Colonoscopy and Polypectomy Medical Transcription Operative Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Screening examination.

POSTOPERATIVE DIAGNOSIS:  Multiple colonic polyps.

OPERATION PERFORMED:  Total colonoscopy and multiple polypectomies including snare polypectomy.

ENDOSCOPIST:  John Doe, MD

ANESTHESIA:  IV fentanyl, Versed and Phenergan in incremental doses.

DESCRIPTION OF PROCEDURE:  Digital examination and inspection was normal.  The Olympus colonoscope was introduced into the rectum.  The scope was advanced without difficulty to the cecum.  The appendiceal orifice was identified.  There was stool inspissated within the appendiceal orifice.  Attempts were made to wash the stool out; this was unsuccessful.  The scope was gradually withdrawn.  In the proximal ascending colon, 3 polyps were noted, 2 were pedunculated, each removed using snare cautery.  They were retrieved and sent for histopathologic analysis.  The scope was reintroduced to this point.  Hemostasis was good.  There was a 4 mm sessile polyp, which was removed in multiple pieces and multiple passes using the cold biopsy forceps technique.  The scope continued to be withdrawn.

In the distal transverse colon, there were 5 colon polyps; 3 were removed using snare and cautery.  They were retrieved and sent for histopathologic analysis.  A 6 mm sessile polyp was removed using a hot biopsy forceps technique and a 4 mm sessile polyp was removed using the cold biopsy forceps technique.  The scope continued to be withdrawn.  At 70 cm from the anal verge, in what appeared to be the hepatic flexure, near the splenic flexure, 3 polyps ranging in size from 8 mm to 6 mm were removed by snare and cautery and retrieved and sent for histopathologic analysis.  At 50 cm from the anal verge, there were 4 colon polyps ranging in size from 1 cm to 3 mm in diameter.

Snare polypectomy was performed, and a cold biopsy forceps polypectomy was performed.  The tissue was retrieved and sent for histopathologic analysis.  Good hemostasis was observed after all cautery.  Toward the end of the procedure, it was noted that the patient had some diminutive polyps in the rectum; however, he was becoming restless and combative, although he was well sedated until this point.  It was felt that it was not prudent to proceed with removing these polyps at this moment.  It was felt, given the multiplicity of polyps and the multiple polypectomies, that this patient will require an early followup colonoscopy to make sure that all more proximal polyps are removed and, at that time, the diminutive rectal polyps could be removed.  The patient was brought to the recovery area in good condition.

PLAN:  Check biopsy results.  Assuming there is no unusual dysplasia, I will repeat the colonoscopy on this patient in 3 months to make sure all polyps are removed.  Then, longer intervals between colonoscopies will be recommended.

Colonoscopy to Ileotransverse Anastomosis Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  High-risk colon polyp surveillance status post right hemicolectomy with ileotransverse anastomosis for large tubulovillous adenoma of the transverse colon.
2.  History of small bowel carcinoid tumor.

POSTOPERATIVE DIAGNOSES:
1.  Small benign polyps and superficial, possibly ischemic, ulcers of the side-to-side ileotransverse colon anastomosis.
2.  Tiny benign rectosigmoid colon polyps.
3.  Moderate sigmoid colon diverticulosis with no acute diverticulitis.

PROCEDURES PERFORMED:
1.  Colonoscopy to ileotransverse anastomosis and into the distal ileum.
2.  Hot and cold biopsies of the ileotransverse anastomosis.
3.  Hot forceps polypectomy, rectosigmoid colon.

ENDOSCOPIST:  John Doe, MD

PREP:  Fleet Phospho-soda, with excellent prep and visualization entire extent of examination.

FINDINGS:
1.  Intact side-to-side ileotransverse colon anastomosis with postsurgical changes and a couple of small 2 to 3 mm hyperplastic-appearing polyps and a couple of small, less than 5 cm superficial ulcerations with white exudate base in the anastomosis blind pouch areas.  There was wide patency of the anastomosis ileal and colonic openings and lumen.
2.  Normal distal ileal mucosa.
3.  Moderate number of small as well as occasional large-mouth diverticula localized at the sigmoid colon with no acute diverticulitis.
4.  Two tiny 2 to 3 mm benign-appearing sessile proximal rectal and rectosigmoid area hyperplastic-appearing polyps removed with hot biopsy forceps.
5.  Normal colonic vascularity with no evidence of arteriovenous malformations.

ANESTHESIA:  Demerol 100 mg and Versed 10 mg, both slow IV push, titrated.

DESCRIPTION OF PROCEDURE:  After obtaining informed consent, the patient was placed on the left side and subsequently sedated with IV Demerol and Versed, titrated.  The external perineal area was inspected and appeared normal.  Digital rectal examination revealed no evidence of tenderness, masses or strictures.  The finger was used as a guide to insert the Olympus video colonoscope through the anus into rectum.  A small amount of air was insufflated to distend the lumen.  The scope was then easily advanced proximally using the push/pull technique all the way to the level of the transverse colon, where there was noted to be a side-to-side ileal Billroth II-appearing saddle-type anastomosis of the ileum and transverse colon that was widely patent.  The scope was advanced into the ileum proximal to the anastomosis and this was inspected and appeared normal.  The scope was then withdrawn back to the anastomosis where there were postsurgical changes with a couple of ischemic-appearing ulcerations that were small and shallow along with a couple of small hyperplastic and inflammatory polyps.  Cold biopsies were obtained of the ulcerated areas and hot biopsy forceps were used to remove a couple of these small polyps with an Endostat II power source with monopolar coagulation, current setting of 20.  Another couple of tiny polyps were also removed with hot biopsy forceps and the same current power setting from the rectosigmoid colon region.  No other biopsies were taken.  Prior to withdrawal of the scope from the patient, air was removed from the colon with the patient tolerating the procedure well with no evidence of immediate complication.  He was transferred to the recovery area in stable condition.

IMPRESSION:
1.  Some postsurgical mucosal changes seen in the area of the side-to-side ileotransverse colon anastomosis with some ischemic-appearing ulcerations.  There was no evidence of gross neoplastic changes involving the mucosa.
2.  The rectosigmoid polyps are also more likely to be hyperplastic.
3.  Moderate sigmoid colon diverticulosis.

RECOMMENDATIONS:
1.  High-fiber diet with avoidance of nuts, seeds and popcorn.
2.  Carcinoid screening workup to include a 24-hour urine collection for 5-HIAA, upper endoscopy down into the duodenum, barium small bowel follow-through x-ray examination, and nuclear medicine octreotide scan.
3.  Repeat colonoscopy in 3 years for colon polyp surveillance.

Orthopedic - Arthroscopy and Meniscectomy Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right knee lateral meniscus tear.

POSTOPERATIVE DIAGNOSES:
1.  Right knee lateral meniscus tear.
2.  Loose body.
3.  Lateral femoral condyle chondral lesion.

OPERATION PERFORMED:  Right knee diagnostic and operative arthroscopy with arthroscopic partial lateral meniscectomy, arthroscopic loose body removal and arthroscopic lateral femoral condyle microfracture.

SURGEON:  John Doe, MD

ANESTHESIA: General and local.

ESTIMATED BLOOD LOSS:  Minimal.

TOURNIQUET TIME:  None.

COMPLICATIONS:  None apparent.

DESCRIPTION OF OPERATION:  After the establishment of a general anesthetic, IV antibiotics were given.  The patient was positioned supine.  The right lower extremity was prepped and draped in the normal sterile fashion.  Using blunt trocars, superolateral and inferolateral portals were created.  A medial portal was created under direct vision to protect the medial meniscus.  Systemic evaluation of the knee was performed.  The suprapatellar pouch had no significant loose bodies or arthrofibrosis.  There was significant arthrofibrosis on the infrapatellar fat pad region and the medial and lateral gutters, which was debrided back to a stable base, freeing up the patellofemoral joint.  There was no significant further impingement on the medial and lateral condyles.  There were grade 2 changes on the undersurface of the patella diffusely, as well as in the trochlea, especially at 30-60 degrees of range of motion.

