Scleral Buckle Procedure Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY 

PREOPERATIVE DIAGNOSIS:  Retinal detachment, proliferative vitreoretinopathy, right eye.

POSTOPERATIVE DIAGNOSIS:  Retinal detachment, proliferative vitreoretinopathy, right eye.

OPERATION PERFORMED:  Scleral buckle procedure, vitrectomy, membranectomy, laser photocoagulation, silicone oil injection, peripheral iridectomy, right eye.

SURGEON:  John Doe, MD

ANESTHESIA: General.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and general anesthesia was administered. The face was prepped and draped in the usual sterile ophthalmic fashion and a lid speculum was placed in the right eye. The conjunctiva was opened for 360 degrees and each of the 4 rectus muscles were isolated and tagged in turn using 2-0 black silk sutures. Three mL of 0.25% Marcaine was delivered into the peribulbar space using a blunt tip cannula. Indirect ophthalmoscopy with scleral depression was performed for 360 degrees. The retinal detachment was very thin with atrophic areas and areas of underlying pigmentation, but there were no definite retinal holes or tears visualized. It was decided to perform an encircling buckle and perform peripheral laser photocoagulation for 360 degrees. A 240 band was selected. Nylon 5-0 sutures were placed at a measured distance of 5 mm posterior to the muscle insertion superonasally and superotemporally and 6 mm inferonasally and inferotemporally. The 240 band was placed around the globe, under the muscles and through the sutures, and affixed using a #70 sleeve at the 2 o'clock meridian and pulled up to achieve a moderate height. The 5-0 nylon sutures were tied down. 

At this time, attention was turned to the vitrectomy. Using the 25 gauge system, trocars were placed through the sclera at a measured distance of 3.75 mm posterior to the surgical limbus at the 9:30, 2:30, and infratemporal meridians. The infusion cannula was placed inferotemporally, the tip of the cannula could be seen to be free of tissue, and the infusion cannula was turned on. Using the wide-angle lens system, the light pipe, and the microvitrector handpiece, a core pars plana vitrectomy was carried out. It was discovered that there was no remaining vitreous in the eye and apparently a vitrectomy was performed during one of the previous surgeries.

A small retinotomy was performed in the periphery, in the nasal periphery of the retina. A silicone-tip extrusion cannula was used to remove subretinal fluid, which was quite viscous. An air-fluid exchange was then performed and the retina was reattached at this point. Endolaser photocoagulation was performed along the slope of the buckle for 360 degrees and completely surrounding the retinotomy site using the following laser settings; 200 micron spot size, 0.2 seconds of exposure, 500 milliwatts of power using a total of 900 laser applications. An inferior peripheral iridectomy was performed using a vitrectomy handpiece. Silicone oil, 5000 centistokes, was then injected into the eye. The sclerotomy site where the silicone oil was injected was closed using 7-0 Vicryl sutures. The 25 gauge trocars were removed.

Saline was flushed over the cornea and conjunctiva to remove any residual silicone oil bubbles. Three mL of 0.25% Marcaine was delivered into the peribulbar space using a blunt tip cannula. The 240 band was trimmed as well as the 5-0 nylon sutures. Conjunctiva was closed using 6-0 plain gut sutures. Subconjunctival injections of Ancef and dexamethasone were delivered. Scopolamine 0.25%, Maxitrol, and Alphagan eyedrops were placed in the eye, as well as a patch and shield. The patient was awakened from general anesthesia and taken to the recovery room in the right-side-down position, having tolerated the procedure without complications.


Ankle Arthrotomy and Brostrom Gould Operation Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Anterior talofibular ligament tear, right ankle.
2.  Workers' compensation injury, right ankle.
3.  Joint pain, right ankle.

POSTOPERATIVE DIAGNOSES:
1.  Anterior talofibular ligament tear, right ankle.
2.  Workers' compensation injury, right ankle.
3.  Joint pain, right ankle.

OPERATION PERFORMED:
1.  Open ankle arthrotomy, right ankle, with debridement of synovitis.
2.  Modified Brostrom-Gould ankle ligament repair/stabilization, right ankle.

SURGEON:  John Doe, DPM

ANESTHESIA:  General.

HEMOSTASIS:  Pneumatic thigh tourniquet inflated to 300 mmHg.

ESTIMATED BLOOD LOSS:  Less than 5 mL.

INJECTABLES:  Marcaine plain 0.5%.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  Under mild sedation, the patient was brought to the operating room and placed in the supine position.  General anesthesia was achieved.  The patient was put into the lateral position on the beanbag and the harnesses to the lower limb were appropriately padded.  The upper extremity was also protected by Anesthesia.  The leg was then scrubbed, prepped and draped in the usual aseptic manner.  It was elevated and exsanguinated with an Esmarch and the tourniquet inflated to 300 mmHg.  A common peroneal block was given with 0.5% Marcaine plain.  Attention was directed to the patient's lateral ankle where a curvilinear incision was made along the anterior portion of the fibula, extending down to the tip of the distal fibula.  This was made to the epidermis and dermis down to the subcutaneous tissue.  Any bleeders were cauterized as necessary.  We carried our incision down to the extensor retinaculum, which appeared to be somewhat torn with a little bit of fatty herniation to the area.  This was retracted in an inferior position.  We extended our incision deeper down to the level of the ankle joint capsule.  There was noted to be a partial tear with some synovial tissue and coloration to the area.  We made an incision through the capsule along the margin of the lateral gutter down to the distal portion of the fibula.  It was noted that the patient's synovial tissue billowed to the area and that the intracapsular portion of the ligament appeared to be thickened and dystrophic and invaginated to the lateral gutter.  This correlated directly to where the patient's pain had been located.  We debrided the dystrophic tissue down to healthy margins and flushed the wound copiously with normal sterile saline.  The ankle joint was explored and no signs of osteochondral lesion could be noted and the synovial tissue debrided out and we reflushed again with normal sterile saline.  We then reapproximated the capsule and ligament with 2-0 Ethibond and figure-of-eight stitch technique with excellent reapproximation noted.  There was not noted to be any further invagination to the lateral gutter.  This was performed along the entire course of the ankle joint capsule.  We then plicated the extensor retinaculum up over the repair to reinforce the stabilization.  Subcutaneous tissue was then repaired with 3-0 Vicryl and the skin was closed with skin staples.  A local periligamental block was given with 0.5% Marcaine plain.  The area was then dressed with Adaptic, 4 x 4, Kling, Kerlix, ABD and then Ace wrap.  We then applied a modified Jones compression type cast with the patient's foot held in a dorsiflexed and mildly everted position.  Before the cast was applied, the ankle joint was tested and noted to be very secure and stable.  No anterior drawer on inversion stress was noted whatsoever.  Tourniquet was deflated and prompt return of good response was noted to all digits of the patient's right foot before the cast was applied.  The patient tolerated the procedure well and was transferred to the recovery room with vital signs stable.  Neurovascular status returned promptly following release of the tourniquet.

Laparoscopic Ureteronephrectomy Medical Transcription Sample

PREOPERATIVE DIAGNOSIS:  Healthy kidney donor. 

POSTOPERATIVE DIAGNOSIS:  Healthy kidney donor. 

PROCEDURE PERFORMED:  Laparoscopic left ureteronephrectomy. 

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia. 

COMPLICATIONS:  None. 

BLOOD LOSS:  100 mL. 

SPECIMENS:  Left kidney for transplantation. 

