Bilateral Upper Lid Blepharoplasty Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Brow ptosis with asymmetry.
2. Bilateral upper lid blepharochalasis.
3. Bilateral lower lid blepharochalasis.
4. Submental lipodystrophy.

POSTOPERATIVE DIAGNOSES:
1. Brow ptosis with asymmetry.
2. Bilateral upper lid blepharochalasis.
3. Bilateral lower lid blepharochalasis.
4. Submental lipodystrophy.

OPERATIONS PERFORMED:
1. Right transblepharoplasty Endotine browlift.
2. Bilateral upper lid blepharoplasty.
3. Bilateral lower lid transconjunctival blepharoplasty.
4. Submental liposculpturing.

SURGEON:  John Doe, MD

ANESTHESIA:  General plus supplemental 1% lidocaine with adrenaline.

DESCRIPTION OF OPERATION:  With the patient positioned in the supine position on the operating room table, satisfactory level of general anesthesia was obtained. Attention was turned to place Thromboguards in lower extremities and pillows behind the knee. The face and neck were prepped with Betadine gel and draped in the sterile manner after instillation of Lacri-Lube ointment, both eyes. Attention was then turned to injection of the brow bilaterally with 1% lidocaine with 1:100,000 adrenaline as well as subperiosteal area of the forehead. Once this was completed, attention was turned to marking the upper eyelids and injecting 1% lidocaine with epinephrine and then a transconjunctival injection of 1% lidocaine with adrenaline was placed in both sides.

Attention was then turned to the right upper eyelid where a crease incision was made, carried down through the subcutaneous tissue. Superior dissection was then carried up to the level of the superior orbital rim. Attention was turned to scoring periosteum along the orbital rim, above the orbital fat pad, and once this was completed, attention was turned to elevating periosteum up to the upper third of the forehead using a Freer elevator. After this was completed, attention was turned to the drilling of Endotine hole 4 mm above the inferior aspect of the orbital rim. After this was completed, a 3 mm Endotine device was placed. Periosteum was suspended over the top of the Endotine and secured. After this was completed, attention was turned to opening the orbital septum. Medial and middle fat compartments were evacuated of excessive fatty tissue and attention was then turned to hemostasis. Closure was performed with subcuticular running 5-0 Prolene. Attention was then turned to the left upper eyelid where crease incision was made. Skin strip was removed. Orbicularis muscle strip was removed. The orbital septum was opened and excessive fatty tissue was resected and hemostasis was obtained.

No Endotine device was placed on the left side due to the fact that the left brow was higher than the right to begin with and attention was then turned to closure of the upper eyelid with 5-0 subcuticular Prolene. The brow was then taped superiorly with half-inch Steri-Strips in the right side and secured with transverse Steri-Strips above the level of the brow bilaterally. After this was completed, the attention was then turned to the lower eyelid. Starting on the right side, a transconjunctival incision was made with the Colorado-tip Bovie. Traction suture, 6-0 silk, was placed on the superior conjunctival flap. Oblique dissection was carried towards the orbital rim until the fat compartments were opened. The medial, middle, and lateral fat compartments were evacuated of excessive fatty tissue and hemostasis was obtained. Closure of the conjunctiva was now done with interrupted buried 6-0 rapidly absorbing gut.

Attention was then turned to the left lower eyelid where the exact same procedure was performed without complications. After this was completed, the eyes were irrigated with balanced salt solution, two drops of tetracaine were placed in each eye, and Polysporin ophthalmic ointment was placed. Attention was turned to placing 1% lidocaine with 1:100,000 adrenaline in the previously marked areas of the neck. After adequate hemostasis was obtained, cross-tunneling liposculpturing was performed using decreasing caliber Klein cannulas until adequate contour in submental regions was performed. All areas expressed excessive fluid. Closure was performed with 5-0 nylon and a compression facial garment was applied after cleansing the face, removing all Betadine paint. The patient tolerated the procedure well. Ice compressors applied to the eyes. The patient was transferred to the recovery room in excellent condition.

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General Surgery Consultation Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION:  Evaluation of ileostomy protrusion above the level of the skin.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who came to the hospital with complaint of left-sided pain, left-sided upper extremity and chest pain, and weakness.  This patient underwent emergency operation of the abdomen a couple of months back.  The patient had presented with small bowel obstruction and upon exploration was found to have tumor involving the right colon, causing intestinal obstruction.  Upon reviewing the record, it appeared that the patient had right hemicolectomy with ileostomy.  Pathology report of the tumor was consistent with grade 2 adenocarcinoma of the colon.  Four lymph nodes were identified and were found to be free of tumor.  Surgical evaluation of this patient was called because family has noted that ileostomy protrudes above the level of the skin and comes out several inches beyond the level of the skin.  The patient currently has symptom of nausea but denies any vomiting.  No abdominal distention or abdominal cramps.

PAST MEDICAL HISTORY:  Significant for gastroesophageal reflux disease and colon cancer.

PAST SURGICAL HISTORY:  Significant for exploratory laparotomy and right hemicolectomy.

MEDICATIONS:  Zantac, Nexium, Paxil and Xanax.

ALLERGIES:  PENICILLIN.

SOCIAL HISTORY:  No history of substance abuse.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6 degrees, pulse 88, respirations 22, O2 saturation 98% on room air and blood pressure 122/64.
ABDOMEN:  Abdomen was completely soft, nontender and nondistended.  Right lower quadrant region of the abdomen was found to contain ileostomy, which was pink and viable.  There was no evidence of parastomal hernia or abnormal protrusion of the mucosa.  There was significant amount of air and stool in the colostomy bag.  No evidence of obstruction.