There were no grade 3 to 4 changes in this region.  The medial femoral condyle had minimal grade 1 to 2 changes at medial tibial plateau, but no formal grade 3 to 4 changes were noted.  The medial meniscus was stable per palpation without evidence of tear.  The PCL was intact.  The ACL had some looseness.  Did have a firm endpoint with anterior drawer.  Importantly, though, there was a large loose body anterior to the ACL, impinging into the notch, which was minimally scarred down to the ACL, impinging the notch with flexion, extension.  This was removed with a basket after the medial portal was enlarged carefully and noted to be approximately 1 cm in length.  Pictures were taken before and after this and anterior drawer was performed.  There was a firm endpoint approximately 4-5 mm and stable per palpation.

Upon entrance of the lateral joint line, there was an anterolateral meniscus tear, which was gently debrided back to a stable base.  There was significant synovial hypertrophy in this region over the lateral femoral condyle, which was gently debrided.  The remaining portion of the anterior mid body was intact.  There was a posterior horn lateral meniscus tear with instability, which was gently debrided back with a combination of baskets and shaver.  Care was taken to protect the articulated surfaces.  The lateral femoral condyle had demyelinating articular cartilage.  This was down to bone and grade 4 in nature.  There was delaminating cartilage around this.  All loose cartilage was removed.  The anterior weightbearing portion was inspected.  Pictures were taken and followed by microfracture technique in approximately 3 mm increments.  A microfracture awl was used to penetrate some chondral bone.  Bleeding was achieved after the pump was turned off.  Pictures were taken.  The scope was removed.  The knee was evacuated.  The portals were closed with buried sutures, followed by Steri-Strips and the insertion in the portals and in the knee of 0.5% Marcaine with epinephrine for a total of approximately 25 mL.  No apparent complications.

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Hand Surgery Medical Transcription Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right small finger flexor tendon contracture.
2.  Proximal interphalangeal joint contracture.
3.  Distal interphalangeal joint contracture.

POSTOPERATIVE DIAGNOSES:
1.  Right small finger flexor tendon contracture and adhesions.
2.  Proximal interphalangeal joint contracture.
3.  Distal interphalangeal joint contracture.
4.  Flexor tendon rupture.

OPERATIONS PERFORMED:  
1.  Right small finger flexor tendon tenolysis.
2.  Proximal interphalangeal joint capsulectomy and complete joint release.
3.  Distal interphalangeal joint capsulectomy and complete joint release.
4.  Flexor tendon repair to the distal phalanx.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia.

ANESTHESIOLOGIST:  Jane Doe, MD

FLUIDS:  600 mL of lactated Ringer's.

ESTIMATED BLOOD LOSS:  Minimal.

TOURNIQUET TIME:  86 minutes.

DESCRIPTION OF OPERATION:  Following informed consent, administration of IV antibiotics and site marking of the right small finger and forearm of the right arm, the patient was taken to the operating room and placed supine on the operating table. Following site verification and time-out of the right small finger, the hand, and forearm, the patient was placed under general anesthesia and the right arm was placed on the hand table. The operating table was turned 90 degrees and a nonsterile tourniquet was placed in the proximal right arm and the right arm and hand were sterilely prepped and draped in the usual fashion. The right arm was wrapped in Esmarch and tourniquet was inflated and left inflated a total of 86 minutes. Following inflation of the tourniquet, a Brunner incision extending from the mild pulp of the distal aspect of the right small finger and extending down the length of the finger down into the palm proximal to the A1 pulley Brunner incisions, zig-zag type incision was made. A sharp dissection was carried through skin and dense scar to the flexor tendon. The A3 pulley that was really just a scar tissue was elevated off of the flexor tendon. The neurovascular bundles, both radial and ulnarly, were left undisturbed during the procedure. The A3 pulley was opened. The flexor tendon was observed. The flexor digitorum superficialis tendon was noted to not be intact. The patient had a single flexor digitorum profundus tendon to the right small finger. There was noted to be sutures distal to the A4 pulley, where the tendon repair had been repaired to a very small stump at the distal attachments of the flexor digitorum profundus tendon at the base of the distal phalanx. Again, the A3 pulley was opened. The A2 and A4 pulleys were left intact. The A4 pulley was very small, but it was intact. The A2 pulley was intact. The A1 pulley was intact as well. The flexor digitorum superficialis tendon was retracted from the proximal interphalangeal joint.

Using the Beaver blade, a capsulectomy of the volar aspect of the proximal interphalangeal joint releasing the collateral ligaments was performed as well as the volar plate and the proximal interphalangeal joint could be extended to full extension. Attention was then turned to the distal interphalangeal joint. Again, the flexor tendon was retracted. A capsulectomy and complete collateral ligament release of the distal interphalangeal joint was performed in a complete extension, to 0 degrees of the distal interphalangeal joint was possible. The joints appeared to be normal with normal articular cartilage. The skin and subcutaneous tissues were dissected free from the tendon proximal to the A1 pulley. The tendon was noted to be intact. Using a Freer, adhesions were broken up surrounding the flexor digitorum profundus tendon through the A1 and A2 pulleys. In the process of doing that, the distal attachment repair site of the flexor digitorum profundus tendon completely ruptured. The flexor tendon was completely released from adhesions down into the mid palm through the pulley system in the finger, and it was noted to have full free movement of the flexor digitorum profundus tendon with complete release of all adhesions through the pulley system, as well as to the bone and surrounding soft tissue.

The distal flexor tendon was then repaired to the base of the distal phalanx. The prior sutures were removed. The micro-Mitek suture anchor was drilled into the base of the distal phalanx and the suture was used to reapproximate the flexor digitorum profundus tendon to the base of the distal phalanx with an intact A4 pulley. The #4 Ethibond sutures were used to secure the distal tendon to the surrounding tissue, and then, using two Keith needles, these were drilled through the distal phalanx exiting through the proximal aspect of the nail dorsally and 3-0 Prolene suture in a Bunnell-type suture pattern was sutured to the distal flexor digitorum profundus tendon, passed through the Keith needles through a button on the dorsum of the nail of the right small finger and tied in place to further secure the attachment of the flexor digitorum profundus tendon to the distal phalanx. The flexor digitorum profundus tendon was noted to be intact and held in its position. The right small finger could be fully extended. The metacarpophalangeal and proximal interphalangeal joints and distal interphalangeal joint could be extended to approximately flexion of about 30 degrees before tension on the flexor digitorum profundus tendon was noted. The finger could be completely flexed by pulling on the tendon proximal to the A1 pulley down into a fully flexed position touching the palm with the tip of the small finger.

The tourniquet was deflated at 86 minutes. Hemostasis was achieved. The distal finger had capillary refill less than 2 seconds. The wound was copiously irrigated and the skin was closed with interrupted 5-0 nylon sutures. A sterile soft dressing and a dorsal hood splint with the right small finger, the wrist flexed approximately 20 degrees, metacarpophalangeal joint flexed approximately 20 to 30 degrees, the proximal interphalangeal joint flexed about 20 degrees and the distal interphalangeal joint flexed about 45 degrees, was placed. The patient was extubated in the operating room and taken to the recovery room in stable condition.

Total Knee Arthroplasty Medical Transcription Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Left knee degenerative joint disease.

POSTOPERATIVE DIAGNOSIS:  Left knee degenerative joint disease.

OPERATION PERFORMED:  Left total knee arthroplasty.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  50 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  Once consent was obtained, the patient was given preoperative antibiotics based on his allergy profile and then he was brought to the operative theater by the anesthesia team and anesthetized in the usual fashion. A well-padded tourniquet was placed on the left proximal thigh and then the left lower extremity was prepped and draped in sterile fashion. After Esmarch exsanguination, the tourniquet was inflated and a midline incision was made followed by a medial parapatellar incision and eversion of the patella. Visualization of the distal femur with distal femoral intramedullary guide placed in the appropriate position and then a 5 degree valgus cut was made on the distal femur, resecting 9.5 mm of bone. This was followed by sizing the femur, which was a size 6, and placement of the size 6 distal femoral cutting guide and then the anterior-posterior cuts were made followed by the chamfer cuts.