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed supine on the operating table. After adequate IV access and IV sedation, the patient was intubated and anesthetized. Venous catheterization was performed by Anesthesiology and a Foley catheter was placed by nursing staff aseptically. The patient was placed in the right lateral decubitus position and her left arm was placed under suspension armboard. All pressure points were padded and the patient was secured to the OR table with the OR beanbag. The kidney rest had been placed previously at maximal height and the bed flexed as well. The abdomen was prepped with Betadine solution and draped with sterile linen and sterile drapes. A midclavicular left subcostal incision was created and a 12 mm balloon port was placed by the Hasson technique. The abdomen was insufflated to 12 cm with CO2 gas and assessed. Multiple adhesions between the spleen and the omentum and the anterior abdominal wall were noted. These overlaid the kidney. A left lateral 5 mm and a left periumbilical 12 mm port were both placed under direct vision. A hand port was placed in the left lower quadrant. Dissection began taking the left colon down at the white line of Toldt mobilizing medially and cephalad. The adhesions between the spleen, the omentum and anterior abdominal wall were taken down with Harmonic scalpel. The splenorenal ligament was divided with Harmonic scalpel. The adrenal gland was noted on the upper pole of the kidney and was followed down to the renal vein and the adrenal vein. The renal and adrenal veins were both dissected down the anterior surface. The adrenal vein was circumferentially dissected, ligated with clips x 4, and divided between ligatures. The adrenal gland was now taken off of the upper pole of the kidney with Harmonic scalpel. There was an upper pole vessel from the adrenal gland to the upper pole of the kidney, which did not communicate with the renal artery and was divided with the Harmonic scalpel creating a small dime-size area of ischemia. The rest of the upper of the kidney was mobilized and the kidney was retracted inferiorly. The renal vein was now dissected out lower surface. The gonadal vein was circumferentially dissected and was divided after ligated with clips x4. A very large lumbar vein was noted coming off of the renal vein on the posterior surface of the lobe of the gonadal vein. This vein was quite broad-based and immediately branched into 5 different vessels that were all large and engorged. The vein was circumferentially dissected down to the surface of renal vein and then was divided with endoreticulating vascular stapler. 

The renal vein was now circumferentially mobilized down. With the renal vein elevated anteriorly, the takeoff of the renal artery was identified. The demarcation was developed with a Maryland dissector. All neurovascular tissues cephalad of the renal artery were then divided with the Harmonic scalpel inferiorly. The retroperitoneum was entered below the inferior pole of the kidney and above the gonadal vein. The tissues were then dissected sharply and bluntly, very carefully elevating the ureteral complex all the way down to the iliac vessels. The kidney was now brought out off of the retroperitoneum with Harmonic scalpel dividing the fibrous tissues on the back of the Gerota's fascia. The posterior surface of the renal artery and renal vein were now cleared of neurolymphatic tissues. The kidney was placed back into the retroperitoneum, into its normal position. The pneumoperitoneum was dissipated. The ureter was grasped, brought up through the hand port, was dissected down towards the bladder, was clamped below the iliac vessels, and divided leaving the ureter free to urinate within the peritoneum. The distal ureter was ligated with a 0 silk ligature. The kidney was now diuresed for 45 minutes with increased fluid management. The patient received 5 liters of fluid prior to excision of the kidney. With Dr. Doe now ready in the donor room, the abdomen was reinsufflated, the kidney was elevated, and the vessels were placed on mild tension and endoreticulating vascular stapler was placed across the artery at its junction with the aorta and deployed dividing the artery. The renal vein was divided with a serial load of the endoreticulating vascular stapler. Kidney was brought through the hand port and given to Dr. Doe under iced UW for preparation and the recipient on the back table. 

The abdomen was reinsufflated. The abdomen was aspirated of as much urine as possible. The dissection bed and the peritoneum were irrigated with copious amounts of sterile saline and aspirated as dry as possible. The spleen and adrenal gland were identified at their dissection locations and had no injuries and were not bleeding. This staple line of the renal artery takeoff on the aorta was identified and it was not bleeding. The staple line of renal vein was also identified at the corner. The rest of it was below the aorta and was unable to be seen towards the vena cava. There was no blood welling up through this area and staple lines were intact. The distal dissection planes of the ureter were identified. There was some small clotted blood on the peritoneal surface in the retroperitoneum, this was cleared and aspirated from the peritoneum. There was no other bleeding noted. The distal tie on the distal ureter was intact and verified down towards the bladder. Iliac vessels were unharmed. The abdomen was now desufflated and aspirated off all CO2 gas and liquid as much as possible. The 12 mm balloon ports were closed with figure-of-eight of 0 Vicryl suture incorporating the peritoneum and the fascia within the suture. Hand was placed to the hand port and the surface was palpated and found to have no bowel or omentum caught up with the sutures. The hand port was now closed. The peritoneum and posterior fascia were closed with a single running simple 0 PDS suture. An On-Q pain pump was now brought in 2 inches from the incision laterally and tunneled down underneath the oblique anterior fascia. The catheter was placed in the muscle layer between the anterior and posterior sheaths. The anterior sheath was now closed with another running 0 PDS suture in a simple running fashion. The subcutaneous tissues were irrigated with sterile saline and antibiotic solution. The pain pump catheter was pulled back gently to assure that it was not caught up within the sutures. It was then loaded with 15 mL, 1.25% Marcaine without epinephrine. The Scarpa's layer and all incisions were brought together with 3-0 silk suture in an interrupted fashion. Skin incisions were brought together and reapproximated with 4-0 subcuticular Vicryl suture. All incisions were then covered with Dermabond tissue glue. The patient tolerated the procedure well and was taken to the recovery room in awake and stable condition.

Tilt Table Test Medical Transcription Sample Report / Example

DATE OF PROCEDURE:  MM/MM/YYYY

REFERRING PHYSICIAN:  John Doe, MD

PROCEDURE PERFORMED:  Tilt testing.

INDICATIONS FOR PROCEDURE:  Syncope.

DESCRIPTION OF PROCEDURE:  The patient was brought to the electrophysiology laboratory in the fasting state. After signing informed consent, she was laid supine on the tilt table and noninvasive blood pressure cuff monitoring, ECG monitoring and pulse oximetry monitoring were established. The patient was observed in the supine position for several minutes during which time heart rates were in the 70 to 80 beat per minute range with systolic blood pressures 114/133. She was then tilted to the head-up position to 75 degrees and observed for a total of 30 minutes. Heart rate and rhythm were observed continuously and blood pressures were measured every minute. The patient was stable throughout the 30-minute tilt with sinus rhythm in the 70 to 90 beat per minute range and systolic blood pressures ranging between 94 and 134 beats mmHg. The patient did not have significant symptoms during the initial tilt. She was then lowered supine and isoproterenol was begun at a dose of 1 mcg per minute, which resulted in an acceleration of her resting heart rate from 68 to 80. She was then tilted again to 75 degrees. The patient initially did well, but after 20 minutes of tilt, the patient started feeling nauseated and blood pressure fell into the 90s and then subsequently rapidly into as low as 58/40 without compensatory acceleration of her heart rate, which was running in the 80 to 100 beat per minute range. The patient was intensely near syncopal at this point but never did lose consciousness. We observed her for 20 to 30 seconds, during which time she remained highly symptomatic, but did not lose consciousness. During this interval, her radial pulse was absent confirming the presence of hypotension. She was then lowered supine. Radial pulse returned and blood pressure normalized. All the patient's near-syncopal symptoms resolved. The patient states that these symptoms were similar to what she experienced in her prodromal episode prior to syncope 3 months ago. The patient then left the electrophysiology laboratory in stable condition.

IMPRESSION:  Positive tilt testing reproducing near-syncope in the setting of hypotension due to orthostatic hypotension during prolonged head-upright tilt on isoproterenol stimulation.

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Repair of Lip Laceration Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Complex near amputation/laceration, right lower lip.

POSTOPERATIVE DIAGNOSIS:
Complex near amputation/laceration, right lower lip.

PROCEDURE PERFORMED:
Repair of complex laceration, right lower lip.

SURGEON:  John Doe, MD

INDICATIONS:  The patient is a (XX)-year-old male who was bitten by his friend's dog, sustaining a near amputation of the lower third of the right lower lip.

Physical examination in the emergency room revealed the right lower third of the lower lip hanging by a pedicle off the oral commissure. The laceration extended from the commissure down the chin and angling back up towards the one-third border of the lower lip. A second laceration was full thickness, extending from the inferior labial sulcus through the lip and down onto the chin. A further laceration of approximately 3 cm was found to be present along the gingival border of the inferior labial sulcus.

