Repair of Facial and Internal Nasal Lacerations, Open Reduction of Nasal Septal Fracture Operative Example

DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in supine position. IV general anesthetic was induced. An oral endotracheal tube was then passed without difficulty. The patient was then prepped and draped in routine sterile fashion. Lacri-Lube was placed in the eyes bilaterally. Local anesthesia was induced by the infiltration of 1% Xylocaine with 1:100,000 epinephrine to the appropriate areas. After this was taken back, surgery was begun. The facial lacerations on the nasal dorsum were approximately 1.5 cm in length, which was repaired with 6-0 Prolene. He also had multiple smaller lacerations in the left upper eyelid which were again repaired with 6-0 Prolene. The patient had a 1 cm laceration of the mucosa of the upper lip on the right side, which was also repaired with 5-0 chromic. At this point in time, attention was directed to the internal nasal injuries themselves. Old clots were re-evacuated from this area and the site was irrigated. The patient was noted to have several internal nasal lacerations and an open nasal septal fracture. The site was debrided of old clots and the internal nasal lacerations were closed with 5-0 chromic. The patient also had a septal hematoma which was evacuated and mucosa was sutured through-and-through utilizing a straight Keith and 4-0 chromic suture. This was done in a continuous horizontal mattress fashion working away around the entire nasal septum. Once this was completed, the Sayer elevator was placed internally into each naris and the nasal bones were elevated superiorly and reduced to the appropriate position. A 0.25 inch Nu Gauze which was impregnated with antibiotic ointment was then packed lightly into the superior aspects of the nasal bones to provide internal nasal support. Once this was completed, the Denver splint was adapted to the nasal dorsum and the metal reinforcement splint was compressed so as to give proper support externally to the nasal bones. During the procedure, the patient received 1250 mL of crystalloid solution as well as 1 gram of Ancef and 8 mg of Decadron. Estimated blood loss was less than 100 mL. There were no complications during the procedure and no drains were placed. There are no specimens removed.

MT Word Help

Medical Transcription Samples

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

Palmar Fasciectomy and Digital Fasciectomy Operative Example

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine position. After adequate anesthesia was obtained using a general anesthetic, the left arm was prepped and draped in the usual sterile manner. The left arm was then exsanguinated using Esmarch wrap and tourniquet and was inflated to 250 torr. I first turned my attention to the palmar fasciectomy. I made a curvilinear incision from the metacarpophalangeal joint area of the left index finger, curving across the palm and proximally to the carpometacarpal joint base of the small finger. I dissected down through the subcutaneous tissue to the Dupuytren's tissue and then I carefully separated the Dupuytren's tissue from the subcutaneous tissue and skin. I lifted this up so I could trace it back to just distal to the transverse carpal ligament. I then identified its limits on the radial side and the ulnar side of the palm and then identified each of the individual pretendinous cords that extended to the fingers. I released the Dupuytren's proximally and then followed each of the cords. I followed the cord to the index finger, where I preserved Skoog's fiber and followed it distally where it inserted into the skin and into the flexor sheath. I excised it at this point. On the middle finger, in a similar fashion, I followed it past Skoog's fibers, preserving the fibers and then it had a spiral cord that was extending ulnarly. I did follow this slightly more distal out to its attachment close to the base of the proximal phalanx. I protected the neurovascular bundle and released it from this location. I then followed the small finger out and it did extend again in a spiral cord towards the ulnar side. I was able to separate it from the neurovascular bundle and it was excised. I then followed the ring finger past Skoog's fibers and I continued the dissection distally. I released it from the flexor sheath and then I carefully identified the neurovascular bundles radially and ulnarly and traced these out towards the proximal flexion crease of the ring finger. I now did a modified Brunner incision over the palmar aspect of the ring finger and carefully separated the skin from the Dupuytren's tissue. I followed the dissection towards the radioulnar side, then identified over the middle aspect of the middle phalanx the digital nerve and vessel, and then used this to trace proximally to ensure that I protected the neurovascular bundle throughout its dissection. After exposing the digital nerve and vessel on both the radial and ulnar sides, I carefully separated the Dupuytren's disease from the flexor sheath and dissected it proximally. I then followed this underneath the proximal flap and removed it in one lump. I then checked for both lateral cords and retrovascular cords, which were identified and removed and again checked throughout the course of the dissection that the neurovascular bundles were protected. I then was able to demonstrate that I could fully extend the ring finger on both the metacarpophalangeal joint and the proximal interphalangeal joint and I checked to ensure that there were no remaining cords. I then irrigated out copiously and then deflated the tourniquet. I cauterized the small bleeding vessels, and then after irrigation checked to make sure that the flaps were pink and the finger tip was pink. I then irrigated again and extended points of Brunner incisions to the mid lateral line and then I used 5-0 nylon to close the skin. This was done in horizontal mattress stitches. I checked to ensure that again the flaps were all pink and then placed him in a compressive dressing and the fingers were placed in full extension with a splint holding that position. The patient was then taken to the recovery room in good condition.

MT Word Help

Medical Transcription Samples

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

Trial Spinal Cord Stimulator Placement Transcription Example

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the prone position. The pressure points were checked and padded, and routine monitors were placed. Adequate MAC anesthesia was applied. The patient was prepped and draped in a sterile fashion. The L1-2 interspace was located by fluoroscopy. Lidocaine 1% was used for skin anesthesia. A 14-gauge Tuohy spinal cord stimulator was placed through a right primary approach at L1-2 interspace in the mass of the ligamentum flavum. Epidural space was located using loss of air technique. Needle was checked on AP and lateral fluoroscopy. Negative CSF, heme, paresthesia obtained. Spinal cord stimulator electrode was threaded through the catheter in the epidural space without difficulty. The spinal cord stimulator electrode would advance approximately 1-1/2 interspaces and then would not advance further. There appeared to be possibly some scar tissue at this area. Thus, T12-L1 interspace was located. Lidocaine 1% was again used for skin anesthesia. A 15 blade was used to make a skin nick and a 14-gauge Tuohy spinal cord stimulator needle was placed through the skin nick though a right paramedian approach at the T12-L1 interspace, advanced to the ligamentum flavum. Epidural space located using loss of air technique. Negative CSF, heme, paresthesia obtained. Needle tip was checked on AP and lateral views fluoroscopically. The spinal cord stimulator electrode was placed though the needle into the epidural space and advanced under fluoroscopic guidance. The tip could be advanced in the right midline up to approximately the bottom of the T10 vertebra; it would not advance any further than that. Care was taken with multiple attempts, but it wound not advance. Thus, it was left in the tip at the bottom of T10 in the midline and the patient's anesthesia was allowed to be reversed. She was awake and alert. The stimulator was stimulated with multiple electrode settings and had excellent stimulation that covered her low back, right lower extremity pain, from her back to her foot with multiple electrode combinations. Thus, the stylet was removed from the needle. The needle was removed tip intact, taking care not to dislodge the spinal cord stimulator electrode. The anchor was placed over the electrode until it was flush with the skin and clamped in place. Three 2-0 Ethibond sutures were placed around the anchor to secure it to the skin. Sterile dressings were applied. The patient tolerated the procedure well and had excellent range of motion of lower extremities upon completion of the procedure.

MT Word Help

Medical Transcription Samples

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

Deceased Donor Renal Transplantation Operative Sample

DESCRIPTION OF OPERATION: The patient was intubated under general endotracheal anesthesia. A central line was inserted for central venous pressure monitoring in the right internal jugular vein. Bladder irrigating solution was also instilled. The kidney was on a perfusate pump; it was removed. It was a right kidney and we cleaned off Gerota fascia and the right adrenal gland. We separated the artery from the vein. The vena cava was on hold. We oversewed and ligated the upper portion of the cava and tributary lumbar branches were sutured. We used the lower portion of the cuff and swung that over to be a part of our extension graft for the vena cava. The artery and vein were separated. Tributary branches were ligated. A single ureter was cleaned off. We cut the Carrel patch from the aorta for the renal artery from the right side. Kidney was left on ice. Was given 500 mg of Solu-Medrol for infection therapy and 150 mg of IV Thymoglobulin was run over 6 hours.

A curvilinear incision in his right groin was made, one fingerbreadth above the pubis symphysis, two fingerbreadths medial to the anterior-superior iliac spine to the level of the umbilicus. We dissected through subcutaneous tissue and external oblique. We encircled the cord structures and inferior epigastric vessels were retracted medially.

Once we entered through the external oblique, we entered retroperitoneum through the transverse abdominis muscle. Bookwalter retractor was placed to expose the right external iliac artery and vein. As vessels were soft and calcified, Satinsky clamps were placed and vascular clamps on the artery, distal and proximally were placed. Arteriotomy was made. The kidney was removed off ice. We sewed the artery end-to-side with the Carrel patch with running 6-0 Prolene suture.

Subsequently, did a venotomy. Heparinized saline was used to flush it. The distal end of the inferior vena cava was used to sew the right external iliac vein end-to-side with a running 5-0 Prolene suture. Cross clamps were released. The warm ischemia time was 40 minutes and cold ischemia time was 14 hours. The kidney was perfused well, and prior to clamping, we started dopamine and Lasix 80 mg, 12.5 grams of mannitol was given IV. The kidney was pink and well perfused.

We repositioned our retractors to expose the bladder wall. We dissected through the detrusor muscle and mucosa of the bladder wall. The ureter was cut shorter and spatulated on the back wall. A 6 French double-J 12 cm length stent was placed in the transplanted kidney through the ureter and into the renal pelvis, and the distal end was placed into the bladder. Extravesical bladder anastomosis was then made with a running 6-0 PDS suture. The mucosa anterior to this was closed with interrupted 4-0 Vicryl suture.

A JP drain was brought out from a lateral stab incision. Both layers were closed as a single layer with a running #1 PDS suture. Subcutaneous tissue was irrigated. A separate JP drain coming out medially was brought in the subcutaneous tissue, 3-0 Vicryl simple interrupted subdermal stitches were used and staples for the skin. Blood loss was approximately 300 mL. Sponge and needle counts were correct x2. The patient was extubated and transferred to the recovery room in stable condition.

