General Surgery Medical Transcription Operative / Surgical Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Gastric cancer.

POSTOPERATIVE DIAGNOSIS:  Gastric cancer.

OPERATIONS PERFORMED:
1.  Exploratory laparotomy.
2.  Total gastrectomy with Roux-en-Y reconstruction.
3.  Transverse colon resection with primary anastomosis.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General plus epidural anesthetic.

ANESTHESIOLOGIST:  Bradford Doe, MD

DETAILS OF OPERATION:  Following induction of general anesthesia and epidural placement, the patient was prepped and draped in standard sterile supine position. A #10 blade was then used to make a midline incision from the xiphoid process down past the umbilicus a centimeter or two. Bovie cautery was used to take down the subcutaneous tissues, and the linea alba was appreciated and opened along the midline to the preperitoneal fat. The peritoneum was retracted anteriorly and entered sharply, and this was opened along the extent of the incision. Thompson retractor blades were then placed to improve exposure to the upper quadrants, and a survey of the abdomen was performed. Initially, a small lesion along the surface of the caudate lobe was appreciated, and this was biopsied and taken off for frozen section evaluation, which returned with benign findings.

Attention was then turned to the greater omentum, which was taken off the transverse colon throughout the length of the gastrocolic ligament. Care was taken to not enter the mesocolon. Once a good distance of this was performed, some posterior attachments of the stomach wall were taken down with Bovie cautery until the mass along the posterior aspect of the lesser curve of the stomach was noted to be directly adhesed to the transverse mesocolon. At this point, we left this area alone and turned our attention to the greater curvature where the short gastrics were taken down primarily with a LigaSure device. Occasional right angle isolation of the short gastrics near the tip of the spleen was also performed with ligation with 2-0 silk ties. Once the greater curvature and cardia were completely freed to the gastroesophageal junction, we noted a fairly large lymph node at this area. This was isolated and taken off for frozen section evaluation. This returned negative for malignancy as well. The anterior aspect of the stomach did appear to have a 0.5 cm lesion near where the gastric tumor was; this was fairly well proximal. Initially, we felt that we could do a subtotal gastrectomy, however, with a good margin. Once the greater curvature was completely freed and the left gastric actually exposed posteriorly, we turned our attention back to the mesocolon involvement.

Continuing with the procedure, we decided that the patient did have resectable disease without evidence of metastasis, including the two biopsies that we sent off, and so we decided at this point to do an en bloc resection, taking the transverse mesocolon at this point with the hope that the blood supply to the transverse colon would not be compromised. This was done with LigaSure device with occasional right angle ligation of thicker tissues. This attachment was taken down en bloc, and there were some minor further posterior attachments along the stomach wall and pancreas, although these were not related to tumor involvement. This freed up the posterior aspect of the stomach in its entirety. Initially, the colon that was being perfused by the mesocolon divided, appeared viable; although, towards the end of the case and upon reevaluation, there did appear to be enough venous congestion that we felt it safer to be resected. 

Using a LigaSure device, the remainder of the gastrocolic ligament was taken down to the pyloric junction. Occasional 3-0 silk ties were also placed for the perforating vessels at the pylorus. The lesser omentum was opened and cleared of connective tissue to the pylorus on the superior aspect as well. Using a 55 mm blue load GIA stapling device, the pylorus was divided at this time. Once the duodenum was transected, further dissection of the lesser curve was performed to the left gastric artery, which was identified. The peritoneal reflection along the epiphrenic fat pad was then taken down to free up further the GE junction somewhat. Then, the planned transection point along the lesser curve to create a subtotal gastrectomy was identified, and the left gastric taken down toward its base, and at this point isolated with a right angle and doubly ligated with 2-0 silks. There were no other attachments to the stomach except for just very proximally along the esophagogastric junction, and so our planned transection point was adequate.

Using a 90 mm TA stapling device, the stomach was divided at this point, leaving a small approximately 5 x 6 cm gastric pouch. Care was taken to keep the mass as well as the lesion along the anterior aspect of the stomach along the serosa included within the specimen. Once the TA stapling device was fired, crushing Kocher clamps were placed distally, and the stomach was sharply divided at this point. We opened the specimen and it looked like we had only about a 1 cm margin from the grossly involved mucosa of the gastric tumor. Initially, we decided that this would be adequate enough, as we were waiting for frozen section to return with our lymph node sampling near the GE junction. With this, we decided to create a Roux-en-Y gastrojejunostomy due to the small size of the gastric pouch.

The ligament of Treitz was identified, and approximately 20 to 30 cm downstream from this, an avascular plane was opened with Bovie cautery, and a GIA stapling device was used to come across the small bowel. The LigaSure device was then used to take down the mesentery down towards its base. This created enough mobility to bring up the Roux limb. This was brought up and with stay sutures of 3-0 silk.  The remnant in stomach was placed adjacent to the Roux limb. Enterotomies were made in both the stomach and small bowel, and a 55 mm blue load stapling device was used to create a stapled anastomosis. Allis clamps and a couple of 3-0 silk ties were used to reapproximate the enterotomy, and using the 90 mm TA stapling device, the enterotomy was stapled off. With the frozen section returning with negative malignancy within the sampled lymph nodes, we reevaluated the situation and felt it best to do a total gastrectomy to have a further proximal margin, as we only had about a 1 cm gross margin with the subtotal colectomy specimen. This was felt to be appropriate for attempted curative resection.

The remaining portion of the epiphrenic fat pad was then cleared off, and some of the esophagus was mobilized from the mediastinum with an adequate length of esophagus returning into the abdomen. The Roux limb was opened along its mesentery at an avascular plane just distal to the gastrojejunostomy anastomosis and once again divided with a 55 mm blue load GIA stapling device. The remaining mesentery attached to the gastric pouch was taken off with the LigaSure, and then stay sutures of 3-0 silk were placed on either side of the esophagus, and an automatic pursestring applicator device was placed along the esophagus and fired. The remaining attachment of the esophagus to the pursestring device was taken off sharply, and this was sent for frozen section evaluation of the proximal margin, which returned clear. We still had an adequate length of Roux limb to create an EEA stapled anastomosis for an esophagojejunostomy. The pursestring applicator was then removed, and the stay sutures of 3-0 silk allowed for the esophagus not to retract into the chest.