Once this was completed, the size 6 distal femoral trial was inserted with excellent fit. The posterior cruciate ligament retractor was inserted. The proximal tibia was retracted. The patient's patellar tendon was intact. Once the proximal tibia was exposed, extramedullary proximal tibial guide was placed and 9 mm was taken off the lateral side on this varus osteoarthritic patient. Once this was done, a size 4 tray was pinned into place. A drop rod was placed down the front of the tibial tray and found to go right down the tibia, indicating no varus-valgus malalignment. The tibial tray was found to be in good position. A 9 mm trial insert was placed and the knee was reduced. There was full extension, greater than 120 degrees of flexion, with no excess varus-valgus or anterior-posterior instability.

Once this was completed, the patella was resurfaced using the appropriate patellar resurfacing guides and then the patellar surface was peg drilled and a 38 mm tri-peg patellar component was inserted and reduced into the trochlea. The knee was brought through a full range of motion. There was no instability of the patella. There was slight lateral patellar tracking. A lateral release was performed. All components were then removed. The proximal tibia was punched. All bony surfaces were copiously irrigated with normal saline, pulsatile lavage and then dried. Then, the tibial component was cemented into place followed by cementation of the patellar component and finally cementation of the Oxinium distal femoral component polyethylene 9 mm insert, was placed, and the cement was allowed to dry. Once the cement was dry, the knee was brought through full range of motion. There was no instability. There was full range of motion and excellent patellofemoral tracking. The excess cement had been removed prior to drying. The components and soft tissue were copiously irrigated with normal saline and the medial parapatellar incision was closed with Ethibond interrupted figure-of-eight sutures.

The Hemovac drain was inserted prior to closure for postoperative swelling control. The subcutaneous layer was closed with Vicryl in interrupted inverted mattress sutures and the skin was approximated with staples. The wound was cleansed and dressed using Adaptic, 4 x 4s, ABD, Webril, Polar Care pack and Ace bandage followed by a knee immobilizer. The tourniquet was deflated prior to dressing placement. There was no excessive bleeding. Toes were pink and warm with excellent capillary refill and pulses.  The patient was awakened by the anesthesia team, extubated, and moved to the postanesthesia care unit in stable condition. There were no complications.

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Austin Bunionectomy Medical Transcription Transcribed Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity, left first metatarsal.

POSTOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity, left first metatarsal.

OPERATION PERFORMED:  Austin bunionectomy with internal fixation, left first metatarsal.

SURGEON:  John Doe, D.P.M.

HEMOSTASIS:  Pneumatic ankle tourniquet set at 250 mmHg.

ANESTHESIA:  MAC with local.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS: None.

PROPHYLAXIS: Ancef 1 gram 30 minutes prior to incision.

DESCRIPTION OF OPERATION:  The patient was placed on the operating room table in the supine position. Following adequate sedation, a Mayo block was performed utilizing 10 mL of 0.5% Marcaine plain around the first metatarsal. The pneumatic ankle tourniquet was then placed around a well-padded left ankle. The left lower extremity was then scrubbed, prepped, and draped in the usual sterile fashion. Attention was directed to the left and an Esmarch was then utilized for exsanguination. The pneumatic ankle tourniquet was then inflated on the left lower extremity to 250 mmHg. A 6 cm linear longitudinal incision was then made medial and parallel to the extensor hallucis longus involved with the contour deformity. The incision was then deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were electrocauterized as necessary.

At this time, a linear capsulotomy was then performed over the dorsal aspect of the first metatarsophalangeal joint. The periosteal and capsular structures were then carefully dissected free of their osseous attachments and reflected medial and laterally exposing the head of the first metatarsal at the operative site. A sagittal bone saw was then utilized to resect all noted medial prominence. Attention was then directed to the first interspace by the original skin incision, where the extensor hallucis longus was observed and retracted out of the way, exposing the extensor hallucis brevis, which was identified and retracted out of the way. Dissection was then continued deep using blunt dissection down to the level of the fibular sesamoid, which was freed from its soft tissue attachments proximally, laterally, and distally. The conjoined tendon of the abductor hallucis muscle was then identified and resected at its attachment to the base of the proximal phalanx at the hallux. At this time, the level of the contracture present on the hallux was noted to be reduced and the sesamoid apparatus was noted to flow in a normal corrected position.

At this time, attention was directed to the medial aspect of the first metatarsal head at which time a 0.45 inch K-wire was then driven from the medial to lateral in a perpendicular fashion across the head of the first metatarsal, being perpendicular to the line of the second metatarsal with no dorsiflexion or plantarflexion noted. At this time, a V-type osteotomy was created in the metaphyseal region of the bone utilizing a sagittal bone saw. After this was created and placement of the guidewire, the apex of the deformity was pointed distally and the arms were approximated plantarly and proximal, dorsally. Upon completion of the osteotomy, the capital fragment was distracted and shifted laterally into a more corrected position impacted on the first metatarsal shaft. At this time, a 0.45 inch K-wire from the DePuy screw set was then driven from dorsal to plantar across the osteotomy site to serve as temporary fixation.

Following standard AO technique procedures, one 20 x 2.7 mm FRS DePuy bone screw was then inserted and placed across the osteotomy site with excellent compression noted. At this time, the K-wire was then removed and attention was then directed to the medial bone shelf, which was resected utilizing a sagittal saw and passed from the operative site. A power rasp was then utilized to smooth all bony prominences. Correction of the deformity was then reassessed at this time, both clinically and utilizing intraoperative fluoroscopy, and the position of the screw and correction of the deformity was noted to be excellent. The wound was then flushed with copious amounts of sterile normal saline and a medial capsulorrhaphy was then performed. The capsule and the periosteal structures were then reapproximated utilizing 4-0 Vicryl. The subcutaneous layer was then reapproximated utilizing 4-0 Vicryl and the skin was closed in a subcuticular stitch fashion using 4-0 Monocryl. Benzoin and Steri-Strips were then applied.

Upon completion of the procedure, the incisions were then dressed with dilute Betadine-soaked Adaptic covered with dilute Betadine-soaked gauze, Kling, Kerlix and Coban. The pneumatic ankle tourniquet on the left ankle was then rapidly deflated with a prompt hyperemic response noted to all digits of the left foot. A DonJoy ice dressing was then incorporated into the wound dressing, after initial dry sterile dressings. The patient tolerated the procedure and anesthesia well and was transferred to the recovery room in satisfactory condition with vital signs stable and vascular status intact to all digits bilaterally.

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Hematology - Oncology Consult Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Hematological clearance.

Thank you, Dr. Doe, for allowing us to participate in this patient's medical care.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old female who has a history of von Willebrand disorder, which has never been confirmed.  She has been seen by more than one hematologist and the laboratory studies have been repeated in the past.  The patient, however, has history of easy bruising, history of bleeding post laparoscopic procedure, and significant bleeding post arthroscopy.  The patient stated that her family members have been diagnosed of plasminogen activator inhibitor deficiency.  Therefore, she consulted with a hematologist who ordered a test to determine if indeed she could have this.  Indeed, the patient was diagnosed as having plasminogen activator inhibitor deficiency.  She was going to have a tympanoplasty sometime in the recent past, and she was prescribed Amicar prior to the procedure.  The procedure went off uneventfully without any bleeding activity during the procedure, although it was not a significantly invasive procedure.  On further questioning, she denies having any excessive menstrual bleeding.  Usually, her menstruations lasts for approximately 5 days and it comes every 3 weeks, but there were times in the past that she had some vaginal bleeding that lasted sometimes up to 4 months.  Currently, she does not take any aspirin or nonsteroidal anti-inflammatory agents.  The patient stated that 4 days ago, after she ate a ham sandwich, when she was already feeling unwell with abdominal discomfort, she had abdominal crampy pain.  The day that she decided to come to the emergency department, yesterday, the abdominal pain was significant and the patient decided to come to this hospital for evaluation and treatment.  Concomitantly, she developed diarrhea. At the time of my evaluation, the patient was ready to have her breakfast and was hungry and stated that the abdominal pain had significantly decreased and, on a scale of 1 to 10, was a 3.  She denied any chills, any fever, and denied any urinary symptoms.  The patient's menstrual period had started approximately 4 days ago.  She denied any rectal bleeding, but she has been diagnosed with hemorrhoids.