MT Word Help          Orthotopic Liver Transplantation Sample Report

Living Related Kidney Transplant Sample Report

Medical Transcription Samples

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

Laboratory Data Words / Sample Lab Section Transcription Examples

LABORATORY DATA: Hemoglobin 9.3, hematocrit 27.4, white blood cell count 4090, and platelet count of 262,000. Urinalysis showed no nitrites, 15 mcg/dL of protein, and no blood. Stool for occult blood initially was positive, then converted to negative. Sodium 133, potassium 5.1, chloride 104, and CO2 of 18. Initial BUN was 60 and creatinine 5.3, repeat BUN was 29 and creatinine 2.7. Protein 5.5, albumin 2.8, and calcium 8.6. Bilirubin 0.3, AST 9, ALT 20, alkaline phosphatase 101. Magnesium 2.4. Triglyceride 214, cholesterol 190, HDL 25, and LDL 122. Stool for Clostridium difficile is positive. Stool for ova and parasites was negative. Stool for enteric pathogens was negative.

Renal scan showed poor glomerular function. No evidence of obstructions. Abdominal ultrasound showed calcification of the arcuate artery. Chest x-ray showed no infiltrate. KUB showed no free air. EKG showed normal sinus with nonspecific ST flattening.


LABORATORY DATA:  On admission, white blood cell count is 6.9, hemoglobin 8.6, hematocrit 24.6, neutrophil percentage is 29.6, lymphocytes 54.9%, MCV was 94.2, reticulocytes 3.5%.  Sodium 134, potassium 4.2, chloride 102, bicarbonate 24, BUN 18, creatinine 0.8, calcium 8.2.  Total bilirubin is 1.5, direct is 0.3, AST 145, ALT 24, lactate dehydrogenase is 2852, total protein 6, alkaline phosphatase is 76, albumin 3.6, amylase 64, lipase 46.  PT was 17, PTT 31.9, INR 1.3.  UA on admission showed 1+ protein, 1+ blood, negative for leukocyte esterase, negative for nitrites, 2 to 5 white blood cells.  EKG showed normal sinus rhythm.  Chest x-ray showed no evidence of acute cardiopulmonary disease; although, on chest x-ray, there appeared to be some cardiomegaly.


LABORATORY DATA: Hemoglobin was 13.5, hematocrit 39.6, white blood cell 6090, and platelet count of 276,000. D-dimer was negative. Urinalysis did show 3+ bacteria, positive nitrites, and negative protein. Sodium 138, potassium 3.8, chloride 102, CO2 of 28, BUN 19, creatinine 0.9, glucose 136, protein 7.5, albumin 4.1, calcium 9.1. Bilirubin 0.44, AST 19, ALT 36, alkaline phosphatase 76, CK of 50, amylase 35, lipase 164. Triglycerides 209, cholesterol 194, HDL 38, LDL 118. Troponin 0.03. A pH of 7.5, PCO2 31, PO2 105, and bicarbonate of 24. Urine cultures showed no growth.

Electrocardiogram showed normal sinus rhythm with no progressive ischemia. Ventilation/perfusion scan was negative for pulmonary embolism. Chest x-ray showed no infiltrate. Electrocardiogram showed normal systolic function, trace mitral regurgitation, left ventricular diastolic dysfunction.


LABORATORY DATA: Hemoglobin 10.4, hematocrit 31.6, white blood cell count 6050, and platelet count 214,000. Urinalysis did show 1+ bacteria and no nitrites, 100 mcg/dL protein and 25 mcg/dL of blood. Sodium 142, potassium 2.9, chloride 105, CO2 of 25, BUN 60, creatinine 5.2, glucose 51, protein 6.5, albumin 3.1, calcium 8.2, and bilirubin 0.28. AST is 20, ALT is 24, alkaline phosphatase 136. CK 80, repeat CK 77 and 71. Triglyceride 99, cholesterol 115, HDL 46, LDL 51. Troponin 0.05. T3 of 124 and 24-hour urine for creatinine was 9. Urine cultures showed no growth.

Chest x-ray showed congestive heart failure with basilar consolidation and bilateral fluids. Echocardiogram showed ejection fraction of 35% with mitral regurgitation, dilated left ventricle and EKG showed normal sinus rhythm with intraventricular conduction delay.


LABORATORY DATA: Hemoglobin 13.3, hematocrit 41.9, white blood cell count 8040, and platelet count 164,000. D-dimer was negative. INR of 1. Stool for occult blood negative. Sodium 138, potassium 4.5, chloride 102, and CO2 of 34. BUN 26 and creatinine 0.8. Glucose 139. Calcium 8.9. Phosphorus 4.4, CK 45, and magnesium 2.2. Triglycerides 97, cholesterol 167, HDL 72, and LDL 76. Troponin of 0. TSH of 0.66. Sputum culture did show Acinetobacter baumannii.

Chest x-ray showed no infiltrate. CT of the chest showed no infiltrates. Hiatal hernia was noted. EKG showed normal sinus rhythm with poor R-wave progression.


LABORATORY EXAMINATION: EPO was 302. Hemoglobin was 10.4 and hematocrit was 31.3. Sodium 138, potassium 4.5, chloride 104, and CO2 of 28. BUN 4 and creatinine 0.9. Glucose 115. Protein 5.1 and albumin 2.4. Calcium 8.7. Bilirubin 0.3. AST is 23, ALT is 27, alkaline phosphatase 77. CK 45, LDH 156, amylase 30, lipase 130. Magnesium 1.7 and beta hCG was negative. Iron was 1, TIBC 225. Troponin is 0. B12 of 574, folic acid 9.7, haptoglobin 2. TSH 4.6. Rheumatoid factor negative and ANA negative. Blood cultures showed Escherichia coli. Peritoneal culture showed Escherichia coli and urine culture showed Escherichia coli.

Abdominal ultrasound was normal. Pelvic ultrasound showed a 18 mm right cyst. CT of the abdomen was normal. Nuclear scan showed no evidence of pulmonary embolus. Chest x-ray was normal.


LABORATORY DATA:  WBC 9.3, hemoglobin 14.2, hematocrit 40.6, and platelet count 186,000.  APTT 28.4, PT 12.9, INR 0.95.  D-dimer 0.33.  Triglycerides 204, cholesterol 187, HDL 43, LDL 103.  CPK 156, 117, and 127, CK-MB 2.7, 1.5.  Potassium 3.3, magnesium 2.9.  Troponin 0.02 and less than 0.02.  TSH 0.896.  Total T3 of 122, T4 of 6.4.


LABORATORY AND DIAGNOSTIC DATA:  White count 10.6, hemoglobin 11.9, hematocrit 37.8 and platelets 279,000.  Differential was adequate at the time of discharge.  There was 1+ polychromasia, hypochromasia and anisocytosis.  PT, INR, PTT normal.  D-dimer elevated.  Sodium 142, potassium 4.3, chloride 102, CO2 of 30, BUN 22, creatinine 0.9, glucose 162, B-natriuretic peptide 34, magnesium 2.7.  Serial blood sugars obtained.  Glucoses were excellent, occasional low and occasional high.  Urine, positive nitrite, 1+ leukocyte esterase, 1+ bacteria.  CDT screen was positive.  Ova and parasites were negative.  Stool, sputum and blood cultures were all negative.  Chest x-ray had some left basilar atelectasis, questionable infiltrates.  CT of the chest, study is limited due to suboptimal pulmonary artery opacification.  No definite pulmonary embolus seen.  Abdominal x-ray, some scattered air-fluid levels, probably a large bowel.  Knee x-rays, osteopenia and mild narrowing of the medial joint space compartment bilaterally, vascular calcification.


LABORATORY DATA:  White count 10.8, hemoglobin 15.8, hematocrit 47.6, platelets of 236,000. BMP: Sodium 138, potassium 4.4, chloride 102, carbon dioxide 28, BUN 22, creatinine 0.9 and glucose of 85. Serum ammonia level was 126. ESR was 13. Cardiac troponin 0, TSH 1.52, free T4 0.84. Urinalysis was normal. Urine drug screen was also negative. Blood culture showed no growth. Cocci serology, indeterminate IgM level and negative for IgG.

CT scan of the head showed multiple subcutaneous metallic foreign bodies posteriorly. No intracranial abnormalities were seen. CT scan of the chest showed no pulmonary emboli. There was a prior gunshot wound primarily at the left side of the chest. EKG:  Sinus bradycardia with nonspecific ST-T wave abnormalities.


LABORATORY DATA:  CBC:  White blood cell count 6800 with 54% neutrophils, 31% lymphocytes.  Hemoglobin and hematocrit 13.9 and 41.8 respectively with low MCV of 81.6, normal MCH of 27.2, and MCHC of 33.3. Platelet count was 229,000. Coagulation profile:  PT 13.1, PTT 28.2. Chemistry profile:  Sodium 141, potassium 4.1, chloride 104, CO2 of 27, calcium 8.3, and hemoglobin A1c 5.9. Lipid profile:  Cholesterol 136, triglycerides 122, HDL low at 35, LDL 78, cholesterol/HDL ratio is 3.9. Hepatic profile was completely within normal limits. Urinalysis:  Specific gravity 1.020, pH 6 with trace blood, otherwise normal. TSH 2.23. Arterial blood gas:  A pH of 7.39, pCO2 of 42, pO2 of 87, base excess 0, bicarbonate 25.1, and saturation 96%.

A chest x-ray was normal. EKG demonstrated normal sinus rhythm with leftward axis and prolonged QT interval. Colon screening:  Hemoccult cards were negative x3. A 2-hour oral glucose tolerance test included fasting glucose of 106, which was mildly elevated and a significantly elevated 2-hour glucose of 212.


LABORATORY DATA:  BMP:  Glucose 272, BUN 13, creatinine 0.9. GFR greater than 60. Sodium 134, potassium 4.4, chloride 94, CO2 of 26, anion gap 18, calcium 9.8.  CBC:  WBC 20,400, neutrophils 90%, no bands, no eosinophils, no basophils. Hemoglobin 14.2, hematocrit 42.4.  MCV 91.8, platelets 330,000. ESR 94.  Urine:  Yellow, slightly hazy, specific gravity 1.024, pH 5.6, protein 100, glucose greater than 1000. Urobilinogen 0.2, negative bile pigment, small blood. Leukocyte esterase and nitrite were negative. Microscopic reports 2-5 red blood cells. Gram stain of the wound reported 1+ wbc and 1+ gram positive cocci. Serum ketone is greater than 100. MRSA screening is pending. Liver function test:  SGOT 66, SGPT 55, alkaline phosphatase 156, total bilirubin 1.4, direct bilirubin 0.3, indirect bilirubin 1.1, total protein 9.7, and albumin is 3.4.