Further buttressing with 3-0 silk sutures, placed so that the pursestring device would stay in place, and a 25 mm anvil was secured to the open esophagus and secured with the pursestring suture. This fit nicely. The stapled end of the Roux limb was then opened with sharp Mayo scissors and the EEA stapling device advanced through this, in a spike opening about 8 cm distal to the stapled end. This was connected to the anvil and the small bowel advanced onto the esophagus and then fired. The anastomosis had good donuts on either side and appeared to align nicely.  Some further reinforcing 3-0 silks were placed circumferentially around this. An NG tube was placed by Anesthesia down into the distal esophagus and irrigation fluid was placed within the upper quadrant and insufflation with 25 to 60 mL of air was performed through the NG without bubbling being noted, confirming patency of the esophagojejunostomy anastomosis without leak. We were happy with this and attention was then turned to the reattachment of the proximal jejunum to the Roux limb. 

About 60 cm distal to the Roux limb, the proximal jejunum was reinserted with the stapled anastomosis. First, stay sutures of 3-0 silk were placed to allow for approximation of the small bowel to be in a side-to-side fashion with each other. Then enterotomies were made with Bovie cautery and a GIA stapling device placed and fired, creating the stapled anastomosis. Stay sutures of 3-0 silk were then placed to reapproximate the enterotomy, which was closed with another firing of the 90 mm TA stapling device. This suture line was reapproximated with figure-of-eight 3-0 silks and no leak was identified with adding some pressure to the anastomosis line.

Attention was then turned once again to the transverse colon, which appeared to be having some venous congestion due to our resection of that portion of the mesocolon. It was decided safest to resect this area, and so the mesentery was opened along an avascular plane just proximally and distal to this venous congestion site, and a blue load 55 mm stapling device was used to come across the proximal and distal ends of this transverse colon. This was a segment of about 7 cm. A side-to-side stapled anastomosis along the colon was then created, first with stay sutures of 3-0 silk, then enterotomies being made within both ends of the colon, and the GIA stapler device was used to fire across, creating a stapled anastomosis. A further firing of the TA stapling device was used to close the enterotomy created with the colon stapled anastomosis. The mesentery was reapproximated with a running 3-0 silk.

The abdominal cavity was then thoroughly irrigated and hemostasis appreciated. Once we were done, we reevaluated all anastomoses and were happy with how they appeared. The abdominal contents were allowed to return to the abdomen, and the Thompson retractor blades were removed. Seprafilm was placed over the abdominal incision and the fascia was reapproximated with 0 PDS in a running fashion from either end. The subcutaneous tissues were thoroughly irrigated and staples were used to reapproximate the skin. The patient was awakened from general anesthesia, extubated, and taken to the postanesthesia care unit in stable condition. Estimated blood loss was 150 mL. Sponge and needle counts were correct.

Psychiatric Evaluation Sample Transcribed Report - MT Reference Resource

IDENTIFICATION:  This is a (XX)-year-old single male.

PRESENTING COMPLAINT:  The patient reported history of difficult childhood and depression.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male who reported significant medical history of surgery on his left hand after he injured it.  He also reported surgical procedures done on both knees for cartilage repair and drainage of fluid as well in the past.  He did not report any other significant history of medical problems.  According to the chart, he had a problem with gastroesophageal reflux, and in the past, at one point, he had elevated liver function tests.  Apart from that, there was no other significant history provided.  The patient stated that he had a very difficult childhood.  He was physically abused by his father from the age of 4 up until he was 15.  He stated that he had received beatings with sticks, belts, and with his hands.  He was emotionally very disturbed.  When he was a child, he attempted multiple times to kill himself.  He stated all these suicide attempts were because of his physical abuse, to get away from his father.  The patient stated that he was diagnosed with hyperactivity and was treated with medication, Thorazine, which actually sedated him too much and made him like a zombie.  He stated that he took the medication for two years but later on stopped it, after two years, because of the significant side effects and no improvement.


He stated that he was tried on other medications, which he does not remember, but all of his medications were stopped at age 12 when they were found to be not helping him at all.  He stated that he was getting into a lot of trouble, which included fighting, anger control problems as well.  The patient stated that he tried to kill his father on multiple occasions but failed.  At one point, he had tried to stab him twice; at another point, he had injured his back to the point that he was admitted to a hospital.  The patient stated that since age 12, when his medication was stopped, he did not pursue any psychiatric treatment up until many years later.  He stated that during this period he endured a lot of stress.  He reported that in (XXXX) his mother died.  He stated that, after the death of his mother, he started having nightmares and flashbacks, which really bothered him and he was not able to rest at all.  He was started on multiple medications.  At one point, he had taken Remeron, but later, he was started on Elavil and valproic acid, which is Depakote.  The patient stated that Elavil was to help him sleep and Depakote actually was more for his migraine headaches, which were excruciating, and since he had been started on Depakote, his migraine headaches had significantly improved.


At the time of assessment, the patient stated that he continued to have flashbacks and had difficulty sleeping.  He stated that Elavil, he is taking 150 mg at bedtime, is not very helpful.  He is having lots of side effects including dry mouth, constipation, and weight gain.  He wanted to stop Elavil and try some other antidepressant.  He also stated that he wanted to continue Depakene but at a lower dose because he was told that his blood level was higher than normal so he wanted to decrease his medications.  The patient stated that he was willing to take some other antidepressant and agreed to have a washout period.  He was very understanding about the risk of changing the medication including some period when he would be without medication and his condition could get worse, but he was willing to take that chance.  At the time of assessment, he reported that he was eating okay.  He continued to complain of some depressed mood.  Denied any suicidal ideation.  He reported significant homicidal ideation against his father and the family.  He did not report any specific homicidal ideations.  These homicidal ideations were conveyed to psychologist, Mr. (XX), and these issues would be brought up in psychiatric review team meeting.  He did not report any other history of auditory or visual hallucinations or any other side effects.  He felt safe.


The patient reported extensive history of alcohol and drug abuse.  He stated that he started drinking alcohol at a very young age.  He would steal from his grandparents, but he started drinking on regular basis at age 15.  His last drink was in (XXXX).  He admitted to having blackouts, shakes, but denied any DUIs or public intoxication charges.  He was 4/4 on CAGE questions.  He also admitted to marijuana use daily, approximately 3 ounces per day, since an early age.  He admitted to have mixed it with cocaine and smoked it, and he also admitted to have snorted cocaine but he stated that it was not regular; it was only on the weekends, whenever he could find.  He stated that his last substance abuse was in (XXXX).

PAST MEDICAL HISTORY:  As discussed above.

PAST PSYCHIATRIC HISTORY:  As discussed above.