SOCIAL HISTORY:  The patient denies smoking cigarettes and drinks alcohol socially.

ALLERGIES:  SHE HAS NO KNOWN DRUG ALLERGIES.

MEDICATIONS:  She was not taking medications prior to admission.

PAST MEDICAL HISTORY:  Otherwise unremarkable, except for previous laparoscopic evaluation, previous arthroscopy and tympanoplasty.  Denied any hypertension, any heart condition, and denied any liver disease.

FAMILY HISTORY:  As above.  The patient's family members have been diagnosed with plasminogen activator inhibitor deficiency.

REVIEW OF SYSTEMS:  Unremarkable.  She has no history of anorexia, any weight loss, any chest pain, cough, chills or fevers.

PHYSICAL EXAMINATION:
GENERAL:  This is a normal-appearing female in no significant distress at the time of the evaluation.
SKIN:  Her skin color was normal.  She has no petechiae or ecchymoses.
LYMPH NODES:  She has no palpable neck supraclavicular, axillary, inguinal adenopathy.
HEENT:  Evaluation was normal.
LUNGS:  Clear to auscultation.
HEART:  Regular rate and rhythm with normal heart sounds.
ABDOMEN:  Soft and nontender with increased bowel sounds without hepatosplenomegaly and without ascites.
RECTAL:  Examination was deferred.

DIAGNOSTIC IMPRESSION:  Coagulopathy of unclear etiology, von Willebrand disease, which has never been confirmed, and plasminogen activator inhibitor deficiency as per the patient's information.  The patient clearly appears to have tendency of bleeding following procedures.

RECOMMENDATIONS:  In view of this, I have recommended withholding the colonoscopy procedure since the patient could be at risk, particularly if any biopsy is taken during the procedure.  I recommended instead a full diagnostic workup that can be done as an outpatient.  The patient's symptoms have improved significantly and her diarrhea has improved.  She has an appointment to see Dr. Doe as an outpatient in approximately 10 days.  I will attempt to contact you and discuss with you my recommendations.

Thank you for allowing me to see your patient.

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ENT Consult Medical Transcription Transcribed Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

CONSULTANT:  Jane Doe, MD 

REASON FOR CONSULTATION:  Acute dizziness.

IMPRESSION:
1.  Acute exacerbation of chronic benign positional vertigo.
2.  Underlying complex medical history including acute exacerbation of chronic obstructive pulmonary disease, depression, diabetes, and hypertension.
3.  No evidence of external or middle ear disease.
4.  History of presbyacusis exacerbating above.

RECOMMENDATIONS:
1.  Physical therapy evaluation for vestibular evaluation and possible rehabilitation.
2.  Vestibular testing can be performed, but it is generally performed in the office as an outpatient.  We recommend that the patient be followed up once she is discharged and sent back to her extended care facility. 

CHIEF COMPLAINT AND HISTORY:  This is an (XX)-year-old female seen in consultation, who presents with history of increasing shortness of breath.  She has a history of chronic respiratory failure, pulmonary fibrosis, and COPD.  Also, of note, over the last several days, she has had intermittent episodes of acute spinning-type vertigo.  She notes this is typically 2-3 o'clock in the morning when in bed.  She denies any daytime dizziness and notes that she is fairly stable otherwise.  She denies any change in her hearing; although, she has a history of hearing loss.  She denies any tinnitus.  There has been no otalgia and no drainage posteriorly and no drainage in the ears.

PAST MEDICAL HISTORY:  As noted.

PAST SURGICAL HISTORY:  Reviewed at length in the chart. 

LABORATORY DATA:   The data is reviewed and this is relatively normal, except for elevated glucose.

PHYSICAL EXAMINATION:
GENERAL:  On examination today, she is sleeping quietly but is easily awakened.
VITAL SIGNS:  Pulse 86, blood pressure 134/74, and respirations 22.
HEENT:  The head is normocephalic.  Trachea is in the midline.  Both ears, including auricles, external auditory canal and tympanic membranes are all intact.  The middle ear shows no effusion or retraction.  Nose externally is in the midline and internally shows mild septal deviation.  Oropharynx shows upper and lower plates.  She has had a tonsillectomy.  She has an intact gag reflex.  Tongue protrudes in the midline.  There are no ulcerations or lesions present.
NECK:  No lymphadenopathy.
HEART:  Regular rate and rhythm.
LUNGS:  Lung sounds are distant and shallow.

At this point, the patient appears to have had an acute exacerbation of her chronic benign positional vertigo.  She does not appear to have had any distinct treatment for this.  As such, physical therapy including Cawthorne and Brandt-Daroff exercises can generally clear this for the most part.  We recommend physical therapy evaluate them for this.  If she has continued disequilibrium, then certainly vestibular testing should be performed and this could be done in my office.

Thank you for the opportunity to participate in the care of your patient.

Nephrology Consult Medical Transcription Transcribed Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Acute rhabdomyolysis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who unfortunately has residual organic brain syndrome.  The patient was brought in to the emergency department because of new onset of right-sided weakness and inability to talk, which has significantly improved.  The patient is being treated for acute CVA.  It was noted that the patient had a CPK level around 2100 on admission; it has further increased to 19,500.  The patient had been taking Vytorin as an outpatient, and currently, in the hospital, he is on Zetia and Pravachol.  The patient does not have any recent history of falls, trauma, and does not have any history of renal disease, hypertension and diabetes mellitus.

PAST MEDICAL HISTORY:  As stated in history of present illness, also left eye blindness.

OUTPATIENT MEDICATIONS:  Effexor, aspirin, Risperdal, Remeron, and has been recently started on Vytorin.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  He lives in assisted living facility.  No tobacco or alcohol use.

REVIEW OF SYSTEMS:
NEUROLOGIC:  No prior history of stroke or epilepsy.  He did have organic brain syndrome as previously described.
PULMONARY:  No productive cough.
CARDIOVASCULAR:  No chest pain.
GASTROINTESTINAL:  No nausea or vomiting.
GENITOURINARY:  No pain on urination.
MUSCULOSKELETAL:  Denies any joint tenderness or muscle aches, or tenderness to touch.
PSYCHIATRIC:  He has had history of depression.
HEMATOLOGIC:  No overt bleeding complications.
DERMATOLOGIC:  No skin cancer.
ENDOCRINE:  No history of diabetes or thyroid disease.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 118/74, heart rate 64 per minute, respirations 22 per minute.
GENERAL:  The patient is a thin male.  He is comfortable and oriented x3.
HEENT:  Normocephalic.  Right pupil reactive to light and accommodation.  Extraocular movements are grossly intact, relatively pink conjunctiva, anicteric.  Oral cavity shows no obvious lesions of the soft or hard palate.
NECK:  Supple with full range of motion.  No JVD.  Trachea is midline.
LUNGS:  Grossly clear to auscultation and percussion.  No intercostal retractions.
HEART:  Regular in rate and rhythm.  S1 and S2.  No obvious rub or gallop.  There is a soft 1/6 systolic ejection murmur at the left sternal border.
ABDOMEN:  PMI is at the midclavicular line.  Bowel sounds are present.  Soft, depressible, and nontender.  No sign of any palpable masses.  No evidence of hepatosplenomegaly.
EXTREMITIES:  No clubbing, cyanosis or edema.
NEUROLOGIC:  He has still some weakness on the right side.  He is able to talk at this time.  Upon presentation, he did not have any ability to talk.
SKIN:  No active lesions or rash.