LABORATORY/DIAGNOSTIC DATA:  WBC of 16.6, hemoglobin of 12.4, hematocrit of 36.2, platelets of 297,000. Sodium of 131, potassium of 6.5, chloride of 98, CO2 of 23, BUN of 26, creatinine of 1.2. Blood sugar 116, ionized calcium of 1.18.  He has lipase of 42, AST of 72, ALT of 58, alkaline phosphatase of 152, total bilirubin of 5.5, direct bilirubin of 1.4, total protein of 6.9, albumin of 2.4.  Troponin I of 0.13. BNP of 168.  Lactate of 1.3. CK-MB of 4.5.


EKG revealed 96 beats per minute, normal sinus rhythm. Q-wave is slightly prolonged at 446 msec. There are no specific ST-T changes consistent with coronary event. His arterial blood gases showed pH of 7.42, pCO2 of 34, pO2 of 76. Oxygen saturation of 95% on room air. Chest x-ray shows bilateral lower lobe infiltrates, questionable for effusion. CT scan of the abdomen without contrast showed abdominal mass in the prevertebral area around T10 level. There is no free air or free fluid in his CT scan of the abdomen.


LABORATORY EXAMINATION: Hemoglobin 11.4, hematocrit 34.3, white blood cell count 5020, and platelet count 294,000. INR of 1.4. Urinalysis shows positive esterase, negative nitrites, and negative protein. Sodium 144, potassium 4.5, chloride 106, and CO2 of 26. BUN 35 and creatinine 1.4. Glucose of 95. Protein 5.5 and albumin 3.4. Calcium 8.7. Bilirubin 0.7. AST 21, ALT 39, and alkaline phosphatase 86. CK 35. Magnesium 2.2. Troponin of 0.72, although troponin did initially show positive at 1.88. Triglyceride 106, cholesterol 136, HDL 24, and LDL 92. B12 of 812 and folic acid 24. T4 of 1.2 and TSH of 1.29. CEA was 2.2. ANA negative. Hepatitis A negative. Hepatitis B surface antigen negative. Hepatitis B core IgM negative. Hepatitis C negative. The pH is 7.4, PCO2 of 25, PO2 of 79, and bicarbonate of 81. Urine culture showed no growth.

Chest x-ray showed cardiomegaly, right effusion. CT of the chest shows moderate right effusion with no mass. EKG shows atrial fibrillation, poor R-wave progression.


LABORATORY DATA: Gastrin level 56. Hemoglobin 12.2, hematocrit 35.6, white blood cell count 9060, and platelet count 306,000. Sodium 143, potassium 3.6, chloride 107, and CO2 of 24. BUN 11.2 and creatinine 0.9. Glucose 95. Protein 5.7 and albumin 3.2. Calcium 7.9. Bilirubin is 0.65. AST 20, ALT 29, alkaline phosphatase 35. Amylase 79 and lipase 210. Triglycerides 125, cholesterol 226, HDL 90, and LDL 108. CLOtest is negative.

Small bowel series showed rapid transit. No fixed strictures or stenosis. Mild thickening of the distal ileum. Abdominal ultrasound was negative. CT of the abdomen showed inflammatory changes in the mid small bowel. KUB showed no free air. EKG showed normal sinus rhythm with no progressive ischemia.


LABORATORY STUDIES: Hemoglobin was 9.9, hematocrit 29.1, white blood cell count 2055, and platelet count 98,000. INR was 1.4. UA showed 1+ bacteria but no nitrites and 30 mcg/dL of protein. Sodium 143, potassium 3.6, chloride 107, CO2 of 28, BUN 12, creatinine 1.1, glucose 105, protein 6.6, albumin 3.3, and calcium 8.7. Bilirubin was 0.84, AST 69, ALT 57, GGT 48, and alkaline phosphatase 106. Amylase 32 and lipase 177. Magnesium 1.9. Triglycerides 68, cholesterol 126, HDL 39, and LDL 75. T4 of 14 and TSH 0.39. CEA 2.2, CA19-9 of 61, CA125 of 20, and AFP 5.3. Stool culture showed no growth. Urine culture showed no growth.

Gastrografin enema showed severe diverticulosis with spasm. CT of the abdomen showed a left renal cyst and mild splenomegaly. CT of the pelvis was normal. Chest x-ray showed no infiltrate. KUB showed no free air. EKG showed normal sinus rhythm with no acute ischemia.


LABORATORY EXAMINATION: Hemoglobin 12.8, hematocrit 38.5, white blood cell count 5065, and platelet count 183,000. Sedimentation rate of 3. Sodium 134, potassium 4.6, chloride 99, CO2 of 29, BUN 5, creatinine 0.8, and glucose 99. Protein is 6.7, albumin is 3.9, and calcium is 8.6. Bilirubin 0.25, AST 19, ALT 38, and alkaline phosphatase 116. Amylase 42 and lipase 259. Triglycerides 135, cholesterol 232, HDL 72, and LDL 134. T4 of 7.1 and TSH of 0.75. Dilantin level 2.3. Phenobarbital level 5.4.

CT of the chest showed chronic obstructive pulmonary disease with no mass noted, small pericardial effusion was noted. CT of the abdomen showed no evidence of a mass. CT of the pelvis showed no evidence of a mass. EKG showed normal sinus rhythm with no acute ischemia.

Lab Data Transcription Examples #1   Lab Data Transcription Examples #2     

Normal Lab Values         Common Lab / Diagnostic Words and Phrases

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

Lab Terms / Sample Lab Section Medical Transcription Examples

LABORATORY DATA ON ADMISSION: Sodium of 133, chloride of 97, potassium of 4.2, bicarbonate of 25, BUN of 36, creatinine of 2.3, glucose of 93. White blood cell count 7400, hemoglobin 10.1, hematocrit 29.4, platelets 215,000, calcium 9.7, albumin 3.5, total protein 7.1, alkaline phosphatase 79, total bilirubin 1.3, AST 18, ALT 15, amylase 66, lipase 22. Urinalysis was negative.

Chest x-ray showed changes consistent with sarcoidosis with questionable infiltrate in the right upper lobe, as well as right middle lobe of the lung. Abdominal ultrasound showed absence of gallbladder. That is due to the fact that the patient had a cholecystectomy. It showed a dilated common bile duct measuring 7.1 to 8.4 mm. No stones in the duct. Splenomegaly measuring 15.9 cm. Hepatic/portal veins with normal flow.


DIAGNOSTIC TESTS: CT of the head demonstrated a right MCA distribution infarct with mild hemorrhagic conversion without midline shift or mass effect. Chest x-ray showed the presence of a dual lead pacemaker, otherwise unremarkable. LDL was 82, HDL was 25, and troponin was 8.8 on admission, 4.5 at discharge. CK-MB was 6.7 on admission and 3.7 at discharge. Echocardiogram showed moderate left ventricular systolic dysfunction with an estimated ejection fraction of 40% and apical akinesis, dilated aortic root, aortic sclerosis, and trivial aortic insufficiency, right atrial and right ventricular enlargement.


LABORATORY DATA: Laboratory data on admission showed hemoglobin of 9.3 and hematocrit of 28% and 1950 white blood cells including 38 polys, 53 lymphs, 5 monos and 177,000 platelets. PT and PTT were within normal limits. CMP showed mildly increased SGOT of 56 with normal SGPT of 48 and a normal serum creatinine of 0.8.


LABORATORY FINDINGS ON ADMISSION: CBC showed WBC of 4950 per cubic mm, hemoglobin was 8.4 g/dL, hematocrit 25.4%, platelet count 168,000 per cubic mm. CMP showed glucose of 125 mg%, creatinine 4.1 mg%, potassium 5.4 mEq per liter, albumin was 3.1 g%, AST 10 units per liter, ALT 7 units per liter, serum amylase 62 units per liter, and lipase 78 units per liter.


LABORATORY ON ADMISSION: WBC 10.9, platelet count of 323,000, hemoglobin 13.5, hematocrit 39.2. Sodium 135, potassium 4.2, chloride 100, bicarbonate 29, BUN 10, creatinine 0.8, glucose 167. PT was 11, PTT 24, and INR 1.0. Cholesterol 303, triglycerides 120, HDL 34, and LDL calculated was 245.


LABORATORY STUDIES: Sodium 133, potassium 3.2, chloride 95, blood sugar was only 35 mg%, BUN 15, creatinine 1.2, calcium 8.7, and magnesium 1.8. Troponin I was zero. White count was 13,900 with 73% segs, hemoglobin 14.5 gm%. Subsequent white count was 8780, hemoglobin 14.3 gm%. Sedimentation rate was 32 mm per hour. Urinalysis showed presence of sugar and protein, with no significant microscopic findings. Subsequent electrolytes improved; potassium 4.6, sodium 134, chloride 96, BUN 17, and creatinine 1.2. Blood sugars ranged from 150 to as high as 409 from the steroids. Prior to discharge, blood sugar was 188 mg%. Sputum culture did not grow any organism. Urine culture was also negative.

X-ray of the left foot showed degenerative changes with vascular calcification. No osteomyelitis. Chest x-ray showed chronic obstructive pulmonary disease with no definite acute infiltrate. CT scan of the brain showed atrophy without any acute findings. A 12-lead EKG showed normal sinus rhythm with left axis deviation and nonspecific T-wave changes.


LABORATORY EXAMINATION: Hemoglobin 13.8, hematocrit 40.2, white blood cell count 11,200, and platelet count of 203,000. Sodium was 134, potassium 4.8, chloride 94, CO2 of 32, BUN 34, creatinine 1.4, glucose of 236, calcium of 8.9, CK of 5, troponin of 0, triglycerides 65, cholesterol 168, HDL 63, LDL 92, T4 is 7.3, alkaline phosphatase is 94, ALT is 45, AST is 21, bilirubin 0.16, calcium 9.2, protein 7.3, albumin 4.1, and TSH is 0.74. Sputum culture showed no growth. Bronchial culture for AFB was negative. Bronchial culture for fungus was negative.

Chest x-ray showed no infiltrate. EKG showed normal sinus rhythm with no progressive ischemia.