PERSONAL HISTORY:  The patient was single and had three children.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY:  Significant for some kind of mental illness and alcohol and drug abuse.  He stated that all of his family was “crazy.”  He did not report any history of suicide in the family.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old male sitting on a chair.  He was alert, oriented, and cooperative.  Concentration and memory intact.  Speech was normal rate, flow, and tone.  Language was appropriate and goal directed.  Mood was mildly depressed.  Affect was somewhat sad.  No suicidal ideation.  No active homicidal ideation, although he had homicidal ideation against his father and his family.  No auditory or visual hallucinations or delusions noted.  He seems to have reasonable insight into his situation.  His judgment was intact.

DIAGNOSES:

Axis I:            1.  Posttraumatic stress disorder, chronic.
                        2.  Alcohol dependence.
                        3.  History of polysubstance abuse.

Axis II:            Antisocial personality disorder, borderline personality disorder.

Axis III:           Migraine headaches, gastroesophageal reflux disease.

Axis IV:          Legal problems.

Axis V:           Global Assessment of Functioning is 70-75 at the time of assessment.

TREATMENT PLAN:  The patient was seen.  He was educated about symptoms of mental illness and available resources, risks, benefits, side effects of his medications including present medication, Elavil and Depakote.  He was able to ask questions.  He understood the side effects of dry mouth, constipation, blurring of vision, weight gain, organ effects including effects of Elavil on the heart as well as effects of valproic acid on the liver, pancreas, bone marrow, and blood.  He was able to understand about the risks of hair loss, weight gain, tremors, and other side effects from Depakote.  The patient had stated that his medications were not really helpful with his condition.  He was interested in taking another antidepressant.  He was explained in detail that since he was on Elavil, that he would have to have a washout before another medication could be started.  He was able to understand and ask questions about the risk of changing the medication including worsening of mood disorder, psychosis, risk of suicide.  He wanted to try another antidepressant.  He agreed to undergo a period of washout of 7 to 10 days.  Risks, benefits, and side effects of Celexa including sexual side effects, risk of mania, serotonin syndrome were discussed in detail.  He was interested in trying.  We will start him on Celexa 20 mg after receiving a washout.  His last labs were discussed with him.  The patient agreed to continue Depakote at the present time with a plan that once his Celexa is stable that his Depakote dose would be reduced to minimum dose possible.  His case was discussed in detail with Mr. (XX), who is going to provide him with therapy focusing on the issue of his past trauma, mental illness, and substance abuse.  I will continue to follow him closely and provide medication and therapy.  I will see the patient back in approximately 4 weeks.  We will continue to do regular blood tests as well.




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Cardiology Consultation Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY 

CONSULTING PHYSICIAN:  John Doe, MD

REQUESTING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION:  Evaluation and management of new-onset supraventricular tachycardia and chest pain.

HISTORY OF PRESENT ILLNESS:  This pleasant (XX)-year-old male has no known coronary artery disease.  He did undergo a treadmill dual isotope nuclear exercise stress test that revealed reduced perfusion throughout the inferior wall in a relatively fixed pattern consistent with diaphragmatic attenuation artifact.  There are, however, no clear-cut perfusion abnormalities to indicate any areas of significant reversible myocardial ischemia.  He does have a history of hypertension, hyperlipidemia, prostate cancer, benign colon polyps and TIAs.  He has a significant family history with heart problems and diabetes mellitus.  He has two sisters and a half brother who underwent coronary artery bypass grafting.  The patient reports he woke up with weakness and dizziness.  He decided to go to work.  He states he drove himself to work, and after arriving, he experienced palpitations, heart racing and chest pressure, which was nonradiating.  He thought his blood pressure was elevated and contacted his wife to bring him his beta-blocker, atenolol.  After a while, he had associated symptoms of diaphoresis, weakness, difficulty walking, dyspnea with exertion and nausea.  When his wife and son arrived, they assisted him into the car and brought him to (XX) Hospital.  He was found to be in SVT with a heat rate of 150 to 160 beats per minute.  EMS was called and he was taken via ambulance to the emergency department at (XX) Hospital.  En route, he was given IV adenosine intravenously.  He had another episode of SVT at 150 beats per minute in the emergency department and was started on Cardizem drip.  He was subsequently hospitalized for SVT and chest pain.  Cardiology was consulted for cardiac workup.

PAST MEDICAL HISTORY:  Hypertension, hyperlipidemia, prostate cancer, benign colonic polyps, history of TIAs x3 with no residual deficits, lumbar degenerative disease, and gastroesophageal reflux disease.

PAST SURGICAL HISTORY:  Colon resection, hemorrhoidectomy, appendectomy, and polypectomy.

ALLERGIES:  SULFA.

CURRENT MEDICATIONS:  Lovenox 40 mg subcutaneously daily; Cozaar 100 mg daily; hydrochlorothiazide 12.5 mg daily; Catapres 0.2 mg daily; Biaxin 500 mg b.i.d.; amoxicillin 500 mg b.i.d.; Protonix 40 mg b.i.d.; terazosin 10 mg b.i.d.; potassium chloride 20 mEq; Nasonex 50 mcg 1 to 2 sprays each nostril daily.

SOCIAL HISTORY:  He denies consuming beverages containing caffeine.  He is a nonsmoker and a nondrinker.

FAMILY HISTORY:  Mother is deceased and had history of heart problems and diabetes mellitus.  Father is deceased and had a history of peripheral vascular disease.  He has a sister deceased with breast cancer.  He has a sister who underwent a 4-vessel coronary artery bypass grafting.  Another sister had a 3-vessel coronary artery bypass grafting and a half brother who underwent coronary artery bypass grafting.

REVIEW OF SYSTEMS:  Denies fever, chills, pedal edema, vomiting or syncopal episode.  Denies a history of liver abnormalities, hepatitis, cirrhosis, congestive heart failure, diabetes mellitus, chronic lung disease, emphysema, bronchitis, asthma, urinary tract infections, kidney stones, anemia, blood dyscrasias, peptic ulcer disease, hiatal hernia, diverticulitis, colitis, CVA, migraine headaches, thyroid abnormality, carotid artery disease, peripheral vascular disease, leg cramps, glaucoma or gout.