LABORATORY DATA:  BUN 18, creatinine 0.3. On admission, CPK was around 2100.  Subsequently, it has increased to 19,500.

IMPRESSION:
1.  Acute rhabdomyolysis.
2.  Acute cerebrovascular accident.
3.  Hyperlipidemia.
4.  Organic brain syndrome.

The patient is a (XX)-year-old male with no prior history of renal disease, who now is developing acute rhabdomyolysis in the absence of any overt trauma.  At this point in time, it is seriously considered that the onset of the rhabdomyolysis may be associated to the therapy currently being used for treatment of his underlying dyslipidemia.  The patient at this point in time will need discontinuation of the cholesterol-lowering agents and also will need to continue hydration to maintain adequate urinary flow to prevent any precipitation of myoglobin in the renal tubules, which can then result in acute renal failure.  We will also obtain records from the PCP to see what the patient's baseline liver function tests were, they are mildly elevated, and whether any CPKs were done, and to obtain the exact date of initiation of therapy with the cholesterol-lowering agents.

DIAGNOSTIC DATA:  Upon presentation, his EKG showed normal sinus rhythm and he also had an echocardiogram, which showed mild mitral regurgitation and tricuspid regurgitation.  CT of the brain showed no acute pathology.

PLAN:  Further recommendations for the management of this patient will depend on the patient's clinical course and the results of whether the patient has further progressive increase in CPKs.  At this point in time, we would refrain from obtaining special serologic tests to assess for intrinsic muscle disease.

Thank you very much for allowing me to participate in the management of this patient.

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Rheumatology Consult Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Evaluation of inflammatory polyarthritis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who was admitted to the hospital with complaints of low back pain that she states has been going on for the past 2 years.  She denies any history of trauma or injury.  She states that she has been hurting in the back for the past 2 years, and lately, the pain has been getting worse.  She denies any prolonged morning stiffness.  She does not complain of any fever or any chills.  There is no prior history of any connective tissue disease or rheumatic disorder.

PAST MEDICAL HISTORY:  Thyroidectomy.

FAMILY HISTORY:  No history of any connective tissue disease like lupus erythematosus.

SOCIAL HISTORY:  Does not smoke and does not drink.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

CURRENT MEDICATIONS:  Aspirin, cyclobenzaprine, tramadol, Novolin, enalapril, amlodipine, metoprolol, bumetanide, Novolin R, and cefazolin IV.

REVIEW OF SYSTEMS:  The patient has been gaining weight over the last several years.  Denies any recent increase in weight or loss of weight.  Does complain of generalized fatigue and weakness.  Denied any fever or any chills.  She has history of coronary artery disease.  Denying any chest pain or shortness of breath at this time.  Denies any abdominal bloating.  Denies any history of skin rashes.  No history of any prior blood clots or deep venous thrombosis.  Musculoskeletal wise, the patient has been experiencing low back pain for the past 2 years.  Denies any joint pain or joint swelling in her hands, wrists or feet.  She has been having difficulty moving her right shoulder joint.  There is no history of any trauma.  Denies any Raynaud's.  No mouth or nasal ulcers.  Denies any hair loss.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 132/62, pulse 86, respiratory rate 20, temperature 98.6, and T-max was 100.4.
GENERAL APPEARANCE:  The patient is a (XX)-year-old obese female lying in bed, basically being fed with the help of the nurse.
HEENT:  Pupils equal, round, reactive to light and accommodation.  Extraocular movements intact.  No tenderness on palpation over the temporal arteries bilaterally.
CHEST:  Clear, has bilateral breath sounds.
HEART:  S1 and S2.
ABDOMEN:  Soft, obese, and nontender.
EXTREMITIES:  No pedal edema.  Musculoskeletal examination: Limited range of motion of the right shoulder joint, and left shoulder joint seems to move fine.  She is tender on palpation, likely over the anterior and lateral aspect of the right shoulder joint.  Elbow joints appeared to be fine.  Limited range of motion of the hip joints.  She has crepitus in her knee joints, and on examination of her hands, wrists, and feet, there is some puffiness in her right hand, but there was no tenderness on palpation over the PIP, DIP, and the MCP joints.  Her motor power appears to be decreased in the right upper extremity.  She was unable to move the shoulder joint.  It could be because of pain in the shoulder that she is not able to move the right arm.  No obvious muscular wasting observed.
NEUROLOGIC:  She is alert and oriented.

LABORATORY DATA:  CBC shows white cell count of 14.2, H and H of 9.4 and 29.6, and platelet count 229,000.  Chemistries:  Her BUN is elevated at 54, creatinine 2.6, calcium 9.4.  C-reactive protein is elevated at 13.8.  Sedimentation rate was 94.

DIAGNOSTIC STUDIES:  Chest x-ray shows cardiomegaly without acute infiltrate and thoracic spondylosis.  MRI of the lumbar spine shows presence of significant lumbar stenosis at L4-5 due to degenerative grade 1 spondylolisthesis and severe facet arthropathy with synovitis and enhancement involving the facet joints.  Imaging characteristics are suggestive of a possible osteomyelitis.  Technetium bone scan shows increased activity in the region of posterior superior iliac in the sacral ala bilaterally, of uncertain significance, could represent inflammation.

ASSESSMENT AND PLAN:  The patient is a (XX)-year-old female who is admitted with complaints of low back pain with a history of arthritis in her back for the past 2 years.  Her MRI and bone scan does point towards some inflammatory process going on.  The patient is currently on antibiotics for possible infection.  From the rheumatic aspect, I will be getting some baseline labs on her to rule out any underlying autoimmune or rheumatic disorder.  With a high sedimentation rate, limited range of motion of the right shoulder joint, and the amount of discomfort she has in her back, the possibility of inflammatory arthritis is very high.  At this point, I will be getting an MRI of the right shoulder joint because of decreased mobility.  We will hold off empirical treatment with steroid at least until the initial workup is completed in view of high suspicion of infection.  She does not give typical features of polymyalgia rheumatica.  The patient is also being worked up to rule out any underlying malignancy.  Her blood cultures have been negative so far, not showing any growth after one day.

I will be following the patient with you.  Thank you for the consult.

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Infectious Disease Consultation Medical Transcription Sample Report

Neurology Consult Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  TIA versus stroke.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with a history of hypertension and atrial fibrillation with permanent pacemaker, who presented to the ER complaining of acute left-sided weakness and numbness 1 day prior to admission.  The patient reports that she woke up on Tuesday morning with left-sided weakness and numbness.  She presented to the ER about 24 hours later for evaluation.  The patient reported at that time that her left side was weak.  She also had some slurred speech.  Admission note from the ER stated that the patient said that her symptoms have resolved, but upon interview, at this time, she states that the symptoms actually have not completely resolved.  The patient has a history of chronic atrial fibrillation and is on Coumadin, and her INR on presentation was therapeutic at 2.6.

PAST MEDICAL HISTORY:  Hypertension, atrial fibrillation, status post permanent pacemaker placement, history of gastrointestinal polyps, and history of Helicobacter pylori infection.

PAST SURGICAL HISTORY:  Cholecystectomy; hysterectomy; right breast tumor removal, which was benign, and pacemaker placement in the past.

MEDICATIONS:  As an outpatient, Coumadin, Cozaar, digoxin, and atenolol.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient denies any drugs, alcohol or tobacco.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Stable.
HEART:  S1 and S2, paced.
NECK:  No bruits.
NEUROLOGIC:  Mental status:  The patient is awake, alert, and oriented x3.  Speech is fluent.  Good comprehension.  Cranial Nerves:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Face is symmetric.  Tongue is midline.  Palate is symmetric.  Motor:  5/5 in the right and 4+/5 in the left with some apparent give-way weakness.  Of note, there is no pronator drift present in the upper extremity.  Good tone.  No tremors noted.  Reflexes are 1+ in right upper extremity, 2+ in left upper extremity, 1+ at the knees bilaterally, and 1+ at the ankles bilaterally.  Plantars are downgoing bilaterally.  Sensory:  Decreased pinprick in the left face, arm, and leg.  Decreased vibration on the left.  Coordination is intact, finger-to-nose, with a mild intention tremor, but no ataxia.