LABORATORY EXAMINATION: Hemoglobin 10.6, hematocrit 31.4, white blood cell count 8200, and platelet count of 305,000, INR of 1.9, PTT of 42.6. Urinalysis showed no nitrites, no protein, and no blood. Sodium 144, potassium 3.8, chloride 107, CO2 of 26, BUN 18, creatinine 2.6, glucose 112, protein 5.2, albumin 2.1, calcium 8.3, and bilirubin 0.26. AST is 24, ALT is 22, alkaline phosphatase 213, amylase 88, lipase of 152, magnesium 1.4, digoxin 0.62, vancomycin 15.9, pH of 7.290, PCO2 51, PO2 76, and bicarbonate of 37.
A CT of the chest showed bilateral effusions with basilar pneumonia. Nuclear scan was indeterminate for pulmonary embolus. KUB showed distension of the bowel. Venous Doppler of the left upper extremity showed normal flow pattern. EKG showed normal sinus rhythm, right axis deviation, anterior T-wave inversions.


LABORATORY DATA:  Cardiac biomarkers were not done. CBC:  Hemoglobin 13.3, hematocrit 38.8, MCV 93.3, WBC 19.4, neutrophils 88, no bands, lymphocytes 3%, monocytes 9%, platelets 276,000. BMP:  Glucose 141, BUN 28, creatinine 1.6, GFR 42, sodium 136, potassium 4.1, chloride 104, calcium 8.6, CO2 of 26, amylase 142, lipase 56, SGOT 66, SGPT 38, ALT 94, total bilirubin 2.9, direct bilirubin 0.9, indirect bilirubin 2, total protein 7.2, albumin 3.4, lactic acid 1.2. PT 31.4, INR 3. Urine:  Yellow, clear. Specific gravity 1.025. Protein 100 mg/dL, negative for glucose, ketones, nitrite and leukocyte esterase. Microscopic appeared to be 5-20 red blood cells with occult bacteria, no white cells.


LABORATORY STUDIES: White count of 13,300 with 73% segs and hemoglobin 13.2 gm%. Her admission electrolytes showed hypokalemia with potassium of 3.3, chloride of 97, BUN of 35, and creatinine 1.6 consistent with renal insufficiency. Magnesium was only 1, which improved to 1.9. Followup potassium was 4.8. Her blood sugar on admission was 122 mg%. Subsequent blood sugar went up as high as 370 mg%. Subsequent BUN and creatinine stayed mildly elevated. Upon discharge, BUN was 32 with a creatinine of 1.4 and potassium of 3.6. Digoxin level was elevated at 2.98 on admission, repeat of 3.40. Arterial blood gases showed pH of 7.42, PCO2 39, and PO2 76. The sputum culture grew Candida albicans.

Serial 12-lead EKG showed atrial fibrillation with poor progression of R waves in the precordial leads and occasional aberrancy. Chest x-ray showed no acute infiltrate initially. A repeat chest x-ray showed a vague density in the left apex suggestive of granuloma.


LABORATORY EXAMINATION: Hemoglobin 13.4, hematocrit 38.5, white blood cell count 13,900, and platelet count 152,000. Sodium 137, potassium 3.7, chloride 98, and CO2 of 27. BUN 23 and creatinine 1.1. Glucose 172. Protein 6.4 and albumin 3.2. Calcium 8.7. Bilirubin 0.4, AST is 26, ALT is 29, GGT 36, alkaline phosphatase 96, CK is 78, amylase 26, and lipase 162. Triglycerides 157, cholesterol 224, HDL 37, and LDL 158. PSA of 46.8. Troponin 0.3.

Abdominal ultrasound showed a cholelithiasis. Nuclear scan showed no excretion into the small bowel. Chest x-ray showed recurrent aspiration pneumonia. CT of the chest showed question aspiration pneumonia. Thoracic spine showed degenerative changes. CT of the abdomen showed a 4.5 cm abdominal aortic aneurysm, diverticulosis with question of a metastatic lesion of L1. Sigmoid diverticulosis was noted as well. Bone scan showed question of metastatic lesion of L1. EKG showed sinus tachycardia with a right bundle branch block.


LABORATORY EXAMINATION: Hemoglobin 12.4, hematocrit 35.7, white blood cell count 12,500, and platelet count 169,000. Urinalysis showed 3+ bacteria, no nitrites, positive protein. Sodium 142, potassium 4.2, chloride 104, and CO2 of 30. BUN 42 and creatinine 1.2. Glucose 75. Protein 5.1 and albumin 2.1. Calcium 8.7. Bilirubin is 0.39, AST is 18, ALT is 24, alkaline phosphatase is 66. Magnesium is 1.9. TSH is 0.07. Amylase of 27 and lipase of 97. Triglycerides 90, cholesterol 185, HDL 57, LDL 110. B12 768, folic acid greater than 24. CEA 2.7. Digoxin of 1.36. Blood cultures x4 showed no growth. Sputum culture showed Candida.

Chest x-ray showed no infiltrate. CT of the pelvis showed diverticulosis. Bilateral venous lower extremity Dopplers were negative and EKG shows atrial fibrillation.

Lab Data Transcription Examples #1   Lab Data Transcription Examples #2     

Normal Lab Values         Common Lab / Diagnostic Words and Phrases

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

Rehab Discharge Summary Transcription Sample

DISCHARGE DIAGNOSES:
1. Disability/mobility.
2. Disability of activities of daily living.
3. Spasticity.
4. Neurogenic bladder.
5. Contractures of upper extremities.
6. C5 ASIA C SCI.
7. Recurrent urinary tract infections.
8. Recurrent skin breakdowns.
9. Status post tracheostomy closure.
10. Recurrent pneumonia.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who sustained a C5 spinal cord injury on MM/DD/YYYY with resulting quadriplegia. He was initially evaluated and treated at XYZ Hospital and was noted to have C1, C4, C5 and C6 fractures. He had a prolonged hospitalization requiring a tracheostomy tube, PEG tube, and ultimately recovered and was sent home. However, he has not had access to healthcare since that time, except for the routine visits to the emergency room. Recently, he did gain benefits through litigation and was admitted to neurological rehabilitation for further evaluation. Since his accident, he has had overflow incontinence and currently has a Foley catheter in place.

HOSPITAL COURSE: The patient was admitted to rehab on MM/DD/YYYY. The patient participated in inpatient acute rehabilitation program, which included interdisciplinary PT, OT, speech language pathology, rehab nursing, case management, therapeutic recreation, neuropsychiatry, and physiatry.
1. Disability/mobility: Upon admission, the patient was totally dependent for bed mobility, transfer mobility, and wheelchair mobility. The patient had been lying in a bed for well over a year without getting up out of the bed. The patient participated in interdisciplinary PT, OT, TR mobility programs and he progressed well. At discharge, the patient had improved to being able to drive a powered wheelchair with proportional head control. The patient was utilizing a switch with the right elbow and able to tilt to complete weight shifts. The patient was working on rolling to right and left with maximum assistance using leg straps, and the patient was transitioning from side-lying to sitting with maximum assistance of one. The patient was able to direct staff to help him complete 20-minute weight shift in the manual wheelchair.
2. Disability of ADLs: Upon admission, the patient was totally dependent for ADL care, bathing, grooming, and eating. The patient participated in interdisciplinary OT/rehab nursing ADL program and progressed well at discharge. The patient was able to wipe his face with his right hand with minimum to moderate assistance. The patient’s caregiver/family were receiving education on how to position the patient and transfer the patient at discharge.
3. Community reentry: Upon admission, the patient was completely bed bound and house bound. The patient participated in the OT/therapeutic recreation community reentry program, and he progressed well. At discharge, the patient was working on learning resources that were available to him and how to access them. The patient had been set up with a peer mentor that he could talk to, who was six years post injury.

DISCHARGE MEDICATIONS: The patient was discharged on Percocet 1-2 tablets q.6 h. p.r.n., Senokot two tablets b.i.d., baclofen 20 mg q.i.d., and Neurontin 600 mg t.i.d.

More Physical Medicine and Rehab Sample Reports

Medical Transcription Samples

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

Repeat Low Transverse Cesarean Section Sample Report

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and spinal anesthetic was administered.  The patient was prepped and draped in the usual sterile fashion for cesarean section.  After confirmation of adequate level of anesthesia, a Pfannenstiel incision was made on the patient's skin.  Using sharp dissection, the incision was carried down to the peritoneum, which was opened superiorly and extended in a transverse manner.  A bladder blade was placed.  The vesicouterine peritoneum was dissected in order to create a bladder flap, which was also retracted with the bladder blade.  A transverse incision was made in the lower uterine segment and the incision was carried laterally and superiorly bluntly.  A live-born, 10 pound 5 ounce male infant was delivered from the cephalic presentation with clear amniotic fluid.  Apgars of 9 and 9.  The infant's cord was doubly clamped and cut, and the infant was handed to the neonatology staff in attendance.  Cord blood was obtained.  The placenta was delivered manually.  The uterus was wiped clean of any retained membranes.  The uterus was delivered onto the anterior abdominal surface for repair.  Right tube and ovary were within normal limits.  There was a 4 cm ovarian cyst that was known to us from the prenatal course, consistent with dermoid.  The uterine incision was repaired in a single layer with #1 chromic suture.  It was a running interlocking stitch started from each angle.  A couple of additional interrupted stitches were required for complete hemostasis.  Once hemostasis was obtained, the area was irrigated thoroughly and hemostasis was confirmed.  At this time, our attention was turned towards the left-sided ovarian cyst.  The ovary was surrounded by two moist laps.  Using a scalpel with a 10 blade, an incision was made directly above the cyst away from the infundibulopelvic ligament.  Immediately upon making the incision, the cyst was ruptured, yielding sebaceous fluid, solid elements and hair consistent with a dermoid cyst.  All of the elements were removed.  The cyst wall was excised.  The ovarian capsule was reapproximated using 3-0 Vicryl suture.  The area was irrigated thoroughly and then the ovary was wrapped with Interceed.  At this time, the uterine incision was checked for hemostasis.  After hemostasis was confirmed, the area was irrigated thoroughly.  The uterus was placed back into the abdominal cavity.  The pelvis was then irrigated using copious amounts of sterile saline.  The abdominal wall was then closed as follows.  The fascia was reapproximated from each angle using 0 Vicryl.  The subcutaneous was irrigated and the skin was closed with staples.  Estimated blood loss was 750 mL.  There were no apparent intraoperative complications.  The Foley catheter drained clear urine at the end of the procedure.  Counts were correct.  Specimens consisted of the left-sided dermoid cyst.  The patient tolerated the procedure well and was taken to the recovery area in satisfactory condition.