PHYSICAL EXAMINATION:
GENERAL:  This pleasant (XX)-year-old male is well developed, well nourished, in no acute distress.
VITAL SIGNS:  Afebrile with temperature 98.6 degrees, pulse 68 and regular, respirations 21 and nonlabored, blood pressure 118/58, and O2 saturation 97% on room air.
HEENT:  Normocephalic and atraumatic.  Eyes symmetrical and anicteric.  Mucous membranes are pink and moist. 
NECK:  Supple.  No jugular venous distention or carotid bruits. Trachea midline.  CHEST:  Diminished at the bases with occasional wheezing.  No rhonchi, rales or rubs.
HEART:  S1 and S2, regular rate and rhythm.  A 1/4 systolic murmur.  No rubs, gallops or S3.
ABDOMEN:  Positive bowel sounds in all four quadrants and nontender.  No abdominal bruit, fluid wave or hepatomegaly.
EXTREMITIES:  Pulses are +2 and equal.  No clubbing, cyanosis or edema.
NEUROLOGIC:  Alert, awake and oriented x3, cooperative.  Moves all extremities.  Gait smooth and balanced.

LABORATORY AND DIAGNOSTIC DATA:  WBC 9.4, hemoglobin 14.4, hematocrit 42.6, and platelet count 186,000.  APTT 28.2, PT 12.8, INR 0.94.  D-dimer 0.36.  Triglycerides 206, cholesterol 188, HDL 45, LDL 106.  CPK 158, 119, and 128, CK-MB 2.8, 1.6.  Potassium 3.4, magnesium 2.9.  Troponin 0.02 and less than 0.02.  TSH 0.897.  Total T3 of 124, T4 of 6.6.

Chest x-ray reveals tortuous and ectatic aorta with atherosclerosis, degenerative changes in the spine, consolidating infiltrates, significant pleural fluid collection or pneumothorax not identified.  Echocardiogram revealed normal overall left ventricular systolic function, 62%, left ventricular hypertrophy, trace to mild pulmonic insufficiency, trace to mild mitral regurgitation and trace to mild tricuspid regurgitation.

IMPRESSION:
1.  Chest pain, rule out angina with a significant family history of coronary artery disease.
2.  Supraventricular tachycardia with heart rate in 150s to 160s.
3.  Hypertension.
4.  Hyperlipidemia.
5.  History of transient ischemic attacks with no neurologic deficits.
6.  Gastroesophageal reflux disease.

RECOMMENDATIONS:
1.  Serial cardiac enzymes and troponin to rule out myocardial infarction.
2.  Discontinue Cardizem drip and change to Cardizem 30 mg by mouth every 6 hours with parameters.
3.  A 2D echocardiogram to evaluate for wall motion abnormalities, valvular heart disease and estimate the ejection fraction.
4.  NPO after midnight.
5.  Schedule for treadmill dual isotope nuclear exercise stress test to evaluate for cardiac ischemia.
6.  Further orders and recommendations pending the patient's clinical course.

Thank you, Dr. Doe, for this consultation and allowing us to participate in the care of this patient.

Psychiatric Consultation Medical Transcription Transcribed Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

CONSULTING PHYSICIAN:  John Doe, MD

REQUESTING PHYSICIAN:  Jane Doe, MD

IDENTIFICATION DATA/REASON FOR CONSULTATION:  The patient is a (XX)-year-old male who is admitted for assessment and treatment of alcohol problem and depression.  Current assessment is requested to review and recommend on his psychological symptoms.

SOURCES OF INFORMATION:  Include face-to-face interview with the patient, collateral information from review of the chart, and the patient's wife who is present at the bedside.

CHIEF COMPLAINT:  The patient reports, "I have been feeling depressed, under stress, drinking more alcohol lately."

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who claims to have some stress and not having support from the family, etc.  Apparently, under the stress, he has more anxiety, more depression and started drinking more alcohol.  He claims to have been drinking pretty regularly over the past couple of weeks though he started drinking more about a couple of months ago, almost up to a pint a day of vodka.  Apparently, he does have some withdrawal symptoms in the morning and started drinking again.  He reports of no legal problems, no medical problems, no family problems because of the alcohol.  He apparently was living in a hotel on Wednesday night under the influence of alcohol.  He felt very depressed and thought of jumping off of the balcony.  At that time, he felt uncomfortable and asked his wife to bring him to the hospital.  The last use of alcohol is Wednesday night.  He reports of mild tremulousness but otherwise no hallucinations, no sweating, no paranoia.  He reports of no current suicidal ideation or plans.  He denies of hallucinations.  He admits to trouble with sleep at night.  He claims to have good appetite.  He reports feeling sad, some crying episodes.  He denies irritability or racing thoughts.  He denies other illicit drug abuse.  He denies any panic attacks.  He does admit to some trouble with attention span for many years.  Claims the symptoms of alcohol abuse and also depressive symptoms were gradually getting worse over the past couple of months.  He expressed his intent to seek help on outpatient basis.

PAST PSYCHIATRIC HISTORY:  The patient has no prior psychiatric hospitalizations, suicide attempts or assaults on others but admits to taking antidepressant medications such as Paxil and Xanax many years ago for depressive symptoms.  He reports that Paxil did not work on him but Xanax did work on him good but also caused excessive sedation, which he did not like.  No history of illicit drug use.  History of alcohol problem off and on, alcohol use from age (XX) though he reports drinking only during the weekends and socially.  Only in the past few months, he reports of alcohol getting over his usual limits.  Reports of smoking half a pack of cigarettes per day.

ALLERGIES:  NONE KNOWN.

PAST MEDICAL AND SURGICAL HISTORY:  He has a diagnosis of psoriasis.  No history of surgeries.

CURRENT MEDICATIONS:  Multivitamin and Protonix.

SOCIAL/PERSONAL HISTORY:  He is a married male who reports of one child.  He claims to have been married for (XX) years.  He reports of some college education. 

FAMILY HISTORY:  Negative.

REVIEW OF SYSTEMS:  He reports of no chest pain, no shortness of breath, no headache, no blurred vision, no nausea, no fever, no chills, no constipation, no diarrhea.  He does admit to mild tremulousness of the upper extremity.

PHYSICAL EXAMINATION:  Reviewed the vital signs from the chart.

MENTAL STATUS EXAMINATION:  The patient is an average-built male who is dressed in a hospital gown, sitting in bed, in no acute physical distress.  No involuntary movements noted though at times fine tremors of the hands were noticed.  No agitation is noticed.  Psychomotor activity within normal limits.  Speech and language functions are intact and adequate.  State of mood, he feels depressed.  Affect is appropriate.  Good range of emotions noted, depressed.  Thought process is linear and coherent.  Thought content shows recurrent psychotic symptoms.  No suicidal ideation or plans.  No homicidal ideation or plans.  The patient denies of hallucinations and does not appear to be reacting to internal stimuli.  Cognitive functions are intact for orientation to place, person, day.  Memory is intact to remote, recent, and immediate recall.  General fund of information is average.  Intellectually appeared average.  Insight and judgment good.