DESCRIPTION OF PROCEDURE:  The patient underwent sterile prep followed by injection of 1% Xylocaine with epinephrine. Debridement of the wounds was performed. The wounds were vigorously scrubbed. Once this was completed, the tissue was rearranged and the remaining border was lined up at the oral commissure as well as one-third border with 6-0 nylon suture. Further 6-0 nylon suture was used to repair the multiple wounds to the chin area. A 4-0 chromic suture was used in an inverted fashion to repair the vermilion and mucosal aspect of the lip down to the inferior labial sulcus. A 4-0 chromic suture was also used to repair the gingival labial sulcus wound. The patient did receive 1 gram of Rocephin in the emergency room and was given a prescription for Augmentin 500 mg t.i.d. The patient's father was instructed to watch for signs of infection and to call immediately if any redness, fever or significant swelling occurred. The patient has been instructed to be on a soft diet and was given ice to his lips. He will be followed up in the office next week.

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ERCP Medical Transcription Sample Report / Example

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Elevated liver function test and elevated bilirubin.
2.  Mildly dilated common bile duct on ultrasound.

POSTOPERATIVE DIAGNOSIS:
Attenuated intrahepatic duct.

PROCEDURE PERFORMED:
Endoscopic retrograde cholangiopancreatography.

SURGEON:  John Doe, MD

SEDATION:  Demerol 75 mg and Versed 6 mg IV.

DESCRIPTION OF PROCEDURE:  The patient was placed in the left lateral decubitus position. We sedated the patient as outlined above. The video endoscope was inserted in the esophagus and advanced into the descending duodenum. The duodenal mucosa was normal. The papilla appeared normal. Free cannulation of the common bile duct was easily obtained and a cholangiogram was performed. Initially, there were four filling defects at the distal duct, two of them were rectangular and the other two were rounded. We were somewhat concerned about there being bubbles, as we did see a couple of bubbles coming in out of the papilla, but they did not appear to rise. They appeared to be irregularly-shaped filling defects. The rest of the common bile duct was about a centimeter. The gallbladder did fill; it appeared normal. The liver appeared small and somewhat dense.

At that point, because those seemed to persist, we put a balloon up. We did a sphincterotomy in the 12 o'clock position for about 1.2 cm. We placed a 12 mm balloon up, dragged it throughout, and some sludge did get removed, but no stones. The filling defects were no longer present. Although we did not see stones come out, we could actually see the balloon easily come through, approximating the duct. Therefore, we were suspicious that there may have been just air bubbles in this situation post treatment.

At this point, reviewing the cholangiogram, we were uncomfortable that her intrahepatic duct did not fill very well. We attempted to put the catheter up. We could not get the catheter very well into the right side of the liver. We put a balloon up and did a cholangiogram under pressure with the balloon inflated. This did fill the intrahepatic ducts better. They appeared again difficult to fill the right side little bit, but we did not see any strictures. The intrahepatic ducts did drain very well, as well as the common bile duct.

At this point, we felt that the cholangiogram was negative and the scope was withdrawn. The patient tolerated the procedure well.

IMPRESSION:  Elevated liver function test. Dilated duct may be an age issue. At this point, still need to consider drug-induced changes versus autoimmune process.

RECOMMENDATIONS:  We will proceed with CT scan of the abdomen to evaluate the liver.

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MRA Circle of Willis and Head MRI Medical Transcription Sample

MRA SKULL BASE/CIRCLE OF WILLIS  

CLINICAL HISTORY:  The patient is a (XX)-year-old female with headaches.

FINDINGS:  Data acquisition was performed using time-of-flight technique with conventional angiographic type reconstructive images.

With respect to the posterior circulation, the upper portion of the vertebral arteries is not included in the field of view.  There is a normal appearance to the basilar artery without evidence of stenosis or aneurysm.  The left posterior cerebral artery has a normal origin off the basilar tip.  The right posterior cerebral artery has a normal developmental variant origin off the anterior circulation.

With respect to the anterior carotid circulation, there is a normal appearance of the petrous, cavernous and supraclinoid carotid vessels.  There is a normal appearance to the M1 and A1 segments without evidence of aneurysm or stenosis.  There is a normal complement of branches off the middle cerebral artery in the region of the articular cortex/sylvian fissure.  As was previously described, posterior cerebral artery appears to have its origin off the right internal carotid artery.  There may be a minute focal narrowing at the origin of the right posterior cerebral artery; the significance of this is uncertain, it may be artifactual.  The visualized portions of the right posterior cerebral artery show normal appearance in caliber.

IMPRESSION:  MR angiogram skull base/circle of Willis showing no evidence of aneurysm or vascular malformation.  Normal variant origin of the right posterior cerebral artery off the anterior circulation.  Tiny focal narrowing near the takeoff of the right posterior cerebral artery of questionable clinical significance; distal to this, the vessel has normal caliber.

Thank you for your kind referral.

HEAD MRI PRE AND POST CONTRAST

No prior studies available for comparisons.

CLINICAL HISTORY:  The patient is a (XX)-year-old female with headaches, possible trigeminal neuralgia.  Evaluate for tumor or MS.

TECHNIQUE:  Multiplanar images were obtained using multiple pulse sequences.  Post-gadolinium axial and coronal T1 weighted images were obtained.

FINDINGS:  Ventricular system overlying sulci are within normal limits.  T2 and inversion recovery images show no abnormal signal within the periventricular and deep white matter tracts to indicate a diffuse demyelinating process.  There is no intracranial mass, midline shift or extra-axial fluid collection.  Following administration of gadolinium, no abnormal areas of enhancement were seen.  Particular attention was directed to the region of Meckel cave and the fifth nerve complex.  There is no evidence of fifth nerve tumor or abnormal enhancement.  Incidental note is made of some minor inflammatory changes in the left maxillary sinus.

IMPRESSION:  Head MRI, essentially within normal limits.  Minor inflammatory changes within the left maxillary antrum.

Thank you for your kind referral.

Entropion Repair Medical Transcription Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY 

PREOPERATIVE DIAGNOSIS:  Involutional entropion, right lower eyelid.

POSTOPERATIVE DIAGNOSIS:  Involutional entropion, right lower eyelid.

OPERATION PERFORMED:  Entropion repair of right lower eyelid.

SURGEON:  John Doe, MD 

ANESTHESIA:  Local infiltrative, topical ocular, with monitored anesthesia care.

ESTIMATED BLOOD LOSS:  15 mL.

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating room table. Previously, an alcohol pad had been used to defat the skin of the right lower lid as well as the right lateral canthus. After this, a gentian violet marking pen had been used to mark the right lateral palpebral raphe. The patient received appropriate preoperative monitoring and sedation and a solution of 2% lidocaine with 1:200,000 parts epinephrine was instilled subcutaneously along the length and breadth of the right lower lid and the right lateral canthus. In addition, an infraorbital nerve block was performed by delivering the same solution in the area of the infraorbital foramen. The anesthetic agent was massaged into place. The surgeon performed a surgical scrub. The patient was prepped and draped in the usual sterile fashion for ophthalmic surgery. A hard corneoscleral shield was placed before the cornea of the right eye after a series of 0.5% topical tetracaine drops had been applied. 

A double armed 4-0 chromic suture was then passed through the white band of the lower lid retractors transconjunctivally to exit in an infraciliary position, rotating the right lower lid outward and reattaching the right lower lid retractors. A series of three of these double armed 4-0 chromic sutures were thus passed. The right lower lid was everted into the correct position. Attention was directed to the right lateral canthus. A #15 Bard Parker blade was used to incise the previously demarcated gentian violet line. A sharp Westcott scissor was used to fashion a lateral canthotomy and cantholysis. The inferior crus of the lateral canthal tendon was released from its attachment using Ellman radiofrequency unit dissection. The right lower lid was noted to swing freely. The orbicularis oculi muscle was also released in a posterior orbicularis fascial plane. A right lateral tarsal strip was fashioned by resecting a full thickness portion of the right lower lid at the appropriate amount of right lower lid tightening, which was previously measured by the overlapping technique, estimating the amount of excess eyelid to form good apposition and no lower lid lag at the lateral canthal angle.