Pediatric Discharge Summary Sample Report #1     Discharge Summary Sample Reports #2

Neonatal / Infant Discharge Summary Sample          Delivery Note Transcribed Sample Report

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

Laparoscopic Cholecystectomy with Intraoperative Cystic Duct Cholangiogram Operative Sample

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, and after induction of general endotracheal anesthesia, the abdomen was prepped and draped in the usual manner.  The patient had previous lower midline incision from a cesarean section, so we decided to proceed with open insertion with a Hasson blunt cannula in supraumbilical location and this was performed.  After the insertion of the cannula, the laparoscope was inserted, and initial exploration showed that there was no damage to visceral structures during the above procedures.

Attention was then turned to the right upper quadrant where two 5 mm trocars were placed in subcostal area, one in the anterior axillary line and one in the midclavicular line.  A 10 mm trocar and sleeve was placed in the upper abdomen, in the midline, approximately 7 cm inferior to the xiphoid process, subsequently entered the abdomen just to the right of the falciform ligament.  The patient was placed in a slightly reversed Trendelenburg position and turned toward the left.  Initial exploration showed a tensely distended gallbladder with a clearly gangrenous corpus and fundus.  Aspiration was performed and turbid fluid was sent for culture and sensitivity.

The gallbladder was extremely friable, as several areas of the wall were essentially dead, and therefore, it was difficult to deal with, but we were able to grasp the fundus and retract superiorly.  There was a good deal of very thick dense inflammation on Hartmann pouch.  There were also inflammatory adhesions of the entire area to the anterior duodenum, distal stomach, and omentum.  Using careful blunt dissection as well as some sharp dissection, the area was approached and we were able to gain access to the hepatoduodenal ligament.  The cystic duct was identified and clip placed on the gallbladder site.

A small ductotomy was made and a 19 gauge catheter was inserted medially through a separate puncture wound in the right upper quadrant and entered into the cystic duct, and a clip was applied for proximal tension over the duct and catheter.  A cystic duct cholangiogram showed that there was free flow of the duodenum, no stones.  The ductal system was intact.  The clip and catheter were then removed and two clips were placed distally in the cystic duct proximal to the center of common bile duct and the cystic duct was divided.  Anterior and posterior branches of the cystic artery were identified.  The clips were placed on both sides and the artery was divided.

The gallbladder was dissected free from its bed using electrocautery as well as blunt and sharp dissection.  In the inferior portion, dissection was difficult due to thick inflammatory tissue, and then more superiorly, the wall was essentially disintegrated with gray necrotic tissue.  On completion, the gallbladder was removed through the upper abdominal portal, and there was satisfactory control of the cystic duct and arteries and good hemostasis.  The operating field was copiously irrigated and aspirated.  The hemostasis was assured.

Because of the degree of inflammation and possibility of bile leakage from the severely inflamed cystic duct stump, it was decided to leave a drain in the area and a large round Jackson-Pratt drain was placed in the area and brought out through a separate puncture wound for which one of the lateral 5 mm port openings was utilized.  The upper abdominal vessel defect in the midline was closed with a single suture of 0-Vicryl using a Carter-Thomason device.  Then, the pneumoperitoneum was relieved as much as possible and the fascial defect in the supraumbilical area was closed with two sutures of 0-Vicryl.  All skin incisions were closed with subcuticular.  The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.

More Laparoscopic Cholecystectomy Sample Reports

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

Shoulder Arthroscopic Rotator Cuff Repair and Arthroscopic Acromioplasty Operative Example

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed on the operating table in the supine position. Interscalene block was given by the anesthesiologist. At this point, general anesthesia was induced by the anesthesiologist. The patient was placed in the beach-chair position. All bony prominences were padded. SCD boots were placed on both legs and cycled throughout the entire surgery. The patient was then placed semi-upright in the beach-chair position. The right shoulder was prepped and draped in the usual sterile fashion. At this point, a standard diagnostic shoulder arthroscopy was performed with standard posterior portal. Following findings were obtained; full thickness anterior rotator cuff tear, minimal degeneration of the anterior labrum. At this point, the scope was placed in the subacromial space. The rotator cuff tear was identified. The repair was conducted using the Arthrex PushLock anchors creating a suture bridge. First, the bursa was debrided with a Mitek VAPR. Then, the rotator cuff was debrided with a 4.0 full radius shaver. The bony wedge was debrided as well with a 4.0 full radius shaver. At this point, two medial articular anchors were then placed through a separate stab wound/incision adjacent to the acromion. These sutures were then passed using the Scorpion suture passer through the medial most portion of the rotator cuff tendon, in a mattress fashion, in each anchor. Once this was done using arthroscopic knot-tying techniques, the rotator cuff was tied down to the two medial anchors. At this point, one suture limb of the anterior anchor and one suture limb of the posterior anchor were placed together and passed through a PushLock anchor placed through the lateral portal further down the lateral aspect of the greater tuberosity. The first anchor was placed posteriorly and then this suture was secured into this knotless anchor. Next, a second PushLock anchor was passed more anterior, taking the other limb from the anterior medial anchor in the anterior limb of the posterior medial anchor, passed through the second PushLock suture and this one was placed and secured anteriorly. This created a crusting suture bridge repair. There was no defect noted after probing with an arthroscopic probe. Next, the shoulder was brought back to the neutral position from the abducted external rotation position and an acromioplasty was performed with a 4.0 barrel bur. The portals were then closed with 4-0 nylon single interrupted sutures, bulky sterile dressing, and a shoulder immobilizer was applied. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

MT Word Help

Medical Transcription Samples

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

Colonoscopy with Snare Polypectomy Example Report

DESCRIPTION OF PROCEDURE:  Informed consent was obtained after explanation of the risks, benefits and alternatives to the procedure. The patient was premedicated to achieve conscious sedation. Rectal examination revealed small external hemorrhoids. The video colonoscope was inserted in the rectum and gently advanced to the cecum under direct visualization with some minimal difficulty due to looping and redundant colon. The cecum was intubated and identified by the appendiceal orifice and ileocecal valve. The cecum was normal as was the ascending colon, hepatic flexure, transverse colon, splenic flexure and descending colon. Overall, the preparation was good. In the sigmoid colon, there were two polyps, one was flat and hyperplastic appearing. It was 6 mm in size and removed using cold snare polypectomy technique. The second polyp was 7 mm in size and also sessile in nature, was removed using cold snare polypectomy technique. There was excellent hemostasis. Both polyps were retrieved and sent to pathology. The rectum had small-to-moderate sized internal hemorrhoids seen on frontal and retroflexion view. The patient tolerated the procedure well and was returned to the recovery room in stable condition.

MT Word Help

Medical Transcription Samples

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

EGD with Cold Forceps Biopsy Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  History of Crohn's disease with a recent colonoscopy done, which was negative.
2.  Continued epigastric pain.
3.  New onset constipation.
4.  Occasional rectal bleeding.

POSTOPERATIVE DIAGNOSES:
1.  Mild antral gastritis.
2.  Gastric polyp in the proximal body.
3.  Irregular-appearing squamocolumnar junction.

PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with cold forceps biopsy.

SEDATION:  Monitored anesthesia care per the anesthesiology department.

DESCRIPTION OF PROCEDURE:  The risks and benefits of the procedure were discussed in detail with the patient and all questions were answered in the clinic. An informed consent was then obtained.

The patient was placed in the left lateral decubitus position and sedated as outlined above. The video endoscope was then inserted through the mouth and advanced to the second portion of the duodenum under direct visualization without any difficulty. Duodenoscopy revealed a normal-appearing postbulbar duodenum as well as duodenal bulb. The scope was then withdrawn to the stomach. The gastroscopy revealed linear antral erythema and a few superficial erosions consistent with mild antral gastritis. Multiple antral biopsies were obtained for histopathology to rule out Helicobacter pylori infection. The remainder of the visualized mucosa in the distal gastric body appeared grossly normal. Retroflexion revealed a normal-appearing angularis as well as gastritic cardia and fundus. There was no evidence of a hiatal hernia. A small 3 mm polyp was noted in the proximal gastric body. This was biopsied with cold forceps. The scope was then withdrawn through the distal esophagus. The squamocolumnar junction was at approximately 38 cm and appeared slightly irregular. Biopsies were obtained to rule out short-segment Barrett's esophagus.

Air was then removed from the patient's stomach and the scope was then withdrawn. The patient tolerated the procedure well. There were no apparent complications noted.

IMPRESSION:
1.  Mild antral gastritis.
2.  Gastric polyp.
3.  Irregular-appearing squamocolumnar junction.

RECOMMENDATIONS:  Will follow up on the biopsy result. If there is any evidence of a Helicobacter pylori infection, will initiate triple-based therapy. If the distal esophageal biopsies reveal Barrett's esophagus with no dysplasia, the patient will need a repeat surveillance esophagogastroduodenoscopy in 2 to 3 years. Will prescribe the patient Carafate to see if this improves her epigastric pain and will also order an ultrasound of the liver and gallbladder to rule out biliary causes of her pain.  Advise the patient to call my office in 1 week to get the biopsy results and to hold all aspirin and NSAID products for 10 days. The patient should followup with her primary care physician on her routinely scheduled appointment and she can follow up with me in 4 to 6 weeks for followup visit.

*************************************************************************

DESCRIPTION OF PROCEDURE:  The risks and benefits of the procedure were discussed in detail with the patient, all questions were answered, and informed consent was then obtained. The video endoscope was inserted through the mouth and advanced to the descending portion of the duodenum under direct visualization without any difficulty. Duodenoscopy revealed a normal-appearing postbulbar duodenum as well as duodenal bulb. The scope was then dropped to the stomach. Gastroscopy revealed a normal-appearing antrum as well as distal gastric body. Retroflexion revealed a normal-appearing angularis as well as gastric cardia, fundus, and proximal gastric body. There was no evidence of a hiatal hernia. The scope was then withdrawn to the distal esophagus. The squamocolumnar junction was mildly irregular at approximately 45 cm. Multiple biopsies were obtained to rule out short-segment Barrett esophagus. The remainder of the esophageal mucosa appeared grossly normal. I tried to visualize the pharynx to the best of my ability. Limited visualization revealed no gross abnormalities. Air was then removed from the patient's stomach. The scope was then withdrawn. The patient tolerated the procedure well. There were no apparent complications noted.