LABORATORY DATA:  CBC showed white cell count of 4.7, hemoglobin of 9.8, hematocrit of 29.4 and platelet count of 248,000.  BMP showed sodium 142, potassium 3.6, chloride 111, CO2 of 22, glucose 102, BUN 14, creatinine 0.7 and calcium 8.9.  Urinalysis showed 0 to 4 red cells, 0 to 4 white cells, 0 to 4 squamous cells and 1+ bacteria.

RADIOLOGICAL DATA:  CT of the brain showed a subtle area of low attenuation, right parietal lobe, probably consistent with volume averaging.  The possibility of edema or ischemia cannot be excluded.  Portable chest x-ray showed that the heart is at the upper limit of normal in size with bilateral apical pleural thickening and some degenerative changes of the thoracic spine, bilateral shoulders.  Two views of the shoulder were obtained on the left side and showed degenerative changes involving the left shoulder with elevation of the left humeral head that could be consistent with rotator cuff injury.  Lung scan performed showed low probability of air trapping.  MR angiography of the neck was done and showed no evidence of carotid bifurcation disease or stenosis, patent left and right vertebral arteries, poorly visualized left vertebral artery origin stenosis cannot be completely excluded.  MR angiography of the head performed showed a 2.5 mm left posterior communicating artery infundibulum.  MR of the brain performed showed age-appropriate involutional changes, scattered nonspecific foci of increased signal throughout the white matter of both cerebral hemispheres and the posterior pons.  Given the patient's age, finding likely represents the sequelae of chronic microvascular ischemic disease.  No acute infarct demonstrated and minimal sphenoid sinus disease.

ASSESSMENT AND PLAN:
1.  This is a (XX)-year-old female with history of colon cancer who does not have any evidence of intestinal obstruction, parastomal hernia or stomal necrosis.  Based on the history, this patient has not had detailed workup done for her colonic cancer.  The patient needs to be evaluated by a hematologist/oncologist.
2.  CEA level should be obtained.
3.  A CT scan of the abdomen and pelvis should be performed to rule out the possibility of metastatic disease and consultation with GI should be obtained.  I see that Dr. John Doe from GI has already been involved.  Besides, this patient is extremely weak and weighs only about 70 pounds.  Her nutritional status requires aggressive support.  The patient may get benefit with milkshakes of Ensure if her oral intake is not good.

Family has discussed the possibility of reversal of colostomy.  I have counseled the patient and the family to focus on evaluation of the patient by an oncologist first and perform detailed cancer workup and support her nutritional status so that the patient can gain weight first.  Once the patient's clinical condition improves and she gains more weight, then possibility of ileostomy reversal can be considered.  At this point, there is no acute surgical emergency that requires me to offer immediate surgical intervention.

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

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Repair of Peroneal Brevis Tendon Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

OPERATION PERFORMED:  Repair of peroneal brevis tendon, left ankle.

DESCRIPTION OF OPERATION:  The patient was brought from the short-stay unit to the operating room and placed on the operating room table in the supine position. At this time, the patient's left lower extremity was elevated 60 degrees above the horizontal plane. Pneumatic thigh tourniquet was then placed. Following successful intubation, the patient's left lower extremity was scrubbed, prepped, and draped. At this time, the patient was returned to the lateral position. An Esmarch bandage was then utilized to exsanguinate the patient's left lower extremity. A pneumatic thigh tourniquet was then inflated to 350 mmHg.

At this time, attention was directed towards the patient's left lateral ankle at the malleolar region, where a 7 cm hockey stick incision was then created just to pursue the patient's lateral malleolus along the course of the peroneal tendons. The incision was then deepened down through the layers of subcutaneous tissue using sharp and blunt dissection and all venous tributaries were isolated and electrocauterized as encountered. All the vital neurovascular structures were generally retracted in the medial and lateral fashion as well. Dissection continued down through the layers and the deep tissues. Peroneal retinaculum was identified and was incised appropriately. At this time, the tendon sheath of the peroneal brevis and longus tendons were identified and the tendons were palpated as proximally and as far as the incisions would allow. The tendon sheath was then incised in the longitudinal fashion along the course of the tendon, as far as the incision would allow.

At this time, it should be noted that sural nerve was identified and was retracted out of the incision site appropriately. As the incision continued, the peroneus brevis and longus tendons were identified accordingly. The peroneus brevis tendon course was followed inframalleolar where 5 cm multiple linear longitudinal tears were noted. The region of the tendon was isolated and all fibrotic and nonviable tendon was debrided. Inspection of the tendon continued distally. The peroneus brevis was isolated and tubularized utilizing 3-0 FiberWire in a continuous running suture fashion. At this time, the proximal aspect of peroneus brevis and peroneus longus tendon were inspected as far as the incision would allow and was noted to be intact, white, and glistening in appearance. It should be noted at the area of longitudinal tendon, there was a tourniquet of fibrous tissue around the peroneus brevis tendon, which needed to be incised to allow for tendon release. The wound was then flushed with copious amounts of normal saline, which had been done periodically throughout the procedure.

Attention now was directed toward closure of the incision site, which consisted of 3-0 Vicryl in simple interlocking running suture technique for closure of the deep tissues including peroneal tendon sheath and peroneal retinaculum. A 4-0 Vicryl was then used for subcutaneous stitch and the skin was then closed utilizing skin staples with the skin being everted in a 60-degree manner before the skin staple was applied. The left lower extremity was then dressed with a Jones compressive dressing with added posterior splint for stabilization. The foot was splinted in mildly plantarflexed and everted position to release any excess force on the peroneal tendon for further healing. The Jones compressive dressing consisted of alternating Webril and Ace bandages x3 layers after sterile dressings were applied to the left lower extremity consisting of 4 x 4s, 4 x 8s, 2-inch Kling, and Kerlix.

The patient tolerated the procedure and anesthesia well with successful extubation without complications, and the patient was then transported from the operating room to the recovery room with vital signs stable, vascular status intact to all aspects of patient's left lower extremity.