The right lower lid was noted to be in appropriate contour and position when compared to the left lower lid. The lateral tarsal strip was then anastomosed to the orbital tubercle 5 mm posterior to the anterior face of the lateral orbital rim utilizing a 4-0 double armed Prolene suture in a horizontal mattress fashion. The lid level and contour was again noted to be appropriate and the lid margin was repaired in a standard three-lid margin technique, anastomosing just anterior to the mucocutaneous junction, the lash line and the gray line. The ends of the previous suture were left long and incorporated into the subsequent one to prevent corneal irritation. The lateral palpebral raphe was repaired with a series of interrupted 6-0 fast absorbing plain suture. The hard corneoscleral shield had been removed after a series of 0.5% topical tetracaine drops had been applied. The patient tolerated the procedure well. The eye was dressed with Maxitrol ointment and the patient was taken to the recovery room in stable condition.

Delivery Note Medical Transcription Sample Report / Example

DATE OF DELIVERY:  MM/DD/YYYY 

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old G1, P0 at 39-3/7 weeks with an EDD of MM/DD/YYYY based on a 6-week ultrasound. The patient presented to L and D with complaints of contractions every 3 minutes and leaking of fluid since 0400 on MM/DD/YYYY. The patient reports positive fetal movement and denies vaginal bleeding. Prenatal care began at 9 weeks x15 visits. Total weight gain was 37 pounds. The patient is A positive, rubella immune, GBS positive. She has no known drug allergies.

Upon admission, vaginal exam was 1, 80% and -1 station per the RN. Fetal heart tones were 124, positive long term variability, positive acceleration and no decelerations. Uterine contractions every 2 to 3 minutes, 60 to 80 seconds and moderate to palpation.

ASSESSMENT:
1.  Term pregnancy. 
2.  Spontaneous rupture of membranes. 
3.  Spontaneous labor. 
4.  Reassuring fetal status.

PLAN:  Admit the patient to the labor and delivery unit. Dr. Doe informed and agrees with plan. GBS protocol, ampicillin. The patient encouraged to ambulate, shower, use the birth ball. Reassess in 3 to 4 hours or p.r.n.

At 1500 hours on MM/DD/YYYY, the patient continued to breathe with contractions. Her husband was at her side and was quite supportive. Vital signs were stable. Fetal heart tones were in the 120s with average long term variability, positive accelerations, no decelerations. Uterine contractions were every 2 to 5 minutes for 50 to 90 seconds, moderate to palpation. Vaginal exam at that time was 2, 80%, -1 station. There had been minimal cervical change; however, fetal heart tones remained reassuring. Plan was to start Pitocin per protocol after having reviewed the options with the patient, who was agreeable to the plan. Continue to ambulate, use the birth ball or shower, and reevaluate after 3 to 4 hours. Dr. Doe was made aware of the plan and agreed.

At 2100 hours, the patient reported being more uncomfortable during the contractions but able to rest between. She was feeling most of her pain in her back. Her husband was at the bedside providing support. The patient was ambulating and using the birthing ball and showering but was requesting an epidural. Vital signs remained stable, as did the fetal heart tones. The vaginal exam was 5, 80%, 0 to -1 station. 

At 2300 hours, the patient was resting comfortably with her epidural. Temperature at that time was 99.6 and Tylenol per rectum was given. Fetal heart tones were 120s with average long term variability but prolonged decelerations down to the 90s and sometimes 60s x3 minutes with prolonged uterine contractions. Uterine contractions were every 1-1/2 to 5 minutes and there was coupling and they were lasting 50 to 70 seconds and moderate to palpation. The vaginal exam was 7 to 8 cm, 80%, 0 to -1 station and caput was forming. Pitocin was at 16 mU. Dr. Doe was informed of decelerations, which seemed to be eliminated by maternal position changes and agreed with the plan to continue Pitocin augmentation.

At 0400 hours, the patient was reporting increased vaginal and rectal pressure and had an urge to push. She was still comfortable with her epidural. Vital signs:  Temperature was 98.8, fetal heart tones were 144 with minimal long term variability but positive accelerations and early decelerations with contractions. Uterine contractions were every 1-1/2 to 5 minutes with coupling and lasted 60 to 100 seconds long, strong to palpation. The Pitocin was at 10 mU. Vaginal exam was complete, +1 station with caput. The patient was only feeling mild urges to push and so the plan was to continue laboring down and to begin pushing efforts when there was a stronger urge.

At 0600, the patient was complete and laboring down. She reported a strong urge to push and pushing was begun. The patient pushed effectively. Fetal heart tones were 130s with minimal to moderate long term variability with no accelerations. There were variable decelerations down to the 70s x 1-1/2 to 2 minutes with pushing efforts with a slow return to baseline after the contraction. O2 was applied and Pitocin was turned off. Dr. Doe was paged and Dr. Jane Doe, the house officer, was requested to evaluate the patient for possible vacuum extraction. Dr. Jane Doe presented at the patient's bedside for evaluation of fetal station which was 0 with caput at +1 in LOA position. Dr. Jane Doe recommended restarting the Pitocin after 30 minutes of rest at 4 to 5 mU and then increase slowly to allow the fetus to labor down. After turning on the Pitocin, fetal heart tones were in the 130s with moderate long term variability, positive accelerations and no decelerations. Uterine contractions were every 3 to 5 minutes, lasting 60 to 90 seconds and strong. The patient was resting comfortably with the epidural. Dr. Doe was aware and continued to agree with the plan. At 0830 hours, report was given to certified nurse midwife, who resumed the care of the patient.

LABOR PROGRESS:  At 0900, the patient was pushing with contractions. She was feeling pressure but was still comfortable with the epidural. The patient stated that she was exhausted. The Pitocin was restarted at 2 mU as the RN realized that the catheter had come loose from the patient's IV and the Pitocin was not being delivered to the patient. Pitocin currently now at 18 mU per minute. Contractions were every 2 to 6 minutes, 50 to 60 seconds long. Fetal heart tones were 125, average variability, 15 x 15 accelerations with mild variable decelerations with good return to baseline. Vaginal exam at 0830 hours was complete, 100%, with the head at the 0 station and the caput at +2 station. The patient appeared to be making some progress with pushing; however, Dr. Doe was consulted and was asked by the CNM to assess the patient after leaving an OR case. The plan was that the patient would continue pushing provided fetal heart tones remained stable until Dr. Doe was able to get out of the OR to evaluate her. The plan was to consider vacuum extraction.

DELIVERY NOTE:  The patient pushed extremely well and through excellent maternal efforts and frequent position changes, the infant rotated and descended and normal spontaneous vaginal delivery occurred at 0950 hours in the LOA position over intact perineum. Meconium-stained fluid was noted as the head came over the perineum and Neonatology was called to the room. The mouth and nose were bulb suctioned on the perineum by the CNM. The shoulders delivered easily and a nuchal cord loose x1 was noted and reduced with the delivery of the body. The cord was immediately clamped x2 and cut by the father of the baby and the infant was taken to the warmer for evaluation by Neonatology. The placenta delivered spontaneously at 0958 hours, was complete, had a 3-vessel cord, and was in the Schultz fashion. EBL was 200 mL. Pitocin was run open after the delivery of the placenta. The vagina was inspected and a first-degree vaginal and left first-degree labial laceration were repaired with 2-0 chromic and 3-0 Vicryl respectively. The fundus was firm, midline, and -2. There was light lochia. Infant’s Apgars were 6, 8 and 9. Weight was 7 pounds 16 ounces. The mother and the infant were left in stable condition.

Kiwi Vacuum Delivery Medical Transcription Procedure Sample

DATE OF DELIVERY:  MM/DD/YYYY 

PRE-DELIVERY DIAGNOSES:
1.  Term pregnancy.
2.  Nonreassuring fetal heart rate tracing, mainly variable decelerations.

POST-DELIVERY DIAGNOSES:
1.  Term pregnancy.
2.  Nonreassuring fetal heart rate tracing, mainly variable decelerations.

TYPE OF DELIVERY:  Kiwi vacuum delivery.

ESTIMATED BLOOD LOSS:  200 mL

BRIEF HISTORY:  This (XX)-year-old gravida 2, para 1 presented at 39 weeks' gestation for induction of labor because of history of cervical dilation and a discussed risk of precipitous labor and a cord prolapse. This pregnancy was uneventful. The patient was GBS negative.
PAST SURGICAL HISTORY:  Noncontributory. The patient had one spontaneous vaginal delivery.

MEDICATIONS:  None except for vitamins.