LABORATORY DATA:  The patient's chart was reviewed for laboratory test results, which showed urine drug screen positive for marijuana.  Glucose level at 122.  Serum chemistries otherwise negative.  Alcohol level less than 13.

SUMMARY:  This is a (XX)-year-old male with history of alcohol abuse and possible marijuana abuse, who presents with depressive symptoms over the past 2 months due to multiple psychosocial stressors.  No significant family history.

MEDICAL DECISION MAKING AND OTHER DIAGNOSES:

Axis I:
1.  Major depressive disorder, recurrent, moderate.
2.  Alcohol abuse.
3.  Cannabis abuse.

Axis II:  Deferred.

Axis III:  Per past medical history.

Axis IV:  Stress and problems with medical conditions, other psychosocial stressors.

Axis V:  Current Global Assessment of Functioning of 70-75.

RECOMMENDATIONS AND PLAN:  After psychiatric assessment was completed, the diagnostic impression and proposed treatment plans were reviewed with the patient.  No imminent danger to self or others currently.  He is willing to seek help on outpatient basis for depression and also alcohol problems.  He seeks to stay sober.  He has no current suicidal ideation or plans.  No homicidal ideation or plans.  The risks, benefits, side effect profile and alternatives were discussed with the patient and his wife with regard to treatment with antidepressant medications such as either Wellbutrin or Lexapro.  The patient chose to take Lexapro.  The patient agreed to take the medication as recommended.  Prescription for 30-day supply was given to the patient and left in the chart.  The patient can be discharged to home from psychiatric point of view.  I do not see any reason for the patient to be monitored one-to-one at present.  Continue medical management as appropriate.  The patient can be discharged from psychiatric point of view once medically stable and cleared.




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Psychiatry - Psychiatric Assessment Medical Transcription Transcribed Sample

IDENTIFICATION:  This is a (XX)-year-old single male.

PRESENTING COMPLAINTS:  The patient reported history of agitation and stress as well as depression.

HISTORY OF PRESENT ILLNESS:  The patient denied any significant history of medical problems whatsoever.  He reported having psychiatric problems since his childhood.  He stated that he had a very difficult childhood.  His mother was only (XX) years old when she gave birth to him.  She was not really there to take care of him.  She was partying most of the time.  She was drinking as well and was physically abusive towards him.  The patient stated that he was abused by his stepfather and mother physically.  He denied any history of sexual abuse.  He stated that he had a chaotic upbringing at home and really became depressed.  He was exposed to crime at an early age and had been incarcerated in juvenile facilities as well.  The patient reported that in (XXXX) he was incarcerated in a juvenile facility when, because of the home stress, he tried to hang himself.  He was depressed at that time.  He stated that he was diagnosed with depression and hyperactivity and in the past had been treated with medications, including Ritalin and Zyprexa.  He denied any other history of suicide attempts.  He denied any history of auditory or visual hallucinations whatsoever.  He reported that he had never been admitted to a psychiatric facility in the past.

At the time of assessment, the patient reported that he had been receiving treatment for depression.  He stated that he had been depressed for a long time.  He stated that his depression was basically partly agitation, stress, as well as sad mood.  He stated that in (XXXX) he became agitated to the point that he started cutting on his arm.  The patient reported that he was seen by the psychiatrist and was started on lithium for agitation.  He reported that his condition improved significantly.  The stress had subsided since then.

At the time of evaluation, the patient reported that he was doing fairly well with lithium.  He reported that he did not need Vistaril.  He had been resting well.  He had been eating okay.  He denied any depressed mood.  Denied any suicidal or homicidal ideation.  He denied any auditory or visual hallucinations.  He reported that he felt much better and wanted to continue taking lithium carbonate.  He stated that in future, if he continues to do well, he would consider trying to get off of the medication, if at all possible.  He did not report any side effects of the medications.  He stated that his mood was very stable and did not have any mood swings, periods of agitation or anger.  He did not report any past history of mood swings, which were consistent with mania or hypomanic episodes whatsoever.  He did not report any symptoms, which were consistent with psychosis in the past.

PAST MEDICAL HISTORY:  As discussed above.

PAST PSYCHIATRIC HISTORY:  As discussed above.

PERSONAL HISTORY:  The patient was single.  Did not have any children.

ALLERGIES:  He was not allergic to anything.

FAMILY HISTORY:  The patient denied any significant history of medical or psychiatric problems in the family.  There was no history of suicide.

SUBSTANCE ABUSE HISTORY:  The patient reported that he started drinking at the age of (XX).  At his peak, he was drinking every other day.  He denied any history of DUIs or public intoxication charges.  He was 0/4 on CAGE questions.  The patient admitted to having smoked embalming fluid.  He had abused cocaine in the past by snorting.  He stated that he started using drugs at the age of (XX).  At his peak, he was using 3 grams of cocaine by snorting every day.  His last use was in (XXXX).  He did not report any cravings, withdrawals or any other desire to take any drugs.  He did not report any intravenous drug abuse whatsoever.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old male sitting on a chair.  He was alert, oriented, and cooperative.  Concentration and memory intact.  Speech was normal in rate, flow, and tone.  Language was appropriate and goal directed.  Mood was euthymic.  Affect was full.  No suicidal or homicidal ideation, auditory or visual hallucinations or delusions.  No flight of ideas, loosening of association, tangentiality, or circumstantiality.  He seemed to have good insight into his situation.  His judgment was intact.
 

DIAGNOSES:

Axis I:             1.  History of adjustment disorder with mixed emotions.
                        2.  Alcohol abuse.
                        3.  Polysubstance abuse. 

Axis II:           Antisocial personality disorder, primary diagnosis.

Axis III:          Deferred.

Axis IV:          Legal problems.

Axis V:           Global Assessment of Functioning 70-75 at the time of assessment.