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Ob-Gyn Medical Transcription Operative Procedure Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Symptomatic leiomyomatous uterus.

POSTOPERATIVE DIAGNOSES:
1.  Symptomatic leiomyomatous uterus.
2.  Pelvic endometriosis.
3.  Dense right adnexal adhesions.

OPERATIONS PERFORMED:
1.  Laparoscopic-assisted vaginal hysterectomy with right salpingo-oophorectomy.
2.  Lysis of adhesions.
3.  Ablation of pelvic endometriosis.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

ANESTHESIOLOGIST:  Jane Doe, MD

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  150 mL.

DRAINS:  Foley catheter to bladder.

SPECIMENS:  Cervix, uterus and fibroids, morcellated, right fallopian tube and ovary.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite in stable condition. Informed consent had been obtained. Risks have been outlined. The patient was aware of the risks of surgery including but not limited to stroke, embolus, phlebitis, pain, infection, hemorrhage, heart, lung, and anesthesia complications as well as injury to the internal organs such as the bowel, bladder, blood vessels, nerves, kidneys, ureters and pelvic organs. She was aware she could form adhesions postoperatively, which could result in chronic pain or even obstruction of loop of bowel or a ureter. The patient had received intravenous prophylactic antibiotics. She is aware of the options to the surgical procedure. She was aware this is a permanent sterilizing procedure. She had antiembolic stockings and pneumatics in place in the lower extremities.

The patient was placed under general endotracheal anesthesia and positioned in the modified lithotomy position in adjustable Allen stirrups. The abdomen, perineum and vagina were prepped and draped in standard fashion for the laparoscopic-assisted vaginal hysterectomy. An indwelling catheter was placed in the bladder. Pelvic examination was performed which revealed a retroverted, irregular, mobile uterus, size of an 8- to 10-week gestation, consistent with fibroids. Sponge stick was placed into the posterior vaginal fornix for manipulation purposes. This was found to be adequate and we really had to utilize the sponge stick and certainly did not require placing a more traumatic elevator.  After infiltration of the area with Marcaine and epinephrine solution, incision was made in the navel through which the Veress needle was placed with care into the peritoneal cavity.  After saline drop test, a pneumoperitoneum was created with 1.9 liters of carbon dioxide with normal filling pressures to 7 to 8 mmHg. The needle was then withdrawn. A 5 mm clear bladeless laparoscopic trocar sleeve with laparoscope inserter was then advanced under direct visualization with video camera assistance through the umbilical incision into the abdominal cavity, after elevation of the anterior abdominal wall. The laparoscope was advanced and inspection was commenced. Two right and left suprapubic incisions were made well medial to the epigastric vessels, in a hemostatic fashion, again after infiltration of the regions with the Marcaine and epinephrine solution, two additional blunt 5 mm laparoscopic trocar sleeves were passed under direct intraperitoneal visualization with the laparoscope. Blunt grasping forceps and the 5 mm ACE curved shears attached to the Harmonic scalpel were passed through the lower ports initially. Inspection was performed with the findings as noted above. Representative photographs were obtained.

Attention was turned initially to proceeding with adhesiolysis. The mild left adhesions were lysed with Harmonic scalpel. Care was taken to proceed with a more careful adhesiolysis procedure involving the right tube and ovary. Right ovary was teased off the pelvic sidewall where it was adhered primarily in a blunt fashion. Implants of endometriosis were coagulated with the Harmonic scalpel. There were some raw surfaces left on the sidewall, but this seemed to be in the region of the ureter; therefore, we did not proceed with an extensive dissection and removal of this region. Carefully, at the end of the procedure, this area was reinspected and was noted to be hemostatic. There were no obviously visible implants of endometriosis remaining at the end of the procedure. At this point, tube and ovary had freed up and attention was turned to performing the laparoscopic portion of the surgical procedure. Initially, the right uterine pedicles were taken. The tube and ovary were retracted medially and the ovarian vessel pedicle was carefully grasped, coagulated and transected. The dissection was then carried across the upper broad ligament tissues, round ligament and lower broad ligament tissues. The leaves of the broad ligament were bluntly separated at the site of the lower uterine segment. An incision was made anteriorly to the peritoneum and the vesicouterine fold. The bladder was then bluntly dissected down towards the cervix. Hydrodissection with a suction irrigator was utilized as well. The ascending branches of the uterine artery were identified. These were carefully coagulated with the Harmonic scalpel along with bipolar cautery forceps. Inspection at this point revealed excellent hemostasis except for some back bleeding coming from the right ovary. This was controlled with Harmonic scalpel and bipolar cautery forceps. A suction irrigator was passed to irrigate the operative area and aspirate out the bloody fluid.

Attention was turned to the left uterine pedicles. The dissection was carried initially across to the utero-ovarian ligament and vessels so that the ovary was conserved. Dissection again was performed with the Harmonic scalpel. The proximal fallopian tube was then taken followed by the round ligament and broad ligament tissues. Again, the ascending branches of the uterine artery were identified, skeletonized, grasped and coagulated with the Harmonic scalpel and also with bipolar cautery forceps. At this point, the pneumoperitoneum was released and inspection was performed to assure hemostasis of all pedicles prior to turning vaginally. Some clear fluid was left in the pelvis. A Deaver retractor and weighted speculum were placed into the vagina. The cervix was grasped with a Jacobs clamp. The mucosa of the cervicovaginal junction was then injected circumferentially with the Marcaine and epinephrine solution. With curved Mayo scissors, an incision was made through the midline, posterior vaginal mucosa, peritoneum and the posterior cul-de-sac. The weighted speculum with a long narrow blade was then repositioned into the peritoneal cavity. With the scalpel, incision was made anteriorly from the mucosa to the cervicovaginal junction. With blunt and sharp dissection, the bladder was dissected off the cervix. The anterior cul-de-sac was ultimately reached and a Deaver retractor was placed to gently elevate the bladder anteriorly. Curved Z-clamps were utilized to take the remaining pedicles. Initially, the uterosacral and cardinal ligament complex was clamped, transected, Heaney suture-ligated with 0 Vicryl sutures and then tagged. The uterine vessels were clamped, transected and suture-ligated with 0 Vicryl sutures. Broad ligament tissue was grasped, clamped, transected and suture-ligated.