ALLERGIES:  None.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Stable. ABDOMEN:  Soft, nontender, and nondistended. CERVIX:  Initially 4-5 cm dilated, but quickly progressed to 9 cm cervical dilatation with Pitocin.

COURSE AND DELIVERY NOTE:
The patient required epidural for pain control. Once fully dilated, she began pushing. She had a relatively short second stage of labor. Towards the end of the second stage of labor, she developed variable decelerations, some with late component. This nonreassuring fetal heart rate tracing was discussed with the patient and her partner, as were the delivery options including a Kiwi vacuum delivery. The pros and cons and the risks of the vacuum delivery were discussed in detail, as were the alternative approaches. The patient and her partner decided to proceed with a Kiwi vacuum delivery. The cervix was completely dilated. The fetal scalp was visible between labor in-between contractions. The bladder was empty. The position was right occiput anterior. Between contractions, a flat Kiwi vacuum was applied and its position was rechecked and found to be appropriate. Over the next contraction, with the patient pushing and minimal amount of traction on the vacuum, the head of the baby boy was delivered and suctioned and the rest of the delivery followed without difficulty. A right mediolateral episiotomy was first performed to facilitate delivery. This was later repaired with 2-0 chromic suture. The rectum was checked post repair and found to be intact. Complete placenta with a 3-vessel cord was delivered. The baby's Apgars were 9, 9 and 9 at one, five and ten minutes respectively and the weight was 6 pounds 10 ounces. The cord pH was sent and it came back at 7.33 with a base excess of -3.2. Estimated blood loss for the procedure was approximately 200 mL. There were no complications. Both the patient and the baby were stable postdelivery. Instrument, needle and sponge counts were correct x2 at the end of the delivery.

Forceps Delivery Medical Transcription Operative Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PRE-DELIVERY DIAGNOSES:
1.  Term pregnancy.
2.  Nonreassuring fetal heart strip.

POST-DELIVERY DIAGNOSES:
1.  Term pregnancy.
2.  Nonreassuring fetal heart strip.

PROCEDURE PERFORMED:
Forceps delivery.

ESTIMATED BLOOD LOSS:  300 mL

BRIEF HISTORY:  This (XX)-year-old gravida 1 presented at 38 weeks and 1 day gestation with history of spontaneous contractions. There was no history of ruptured membranes. No bleeding. The cervix was 2 cm dilated in the office earlier that day. This pregnancy was uneventful except for the abnormal quadruple screen for which the patient declined to have amniocentesis.

PAST MEDICAL HISTORY:  Noncontributory.

MEDICATIONS:  None except for vitamins.

ALLERGIES:  None.

PHYSICAL EXAMINATION:  On examination, vital signs are stable. Cardiovascular and chest examination normal. Abdomen is soft. Palpable contractions are noted. Cervix is 3 cm dilated with the presenting part at station 0 and 90% cervical effacement. Fetal heart rate was reactive.

COURSE AND DELIVERY NOTE:
The patient was admitted and mildly elevated temperature was noted. She was given ampicillin and Tylenol, and Pitocin was started for augmentation. The patient progressed with contractions and artificial rupture of membranes revealed clear fluid. Once fully dilated, the patient began pushing. During the second stage of labor, the patient developed some decelerations. The cervix was completely dilated. The fetal scalp was visible between labor in-between contractions. In view of the nonreassuring fetal heart rate tracing, the patient was presented with an option of a forceps delivery and explained the pros and cons and risks of the procedure, which the patient found acceptable. The bladder was drained. Between contractions, solid McLane forceps were applied and the position was rechecked and found to be appropriate. Over the next contraction, with the patient pushing and minimal amount of traction on the forceps, the head of the baby girl was delivered and suctioned and the rest of the delivery followed without difficulty. A pudendal block was used in addition to the epidural prior to forceps delivery. Complete placenta was delivered shortly thereafter. The baby's weight was 6 pounds 4 ounces and the Apgars were 9, 9 and 9 at one, five and ten minutes respectively. The cord gases were sent and the pH came back as 7.24 with base excess of -2.4. A right mediolateral episiotomy was performed to facilitate the delivery. This was later repaired with 2-0 chromic suture. There were no extensions. The rectum was checked post repair and found to be intact. Estimated blood loss for the procedure was approximately 300 mL. There were no complications. Both the baby and the patient were stable postdelivery. The instrument, needle and sponge counts were correct x2 at the end of the delivery.

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Bunionectomy and Akin Osteotomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus, left foot.
2.  Hammer digit syndrome, second, left foot.

POSTOPERATIVE DIAGNOSES:
1.  Hallux abductovalgus, left foot.
2.  Hammer digit syndrome, second, left foot.

OPERATIONS PERFORMED:
1.  Bunionectomy with a first metatarsal osteotomy and screw fixation of the left.
2.  Akin osteotomy of the proximal phalanx of the hallux with screw fixation of the left.
3.  Arthroplasty of the second proximal interphalangeal joint of the left.
4.  Tenotomy of the extensor digitorum longus tendon and capsulotomy of the second metatarsophalangeal joint of the left with K-wire fixation of the second digit, left foot.

SURGEON:  John Doe, MD

HEMOSTASIS:  Esmarch bandage for approximately 90 minutes.

MATERIALS USED:
1.  Two 2.7 mm diameter screws in the first metatarsal; one 18 mm in length and one 20 mm in length.
2.  A 2 mm Synthes screw in the proximal phalanx of the hallux, 24 mm in length, and 0.045 inch K-wire in the second digit, left foot.
3.  Also used 2-0, 3-0, 4-0, 5-0 Vicryl and 5-0 nylon.

INJECTABLES:  Preoperatively, 20 mL of 0.5% Marcaine plain and postoperatively 3 mL of dexamethasone phosphate.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room in the supine position with IV intact for intravenous sedation. He was given 1 g of Ancef IV piggyback for prophylactic antibiotic. He was transferred from the cart to the operating room table and administered IV sedation via the anesthesia department. Under aseptic conditions, preoperative injection was then given. After proper surgical scrub, he was prepped and draped. The left foot was exsanguinated using a Martin bandage tourniquet. Attention was then directed to the large dorsomedial prominence at the hallux and the first metatarsal. A 7 cm linear skin incision was made over the proximal phalanx of the hallux onto the first metatarsal. Dissection was carried down through the superficial tissue under loupe magnification making sure to avoid any neurovascular structures and coagulating any other bleeding venous structures. Dissection was carried down through the deep tissue where a thickened capsule was noted over the first metatarsophalangeal joint and much xanthochromic thickened joint fluid was noted to be within that joint itself. Upon inspection of the cartilage at the joint, it was laterally deviated and mildly eroded on the medial surface. The large first metatarsal prominence was delivered into the area under dissection. The prominence was partially transected with a sagittal saw and dissection was carried down laterally into the first interspace to free up the lateral sesamoid. The sesamoidal metatarsal, sesamoid phalangeal ligaments were all transected, as well as the abductor hallucis tendon. This allowed for more hallux range of motion but it still appeared to be in a lateral deviated position.

Therefore, a first metatarsal osteotomy was performed. The Z or scarf osteotomy was done utilizing the sagittal saw. Capital fragment was freed and shifted laterally. Metatarsal fragment was transfixed to the metatarsal shaft itself with a 0.062 inch K-wire for temporary fixation. Bone clamp was used to fixate the most proximal piece and two 2.7 mm screws were then applied according to the AO technique. Temporary fixation of the K-wire was taken out and the bone was smoothed off utilizing the sagittal saw and a rotating bur. Noting that there was still some lateral deviation to the hallux, an Akin osteotomy was performed on the proximal phalanx, keeping the most lateral proximal apex intact as the secondary point of fixation. The triangular wedge was removed from the Akin osteotomy and the digit attained a more rectus position. A 2 mm Synthes screw was used, 24 mm in length, to transfix into the osteotomy according to AO technique. There was rigid fixation noted at each side. The area was copiously irrigated with Neosporin solution. The wedge was taken out of the dorsal capsule since there was excess capsule and closed with 2-0 Vicryl. The digit attained a more rectus position and, therefore, the subcutaneous tissue was closed with 3-0 Vicryl. Skin was closed with 4-0 retention sutures and 5-0 Vicryl running intracuticular, bolstered by Steri-Strips.

