cleansed and dried Morse taper and hip re-reduced and range of motion confirmed. Excellent stability was achieved. The patient was given heparin 2000 units intravenously prior to hip reduction. The hip was thoroughly irrigated and inspection showed excellent hemostasis had been established. The posterior capsule was reapproximated to the posterior aspect of the greater trochanter through drill holes through bone with #1 Ethibond suture into the gluteus minimus proximally. The fascia of the thigh was reapproximated with interrupted #1 Ethibond suture in figure-of-eight fashion. Superficial layers were closed with 0 and 2-0 Vicryl sutures, and the skin was reapproximated with skin staples. A sterile compressive dressing was placed. The patient was transported to the recovery room awake and in stable condition.
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