Once the uterus had been totally freed up by inspection and digital examination, attention was turned to removal. The uterus was too large to be removed intact. Therefore, a careful morcellation procedure was performed by pouring out central portions including the cervix and mid-fundal region. Some fibroids also were isolated and removed. A combination of sharp dissection with the scalpel and Jorgenson scissors was utilized. Ultimately, the specimen was delivered through the vagina and handed off the operative field. Inspection of all pedicles was performed at this point to assure hemostasis. Some oozing around the right uterine artery was controlled with further 0 Vicryl sutures. Inspection was performed at this point to assure hemostasis. After inspecting for several minutes, attention was turned to closure of the peritoneum and the pelvic floor. Prior to this, clots and blood were evacuated from the pelvis with a sponge stick. A pursestring suture of 0 Vicryl was placed to close the peritoneum and the pelvic floor. The uterosacral and cardinal ligaments were then anchored to the apices of the vagina with intraoperative figure-of-eight sutures of 0 Vicryl. The pubocervical and rectovaginal fascias at the vaginal apex were reapproximated with several 0 Vicryl sutures. The vaginal mucosa was then closed with 0 Vicryl sutures. Inspection of the vaginal cuff for several minutes was performed and excellent hemostasis was noted. A sponge stick was placed.

The laparoscope was reinserted and a pneumoperitoneum was re-created. The bipolar cautery forceps and suction irrigator were passed and inspection of the pelvis was performed. Peritoneal lavage was performed. All bloody fluid and clots were evacuated from the peritoneal cavity. Couple of small oozing points were controlled with bipolar electrocautery. The pneumoperitoneum was released at this point for several minutes under minimal pressures. The pedicles and the pelvis were carefully inspected to assure hemostasis. Excellent hemostasis was noted. We had also carefully inspected to assure there were no remaining visible implants of endometriosis that required ablation. At the end of the procedure, approximately 50 mL of clear irrigation fluid was left in the pelvis. The laparoscopic instruments were removed. The three incisions were closed with 4-0 Vicryl deep and subcuticular skin sutures followed by Steri-Strips. The patient was awakened, extubated and returned to the recovery room in stable condition. The instrument, sponge and needle counts were reported as correct. Estimated blood loss was 150 mL. There were no complications.

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Rhytidectomy, Brow Lift, Blepharoplasty MT Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Aging face.

POSTOPERATIVE DIAGNOSIS:  Aging face.

OPERATIONS PERFORMED:  Rhytidectomy, endoscopic brow lift, upper lid blepharoplasty, lower lid blepharoplasty and periorbital fat transfer. 

SURGEON:  John Doe, MD 

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  Negligible.

FLUIDS:  Crystalloids.

COMPLICATIONS:  None.  

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position.  SCDs were in place and functioning prior to the induction of general endotracheal anesthesia.  A Foley catheter was inserted.  Lacri-Lube was placed in the eyes and the patient's head and neck prepped and draped in the usual sterile fashion.  Lidocaine 1% with 1:100,000 epinephrine was injected into the scalp incisions that were used for an endoscopic brow lift.  The lateral vectors of the pole had an incision placed at the apex in the scalp.  Two paramedian incisions were placed in the scalp on either side of the midline.  A 15 blade was used to make the incision followed by dissection of the subperiosteal plane.  Dissection was performed to the orbital rim where the periosteum was incised lateral to the supraorbital neurovascular bundle bilaterally.  Medially, the patient's periosteum was incised with the corrugator muscle group partially excised.  Z retractor was placed with the forehead advanced in the superolateral direction with the 2 x 8 mm endoscopic screw placed through the outer cortex and a 2-0 PDS placed through the composite flap to the microscrew.  This was performed bilaterally.  The incisions were then closed with a stapling device.

Attention was then turned next to the face.  An incision was made along the temporal hairline, along the sideburn, along the root of the helix in the post-tragal area, along the lobule, along the postauricular sulcus.  The skin was elevated with the help of transillumination, blepharoplasty scissors.  After the skin was elevated in a limited fashion, an SMAS flap was then designed along the body and arch of the zygoma and then inferiorly beyond the angle of the mandible.  The SMAS flap was elevated from lateral to medial and from superior to inferior with the dissection performed to the zygomaticus major muscle across the masseteric cutaneous ligaments and inferior to the angle of the mandible.  The SMAS was doubled over at the lateralmost section and advanced in a superolateral direction and affixed the superficial layer of the deep temporal fascia with 3-0 Surgilon.  The platysma was advanced to the mastoid using a 3-0 Surgilon.  Further inset was performed along the arch, body of the zygoma and on the neck.  Irrigation was performed followed by meticulous hemostasis.  The above was then repeated on the opposite side of the face.

Suction-assisted lipectomy was performed in the submental region with a submental incision then performed and dissection performed to the cricoid cartilage.  The medial borders of the SMAS were advanced to the midline with a plication performed with a buried 3-0 Surgilon.  A back cut was performed at the cricoid cartilage.  The flaps were then evaluated with the skin advanced in the superolateral direction and a pilot cut performed with a 3-0 Surgilon placed at the apex of the helix.  A 7-French JP drain was placed in the subcutaneous plane followed by another cardinal stitch placed in the postauricular sulcus with 3-0 nylon.  The redundant skin was excised.  The preauricular skin was closed with a running 6-0 Prolene followed by the postauricular skin closed with an interrupted 5-0 Prolene followed by defatting of the tragal flap and inset over a de-epithelialized tragus with fast-absorbing gut.  The postauricular sulcus was closed with 5-0 Prolene.  The above was then repeated on the opposite side of the face.  The submental region was then closed with running 6-0 Prolene.