LABORATORY AND DIAGNOSTIC DATA: CT of the brain done was negative for acute event.  Repeat CT of the brain done 24 hours later was also negative.  INR was 2.69 on admission.  Chest x-ray was negative.

ASSESSMENT:
1.  Left-sided numbness and weakness.  The patient's main complaint consists of left-sided numbness of the face, arm, and leg.  This could possibly be consistent with a thalamic lacunar stroke.  Her weakness appears to be secondary to give-way rather than actual weakness.  I did not recommend repeating CT of the brain any further as the second CT was done 72 hours after the event, which should show an acute lesion.  I recommend checking a lipid profile.  I agree with baby aspirin.
2.  Peripheral neuropathy.  Not mentioned above. The patient complains of burning and tingling of her feet, started about 2 months ago.  Will send workup for neuropathy.

PLAN:
1.  Physical therapy/occupational therapy evaluation.
2.  Agree with aspirin therapy.
3.  Will send neuropathy workup.
4.  Will start gabapentin 200 mg p.o. q.h.s. for neuropathic symptoms.
5.  EMG/nerve conduction studies as an outpatient.

Thank you, Dr. Doe, for this consult.  We will follow along with you.


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Cardiology Consult Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Not dictated.  

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who presented to the emergency department with abdominal pain and peritonitis.  The patient has been treated for that, but she does also have a history of peripheral vascular disease and is scheduled to undergo surgery within the next 3 weeks.  The patient requires cardiac clearance and had been scheduled for outpatient stress test this week, which she was unable to make due to her hospitalization.  At this time, the patient denies any anginal symptoms.  Prior to her MI, she had complaints of left arm pain but no chest pain.

PAST MEDICAL HISTORY:  Significant for peripheral vascular disease, history of coronary disease with previous myocardial infarction and angioplasty.  She has a history of diabetes; hypertension; dyslipidemia; COPD; and end-stage renal disease, on peritoneal dialysis.

HOME MEDICATIONS:  The patient is on Hectorol 2.5 mcg daily; Altace 2.5 mg daily; Plavix 75 mg daily; Renagel daily; Amaryl 2 mg daily; aspirin 1 daily; Toprol-XL 100 mg daily; Norvasc 10 mg daily; Catapres patch weekly; iron supplement; Lipitor 20 mg daily; potassium supplement 10 mEq daily; and Fosrenol 500 mg 3 times a day.

ALLERGIES:  SULFA.

SOCIAL HISTORY:  The patient does have a history of tobacco use.  She does not use alcohol or illicit drugs.

REVIEW OF SYSTEMS:
GENERAL:  No complaint of fever, chills or weight loss.
CARDIOVASCULAR:  Denies any chest pain or anginal equivalent.  No complaint of palpitations.
RESPIRATORY:  Positive for shortness of breath secondary to COPD with no acute change in her status.
GASTROINTESTINAL:  Positive for abdominal pain and peritonitis.  No blood in bowel movements or dark tarry stools.
GENITOURINARY:  End-stage renal disease, on dialysis.
NEUROLOGICAL:  No TIA or CVA symptoms.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a (XX)-year-old female in no acute distress.
VITAL SIGNS:  Stable.  The patient is afebrile.
HEENT:  Negative.
NECK:  No jugular venous distention or carotid bruits.
HEART:  Regular rate and rhythm.  No murmurs are heard.
LUNGS:  Clear bilaterally.
ABDOMEN:  Moderately tender throughout due to peritonitis, was not deeply palpated.  Bowel sounds present.
EXTREMITIES:  No edema or cyanosis.  She has faint peripheral pulses on the left; pulses on the right were nonpalpable.
NEUROLOGICAL:  No focal deficits.

DIAGNOSTIC DATA:  EKG is not done at this time.

LABORATORY STUDIES:  CBC:  WBC is 13.2, hemoglobin 10.4, hematocrit 31.6, and platelet count 184.  Metabolic panel:  Potassium is 4.8, BUN 49, creatinine 8.6, and TSH is within normal limits.

IMPRESSION:
1.  Coronary disease with history of myocardial infarction, status post percutaneous transluminal coronary angioplasty and stent.
2.  Peripheral vascular disease.
3.  End-stage renal disease, on peritoneal dialysis.
4.  Peritonitis, stable.
5.  Chronic obstructive pulmonary disease with history of tobacco use.
6.  Diabetes mellitus.
7.  Hypertension.
8.  Dyslipidemia.

RECOMMENDATIONS:  The patient is scheduled for peripheral vascular surgery.  We will proceed with a dual isotope stress test and 2D echocardiogram for clearance and obtain a 12-lead EKG for baseline.

Thank you for allowing us to participate in the patient's care.

History and Physical Medical Transcription Sample Transcribed Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:  Not Dictated.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old white female who was in her usual state of health until yesterday morning when she began noticing shortness of breath with cough productive of clear phlegm and wheezing. She used her albuterol inhaler, but it did not improve. She had a neighbor bring her to the emergency room. She has been treated aggressively here in the emergency room and is feeling somewhat better. She reports no fever. No nasal congestion or sore throat. No nausea, vomiting or diarrhea. She does report some tightness at the base of the neck, which was unrelieved by nitroglycerin but was relieved by the respiratory treatments. The patient has a long-standing history of asthma. Usually uses Flovent and Serevent inhalers routinely, as well as Singulair.

PAST MEDICAL HISTORY:
1. Minimal atherosclerotic heart disease. She was admitted 8 years ago with an episode of atypical chest pain. Heart catheterization showed a 15-25% mid diffuse left anterior descending obstruction. The patient had a renal artery, on the left side, with greater than 90% stenosis. This was treated with angioplasty and stent by Dr. Doe that same month. He wanted to redo the stent indicating that there is probably some recurrent disease. She has not yet consented to this.
2. Dysrhythmia. Dr. Jane Doe, her prior cardiologist, had recommended pacemaker and AICD. I do not believe she ever had an electrophysiologic study. She has not been noted to have any arrhythmia problems in the last year or two.
3. Stroke with diplopia in the late 1980s. CT scan apparently showed an abnormality in the brain stem. She had a carotid Doppler done in September 1991, which did not show any significant stenoses.
4. Hypothyroidism. Followed by Dr. Jack Doe. She had Graves disease. Unsure how it was treated.
5. Recent episode of what sounds like vertigo. She did come to the emergency room about a week ago for this. She was treated in the emergency room, improved, went home, and has had no further problems.

PAST SURGICAL HISTORY:
1. Hysterectomy.
2. Left breast biopsy x3.

MEDICATIONS: Flovent 110 mcg 2 puffs b.i.d., Serevent 1 puff b.i.d., albuterol p.r.n., and Singulair 10 mg daily. She has used Rhinocort in the past. Levoxyl 137 mcg half tablet daily.

ALLERGIES: PENICILLIN CAUSED A RASH, CODEINE CAUSED CNS SYMPTOMS, NOVOCAIN AND XYLOCAINE ASSOCIATED WITH SYNCOPE, ACCUPRIL CAUSED A COUGH. SHE HAD A TAPE REACTION WITH CATHETERIZATION.

FAMILY HISTORY: Mother died in childbirth. Father died of heart disease. Sisters have breast cancer, diabetes, atrial fibrillation and hypertension. A brother had prostate cancer.

SOCIAL HISTORY: The patient is widowed. She has no family in town. She lives alone. She does not smoke or drink. She follows no special diet.