Esophageal Motility / Manometry / Bravo pH Sample       Colonoscopy EGD Sample Reports

Medical Transcription Word Seeker - Google Search for MTs - Search Only Medical Sites

Laboratory and Diagnostic Data Medical Transcription Examples

LABORATORY DATA: Showed amylase and lipase normal at 42 and 43 respectively. UA showed small blood, 3-5 red cells, 5-10 white blood cells, 3-5 hyaline casts, 0-3 granular casts, and occasional WBC clumps. Glucose 97, BUN 11, creatinine 0.7, sodium 137, potassium 3.9, chloride 102, CO2 of 26. White count 13.3, hemoglobin 12.5, hematocrit 37.1, 84% neutrophils, 9% lymphocytes. Liver functions were normal.


LABORATORY DATA: Laboratory data reviewed today included CBC showing a hemoglobin of 12.7, hematocrit of 32, white blood cell count of 10, platelet count of 395. Renal panel was fairly uneventful with a sodium of 138, potassium 4.4, chloride of 103, CO2 of 26, BUN of 13, and creatinine of 1.3 with a glucose random of 154 which is elevated slightly. His fingerstick glucoses have ranged from 170-255 in the past 24 hours.


LABORATORY DATA:  BMP:  Sodium 138, potassium 6.4, chloride 108, bicarbonate 18, BUN 86, creatinine 6.4, glucose 138, phosphorus 6.9, magnesium 2.6. Liver Function Tests:  AST 26, ALT 20, alkaline phosphatase 229, total bilirubin 0.7, albumin 3, total protein 6.9. Troponin I 0.03. i-STAT lactate 2.1. CBC:  White blood cell count 8.2, hemoglobin 10.4, hematocrit 31, platelets 277. Coagulation Studies:  PT greater than 110, INR greater than 14, PTT 146.7. ABG:  pH 7.26, pCO2 37, pO2 163, oxygen saturation 99% on 3 liters nasal cannula. Urinalysis:  Trace protein, trace glucose, large blood, moderate epithelial cells, 4 to 10 hyaline casts, 20 to 50 red blood cells, few bacteria, 2 to 5 white blood cells.

Head CT without contrast, per radiology reading, shows extensive atrophy and chronic white matter ischemic changes. No acute infarct. No hemorrhage or mass. Old right cerebellar hemispheric infarct. Portable chest x-ray, per radiology reading, showed cardiomegaly without superimposed failure. The retrocardiac infiltrate previously seen has almost completely resolved. EKG shows atrial fibrillation at a rate of 84, normal axis. No ischemic ST or T wave changes. There is some nonspecific T wave flattenings in leads III and aVF, which are unchanged compared with prior EKG. QTc is prolonged at 495 milliseconds.


LABORATORY DATA: Include CBC with a white blood cell count 11.2, hemoglobin 13.6, hematocrit 40.1, platelets 236. Renal panel shows sodium 138, potassium 3.6, chloride 108, bicarbonate 23, BUN 12, creatinine 1, glucose 87. INR is 4.1. Urinalysis shows trace ketones, moderate blood, 100 protein, 10-20 red blood cells, too numerous to count white blood cells, moderate bacteria. This was sent for culture. Urine pregnancy test is negative. Wet prep is negative for trichomonas, negative for yeast.


LABORATORY DATA: Laboratory studies include a CBC with a white blood cell count of 8.7, hemoglobin 14.6, hematocrit 42.9, platelets 408. Renal panel shows sodium 138, potassium 3.9, chloride 108, bicarbonate 24, BUN 12, creatinine 0.9, glucose 88. Cardiac enzymes are normal with a CK-MB of less than 1, troponin less 0.05. Second set was also normal at less than 1 and less than 0.05 respectively. She had a urinalysis showing 30 protein, trace ketones, many bacteria, trace leukocyte esterase, 3-5 white blood cells, moderate blood, 3-5 red blood cells, 4.0 urobilinogen. Urine pregnancy test is negative. Urine tox screen is positive for cocaine.


LABORATORY DATA: Her CBC shows a white count of 14.2. Hemoglobin is 13.5. Platelets are 239. Neutrophils are 90%. Lymphocytes are 5%. Her renal shows a sodium of 144, potassium 3.2, chloride 103, bicarbonate 24. BUN 17 and creatinine 0.9. Glucose is 143. AST 21, ALT 17, bilirubin 3.6 total, bilirubin direct 0.5. Protein is 8. Albumin is 5. Calcium is 10. Lipase is 21. Alkaline phosphatase is 49. Her urinalysis was orange and hazy. Specific gravity was 1.032. She had 100 protein and 80 ketones. Glucose was negative. There were many bacteria. Negative for leukocyte esterase. Negative nitrites. She had 3 white blood cells, was negative for blood, 5 red blood cells. Moderate bilirubin in urine. She had 2 urobilinogen. Her beta hCG was negative.


LABORATORY DATA:  CBC showed WBC of 11,600, neutrophils 31% and lymphocytes 44%, and hemoglobin 14.6.  On MM/DD/YYYY, his WBC was 16,400, hemoglobin 13.8, and neutrophils 40%, and lymphocytes 48%.  Serum chemistry revealed normal serum electrolytes, revealed a low calcium of 8.2, total protein 4.3, and albumin 1.3.  Urinalysis; 3+ protein.  On MM/DD/YYYY, urinalysis showed 3+ protein and WBC 14,700, hemoglobin 13.4, neutrophils 38%, lymphocytes 53%, and platelets 576,000.  Serum chemistry still showed a low albumin of 1.7, total protein of 5.4, potassium of 5.8, CO2 of 18, and glucose 120.  A 24-hour urine revealed a total protein of 1100.  Serum chemistry revealed significant improvement with normal electrolytes, creatinine of 0.3, BUN 19, total protein 6, albumin 2.8, and calcium 9.3.  His cold agglutinin also was reported positive at 1:512.  His RSV was negative.


LABORATORY/DIAGNOSTIC DATA: Serum chemistries were within normal limits, except for markedly elevated glucose of 425 with no anion gap. CBC was within normal limits with a white count of 5.7. Serum ketones were negative. LFTs showed mild elevation of his AST at 97, but otherwise unremarkable. Lipase was normal at 32. Calcium, magnesium and phosphorous were within normal limits. Cardiac markers, CK-MB and troponin I were negative on the first two sets with a BNP of less than 5. Chest x-ray shows no acute cardiopulmonary pathology. EKG: Shows normal sinus rhythm at 84 beats per minute. He had sinus rhythm with a first-degree AV block and PR interval of 212 milliseconds. He had left axis deviation with a left anterior fascicular block and a QRS of 90 milliseconds and QTc was 422 milliseconds. He had mild T-wave flattening in V3 with poor R-wave progression in the precordial leads in comparison to a prior EKG. There was no significant change.


LABORATORY AND DIAGNOSTIC DATA:  Hemoglobin 10.4, hematocrit 30.6, white blood cell count 7400, and platelet count 286,000.  Stool for occult blood negative.  Sodium 142, potassium 3.6, chloride 102, CO2 of 30, BUN 16, creatinine 1.8, glucose 86, phosphorus 3.4, calcium 8.6, and magnesium 1.6.  Triglycerides 124, cholesterol 104, HDL 25, and LDL 154.  Urine culture showed pseudomonas and Staphylococcus aureus.

CT of the abdomen showed small pleural effusions, cholecystectomy, and no CA.  CT of the pelvis showed sigmoid diverticulitis.  CT of the chest showed left subclavian axillary vein thrombosis with atelectasis.  V/Q scan showed no evidence of pulmonary embolus.   Chest x-ray showed no infiltrate.  Venous Doppler study showed thrombi in the axillary, basal, and cephalic veins of the left upper extremity.  EKG showed right bundle branch block.


LABORATORY AND DIAGNOSTIC DATA:  Hemoglobin 10.6, hematocrit 31.2, white blood cell count 10,600, and platelet count 384,000.  UA showed no protein, no blood, and no glucose.  Sodium 143, potassium 3.3, chloride 104, CO2 of 26, BUN 9, creatinine 1.2, glucose 106, protein 6.1, albumin 2.8, calcium 8.3.  Bilirubin 0.4, AST 16, ALT 37, alkaline phosphatase 87.  Amylase 97, lipase 546, repeat lipase 493.  Magnesium 1.4, iron 24, TIBC 282.  C-reactive protein 16.  CEA 2.2.  RPR negative.  Rheumatoid factor negative.  ANA negative.  A pH of 7.35, pCO2 34, pO2 80, and bicarbonate of 19.  Urine negative.

CT of the brain showed old bilateral infarcts.  MRI of the brain, old bilateral infarcts were seen.  HIDA scan, gallbladder not visualized consistent with cystic duct obstruction.  Chest x-ray showed no infiltrate.  Abdominal ultrasound showed a single gallstone, mild right hydronephrosis.  Renal ultrasound showed mild prominence of the right extrarenal pelvis.  EEG showed slowing secondary to diffuse cortical dysfunction.  EKG showed normal sinus rhythm with nonspecific ST changes.


LABORATORY AND DIAGNOSTIC DATA:  CBC showed white count of 6300, hemoglobin 11.1.  On MM/DD/YYYY, white count was around 3200 and hemoglobin was around 9.1.  On MM/DD/YYYY, white count was 4200, hemoglobin 9.2, platelets 256,000, 64 segs, 23 lymphos, and 8 monos.  Urinalysis showed trace amount of blood.  Sodium was 142 on admission, potassium 3.8, chloride 104, CO2 of 18, glucose 140, BUN 26 and creatinine 1.3.  LFT was normal.  Electrolytes on MM/DD/YYYY was essentially unremarkable.  On MM/DD/YYYY, sodium 138, potassium 4.6, chloride 105, CO2 of 24, glucose 125, BUN 12, creatinine 1.1, and magnesium 1.5.  Magnesium was 1.4 on MM/DD/YYYY.  Free T4 was 0.8.  TSH was 1.2, which was normal.  Amylase and lipase was 72 and 199 on MM/DD/YYYY, which were in the normal range.  Urine culture and sensitivity showed no growth.