Attention was then turned to the eyes.  A very conservative upper lid skin excision was performed with greater skin excised from the right than the left.  Injection was performed with 1% lidocaine with 1:100,000 epinephrine.  The pattern of skin excision had previously been planned with the patient awake and alert in the holding area with the amount of skin estimated.  A 15 blade was used to make a skin-only excision.  The orbicularis and septum were perforated nasally with a modest amount of the central fat pad excised.  The upper lid was then closed with a running 5-0 Prolene.  The above was then repeated on the opposite eye.  Corneal protectors and Lacri-Lube were placed.  Lidocaine 1% with 1:100,000 epinephrine was injected along the potential subciliary incision.  A 15 blade was used to make the incision followed by enlarging the incision using blepharoplasty scissors.  The skin-only dissection was performed to the junction of the pretarsal and preseptal orbicularis where a submuscular plane of dissection was then obtained.  The arcus marginalis was incised using electrocautery along the inferior orbital rim.  A modest amount of fat was excised from the medial, central and lateral fat pads using electrocautery.  A preseptal orbicularis flap was created, which was then affixed to the lateral orbital rim using a 4-0 Monocryl.  The redundant skin was excised.  Closure was performed with a 6-0 fast-absorbing gut.  The above was then repeated on the opposite side.  The corneal protectors were removed with excellent size, shape and symmetry of her lids demonstrated.  The eyes were irrigated with BSS followed by placement of Blephamide.

The fat was then harvested from the patient's flanks using a Coleman fat harvesting needle.  This was placed in 3 mL syringes and spun in a centrifuge.  Lidocaine with epinephrine was placed along the nasolabial creases, the prejowl hollow and into the white roll of the lips.  The spun fat was decanted of supernatant and then injected using a Coleman injecting needle in the nasolabial creases, the prejowl hollow and the white roll of the lips.  The head and neck were cleansed.  Polysporin and Xeroform were placed.  The patient was then placed in a head wrap.  All sponge and needle counts were correct x2.  The patient was then transferred to the postoperative recovery room in stable condition.

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Renal Consultation Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Abnormal renal function.

HISTORY OF PRESENT ILLNESS:  The patient is an (XX)-year-old female who was admitted to the hospital after presenting with respiratory distress, ultimately requiring intubation because of a combination of x-ray findings suggestive of both airspace disease as well as congestive heart failure, and the patient was treated for both congestive heart failure and pneumonia.  In this setting, the patient had an element of abnormal renal function with creatinine going as high as 2.9.  It was already abnormal on admission in the low 2s.  The patient also now has been noted to have new onset of hyponatremia with a sodium of 130.  Because of these abnormalities, I was asked to see this patient in consultation.  The patient has a longstanding history of hypertension but was unable to state the exact duration.  She denies any history of diabetes mellitus.  She denied any nausea or vomiting, any diarrhea, no melena, no difficulty urinating, no presence of blood in the urine and no history of recurring urinary tract infection or pyelonephritis.

PAST MEDICAL HISTORY:  As stated in the HPI.  She also has COPD secondary to history of tobacco use, hypothyroidism, coronary artery disease with prior history of MI, hypertension, depression and did have some element of chronic renal insufficiency which she is aware of.

PAST SURGICAL HISTORY:  Appendectomy.

OUTPATIENT MEDICATIONS:  Lexapro 10 mg once a day, Plavix 75 mg daily, Lipitor 20 mg daily, aspirin 81 mg daily, Coreg 6.25 mg daily, Isordil 10 mg p.o. 2 times a day, Lasix 10 mg p.o. 2 times a day and Synthroid 150 mcg p.o. once a day.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY:  Not significant for renal disease.

SOCIAL HISTORY:  The patient had chronic tobacco use in the past, but has since discontinued.  No alcohol abuse.

REVIEW OF SYSTEMS:

NEUROLOGIC:  The patient denied any prior history of epilepsy or stroke.

PULMONARY:  She has COPD and emphysema.  She did not have any hemoptysis as stated in the HPI.

CARDIOVASCULAR:  She did not have any recent chest pain, palpitation or leg edema.

GASTROINTESTINAL:  She has a history of hemorrhoids, but no recent vomiting blood or blood in the stools.

GENITOURINARY:  Normally no pain urinating.  No presence of blood in the urine.

MUSCULOSKELETAL:  She has arthritis, particularly on the knees and shoulders, but no chronic use of nonsteroidal anti-inflammatory drugs.

PSYCHIATRIC:  No overt history of depression.

HEMATOLOGIC: No overt bleeding complications.

DERMATOLOGIC:  No skin cancer.

ENDOCRINE:  She has thyroid disease.  No overt diabetes mellitus.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 114/48, heart rate 72 beats per minute and respirations 20 per minute.  She is extubated at this time.  Temperature 97.8.

GENERAL:  The patient is alert and oriented x3 and has adequate insight into her current condition.  She does have some poor memory recall.

HEENT:  Normocephalic.  Pupils are reactive to light and accommodation.  Extraocular movements are grossly intact. Somewhat pale conjunctivae.  Anicteric.  Oral cavity shows no lesions of the hard or soft palate.  Adequate moisture in the mucosa.

NECK:  Supple with full range of motion.  No JVD.  Trachea is midline.  No obvious palpable neck masses.

LUNGS:  Fairly clear to auscultation at this time.  There is some increased percussion and no obvious retractions.

HEART:  Regular in rate and rhythm.  S1 and S2.  No obvious murmur, rub or gallop auscultated at this time.  PMI slightly displaced from midclavicular line.