REVIEW OF SYSTEMS: The patient has some proptosis. An MRI scan showed this secondary to retroorbital fat. She has an ANA, which is slightly positive at 1:160 nucleolar with a sedimentation rate of only 16. No other rheumatologic symptoms. The patient did have hypertension secondary to her left renal stenosis. She is not on any medication at this time.

PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is currently afebrile with normal vital signs. Blood pressure was 135/78. O2 saturation is 97% on oxygen.
HEENT: ENT examination is unremarkable.
NECK: Supple without nodes or enlarged thyroid. Carotids are 2+ with a right carotid bruit.
LUNGS: Clear at this time with some slightly diminished breath sounds throughout.
HEART: Regular with a grade 1-2/6 systolic murmur at the right upper sternal border.
BREASTS: Without masses.
ABDOMEN: Soft and nontender. Bowel sounds are normal without organomegaly.
EXTREMITIES: Without edema. Pedal pulses are 2+.
NEUROLOGICAL: Nonfocal.
SKIN: Unremarkable.

LABORATORY DATA: Potassium 3.5, BUN 21, creatinine 1.2, and glucose 84. The rest of the profile, including liver enzymes, is normal. The CPK is 234 but the MB CPK is 3.5. Troponin is normal. EKG shows no significant ischemic changes. There is an inverted T wave in V3 and V4. INR is 0.92, PTT 28.6, hemoglobin 13.8, white blood cell count 3600, normal differential, and platelets are 155,000.

IMPRESSION:
1. Exacerbation of underlying asthma.
2. Minimal atherosclerotic heart disease.
3. Renovascular hypertension.
a. Status post left renal artery angioplasty and stent.
b. Normotensive post procedure.
4. History of dysrhythmia.
5. Stroke, late 1980s, with resolution.
6. Hypothyroidism.
7. Right carotid bruit.

PLAN: The patient is admitted to the hospital to continue pulmonary toilet with intravenous steroids. Singulair will be continued, as will her Flovent and Serevent. Carotid sonogram will be done.


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Selective Coronary Cineangiography and PCI Transcribed Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURES PERFORMED:
1.  Diagnostic selective coronary cineangiography.
2.  Percutaneous coronary intervention of an occluded right coronary artery.
3.  Intracoronary nitroglycerin and Integrilin injection.

OPERATOR:  John Doe, MD

DESCRIPTION OF PROCEDURE:  The patient was transferred from an outside hospital after a diagnostic catheterization. The patient was brought to the catheterization lab in the usual fasting state. Informed consent was obtained and the patient was prepared and draped in the usual fashion. Following this, we obtained access to the left groin and a 6 French sheath was placed. We did not obtain access to the right groin as an Angio-Seal device was placed recently. Following this, we proceeded to advance a 5 French JR4 catheter and obtained multiple images of this vessel. Following this, we advanced a 5 French JL4 catheter to the ostium of the left main coronary artery and obtained multiple images of the left system.

Subsequently, these catheters were removed and the images were reviewed and decision was made to proceed with PCI of the occluded right coronary artery. Heparin, 5000 units, was administered. Following this, we advanced a 6 French JR4 guide catheter up to the ostium of the right coronary artery. We used an Asahi 0.014 Prowater wire to cross this lesion. After the lesion was crossed, we advanced a 2.5 x 15 mm Voyager balloon and multiple inflations were performed in the mid and proximal portions. Following this, angiography revealed flow down the vessel. There was significant thrombus in this vessel, especially in the proximal region, which was suggestive of probably an acute occlusion in this area. Subsequently, the patient received intracoronary nitroglycerin and repeat angiographic images after that showed some resolution of the thrombus.

Following this, we proceeded to advance a 3 x 33 mm Cypher drug-eluting stent into the mid and distal portion of this vessel and this was deployed at about 16 atmospheres for 30 seconds. Subsequently, we advanced a 3.5 x 28 mm Cypher drug-eluting stent into the proximal portion and this was deployed at 16 atmospheres for 30 seconds. Subsequently, angiographic images were obtained in multiple views and we determined that there was slight haziness proximal to the stent deployment; this was not thought to be due to a thrombus or dissection. Good distal flow was noted and excellent stent deployment was also noted. The patient was stable during the procedure and had no complaints. After confirming that we were in the true lumen in the distal portion of this vessel, the patient was given Integrilin infusion per protocol for platelet inhibition. Sheath was sewn in place and the patient was subsequently transferred to the CVR for sheath removal and will be admitted for further management.

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LABORATORY DATA:  On admission, the patient's CBC showed normal white count, low H and H with MCV of 101, and platelet count was normal indicating macrocytic anemia. By discharge, the patient's white count was 8.9, hemoglobin was 8.8, hematocrit 26.7, and platelet count was 230,000. PT/INR and PTT were normal. Chemistry profile showed, on admission, an elevated sodium at 146, uncontrolled blood sugar at 392, BUN 99, and creatinine of 3.2. AST, ALT, and alkaline phosphatase levels were all normal. By discharge, the patient's chemistry profile showed a sodium of 136, BUN is down to 51 with a creatinine of 1.3. AST, ALT, and alkaline phosphatase levels were normal. The patient's magnesium levels were normal. The patient did have a few episodes of hyperglycemia during her hospital course, probably secondary to IV and p.o. steroids. The patient's cardiac enzymes were normal. She had a BNP on admission that was 186, repeated a few days later and it was 372. The patient also had a urinalysis, as stated earlier, that was abnormal, Candida albicans. The patient's blood cultures showed no growth. The patient had no other diagnostic or invasive interventions during this hospital course.

The patient had a venous Doppler of bilateral lower extremities secondary to severe edema, showed no deep vein thrombosis. The patient also had a chest x-ray on admission that showed right central line placement, slight infiltrate within the left lung base, as well as cardiomegaly with tortuous and ectatic thoracic aorta. The patient had a repeat chest x-ray a few days prior to discharge that showed cardiomegaly. No interval change, no left effusion or left lower infiltrate.


LABORATORY DATA:  On admission showed a CBC that was within normal limits. His white count was normal at 8.5. By discharge, his white count was 6.5, his hemoglobin 11.8, his hematocrit was 32.8, his platelet count was 527. PT/INR at the time of discharge was 22.4, his INR was 1.95. His chemistry profile on admission showed some slight abnormalities, as CO2 was 20. His BUN was 44. His creatinine was 1.3. TSH was normal. On discharge, his chemistry profile was unremarkable except for a slightly elevated glucose of 129. The patient is diabetic. The patient also had some cardiac enzymes on admission that were negative. He had a BNP that was 209. Urinalysis was negative. He had occult blood stools that were negative x2 and he had a urine culture that showed no growth. His blood cultures also showed no growth.

The patient also had an ultrasound of his kidneys during the stay that showed a single right kidney, identified without hydronephrosis. At the time, the patient had complaints of some dysuria as well as some retention. The patient also had a chest x-ray that showed bilateral pleural effusion, bibasilar opacities suggestive of atelectasis or infiltrates.


LABORATORY DATA:  Serology studies showed on admission that the patient's CBC was slightly abnormal. His white count was elevated at 13.3 and H and H and platelet count were normal. By discharge, the patient's white count was 9.3, his hemoglobin was 11.9, his hematocrit was 35.5, platelet count was 243,000, and MCV was 89.6. He does have anemia of chronic disease and was on Aranesp during his hospital stay. PT, PTT, and INR normal. Chemistry profile on admission was also abnormal indicating mild hyperkalemia as well as mild hyponatremia. By discharge, the patient's chemistry profile was within normal limits except for elevated BUN of 38 with a creatinine of 1.7 secondary to his chronic renal failure. The rest of his chemistry profile was within normal limits. Magnesium levels were normal. His CK enzymes and troponins were, I believe, normal. His CK-MB actually was elevated, but he had normal troponins. BNP was 103 on admission, repeat was 65. TIBC 358 with a ferritin level of 265. Urinalysis on admission was negative for any bacteria or pyuria. MRSA screens were negative even though the patient had a history of MRSA and no other studies were performed.