TREATMENT PLAN:  The patient was seen in detail.  He was educated about symptoms of mental illness and available resources. Risks, benefits, and side effects of the medication lithium were discussed including dry mouth, constipation, blurring of vision, tremors, risk of toxicity, risk of toxicity with different medications including nonsteroidals as well as salt restriction and dehydration.  He was informed in detail about risk of diabetes insipidus, hypothyroidism, kidney damage as well as other organ effects.  He was able to ask questions.  He was able to discuss the side effects in detail.  He agreed to have an EKG done.  The plan is to continue him on lithium 900 mg at bedtime to help him sleep and relax, and continue to monitor him closely and follow the lithium levels.  He would be followed regularly by Psychology as well as Psychiatry.  I am going to continue to treat him and provide therapy.  I will see him back in my clinic in approximately 4 weeks.



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Ophthalmology History and Physical Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT/REASON FOR ADMISSION:  Blocked vision from upper lid drooping.

HISTORY OF PRESENT ILLNESS:  This (XX)-year-old gentleman notes obstruction of vision from downward sagging of both upper eyelids. This causes impairment when driving. He believes that this is dangerous. He has had some near accidents. The patient reports that by stretching his eyebrow upward, he is able to see more clearly. He presented first to his primary care physician, who recommended ophthalmological evaluation. His ophthalmologist then requested oculoplasty consultation. There was no history of myasthenia gravis or other neuromuscular disease. The level of the eyelid does not change during the day and there is no associated diplopia. He further reports that he has had injuries in which he has bumped his head because he was not able to see clearly his superior visual fields.

PAST MEDICAL/SURGICAL HISTORY:  Significant for early cataract formation, status post tumor removed from chest, hypercholesterolemia, gastroesophageal reflux disease, hypertension, history of seasonal allergy secondary to dry eye, history of asthma, history of diverticulitis, and hypertension.

MEDICATIONS:  Included Nexium, Advair, simvastatin, albuterol, multivitamin, Ginkgo biloba and saw palmetto. The patient denied taking aspirin or other anticoagulants.

REVIEW OF SYSTEMS:  A 14-point comprehensive review of system is otherwise negative.

SOCIAL HISTORY:  The patient is employed. He does not use tobacco products. He has an occasional alcohol beverage. He exercises by golfing thrice weekly.

FAMILY HISTORY:  Significant for diabetes mellitus, carcinoma, tuberculosis, heart disease, hypertension, and kidney disease.

ALLERGIES:  REPORTED NO KNOWN DRUG ALLERGIES.

OPHTHALMIC EXAMINATION:  Showed a corrected visual acuity measured at 20/50 in right eye and 20/30 in left eye.  With eyelid lift, the patient reported improvement of vision on both sides. Pupils are normal on both sides. Extraocular muscle ductions were intact with no diplopia reported. Confrontation visual fields were 2+ depressed superiorly on the right, and 2 to 3+ depressed superiorly on the left side.  With eyelid lift, this improved the superior restriction bilaterally.  External examination showed 5 mm of eyebrow ptosis on the right side and 6 mm eyebrow ptosis on the left side. There was 1 to 2+ compensatory occipitofrontalis muscle contracture elevating the upper eyelid excessive dermatochalasis and steatoblepharon on both sides, which was graded at 2+ in both eyes. The patient was 2 to 3 Fitzpatrick skin type with 1+ upward Bell phenomenon and a negative ice test for myasthenia gravis for 5 minutes. Basal tear secretion test measured 12 mm wetting on the right, 13 mm wetting on the left side. There was no fatigue on sustained upgaze and no lagophthalmos. The eyelid margin to corneal reflex distance was 0.0 mm in right eye and -1.0 mm in left eye. Vertical palpebral aperture measured 5 mm in right eye and 4.5 mm in left eye.  Levator function was 14 mm in right eye and 15 mm in left eye. The eyelid margin increased to 6 mm in right eye and 5 mm in left eye.

Hand-held slit-lamp examination showed 50% obstruction of the superior pupillary aperture by the upper eyelid excessive tissue and ptosis on the right, and 60% obstruction on the left side by the same phenomenon. There was positive Herring phenomenon further depressing the left upper eyelid when the right upper eyelid was elevated into the appropriate position. There was 2+ lateral entropion formed from the excessive upper eyelid dermatochalasis resting on the superior lash margin and inducing 2+ eyelash ptosis. Lacrimal puncta appeared normal. Conjunctivae and sclerae were normal, iris shape and morphology was normal. The cornea had an adequate tear film height with normal epithelium, stroma and endothelium in both eyes, and anterior chamber depth was 3+ with no cell or flare. The lens showed 1+ anterior cortical and nuclear sclerotic and posterior cortical changes on both sides. Multi series digital external ocular photography documented left greater than right upper eyelid blepharoptosis associated with upper eyelid excessive dermatochalasis and steatoblepharon resting on the superior lash margin, causing obstruction of the superior pupillary aperture despite activation of compensatory occipitofrontalis muscle contracture on both sides. A full-field 246 point screening visual field test performed was reviewed. This documented superior depression to within 4 degrees of the superior pupillary aperture to within 4 degrees of the central visual field on the right side and within 12 degrees of the central visual field on the left side. With upper eyelid elevation retesting, this improved the superior visual field to 52 degrees superiorly on the right side and 43 degrees superiorly on the left side.

IMPRESSION:  Involutional left greater than right upper eyelid levator palpebrae superioris aponeurotic dehiscence and blepharoptosis in both eyes.  This was seen together with involutional and actinic-related upper eyelid excessive dermatochalasis and steatoblepharon with formation of lateral entropion in both eyes.

RECOMMENDATION AND PLAN:  Planned procedure is for bilateral external levator palpebrae superioris aponeurotic resection, upper eyelid, both eyes. This will be combined with bilateral upper eyelid blepharoplasty with correction of lateral entropion in both eyes. I have discussed the risks, benefits, and alternatives to surgery including no surgical intervention. The patient is aware of the risk of bleeding, infection, loss of vision, scarring, asymmetry, eyelid hypesthesia, problems with anesthesia, dry eye formation after surgery, failure of the procedure, as well as a need for revision surgery. All questions were answered. The patient is aware that, after this episode of consultative care, he will return to his regular eye care professionals for ongoing needs.

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Physical Medicine and Rehab Discharge Summary Transcribed Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

ADMISSION DIAGNOSIS:  Status post cerebrovascular accident with right hemiparesis, expressive aphasia, and slurred speech.

SUPPORTING DIAGNOSES:
1.  Loss of strength, balance, mobility, endurance, and self-care.
2.  Hypertension.
3.  Internal carotid artery stenosis.
4.  Coronary artery disease with history of stent in the past.
5.  History of cerebrovascular accident in the past.
6.  History of smoking.