ABDOMEN:  Bowel sounds are present, soft and depressible.  Nontender and nondistended.  No obvious palpable masses.  No obvious abdominal bruits auscultated.  No hepatosplenomegaly.

EXTREMITIES:  No clubbing, cyanosis or edema.  No obvious hemorrhage of the nails.

SKIN:  There is some ecchymosis, but no active rash or lesions.

NEUROLOGIC:  Grossly nonfocal.  Moves all the extremities.

LABORATORY AND DIAGNOSTIC DATA:  As previously described.  Today, sodium is 130, potassium 4.6, chloride 96, CO2 of 22, BUN 74, creatinine 2.4, calcium 7.6, white count of 16.6, hemoglobin 9.6, hematocrit of 30.8 and platelet count 260,000.

Chest x-ray was reviewed and it showed some improvement of mixed airspace and interstitial infiltrate in both lungs suggestive of improving edema, probable small left pleural effusion.  EKG on admission was reviewed, compatible with atrial fibrillation, left ventricular hypertrophy and ST abnormalities.  Currently, on telemetry, she has sinus rhythm.

IMPRESSION:

1.  Acute on chronic renal failure.

2.  Congestive heart failure exacerbation.

3.  Chronic obstructive pulmonary disease.

4.  Pneumonia.

5.  Hyponatremia.

6.  Hypertension.

The patient is an (XX)-year-old female with the above-stated medical history who likely has an element of chronic renal disease on the basis of age-related chronic renal function, hypertensive nephrosclerosis and increased risk of renal atherosclerotic vessel disease, who now developed an acute exacerbation on the basis of adverse changes in renal hemodynamics.  The patient does have a significant elevation of BUN in relation to the creatinine, which is due to the diuretics the patient received, as well as the intravenous steroids she is receiving for treatment of the COPD exacerbation component.  The hyponatremia is on the basis of infusion of hypotonic fluids, as the patient is receiving D5 half-normal saline at this time.

PLAN:

1.  The patient stated she has had a previous renal ultrasound within the last 6 months.  We will request a copy of that renal ultrasound, as well as we will request all records related to previous hospitalizations and office records to ascertain what her baseline renal function is.

2.  We will obtain baseline 24-hour collection for total protein and creatinine clearance at this time.

3.  Given that the patient now has oral intake, I will discontinue IV fluids.

4.  Continue intravenous Lasix.

5.  Defer on a renal scan at this time.

6.  Taper down steroids as possible.

7.  Obtain urinalysis to assess for active urinary sediment.  We will not do urine electrolytes at this time as the patient is currently on diuretics.

8.  Further recommendations will depend on the patient's clinical course.

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

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Cardiovascular Consultation Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Questionable syncope and atrial fibrillation with rapid ventricular response.

HISTORY OF PRESENT ILLNESS:  The patient is an (XX)-year-old female with a history of coronary artery disease with non-Q-wave myocardial infarction, angioplasty, stent delivery to the LAD and reduced ejection fraction of 40%, recently been evaluated at 60% with Coreg therapy.  She is in a rehabilitation center after a hospitalization in July, when she was found down on the floor by nursing staff.  When I interviewed the patient, she has some mild confusion; however, she does adamantly state that she did not pass out.  She denies any dizziness, palpitations, chest pain or shortness of breath prior to this falling episode.  She states that she was attempting to get out of bed to use the rest room when she fell down.  She was found by the nursing staff immediately and they called EMS for transportation to an outside hospital for further evaluation and treatment.

PAST MEDICAL HISTORY:  Coronary artery disease status post non-Q-wave myocardial infarction, angioplasty and stent delivery to the mid LAD.  Cardiac catheterization in July revealed a patent stent and nonobstructive epicardial coronary artery disease, otherwise.  Mild ventricular systolic dysfunction was noted with an EF of 40%.  Mildly elevated right-sided pressures with moderate to severe pulmonary hypertension.  Echocardiogram in July revealed an ejection fraction of 60% with mild concentric left ventricular hypertrophy and moderate pulmonary hypertension.  Past medical history is also significant for pneumonia, methicillin-resistant Staphylococcus aureus, urinary tract infection, severe COPD which is end stage, pulmonary fibrosis, congestive heart failure in the past, diabetes mellitus, atrial fibrillation, dysphagia, hypertension, hypothyroidism, hyperlipidemia and osteoporosis with status post vertebroplasty.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient denies tobacco, alcohol or illicit drug use.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

MEDICATIONS:  MAR reveals aspirin 81 mg p.o. daily, Combivent MDI inhaler 2 puffs every 6 hours, Cozaar 25 mg p.o. daily, Prozac 20 mg p.o. daily, Lasix 80 mg p.o. daily, Lipitor 10 mg p.o. at bedtime, magnesium oxide 400 mg p.o. daily, Nitro-Dur patch 0.3 mg per hour, Os-Cal 500 plus D daily; Pacerone 200 mg p.o. daily, Plavix 75 mg p.o. daily, potassium chloride supplementation at 10 mEq 4 tablets p.o. 3 times a day, prednisone 10 mg p.o. daily, protein powder with meals twice a day, Protonix 40 mg p.o. daily, Synthroid 137 mcg p.o. daily, Tiazac ER 120 mg p.o. at bedtime and 300 mg p.o. every morning, Xopenex nebulizer every 12 hours, and Novolin insulin per sliding scale coverage.

REVIEW OF SYSTEMS:  See HPI for details.