Chest x-ray showed no active infiltrate.  EKG, nonspecific ST-T changes.  No ischemic changes were noted.  Normal sinus rhythm.  Flat and upright abdomen showed some findings consistent with possible ileus with some bowel distention.  CT of the abdomen on MM/DD/YYYY was unremarkable.  Flat and upright abdomen on MM/DD/YYYY again showed some bowel distention.  No evidence of free air was noted.


ADMITTING LABORATORY DATA:  Hematology showed a white blood cell count of 9.7, hemoglobin 16.4, hematocrit 49.8, platelet count 137, slightly elevated RDW at 29.5, neutrophil number was 7.3.  Coagulation studies:  PT is elevated at 18.3, INR is 1.5, PTT 29.2.  Chemistry, sodium 143, potassium 3.7, chloride 100, CO2 of 33, anion gap 10, BUN 14, creatinine 1, estimated GFR of 76.8, glucose 107, calcium 10.1, total bilirubin 1.2, direct bilirubin 0.5, AST 50, ALT 35.  CK was 233.  Troponin done at 1840 was 0.03.  Repeat troponin at 2230 was 0.01.  Total protein 7.2, albumin 4, alkaline phosphatase 86, amylase 94 and lipase 69.  Urine was dark yellow, clear, with 2+ protein, negative for glucose, trace ketones, negative for blood and nitrites.  Urine bilirubin 1+, urobilinogen 2, leukocyte esterase is negative, bacteria were few, hyaline casts 2 to 5.  Urine C and S is pending.


LABORATORY DATA:  Initial laboratory studies; white blood cell count is 13.4 with 49% neutrophils and 40% lymphocytes.  Hemoglobin is 14.2.  Platelets are 408.  Sodium is 136, potassium is 4.2, chloride is 103, bicarbonate is 24, BUN is 14, creatinine 0.8, glucose is 220, magnesium is 1.74.  Coagulation studies were within normal limits.  Troponins were cycled on two occasions and were all less than 0.01.  Bedside glucoses were monitored and ranged between 120 and 310, with most readings in the high 100-200 range.  Lipid panel revealed triglycerides 129, cholesterol 176, HDL 36, LDL 116.  Lipid profile was within normal limits with the exception of an alkaline phosphatase of 119, which is slightly elevated.  Amylase was 34 and lipase was 12.  Initial imaging studies; chest x-ray revealed normal chest for age group.  An EKG revealed sinus rhythm, rate 88, with no significant ST-T wave changes.  Other imaging studies; the patient had a myocardial stress test, which revealed normal myocardial scan and left ventricular ejection fraction 70%.  He had a barium swallow, which revealed no evidence of esophageal stricture and mild esophageal dysmotility.  She had a 2-D echocardiogram, which revealed overall preserved LV and RV functions with mild pulmonary hypertension with an RV systolic pressure of around 30-35 mmHg.  Left ventricular ejection fraction was noted to be in excess of 60%.


LABORATORY DATA:  CBC; RBC was 5.54, hemoglobin 11.6, hematocrit 35.2, platelets 142.  BMP was within normal limits except her glucose, which was 178.  Bedside glucoses varied from 175 to low 300s. LFTs were elevated with an AST of 124, ALT of 118.  Urine toxicology; one was positive for methadone, cocaine and cannabis and then three random urine toxicologies gathered thereafter were negative.  Hepatitis C was reactive.  Iron was 86.  TIBC was 444 and iron binding was 360.


LABORATORY DATA:  At the time of admission, the patient's sodium 134, potassium 4.3, chloride 102, CO2 of 26, BUN 14, creatinine 1.2, glucose 96, calcium 9.2, phosphorus 3.6, magnesium 1.86, bilirubin 2.8, AST/ALT were 23 and 16, troponin was 0.01, BNP was 3769, triglycerides 58, cholesterol 128, LDL 92, HDL 24, alkaline phosphatase is 169.  Chest x-ray was performed at the time of admission, which showed a left cardiac pacemaker in place, cardiomegaly, and pulmonary vascular markings are within normal limits.  No evidence of effusion or pneumothorax.  An EKG was performed at the time of admission, which showed normal sinus rhythm at a rate of 88 with right axis deviation and no ST changes.  The patient's PT and INR were 16 and 1.2.  PTT was 30.2.


LABORATORY DATA/DIAGNOSTIC DATA: Serum chemistries were within normal limits with a creatinine of 1.3 and a mildly elevated glucose of 245. CBC was within normal limits with a mild left shift and his white count was 7.8. His CK-MB and troponin I were negative on the first set. BNP was normal at 62. Coagulation studies were within normal limits. Chest x-ray shows no acute cardiopulmonary pathology and EKG performed for indication of chest pain showed normal sinus rhythm at a rate of 72 beats per minute. He had Q waves in lead III. He had no acute ST elevations or T-wave inversions. He had normal intervals with QTc of 405 milliseconds in comparison to prior EKG. There was no significant change.


LABORATORY DATA: WBC 19.2, hemoglobin 17.8, hematocrit 54.2, platelets 212,000. MCV was 91. The differential was 1 band, 21 neutrophils, 74 lymphocytes, no eosinophils. His sodium was 136, potassium was 3.5, chloride was 106, BUN was 25 and creatinine was 1.1, glucose was 119. AST was 20, ALT was 22. Bilirubin total was 0.7, bilirubin direct was 0.1. Total protein was 8.6, his albumin was 4.8, lipase was 24. PT of 13 and an INR of 1. UA was negative for bacteria, negative for leukocyte esterase and negative for nitrites.


LABORATORY DATA/DIAGNOSTIC DATA: Her initial white count was 17,800, hemoglobin 12.4. Electrolytes were normal. Blood sugar was 115, creatinine 0.7, BUN 7. Her calcium was 9.2. She had moderate bacteria, but negative nitrites, leukocyte esterase and bilirubin. Pregnancy test was negative. Her initial chest x-ray showed clear lungs. The area of right lower lobe opacity was not clearly seen on that chest x-ray. CT angiography was a poor study because of her fat distribution. Pulmonary artery branches were suspicious for diagnostic pulmonary emboli. There is a wedge-shaped area of air space disease in the peripheral aspect of the right lower lobe suspicious for pulmonary infarct. There are bilateral pulmonary nodules, ill-defined in nature, but possibly malignant or septic, as there is a large left axillary lymph node and right hilar lymph node. Mildly dilated pulmonary arteries and a trace of right pleural effusion. CT scan of the abdomen showed a 2.5 cm hypodense lesion in the mid pole of the left kidney considered to be a cyst. There was a left retroaortic renal vein. CT scan of the pelvis showed a mildly enlarged uterus suggesting uterine fibroid and no evidence of a calculus or other disease to cause discomfort.


LABORATORY DATA: The patient's renal panel was obtained which was normal except for blood sugar of 242. CBC is within normal limits. UA hCG is pending. CK-MB and troponin was less than 1 and less than 0.05. BNP was 640. An ABG was obtained after the patient was intubated which was 7.25, CO2 of 56, O2 of 56 and bicarbonate of 26, base excess of 1.4. INR of 1.3. The patient did have an EKG obtained. The EKG showed a sinus rhythm with an abnormal P-wave morphology, with a rate of 90 beats per minute, with a left deviated axis of approximately negative 30 degrees, with normal PR, QRS and QT intervals. The patient had signs of right ventricular hypertrophy with inverted T-waves in leads I, aVL, V1, 2, 3, 4, 5 and 6.


LABORATORY/DIAGNOSTIC DATA: WBC is 4600, hemoglobin 10.4, hematocrit 33.6, and platelets 144,000. INR 1.42. LFTs within normal limits. Cardiac enzymes negative x2. Sodium 141, potassium 4.1, chloride 105, CO2 of 27, BUN 24, creatinine 1.3, and glucose 164. BNP 1637. Triglycerides 61, total cholesterol 134, HDL 31, and LDL 92. Blood culture, no growth to date. Chest x-ray: Increased perihilar markings suggestive of some possible pulmonary edema. A 2-D echocardiogram has been ordered. EKG from yesterday revealed atrial fibrillation, 82 beats per minute, and right bundle branch block.


LABORATORY/DIAGNOSTIC DATA: INR is 0.91. WBC 7.5, hemoglobin 15.8, hematocrit 45, platelet 226,000. LFTs completely normal. Sodium is 141, potassium 3.5, chloride 104, CO2 of 26, BUN 12, creatinine 1.1, glucose 104. Lipids: Cholesterol 174, HDL 26, LDL 72, triglycerides 385. CPK is 371, troponins are negative x3. TSH completely normal. Magnesium was 1.7, which has been repleted. Initial EKG showed SVT with 162 beats per minute. Repeat EKG showed sinus rhythm with 67 beats per minute with left ventricular hypertrophy, no evidence of ischemia. Telemetry showed normal sinus rhythm; however, he had a wide-complex tachycardia versus atrial fibrillation. Chest x-ray: No acute process, just only significant for mild cardiomegaly.

Medical Transcription Word Help

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

Review of Systems (ROS) Medical Transcription Examples

REVIEW OF SYSTEMS: The patient denies any chills. Does note nausea, vomiting, diarrhea. Notes vague headache. Denies any dizziness, blurred vision, focal neurologic deficits, numbness, tingling or paresthesias to his extremities. Does note some increased fatigue and weakness. He denies any upper respiratory symptoms, neck pain or stiffness, chest congestion, cough, hemoptysis, hematemesis or hematochezia. He denies any chest pain, shortness of breath, wheezing, diaphoresis, palpitations. Denies any focal abdominal pain. Does note some crampy abdominal pain associated with episodes of emesis. Otherwise, denies any black, bloody or tarry stools. Denies any urinary frequency, urgency or dysuria, as well as any hematuria. Denies any evidence of rash. The remainder of review of systems is reviewed and negative.