Nuclear medicine renal scan showed split renal function, 45 left and 55 right. Otherwise, fairly symmetrically diminished perfusion consistent with renal disease. No evidence of obstructive uropathy. The patient had a chest x-ray on admission that showed slightly improved CHF and no active pulmonary disease. 


LABORATORY DATA:  White count 12.9, hemoglobin 11.2, hematocrit 34.8, platelets 365, 53% segs, 13 bands, 11 lymphs, 22% monos. Absolute monocyte count was elevated at 2.8. White count was as high as 23.9 previously. PT/INR and PTT essentially unremarkable. Alkaline phosphatase was 258, slightly elevated. Sodium 144, potassium 3.6, chloride 108, CO2 of 26, BUN 22, creatinine was down to 1.7. LFTs were normal. Serial blood sugars were obtained during the hospital stay. Lipase elevated at 274 and 241. This was as high as 290 and 236 previously. Total iron binding capacity 245, unconjugated iron binding capacity 218. Iron level 24. B12 of 280, folate 11.8, and haptoglobin 376. B-type natriuretic peptide was 426. CK-MB and troponins were negative. Urine; trace albumin, trace leukocyte esterase. Stool for occult blood was negative. Cultures on the chart negative.

Venous Doppler of the lower extremities revealed no evidence of DVT. Echocardiogram:  Mild to moderate concentric left ventricular hypertrophy with normal leaflet size and function with normal systolic function, left ventricular diastolic dysfunction, however, and trace mitral regurgitation. EKG:  Sinus rhythm, low voltage. The patient underwent fine needle aspiration with guidance with successful ultrasound-guided drainage, loculated small pocket of fluid adjacent to the anterior abdominal wall, represented purulent material. Ultrasound of the gallbladder:  Pancreas is not enlarged. It has heterogeneous echotexture, nonspecific. Exophytic cyst along the right lobe of the liver was seen on prior CT. No evidence of gallstone or definite right renal stone. Minimal right perirenal fluid and a small fluid collection in the right mid abdomen measuring 4.4 x 4.6 x 1.4. CT of the abdomen limited with small fluid accumulation in the right mid abdomen measuring 1.4 x 2.6, probable liver cyst. Also, possible partial small bowel obstruction, distal ileum, and there is some fecal material in the colon. CT pelvis:  Low-grade partial small bowel obstruction.


DIAGNOSTIC DATA:  CT of pelvis was performed revealing status post prostatectomy, diffuse metastatic disease to bone, large amount of fecal material in the rectosigmoid, and nodular contour to the posterior wall of the bladder, not significantly changed from prior.  Postsurgical CT abdomen revealed approximately a 2.3 cm soft tissue mass just posterior to the left common iliac vein suspicious for metastatic lesion, low attenuation lesion measuring 1.4 cm of parapelvic region of left kidney, most likely representing cyst, atrophy of the right kidney, diffuse metastatic disease to bone and CT appearance of an acute pathologic fracture involving L1 vertebral body.  CT of brain was negative for acute hemorrhage or mass effects and small vessel ischemic changes as well as lacunar infarct, right basal ganglia and internal capsule.  Negative for acute hemorrhage or mass effect.  CT of chest revealed enlarged lymph nodes within the mediastinum with the take-off of the left subclavian artery measuring up to 2.5 cm in size suspicious for metastatic disease.  Incidentally noted but not mentioned in the findings of the report.  There was 1.7 cm soft tissue lesion within the left subclavicular fossa, multiple nodular infiltrates throughout the right upper lobe and superior segment of the right lower lobe.  Differential diagnosis would include infectious etiology versus diffuse osseous metastatic disease.  CT of chest was performed to rule out pulmonary embolus as the patient had atypical chest pain during the course of hospitalization.  There was no PE or multiple osseous lesions.  Stable mediastinal adenopathy and nodular infiltrates persist within the right upper and lower lobes.  X-ray of spine revealed diffuse bony sclerotic metastasis, wedge compression deformity of L1, L3-L4, and L4-L5 degenerative disk disease, also facet degenerative disease on the left at L3 to S1.  


LABORATORY DATA:  CBC day prior to discharge; WBC 5.7, hemoglobin 11.4, hematocrit 35.4, platelets 296, neutrophils 47, bands 12, lymphocytes 35, monocytes 2, eos 4. Sedimentation rate initially was 93, decreased to 37 and increased finally to 60. CRP initially was 8.8, then 5.8, and finally 3.1. Glycosylated hemoglobin was 6.4. Chemistry on the day prior to discharge; sodium 141, potassium 3.9, chloride 102, CO2 of 28, glucose 116, creatinine 0.7, calcium 9.1, total protein 6.4, albumin 2.7, globulin 3.7, alkaline phosphatase 90, ALT slightly elevated at 77 and AST 32. Creatine kinase 16, which is low. Fasting lipids were as follows; cholesterol 103, triglycerides 116, HDL low at 18, LDL 62, VLDL is 23, fasting glucose was 100. Repeat Monospot test was negative. EBV IgG is positive, IgM is negative. Lyme and mycoplasma titers are still pending and EBV titers still pending. Amylase is also slightly elevated at 10.


LABORATORY DATA:  Hemoglobin 18, hematocrit 53.4, platelets 78, and white blood cell count 15.2 initially. Repeat hemoglobin was 15.6, hematocrit 47.2, platelets 63, white blood cell count 10.2. PTT was 31.8, PT was 22.1, and INR was 1.92 and elevated. Sodium was 138, potassium 4.2, chloride 104, CO2 of 24, BUN 18, creatinine 1.1, glucose 122, and calcium 8.8. Repeat sodium 132, potassium 2.8, chloride 103, CO2 of 22, BUN 9, creatinine 1.1, glucose 155, calcium 7.8.

EKG showed sinus arrhythmia at 96 to 142 with left axis deviation. Abdominal x-ray showed diffuse bowel gas pattern. Chest x-ray showed some perihilar questionable congestion. He had a CAT scan of the abdomen and pelvis. The CAT scan was consistent with diverticulitis involving the distal descending colon with localized perforation and extraluminal air adjacent to part of the colon consistent with localized perforation of the descending colon. No evidence of intra-abdominal abscess or free fluid. Mild splenomegaly.

Esophagogastroduodenoscopy with Esophageal Variceal Band Ligation Medical Transcription Procedure Sample Report

REFERRING PHYSICIAN:  John Doe, MD

PROCEDURE PERFORMED:  Esophagogastroduodenoscopy with esophageal variceal band ligation.

INDICATION:  Hematemesis.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained and conscious sedation was achieved with Demerol and Versed. Total sedation used was 75 mg of Demerol and 7 mg of Versed. The patient tolerated the procedure well. The patient was placed in left lateral position and video EGD scope was introduced into the hypopharynx and advanced under direct vision up to the second portion of the duodenum without difficulty.

PROCEDURE FINDINGS:
1.  The distal esophagus showed evidence of large esophageal varices with some of them having red wale sign indicating recent hemorrhage and also high risk for re-bleeding.
2.  Stomach showed evidence of erosive gastritis, but no active bleeding.
3.  The duodenum was normal.

The endoscope was withdrawn and a Saeed Six Shooter band ligation device was placed at the tip of the endoscope and the endoscope was reintroduced. Six bands were placed at different columns, specifically targeting the areas of red wale signs. The band ligation was successful. However, since there were significant varices, a total of ten bands were placed using another Saeed Six Shooter band ligation device.

DIAGNOSES:
1.  Esophageal varices with signs of recent hemorrhage, high risk for re-bleeding.
2.  Erosive gastritis.

RECOMMENDATIONS:
1.  Continue proton pump inhibitors.
2.  Start nadolol 40 mg a day.
3.  See the patient in the office in about two weeks.
4.  The patient will need a repeat upper endoscopy and band ligation in about three weeks.

Thank you, Dr. Doe, for the opportunity to participate in this patient’s care.

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