PHYSICAL EXAMINATION:
GENERAL:  This is an (XX)-year-old female lying supine with the head of bed up to 30 degrees, in very minimal respiratory distress.  The patient states that this breathing pattern is normal for her, and from what I can recall from a previous hospitalization, she is right.
VITAL SIGNS:  Blood pressure in the emergency department 114/74, heart rate 116, respirations 22 and temperature 97.6.
HEENT:  Normocephalic and atraumatic.  Pupils equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae anicteric.
NECK:  Reveals a midline trachea.  No JVD or bruit.
LUNGS:  Reveal inspiratory crackles only.  No expiratory crackles in the upper fields and significantly diminished in the left lower lobe.  Very minimal scattered rhonchi in the right lower lobe.
HEART:  S1, S2, irregularly irregular rhythm.  No S3, S4, click, murmurs or rubs appreciated.
ABDOMEN:  Flat, soft, nontender, and nondistended.  Bowel sounds are active x4.
EXTREMITIES:  No clubbing or cyanosis.  Trace 1+ pitting pedal edema is noted.
NEUROLOGIC:  The patient is alert and oriented x3; however, mildly confused.  Feels that she fell 3 days ago, when actually she fell this morning at approximately 3 a.m.  Husband is at the bedside, who states that she has been somewhat confused over the previous week or so.

DIAGNOSTIC DATA:  EKG done in October reveals a supraventricular tachycardia with an irregular narrow complex, ventricular response, could be atrial fibrillation versus multifocal atrial tachycardia due to 3 P waves being present and differing in morphology.  No significant ST or T-wave changes.  Followup EKG in November revealed once again a supraventricular tachycardia with poor R-wave progression.  Once again, poor R-wave progression is noted in the anteroseptal leads; however, this could be lung disease pattern.  Once again, nonspecific ST and T-wave changes.

IMPRESSION:
1.  Status post mechanical fall with subsequent left humerus fracture, left humeral neck fracture and left facial ecchymosis.
2.  Atrial fibrillation with rapid ventricular response.
3.  Coronary artery disease status post non-Q-wave myocardial infarction.
4.  Angioplasty with stent delivery with catheterization in July revealing a patent stent and mild nonobstructive coronary artery disease, otherwise.
5.  Probable pneumonia.
6.  Methicillin-resistant Staphylococcus aureus urinary tract infection.
7.  Pulmonary fibrosis.
8.  End-stage chronic obstructive pulmonary disease.
9.  Diabetes mellitus.
10.  Hypertension.
11.  Hyperlipidemia.

RECOMMENDATIONS:
1.  Admit the patient to PCU and place on telemetry due to acute arrhythmia.
2.  Rule out myocardial infarction with serial EKGs and serial enzymes.
3.  Workup for heart rate response, would like to start Cardizem drip at 5 mg/hour and continue the patient's p.o. Cardizem.  Also, I would like to check a BNP level.
4.  Due to severe pulmonary fibrosis and potential worsening of dyspnea symptomatology, we would like to discontinue the patient's amiodarone.
5.  Further plans and recommendations are according to the clinical course of this patient.

Thank you, Dr. Doe, for including me in the care of your patient.  We will follow closely along with you.

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Pulmonary Consultation Medical Transcription Transcribed Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Not dictated.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who is status post coronary artery bypass grafting x5 vessels.  He is orally intubated and sedated and pulmonary consultation is requested.  History was obtained from chart review.  The patient began to have chest pain, which occurred mostly at rest.  He saw his primary care physician who did an EKG, which was abnormal.  He was referred to Dr. Doe who did a stress test, which was also abnormal and he underwent cardiac catheterization.  He was noted to have significant disease in his left main.  He had a 70% stenosis in the left anterior descending, 100% stenosis in his right coronary artery and significant disease in the circumflex.  Consultation was obtained with Dr. Doe.  He was found to be an acceptable candidate and he was taken to the operating room, where he underwent coronary artery bypass grafting x5 vessels.  He received a left internal mammary artery to the left anterior descending, saphenous vein graft to the ramus, saphenous vein graft to the obtuse marginal and a saphenous vein graft to the PDA branch sequentially to the posterolateral obtuse marginal branch of the right coronary artery.

PAST MEDICAL HISTORY:  The patient has coronary artery disease as described above.  In record review, there is no history of COPD, but the patient did smoke up until recently.  He does have a history of diabetes mellitus, hyperlipidemia and hypertension.  There is a history of gastritis but no GI ulcers or GI bleeding.  There is no history on the chart of kidney problems, stroke or cancer.

PAST SURGICAL HISTORY:  The patient is status post coronary artery bypass grafting x5 vessels with the left internal mammary artery to the left anterior descending and saphenous vein graft to the ramus and saphenous vein graft to the obtuse margin and a saphenous vein graft to the PDA and sequentially to the PLOM branch to the right coronary artery.

FAMILY HISTORY:  Positive for coronary artery disease.

SOCIAL HISTORY:  The patient smoked 2 packs of cigarettes a day for approximately 20 years and just recently quit.  He only uses alcohol on a rare occasion and the patient was fairly active according to the records, where he walked 6 miles 5 days a week.

REVIEW OF SYSTEMS:  Unable to be obtained secondary to the patient being orally intubated and sedated.

ALLERGIES:  THE PATIENT HAS NO KNOWN ALLERGIES.

HOME MEDICATIONS:  Diovan, Lexapro, Avandia, lisinopril 20 mg, insulin and Starlix.

PHYSICAL EXAMINATION:
GENERAL:  This is a male who is orally intubated and sedated.
VITAL SIGNS:  Temperature 98.6, pulse 96, respirations 22 and blood pressure 94/46, CVP 14, PA 33/19, cardiac output/cardiac index is 4.7/2.2, and SVR is 822.
HEENT:  Pupils are equal and reactive to light and accommodation.
NECK:  Supple.  No JVD, lymphadenopathy or thyromegaly is noted.  Carotid bruits were not assessed secondary to lines and dressings.
CHEST:  Symmetrical.  There is air leak noted in the chest tube; it has drained approximately 550 mL since coming out of surgery.  Sternal dressing is dry and intact.  The patient does have some oozing from his sternal dressing.
LUNGS:  Coarse breath sounds.
HEART:  PMI is not felt.  S1 is normal.  S2 is normally split.  No murmur, gallop or click is noted.
ABDOMEN:  Obese, soft, elastic, nontender and nondistended.  No bowel sounds are noted.  Liver and spleen are not palpable.  No abdominal bruits are noted.
GENITOURINARY:  The patient is noted to have good urinary output.
RECTAL:  Deferred.
EXTREMITIES:  No edema, clubbing or cyanosis is noted.
CENTRAL NERVOUS SYSTEM:  Not assessed secondary to the patient being orally intubated and sedated.