Attention was then directed to the second digit where two semi-elliptical skin incisions were made over the contracted proximal interphalangeal joint, 2 cm in length. The skin wedge was removed. Dissection was carried down to the capsule, proximal interphalangeal joint, which was entered. Dissection of periosteum and capsule of the proximal phalanx was done, exposing proximal phalanx into the site. The enlarged head of the proximal phalanx had erosion of cartilage where it had been articulating with the middle phalanx in the contracted position. Therefore, an arthroplasty was performed at the surgical neck of the second digit. This allowed the digit to become more rectus but still had a dorsiflexed position at the metatarsophalangeal joint. Therefore, an incision was made at the second metatarsophalangeal joint performing an extensor tenotomy, as well as a capsulotomy of the second metatarsophalangeal joint. The digit obtained a more rectus position but still would contract at the proximal interphalangeal joint. Therefore, 0.045 inch K-wire was used, retrograded into the proximal phalanx from distally to keep the second digit rectus. The extensor digitorum longus tendon was used as an interpositional graft at the proximal interphalangeal joint.

The site was copiously irrigated and closed with 4-0 Vicryl and 5-0 nylon. The capsulotomy, tenotomy site was also closed with 5-0 nylon. The site was infiltrated with dexamethasone phosphate and Betadine-soaked Adaptic, as well as a dry sterile dressing was then applied. Tourniquet was removed and immediate warmth and perfusion was noted to return to all the digits 1 through 5 on the left foot. A pin cap was placed over the 0.045 inch K-wire. The patient was transferred from the operating table to the cart into postanesthesia recovery unit. The patient tolerated the procedure well, as well as the anesthesia, and left the operating room with his vital signs stable and vascular status intact.

Allergy Skin Tests Transcribed Samples / Examples

Prick tests were positive to cat and dog as well as horse at 4+/4, mold spores 1 to 2+/4, trees 2+/4, grasses 2+/4, ragweed 4+/4, other weeds 2+/4 and dust mite negative.

The patient had 3+ reaction to grass, 2+ to ragweed, 3+ cat, 2+ dog.

Prick tests were positive to cat at 4+/4, dog 2+/4, Alternaria mold 2+/4, other molds 1 to 2+/4, trees 2 to 4+/4, grasses 2 to 4+/4, ragweed 2+/4, dust mite 4+/4.

Prick tests were borderline positive to cat and dog at 1+/4 and significantly positive to grass and ragweed, both at 3+/4.  Non-ragweed weed was positive at 2+/4.  Several mold spores were negative as well as other pollens, dust mite and cockroach.

Prick testing were only positive to maple/box elder tree pollen.  They were negative to other tree pollens, grass, ragweed, other weeds, dust mite, cockroach, mold spores and pets.

Prick tests were negative to all challenges including environmental triggers, molds, dust mites, pollens and pets.  Foods were done including egg, milk, wheat, soybean, catfish, peanut, walnut, pecan, all of which were negative.  Shrimp was only borderline positive at 1+/4. She frequently eats shrimp without any signs of allergic triggering.

Prick tests were negative to all challenges regarding any environmental triggers.  This included pets, mold spores, all pollens and dust mites.  Food testing revealed only borderline positivity to shrimp, which was 1+/4.  She was negative to egg, milk, wheat, soybean, catfish, peanut, walnut and pecan.  She eats shrimp without having any increased itching or immediate allergic response.

Prick and intradermal environmental allergy skin tests graded negative to 4+, revealed a 4+ reaction to ragweed, a 3+ reaction to mugwort and to DP mite, with a 2+ reaction to DF mite, all using the prick method.

Her skin test showed reactions to mites, cats, horse hair, birch, grass, and ragweed.

Her RAST egg white came at 4.25, egg yolk 0.63, kiwi 42, peanut 44, hazelnut 6.54, Brazil nut 0.48, almond less than 0.34, as was walnut, pecan, and coconut. Cashew nut was 1.6, pistachio 1.3.

Prick and intradermal environmental allergy skin test graded negative to 4+, revealed 4+ reactions to both dust mites and a 2+ reaction to cat dander, all using the prick method.  Later, using the intradermal method, a 2+ reaction was elicited to dog dander.  

Prick tests were positive to several mold spores, feathers, and dog.  They were borderline to grass and ragweed, but very positive to cottonwood tree at 3+/4.  He was borderline to dust mite.  He was negative to milk and borderline to egg.  Peanut was not done.  We assume he has some continued peanut allergy.

She completed her skin testing.  Intradermals were negative to all challenges, which included cat, dog, several mold spores, tree grass, ragweed, and other weeds, as well as dust mite.  She was positive to cockroach at 3+/4 and one mold spore, Helminthosporium at 2+/4.  She was borderline positive to peanut and walnut but negative to cashew.

Prick tests were positive to trees (marked reactivity), grasses, and ragweed (very high).  She was borderline positive to cockroach, negative to dust mite, non-ragweed pollens, mold spores, and pets.  She was moderately reactive to corn at 2+/4 and only borderline positive to weed at 1+/4.  She was negative to cow’s milk.

Prick test positive for mites DF 4+, mites DP 4+, cat 3+, dog 2+ and egg was 2+.  Pollens were negative.  Intradermal test not done for pollens.

Skin testing had been positive to cat 4+, Alternaria 4+, horse 2+, mite DP 2+, mite DF 1+, and intradermal testing to dog 3+.

Skin testing to environmental allergens at last visit had been positive to cat 4+, dog 2+, mite DF 2+, mite DP 2+, ragweed 4+, birch 4+, Cladosporium 3+, grass 4+, maple 4+, oak 4+.


MSE - Mental Status Examination Examples / Words and Phrases

MENTAL STATUS EXAM: The patient appears stated age, a bit drowsy, closing eyes at times, otherwise with fair eye contact. No psychomotor agitation or retardation noted. Speech had normal volume, rate, tone, prosody, and quantity. Mood was described as "okay." Affect was appropriate, a bit sedated. As regards thought content, denies any suicidal or homicidal ideations as well as any auditory or visual hallucinations. No evidence of ideas of reference or delusions. The patient is future oriented, stating she wants to read a book and listen to music at home. Stated that earlier her spirit was not right prior to taking the medications. Thought process, tangential with non sequiturs at times. Insight and judgment limited. Cognition limited. The patient was only oriented to name and place.

MENTAL STATUS EXAMINATION: The patient appears disheveled, older than stated age, malnourished and emaciated. The patient has a psychomotor retardation. Intermittent poor to fair eye contact. Speech is soft and slow with latency in response. Appears to have dysphoric mood. Depressed affect. Thought process was linear but with thought blocking. Thought content without suicidal ideation, homicidal ideation, audio/visual hallucination. No expression of delusional ideation. The patient is awake but appeared confused at times. The patient is oriented to person but not to place and time. Attention and concentration poor. With respect to memory, the patient registered only 1 object out of 3. The patient had poor insight and judgment.

MENTAL STATUS EXAMINATION: This is a patient who appears slightly older than her stated age. She is of a petite build. She exhibits good grooming and hygiene. She is well developed and well nourished and is not in any acute distress. The patient is cooperative with the exam. The patient maintained intermittent eye contact throughout the exam. The patient was pacing continuously throughout the exam making it difficult for her to maintain eye contact. She was unable to sit down. She did seem to have a slight bit of cogwheel rigidity, more so in the left arm. No tics or tremor noted. The patient spoke in somewhat soft tone of voice with normal rate and prosody. Mood was described as "worried," however, the patient denied feeling anxious. The patient is somewhat irritable and her affect does appear anxious, although she denies it. Her affect is somewhat constricted. Thought process is linear. Regarding thought content, the patient states she has worries that she might harm her family. No paranoia or delusions. No current suicidal ideations; although, the patient has expressed worries that she would harm herself in the past. The patient denies having any auditory or visual hallucinations. The patient is alert. The patient has limited insight into her current condition. The patient is expressing poor judgment at this time.