DISCHARGE ORDERS:  The patient was discharged home with a friend, with 24-hour supervision.  The patient is not to drive.  Supervision with ambulation and ADLs.  Diet is 2-gram sodium, low fat.

MEDICATIONS:  Aspirin 325 mg p.o. daily; Lipitor 40 mg p.o. nightly; Plavix 75 mg p.o. daily; Imdur 30 mg p.o. daily; Wellbutrin SR 150 mg p.o. b.i.d.; and Xanax 0.25 mg p.o. b.i.d. p.r.n.

FOLLOWUP:  With primary care physician.  Follow up with Dr. John Doe for possible carotid arteriogram.  Follow up with Dr. Jane Doe of Neurology.  Follow up with Dr. Bradford Doe.  Home care, physical therapy, occupational therapy evaluation, speech therapy, aide, psych social worker, durable medical equipment, single point cane.

BRIEF HISTORY:  This is a (XX)-year-old female with complaints of right-sided weakness and right facial droop.  Reportedly, the symptoms presented the day before.  She has a history and risk factors for stroke including hypertension, heart disease, previous cerebrovascular accidents, and smoking.  Initial CT scan of the brain was negative.  MRI imaging scan, MRA revealed left internal carotid artery occlusion, intermittent occlusion of the left middle cerebral artery.  The patient was admitted under the care of Dr. John Doe.  The patient was seen by Dr. Jane Doe for vascular evaluation.  CT angiogram revealed a completely occluded left common carotid.  She recommended carotid arteriogram in 2 to 3 weeks.  The patient's MRI scan showed an acute infarct of the left ganglion region.  The patient was transferred to rehab on Plavix and aspirin regimen to address her mobility and self-care.

MEDICAL COURSE:  While on rehab, the patient was managed medically by Dr. Jeff Doe.  While on rehab, the patient had developed some chest pains and Dr. Chris Doe was consulted.  She was monitored on telemetry and was felt to have symptoms of coronary artery disease.  The patient was cleared to continue her rehab and was recommended by Dr. Chris Doe to follow up with Cardiology for a stress test in the future.  During her remaining stay, she had no further episodes of chest pains.  She was treated for a urinary tract infection as well as for depression.  She was seen by Dr. Michael Doe of Neuropsych, who assessed the patient to be clinically depressed, exacerbated by her stroke.  However, the patient did not desire any psychotherapy and preferred to continue to address her depression with medications, and at the time of discharge, she was on Wellbutrin b.i.d. 150 mg.

LABORATORY VALUES:  Prior to discharge, her glucose was 92, BUN 14, creatinine 0.8, sodium 141, potassium 4.2, chloride 103, CO2 of 26, alkaline phosphatase 102, AST 14, ALT 36, total bilirubin 0.3, albumin 4, calcium 9.9, and total protein 6.8.  On MM/DD/YYYY, the cholesterol was 168, triglycerides 162, HDL 22, and LDL 117.  WBCs on MM/DD/YYYY were 8200, hemoglobin 12.6, hematocrit 36.8, and platelets 172,000.  RPR was nonreactive.

REHAB COURSE:  The patient was admitted and followed by physical therapy, occupational therapy, and speech.  During her course of rehab, she did have a home visit, did go on community reentry, and issues regarding her social situation were also addressed.  At the time of discharge, the patient, speech wise, was on a mechanical soft, chopped and thin diet.  Her oral motor was within normal limits, except for mild deficits with coordination.  She had mild oral movements and coordination deficits and moderate deficits with fluency of speech.  She was able to follow two-step commands within functional limits.  She had mild deficits with yes/no reliability, moderate deficits with evaluation of questions from a paragraph.  Mild deficits with complex conversation.  Her reading and comprehension were within functional limits.  Cognition was intact but she was noted not to fatigue easily.  She was oriented x3.  Her memory was within functional limits with immediate recent and remote memory.  She had mild problem solving deficits with thought organization, ability to reason, and judgment, and she was known to have a tendency towards depression.  However, her goals were met for the period that she was in rehab, and she was recommended further speech therapy.  Mobility wise, the patient was independent with bed mobility.  She was modified independent with transfers.  For ambulation, she was able to ambulate as much as 150 feet, supervision level, using a single-point cane.  She was supervision for negotiating 12 stairs/steps.  Functionally, she was feeding with independence, grooming and dressing upper body, dressing lower body, and her toileting was at modified independence.  Once again, for both physical therapy and occupational therapy, she was recommended continued therapy in the home with 24-hour supervision.  At the time of discharge, the patient was medically stable.  Laboratory values are provided above for the continuity of care.  Discharge instructions are outlined above.

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Neurology Consultation Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION:  Seizure.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male status post TBI, who was recently readmitted after shunt placement for late hydrocephalus following TBI.  On Tuesday, this patient had seizure, which was felt to be recurrent and status epilepticus.  At that time, he was loaded with IV Dilantin and given Ativan.  The seizure was described as shaking all over, unresponsive, and then oriented only to name, place, and date, complaining of pain in his left arm.  Over the last 24 hours, he has developed leukocytosis and fever.  Had blood cultures drawn, which were negative on Tuesday, along with negative chest x-ray at that time.  His white count then was 15,400.  The question today is whether or not the shunt is infected.  Found to also have mild elevation in his NH3, yesterday, but this has come down.  He was found to be Dilantin toxic as he was IV loaded with Depakote, so his level has climbed to 36.6 today.  His Dilantin is on hold.  His white count has climbed to 22,200, previously 11,800 yesterday.  It seemed to improve, but now it is elevated again.  Nursing reported to me, somewhat later in the morning, that he had had some green discharge from his nose.  However, there was no knowledge of that until we had him down for chest x-ray.

PAST MEDICAL HISTORY:  He had this traumatic brain injury about 3 months back with right basal ganglia hemorrhage, underwent a large right craniectomy with evacuation.  He had a PEG and tracheostomy.  I met him when he was transferred to an outside hospital for vent wean.  He did well medically and neurologically.  He had dense left hemiplegia but was interacting well with his family.  Sometimes, he was verbally abusive but pretty much cooperative with therapies and cognitively doing pretty well.  A head CT had shown bifrontal subdural collections with increased hydrocephalus prior to transfer.