REVIEW OF SYSTEMS: The patient notes fever and chills. Denies any nausea, vomiting or diarrhea. She denies any dizziness or blurred vision. Does note some vague headache. She denies any ear pain, red, itchy or watery eyes as well as any sinus pressure, congestion, or postnasal drainage. She denies any sore throat pain or difficulty swallowing. She denies neck pain, stiffness. She does note chest congestion, productive cough with sputum production as noted above. Denies any wheezing, diaphoresis, palpitations or abdominal pain as well as any back pain but does note some urinary frequency and urgency, but no dysuria. She denies any swelling to her extremities, numbness, tingling or paresthesias to the same. She denies any recent significant weight gain or weight loss. Remainder of review of systems was reviewed and negative.

REVIEW OF SYSTEMS: General: The patient states her appetite has been fine up until the last week. She denies any significant weight change. No fevers or chills. Hematologic: No history of bleeding disorders, blood clots, nor has she received a transfusion in the past. Endocrine: No history of thyroid disorders or diabetes. Respiratory: No history of pneumonia, tuberculosis or asthma. Cardiovascular: The patient denies any history of hypertension, palpitations, angina or cardiovascular disease. Gastrointestinal: No history of peptic ulcer disease, jaundice or hepatitis. Genitourinary: No history of any kidney problems or kidney stones. Neurologic: The patient does have a history of chronic low back pain. Orthopedic: No history of any long bone fracture. Psychiatric: The patient does have a history of depression and is on medication currently.

REVIEW OF SYSTEMS:  Denies fever, chills, sweats.  Eyes:  Denies dryness, irritation, visual loss.  ENT:  Denies earaches, hearing loss, no sinus problems.  Cardiovascular:  Positive for chest pain, palpitations and dyspnea.  Respiratory:  Positive for minor cough.  Gastrointestinal:  Denies heartburn, indigestion, difficulty swallowing, nausea, vomiting, abdominal pain, constipation, diarrhea, bleeding.  Genitourinary:  Denies dysuria, urgency, frequency.  Musculoskeletal:  Denies muscle aches, arthritis or arthralgias.  Skin:  Denies rash or itching.  Neurologic:  Positive for headaches.  Denies focal weakness.  Psychiatric:  There is a history of depression.  She currently denies any depression.  Endocrine:  Denies thyroid problems, polyuria, polydipsia.  Hematologic:  Denies swollen lymph nodes or bleeding tendencies.

REVIEW OF SYSTEMS: Constitutional: No history of weight loss or weight gain recently. No fever, fatigue or chills. Eyes: The patient wears glasses. No history of glaucoma or cataract. Ear, Nose, and Throat: No vertigo. No frequent sore throat. No nosebleed. Genitourinary: No pain urinating. No burning. No nighttime urination. No hematuria. Respiratory: No shortness of breath. No wheezing. No persistent cough. Gastrointestinal: No abdominal pain. No upper or lower GI bleed. No diarrhea or constipation. Cardiovascular: No chest pain. No jaw pain. The patient complains of claudication of lower extremities after exercise. Hematological: Easy bruising. This is most likely due to use of aspirin and Plavix. Musculoskeletal: Complaining of stiffness, muscle pain, and back pain. Neurological: No seizure disorder. No memory loss. No loss of consciousness. Infectious disease: Positive for hepatitis C. Cardiovascular: Positive for high cholesterol and peripheral vascular disease. Endocrinology: Positive for diabetes and hypothyroidism.

REVIEW OF SYSTEMS: The patient notes transient fever. Denies any chills, nausea, vomiting, or diarrhea other than one episode of forced emesis. Denies any headache, dizziness, or blurred vision. Denies any focal neurologic deficits, numbness, tingling, or paresthesias to the extremities or muscle weakness. Denies any upper respiratory symptoms, neck pain, stiffness, chest congestion, cough, hemoptysis, or hematochezia. Denies any chest pain, shortness of breath, wheezing, diaphoresis, or palpitations. Notes generalized periumbilical abdominal distention with associated pain. Denies any black, bloody, or tarry stools as well as any fatty stools. Denies any back pain. Does note some dysuria and urinary urgency. Denies any urinary frequency. Denies any pelvic complaints and is not currently sexually active. She, otherwise, denies any evidence of rash or swelling to her extremities. The remainder of review of systems was reviewed and negative.

REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies. HEENT: Denies oral mucosal lesions. Claims she has had a sore throat and sore glands. She denies further symptoms. No difficulty swallowing. CARDIAC: Negative history of chest pain or palpitation. RESPIRATORY: Negative for shortness of breath, cough, and sputum production. GASTROINTESTINAL: Negative history of nausea, vomiting, or abdominal pain. GENITOURINARY: Negative history of hematuria or dysuria. GYNECOLOGIC: The patient denies possibility of pregnancy. She denies further issues. MUSCULOSKELETAL: Positive history of joint pain and absence of redness, swelling, or trauma.

REVIEW OF SYSTEMS: Constitutional: No fevers, night sweats, or weight loss. Head and Neck: No blurred vision or tinnitus. Pulmonary: No productive cough or hemoptysis. Gastrointestinal: No melena, bright red blood per rectum. Cardiovascular: See HPI. No PND, orthopnea, and no history of arrhythmias. Neurologic: No history of stroke or TIA. Rheumatologic: No history of joint swelling or pain.

REVIEW OF SYSTEMS: Chest tightness. Upper chest and shoulder pain in the right, radiation to the left, shortness of breath and diaphoresis. Worse with deep breathing and change in position. No hemoptysis, hematemesis, or hematochezia. No relevant change in bowel pattern. No leg swelling or leg weakness. No skin rash. No visual or hearing impairment. No fever, chills, shaking or weight loss reported.

REVIEW OF SYSTEMS: No CVA, TIA, or seizures. No chronic headaches. No asthma, TB, hemoptysis, or productive cough. There are no congenital heart abnormalities or rheumatic fever history. The patient is having palpitations. There is no nausea, vomiting, constipation, diarrhea, melena, peptic ulcer disease, or gastrointestinal problems. The patient is a non-insulin-dependent diabetic. He has no thyroid problems. There is no prostate problem. He complains of no dysuria or increased urinary frequency. There is no kidney or liver problem. There is no nausea, vomiting, constipation, melena, peptic ulcer disease, or gastrointestinal problems. The patient has depressive psychiatric problems. He has no bleeding problems, thrombosis, blood dyscrasias or anemia. He has no cancer history. He has never received any blood products in the past. He does have a history of chronic lower back pain and underwent previous lumbar surgery. He requires continued use of nonsteroidal anti-inflammatory medications for his pain. He has no history of gout. No changes in appetite or changes in weight.

REVIEW OF SYSTEMS: Denies any history of weight loss or gain. No fever, no fatigue in the recent past. No change in appetite. Eyes: The patient does not wear glasses. No history of double vision, glaucoma, or cataracts. Ears, Nose, and Throat: No history of vertigo, no frequent sore throat, no hoarseness, and no frequent nosebleed. Genitourinary: No pain urinating, no burning, no frequency, no hematuria, no history of sexually transmitted disease. Respiratory: No history of shortness of breath, no coughing, no wheezing in the recent past, no frequent infection. Gastrointestinal: No history of abdominal pain, no nausea, no vomiting, no upper or lower GI bleed, no diarrhea or constipation. Cardiovascular: No history of chest pain, no jaw pain, no arm pain, no calf pain, no palpitations or swelling of the extremities. Hematological: No easy bruising, hypercoagulable state, no enlarged glands. Musculoskeletal: No stiffness, no muscle pain, no back pain. Neurological: No seizure disorder, no memory loss, no loss of consciousness, no headaches. Skin: No rashes, no sores, itching or burning.

REVIEW OF SYSTEMS: Constitutional: No real or clear history of weight gain or weight loss over the past few years. Positive for low-grade fever in the recent past. HEENT: Multiple problems with teeth, with tooth decay. The patient wears glasses for reading. No history of frequent headaches or epistaxis. Endocrinology: No history of hypothyroidism or hyperthyroidism. No history of diabetes mellitus. Lungs: History of COPD with recent productive cough. Long history of tobacco abuse but she quit some months ago. No wheezing or rales. No hemoptysis. No positive history of tuberculosis. Cardiac: No history of hypertension or hyperlipidemia. No history of murmur or heart disease. Gastrointestinal: Long history of upper and lower GI symptoms with history of pancreatitis, gastritis, duodenitis, peptic ulcer disease, but no clear origin of this chronic and persistent nausea and vomiting as well as intermittent diarrhea. No recent upper or lower GI bleed. Musculoskeletal: History of fibromyalgia with right knee pain, right upper extremity pain, and generalized muscle pain for which she has been taking methadone for a long time. There is intermittent swelling in the right upper extremity, probably secondary to muscle ache. Genitourinary: No dysuria or hematuria. No history of kidney stone. Neurologic: No seizure disorder. No CVA or neuro deficit. Psychiatry: Some history of depression. Hematological: No history of hypercoagulable state. No bleeding disorders.

Review of Systems MT Examples # 2   Review of Systems Example # 3 

ROS Examples # 3

http://sites.google.com/site/medicaltranscriptionwordhelp/

Medical Transcription Samples

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

Cervical Epidural Steroid Injection and Trigger Point Injection Transcription Sample

DESCRIPTION OF PROCEDURE:  The patient was brought in to the operating room and laid in the prone position. The patient's neck and shoulders were prepped and draped in the usual sterile fashion. The skin and underlying subcutaneous tissues overlying the C7-T1 interspace were identified and infiltrated with 5 mL of 1% plain lidocaine. A 17 gauge Tuohy needle was advanced through the anesthetized area into the cervical epidural space under direct visualization with fluoroscopy. Loss of resistance was confirmed with air and saline. An epidural catheter was passed up to the level of C5 on the right side. Three mL of Isovue dye was injected, which confirmed spread of the medication in the cervical epidural space from the level of C2 caudad to the level of T1. This was right greater than left sided spread of the medication. At this juncture, 5 mL of preservative-free 0.9% normal saline with 125 mg of Kenalog was administered. The needle was removed and a bandage was placed over the injection site. Two trigger points were then identified, one on cervical paravertebral area, on the right side, and the other along the trapezius muscle in the right shoulder. This area was prepped and 5 mL of 0.5% Marcaine with 10 mg of Depo-Medrol was deposited at each site in a fanning distribution. The needle was removed and bandages were placed over the injection sites. The patient was returned to the recovery room in stable condition.

MT Word Help

Medical Transcription Samples

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