MENTAL STATUS EXAMINATION: The patient is a well-nourished, well-developed female who looks somewhat older than her stated age. She is oriented to time, date, month, year and person. Her responses are brief, sometimes wide of the point. Attention and concentration are brief. She is primarily preoccupied with "getting back on my meds." She is not an accurate historian and is given to a number of inconsistencies. Motor activity is slightly restless. Her hygiene and grooming are fair. There are no noted abnormal involuntary movements. Her affect is inappropriate, constricted and superficial. Mood is somewhat labile, irritable and impatient. No abnormalities in content of her thought. Speech is rambling, tangential and circumstantial, not very well organized. She is illogical at times and persecutory ideas of reference were present. Hallucinatory disturbances are denied. No history of hallucinations. Memory is impaired, immediate, past and remote. Insight is minimal. Judgment is impaired. She is preoccupied with minute irrelevant details of "a conspiracy." Judgment is impaired. Her thinking is impulsive with frequent distortions and fabrications. Her attention and concentration are brief. Proverb interpretation is concrete. Intelligence is probably below average. She denies suicidal or homicidal ideations. Fund of general knowledge is fair.

MENTAL STATUS EXAMINATION: The patient appears older than her stated age, missing the majority of her teeth, is disheveled, agitated and combative. The patient makes eye contact but in a menacing fashion, is screaming and overall uncooperative with the interviewer. The patient's speech is fluent, although rate and volume are elevated and pressured. The patient did not respond to questions about mood. Her affect is agitated and combative. The patient's thought process is loose, disorganized and tangential. The patient is not willing to respond to questions concerning the presence of any auditory or visual hallucinations; although, she does appear to be responding to internal stimuli. The patient does appear to be endorsing paranoid delusions in some of her statements, particularly towards nursing staff. The patient's cognition is poor. Insight and judgment are poor.

MENTAL STATUS EXAMINATION: The patient appears her stated age. She appears somewhat unkempt and has a very poor body odor. She does not display any psychomotor agitation or abnormal movements. She makes good eye contact. She is not considered a reliable historian but was cooperative and friendly. She is alert and oriented to person, time and place. Speech was of normal volume, rate was pressured, but articulation was clear. Affect seems somewhat constricted but stable and appropriate to content. She did exhibit some flight of ideas. Content was negative for suicidality or homicidality and she did seem to have some odd beliefs of religious nature, however, it is unclear whether these are delusional. She denies experiencing any perceptual disturbances. Her judgment and insight are thought to be poor at this time.

MENTAL STATUS EXAMINATION:  The patient was casually dressed and groomed, appearing her stated age. She approached the session in a calm and cooperative fashion.  No unusual mannerisms or gestures were noted. Eye contact was good and speech was of normal tone, volume, rate and clarity. Mood appeared euthymic and was described in a similar sense by herself. Affect was appropriate. She denied any thought planning or intent towards harming herself or others in any way. Conversation was optimistic and future oriented. Stream of thought was without disorganization. Thoughts or experiences consistent with hallucinations, illusions, delusions, obsessions, compulsions or mania were denied. At no time during the session did she appear to be under the influence of any type of abnormal internal stimuli. Sensorium was alert. Cognitive functioning was intact. Thought style was inclusive of abstract ability. Intelligence as assessed by syntax, vocabulary and general interaction appeared to be in the average range. Insight appeared fair and judgment good.

MENTAL STATUS EXAMINATION: The patient presented as a casually dressed and groomed woman. She approached the session in a somewhat tense fashion, feeling irritable and ill at ease. Eye contact was good while speech was of an elevated tone and volume. No unusual mannerisms or gestures were noted. She did not have any appreciable tremor and no cogwheeling was present on exam. Mood appeared irritable. She described herself in a similar sense. Affect was restricted. She denied thought planning or intent towards harming herself or others. Stream of thought was relevant and coherent, without any type of disorganization. Thoughts or experiences consistent with obsessive-compulsive disorder were denied. However, she did describe a cyclic pattern of mood disturbance, the key features being insomnia, elevated energy, restlessness, inability to concentrate and anger. These go together and last for a week or two, then tends to resolve for several months. She indicated that Tegretol helped. Also, the patient described a history of hallucinations, beginning around age (XX), consisting of a female voice that frequently speaks to her in a degrading manner or tells her to harm people. She indicated that talking to herself sometimes works but Risperdal has helped her out the most. At no time during the session did she appear to be under the influence of mania or psychosis. Sensorium was alert and cognitive functioning was intact. Thought style was inclusive of abstract abilities. Intelligence as assessed by syntax, vocabulary and general interaction appeared to be in the average range. Insight appeared to be fair and judgment adequate.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who is well groomed and appears his stated age. There was clinical evidence of psychomotor agitation. He has difficulty maintaining eye contact and he was easily distractible. However, his speech was coherent and spontaneous with increased rate and volume. He described his mood as anxious. Objectively, his mood was anxious. His affect was sad and restricted and unable to achieve spontaneous emotional reactivity. His behavior was appropriate. His memory was intact for recent and remote events. He was well oriented to place, time and person. His concentration and attention were grossly impaired. He had difficulty doing serial 7s. His general level of intelligence and fund of general knowledge appear to be in the average side. His level of personal hygiene was good. He was able to communicate clearly and his use of language was quite sophisticated. He was able to achieve goal directed ideas without any difficulty. He denied any suicidal or homicidal ideation. His level of abstract reasoning was intact. I was able to establish adequate rapport with him throughout the interview and he was able to follow directions. He denied any ideation of worthlessness or hopelessness. He was very much preoccupied with his current symptoms and stated that if he does not get adequate help, he will snap. He has poor insight into the nature of his prior drug use and mental illness.

Mental Status Exam Examples    MSE Examples                  More Mental Status Terms    

 Psych Sample Report # 1             Psych Sample Report # 2    Psych Sample Report # 3

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Rheumatology Consult Medical Transcription Sample / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman who was scheduled yesterday to have a left knee replacement for chronic pain. She has been on Coumadin since many years, after a myocardial infarction and possible antiphospholipid antibody syndrome and was switched over to Lovenox, I believe, this past Tuesday in preparation for her knee replacement surgery. One day later, this past Wednesday, she developed gross hematuria which persisted on Thursday, and as of yesterday, she was still passing "clots." The patient has had some suprapubic pain recently as well. The patient has never had hematuria in the past.

PAST MEDICAL HISTORY:  The patient was diagnosed, I believe, in the remote past with SLE or lupus. Apparently has a false positive RPR that goes back many years. Long history of various types of chronic pain in her arms, legs, hands. No rash, no photosensitivity, some thinning of hair, mild dry eyes and mouth but no problem with moistening of her food, and she does produce tears. No history of seizure disorder, dysphagia, dyspepsia, weakness, serositis or Raynaud phenomenon. She is para 4, gravida 2, two miscarriages at 3 months. No history of any strokes or any deep venous thrombosis. She had a myocardial infarction in the past, treated with a stent. Hypertension since many years. History of panic attacks since her divorce 4 years ago. History of depression. The patient states that she had an abnormal urinalysis, possibly urinary tract infection, I believe, in the recent past and has had recurrent urinary tract infections over the years.

PAST SURGICAL HISTORY:  Hysterectomy and oophorectomy in the remote past; right knee arthroscopic surgery last year; bilateral carpal tunnel surgery 5 years ago; three D and Cs; lymph node resection in the remote past, no apparent diagnosis; tonsillectomy.

OUTPATIENT MEDICATIONS:  Coumadin since many years, as noted above, prednisone 5 mg every morning for the past 7 years, Plaquenil 200 mg one daily for the past 7 years. Flexeril as needed for leg cramps, Ambien 10 mg at bedtime as needed for sleep, Toprol 25 mg per day, Lexapro, Lipitor 10 mg per day, Xanax, Vicodin up to about 3 a day, Dilaudid for knee pain.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY:  Father deceased at 89. Mother deceased from lupus at age 67. She says that her maternal grandmother had lupus. She has two children. Daughter has fibromyalgia. The son is alive and well. She has one sister with coronary artery disease. Another sister may have lupus recently diagnosed.

SOCIAL HISTORY:  The patient is divorced.

REVIEW OF SYSTEMS:  Chronic pain in the knees, chronic myalgias and arthralgias.