He was returned here about 10 days ago.  At that time, we had begun a workup on his previous admission for possible seizure.  An EEG had been pending but he was transferred out without followup at that point from Neurology.  He was brought back today to further assess his mental status.  Two days ago, he had this episode of shaking, temperature then was 99.4 degrees, and the seizure lasted 1 to 2 minutes.  His blood pressure was 182 at that time, systolic, heart rate in the 170s, O2 saturations 95%, and he was sinus tachycardic.  IV was established and he was given Ativan 2 mg, initially resolved the seizure but then returned to have a second seizure, was felt to be in status for a total of 1 hour and 15 minutes.  He had in total 8 mg of IV Ativan, 5 mg of Valium per rectum, and 2.5 mg of Valium IV.  He was given labetalol for his heart rate and blood pressure, and saturations only dropped to about 93%.  Dilantin 1.2 grams was given IV, and he was monitored and tolerated it well.  NH3 happened to come back to 84 that day.  VPA happened to be 70 that day.

He did not have any vomiting, but the subsequent day, he had some vomiting, was found to have high Dilantin levels, and he had vomiting yesterday as well.  Fever started low grade.  On MM/DD/YYYY, white count was 15,300, but the white count came back down the following day to 12,800.  His blood cultures on MM/DD/YYYY were negative as was a chest x-ray, ammonia resolved with lactulose.  He has not had recurrent seizure, though he has had clonus or shaking of his lower extremities without real change in his mental status as best I can tell.  EEG has not been done yet.  His past medical history was otherwise negative prior to his injury.

REVIEW OF SYSTEMS:  Not available clearly from the patient because he has poor sustained attention, but he does admit to headache at this time.  He is poorly responsive though.

FAMILY HISTORY:  Unknown.  This patient never had seizures as a child.

CURRENT MEDICATIONS:  Dilantin, on hold; Depakote was stopped yesterday, it was 500 mg t.i.d.; baclofen 10 mg q.12h.; Fragmin subcutaneously; trazodone 100 mg h.s.; Elavil 10 mg q.h.s.; and Tylenol and Percocet p.r.n.  Ritalin was started on MM/DD/YYYY but that has been stopped.  He is on ibuprofen p.r.n. for pain.  Elavil was stopped on MM/DD/YYYY.  Current medications this morning were heparin subcutaneously, lactulose q.6h., baclofen 5 mg b.i.d., and his trazodone.  All other medications have been pretty much stopped.

PHYSICAL EXAMINATION:  When I examined him today at 10 a.m., he was sitting upright in a chair.  He was warm to touch.  Vitals were temperature 100.2 degrees, respirations 20, pulse 130, BP 130/68, and O2 saturation 96%.  Laboratories are noted above.  He was mildly tender along the edges of the cranium.  He did not have nuchal rigidity or meningismus.  He was alert.  He was conversant but had poor sustained attention.  He was appropriate with one-word answers and followed all single commands.  His cranial nerve examination was remarkable for well-visualized fundi bilaterally, which were unremarkable in terms of papilledema.  There was normal disk-to-cup ratio.  His ductions were remarkable for asymmetric pupils but grossly conjugate gaze.  He may have a left exophoria.  Flattening of the left face.  Visual fields were not tested.  Gag was not tested.  Carotids were unremarkable.  Cardiac examination revealed rapid rate and rhythm.  Motor examination shows he has left hemiplegia, 2/5 in the arm with a Brunnstrom recovery score of 1 on the basis of severe increase in tone.  Left leg is adducted.  Right leg is mobile with isolated movement throughout, at least 3+/5 strength, same as 2 in the arm, but he seems to have clonus in both ankles if his legs are put on the stretch, and the movement, which is rhythmic and rapid and fairly low amplitude, can be stopped by repositioning his joints.  Along with that movement, there is no alteration in consciousness, no increased respiratory rate over his baseline increased respiratory rate, and there is no oral trauma noted.  Sensory examination was not performed.

DIAGNOSTIC STUDIES:  We went ahead and obtained a head CT, which I reviewed personally and then a CT scan.  This shows the patient has, to my mind, slightly increased herniation of the right brain outward through the craniotomy defect, but in reviewing it with Neuroradiology, they felt there was no significant change.  The left frontoparietal subdural collection seen on yesterday's CT was no longer present.  Chest x-ray was also performed.  In comparison to the prior x-ray, the costophrenic angles were well seen, though there was increased vascular congestion in the pulmonary vessels.  There also appeared to be increased penetration in different technique, compared to the film two days ago.

It is noteworthy, his lung examination revealed decreased breath sounds and breath movements bilaterally, no rales or rhonchi were heard.  Also noteworthy on the examination of the patient was the absence of ataxia and nystagmus.

Dr. Doe and I discussed the patient's triage and strategy for further treatment and felt that with the equivocal chest x-ray, it might be reasonable to consider evaluation by Neurosurgery, but given his tachypnea and fever, I also felt this patient should be given one dose of Zosyn because I believe that he does have pneumonia.  Zosyn would not cross the blood-brain barrier and would not likely interfere with cultures of the CSF.

IMPRESSION:
1.  Lethargy, fever of unknown origin, possibly pulmonary, possibly CSF.  However, CT of the brain shows no evidence of overt increased difficulty in CSF drainage, that is the vent sizes are same as they were the other day and actually the CT looks improved with resolution of the subdural collection on the left.  The patient's clinical examination is somewhat worse because of the temperature, but there is no new focal neurological finding.  Certainly, the Dilantin toxicity also is at play.
2.  Dilantin toxicity:  Probably secondary to the high-loading dose in combination with existing Depakote 1500 mg a day.  The patient currently is being appropriately managed with holding his Dilantin.
3.  Seizure disorder:  The patient was witnessed to have generalized tonic-clonic seizure on MM/DD/YYYY, which has so far not recurred.  He is at risk with the high Dilantin level and needs to have daily Dilantin levels monitored.
4.  Spastic left hemiplegia.
5.  Bilateral lower extremity clonus:  Possibly worsened by his febrile state.

RECOMMENDATIONS:
1.  CT, done.
2.  EEG and follow up here.
3.  Chest x-ray, done.
4.  Neurosurgical evaluation, done.
5.  Hold Dilantin but check daily levels on this patient and restart the Dilantin when his level returns between 15 and 20.  Do not wait to see it drop under 15.  It should be started at a dose of 300 mg h.s.
6.  Continue to hold the Depakote and do not reinstitute for now.
7.  Add folic acid 1 mg a day because he is on AED at this time.
8.  Os-Cal D 500 mg b.i.d. while on AED and nonambulatory.

Thank you for this consultation.  I will continue to follow the patient along with you.


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