PHYSICAL EXAMINATION:
GENERAL:  The patient is an afebrile, pleasant woman, in no acute distress.
VITAL SIGNS:  Stable.
HEENT:  Head normocephalic. Eyes without evidence of hemorrhages, icterus or pallor. Mouth within normal limits.
NECK:  Without masses, adenopathy or thyromegaly.
HEART:  Regular rate and rhythm without murmurs, rubs or gallops.
LUNGS:  Clear to auscultation.
ABDOMEN:  Soft without apparent masses, tenderness or organomegaly.
EXTREMITIES:  Without edema, cyanosis or clubbing. Good dorsalis pedis pulses bilaterally. Articular exam is entirely normal in the upper and lower extremities. Both knees have good range of motion. Hips normal. Gait was normal, tested at the bedside.
NEUROLOGIC:  Deep tendon reflexes +2/4 at the biceps, triceps, patella and Achilles. Excellent proximal and distal muscle strength in the upper and lower extremities.
SKIN:  Few ecchymotic areas in the subcutaneous tissue of the abdomen.

LABORATORY DATA:  The patient’s most recent CMP was reviewed. Carbon dioxide was elevated at 34, calcium was mildly low at 8.3, otherwise normal. Prothrombin time and INR were normal. PTT was minimally elevated at 34.2. Her most recent CBC was normal. Hemoglobin was 12.4 and RBC minimally reduced to 4. Most recent urinalysis showed 10-15 white cells per high power field, otherwise essentially normal. No blood reported. 

ASSESSMENT:
1.  History of systemic lupus erythematosus diagnosed a number of years ago with a history of myalgias, arthralgias, other chronic diffuse pain, false positive RPR, positive ANA by history. This was all given by the patient. Certainly, I cannot confirm the diagnosis based on this initial consultation, but she has been followed in our practice for SLE, apparently for several years now.
2.  Bilateral knee pain. Was scheduled for total knee placement on the left side.
3.  Gross hematuria while on Lovenox.
4.  History of urinary tract infections.
5.  Chronic narcotic use with the use of Vicodin and Dilaudid for her various aches and pain, in particular I believe, for her knee pain.
6.  History of possible antiphospholipid antibody syndrome with a history of myocardial infarction in the past.

RECOMMENDATIONS:  We will check urine culture and sensitivity, ANA, rheumatoid factor, anticardiolipin antibody, lupus anticoagulant. Urologic workup is pending with the urologist. I have also ordered x-rays of her knees. We will continue the patient's prednisone at 5 mg q.a.m. with food and her Plaquenil 200 mg one daily and we will check her CPK level.

Thank you for allowing me to see your patient in consultation.

Rheumatology Consult Sample Report

Metatarsal Cheilectomy / Decompressive Osteotomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left hallux rigidus.

POSTOPERATIVE DIAGNOSIS:  Left hallux rigidus.

OPERATION PERFORMED:  
1.  First metatarsal cheilectomy, left
2.  First metatarsal decompressive osteotomy, left foot.

SURGEON:  John Doe, DPM 

ANESTHESIA:  Local/MAC.

HEMOSTASIS:  Pneumatic ankle tourniquet at 250 mmHg.

ESTIMATED BLOOD LOSS:  Less than 20 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was taken to the OR and placed supine on the operating room table. After 1 gram IV Ancef and adequate IV sedation, a total of 20 mL of 0.5% Marcaine plain was injected about the first ray to achieve local anesthesia. A well-padded pneumatic ankle tourniquet was placed about the left lower extremity. The foot was then prepped and draped in the usual sterile manner. An Esmarch bandage was utilized to exsanguinate the patient's left foot and the ankle tourniquet was inflated to 250 mmHg.

Attention was then directed to the dorsomedial aspect of the first ray, where a linear longitudinal incision was made. The incision was deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were ligated and cauterized as necessary. At this time, a linear longitudinal capsular and periosteal incision was made at the first metatarsophalangeal joint. The capsule was reflected from the medial and dorsomedial aspect of the first metatarsal head. The joint was then inspected for any cartilaginous defects, which were not found. At this time, a sagittal saw was utilized to resect the prominent dorsal eminence on the first metatarsal head. At this time, the motion of the hallux was still restricted, so we decided to do an osteotomy of the first metatarsal. A through-and-through modified Watermann-Green type osteotomy was performed in the distal metaphyseal region of the first metatarsal. An approximately 1 to 2 mm slice of bone was resected from the dorsal aspect of the osteotomy to allow for some plantarflexion and shortening of the first metatarsal. The capital fragment was impacted onto the first metatarsal and a Synthes 3.0 mm headless compression screw was then inserted across the osteotomy site with excellent compression noted.

At this time, the wound was irrigated with copious amounts of sterile normal saline. The screw position was checked under fluoroscopy. The motion of the great toe was deemed adequate. The capsular structures were closed with 2-0 Vicryl suture, the subcutaneous tissues were closed with 4-0 Vicryl suture and skin with 4-0 nylon in horizontal mattress fashion. Upon completion of the procedure, the incision was dressed with Xeroform gauge and a sterile compressive dressing was applied to the left foot. The pneumatic ankle tourniquet was deflated and a prompt hyperemic response was noted to all digits of the left foot. The foot was well padded and a forefoot slipper cast was applied. The patient tolerated the procedure and anesthesia well and was transported to PACU with vital signs stable. The patient will be discharged after a brief postoperative stay with written and oral postoperative instructions.

Laparoscopic Appendectomy Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Acute appendicitis.

POSTOPERATIVE DIAGNOSIS:  Acute appendicitis.

OPERATION PERFORMED:  Laparoscopic appendectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room and laid in the supine position. Appropriate monitors were applied. The patient was intubated and general anesthesia was achieved. The patient had voided prior to entering the operating room. Incision was made at the umbilicus. Veress needle was placed and a pneumoperitoneum was established. A 5 mm bladeless trocar was placed into the abdomen. Diagnostic laparoscopy was performed. Next, a suprapubic incision was made, and a 5 mm bladeless trocar was placed into the abdomen under laparoscopic visualization. Then, the laparoscope was placed into this port site and the umbilical port site was replaced with a 12 mm bladeless trocar. An additional 5 mm bladeless trocar was placed in the left lower quadrant area. The patient was placed in Trendelenburg. Diagnostic laparoscopy was performed. There were no abnormalities noted except for acute appendicitis. There was no evidence of perforation. The appendix was densely adhered to the sidewall and these adhesions were taken down under direct visualization, lifting the appendix up in the air and then incising the peritoneum with laparoscopic scissors and then bluntly reflecting the appendix away from this area. Great care was taken not to dissect in the retroperitoneal area. This was done to free up the appendix up to the area of the cecum. The terminal ileum, which was adherent to the mesoappendix, was also incised and freed up. 

With the appendix able to be visualized, it was grasped and lifted up in the air with a soft bowel grasper and then a window was made in the mesoappendix just adjacent to the appendix with its junction with the cecum. Once this area was cleared off, it was then divided using an endoscopic 45 mm linear stapler. A white cartridge was used for this portion. The stapler was clamped down and left in place for approximately 30 seconds and then the bowel was divided. The mesoappendix was opened up further by incising the peritoneum. A window was made in the mesoappendix and it was divided using gray cartridges for the division. During this division, there was some bleeding from the staple line, which required electrocautery and also hemoclips. This area was irrigated thoroughly and inspected. All the staple lines were inspected. There was no active bleeding noted upon completion of this portion of the operation.

Next, the appendix was placed in an EndoCatch bag and brought out through the umbilical site. The colon closure device was then used to pass an 0 Vicryl suture to close this fascial defect. The trocars were replaced and the area again inspected and irrigated. There was no active bleeding noted from the staple lines. The excess irrigation was aspirated. Diagnostic laparoscopy was performed. There was no active bleeding noted, and there was no abnormal fluid collection noted. Next, the port sites were all infiltrated with 0.5% Marcaine with epinephrine. Approximately 20 mL of 0.5% Marcaine with epinephrine was utilized.  Pneumoperitoneum was released and the fascial suture was tied down and the skin was closed using 4-0 Vicryl in subcuticular fashion. Steri-Strips were applied and sterile dressing. The patient tolerated the procedure well without any complications. Estimated blood loss was approximately 30 mL. All the sponge counts were correct x2. The patient was taken to the recovery room in stable condition.



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