DIAGNOSTIC DATA:  Chest x-ray demonstrates ET and Swan in good position.  No pneumothorax is noted.  The patient does have bibasilar atelectasis.  The patient is orally intubated on FiO2 of 80%, PEEP of 5 and pressure support of 10, rate of 10 and a tidal volume of 960.  ABG demonstrates a pH of 7.32, PCO2 of 42.8, PO2 of 298, base excess of -4 and bicarbonate of 21.6.  EKG demonstrates normal sinus rhythm with nonspecific T-wave abnormality.

LABORATORY DATA:  Sodium 138, potassium 3.6, chloride 110, CO2 of 26, BUN 28, and creatinine 1.2.  INR of 1.36.  WBC of 19.2, platelet count 119,000, hemoglobin 11.8, and hematocrit 34.8.  His activated clotting time is noted to be 700.

IMPRESSION:
1.  Respiratory failure.
2.  Coronary artery disease, status post coronary artery bypass grafting x5 vessels.
3.  Hypertension.
4.  Hyperlipidemia.
5.  Diabetes mellitus.
6.  Renal insufficiency.
7.  Leukocytosis.
8.  Tobacco abuse.
9.  Rule out sleep apnea.

RECOMMENDATIONS:
1.  Will wean the patient's ventilator to an FiO2 of 40%, IMV of 4, PEEP of 5 and pressure support of 10.  We will obtain ABG and mechanics, and if acceptable, we will extubate the patient.
2.  Secondary to the patient's long smoking history, we will begin bronchodilators and aggressive pulmonary toilet.
3.  We will obtain a followup chest x-ray in the a.m.
4.  The patient is noted to have leukocytosis.  We will obtain a CBC and basic metabolic panel in the morning.
5.  The patient's ACT is noted to be elevated and we will correct his coags as necessary.
6.  It appears from record review and examination that the patient has risk factors for sleep apnea.  We will obtain night oximetry prior to discharge.

Further recommendations will be made based on the patient's hospital course.  Thank you very much for allowing me to participate in the care of your patient.  I will follow the patient along with you.

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Internal Medicine Consultation Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Lower abdominal pain.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female, who said that she was doing fine.  She started having abdominal pain located in the lower part of the abdomen; this started yesterday.  She had associated leg pain and shoulder pain.  The pain was predominantly in the left lower quadrant.  It was sore to touch.  Subsequently, she started having loose bowel movements.  She also complained of having chest pain and then nausea.  She did not throw up.  She denies dysphagia, odynophagia, rectal bleeding or melena.  She does have history of irritable bowel syndrome.  She does not have any known allergies. She had a colonoscopy done 4 years ago by Dr. Doe.  At that time, she had a gastroscopy done too.  These endoscopic examinations showed that she had internal hemorrhoids; otherwise, it was unremarkable.  Gastroscopy did not show any findings.  Eight years ago, she had an exercise Cardiolite study done and that was remarkable for mild chest pressure during the test.  Echocardiogram was done 8 years ago as well and that showed mild mitral regurgitation.  She had a cardiac catheterization done by Dr. John Doe.  It showed normal coronary arteries with exception of distal vessels being quite small.  Found to have elevated left ventricular end-diastolic pressure and normal left ventricular function.  Gastroscopy was done 8 years ago as well.  This was done by Dr. Jane Doe and it showed mild patchy hyperemia; otherwise, it was unremarkable.  Flexible sigmoidoscopy was done by Dr. Bradford Doe 8 years ago and that was also unremarkable.  A colonoscopy was done by Dr. Jeffrey Doe 8 years ago and it showed a small polyp.  She had a right palpable breast mass and excision was done by Dr. Ivan Doe 4 years ago. She had uterine fibroids and menorrhagia and she underwent laparoscopic-assisted vaginal hysterectomy by Dr. Christopher Doe.  This was done 6 years ago.

SOCIAL HISTORY:  The patient does not smoke and does not drink alcohol.  She does not use any recreational drugs.

FAMILY HISTORY:  Noncontributory.  Mother is alive and has diabetes.  Father is alive and has heart disease.

REVIEW OF SYSTEMS:  She does not have any neurological, pneumonia, cardiovascular or musculoskeletal symptoms at this time.

PHYSICAL EXAMINATION:
GENERAL:  The patient is alert and oriented to time, place and person.
VITAL SIGNS:  Stable.
HEENT:  Normal examination.  Pupils are responding.  Conjunctivae are pink.  Sclerae are anicteric.  Oral examination is unremarkable.
NECK:  Supple.  No cervical lymphadenopathy.  No thyromegaly.
CHEST:  Clear.  Normal vesicular breathing.  No rales.  No crepitation.  No pleural rub.
HEART:  S1 and S2 audible.  No S3.  No S4.  No murmur.
ABDOMEN:  Soft and nontender except in the left lower quadrant area.  There is guarding but there is no rigidity.  There is no shifting dullness.  Bowel sounds are audible.
EXTREMITIES:  Did not show any pedal edema.  Peripheral pulses are palpable.  No joint deformity.
NEUROLOGIC:  No focal or neurological deficit.

LABORATORY DATA:  WBC 8.2, hemoglobin 12.6, hematocrit 37.4, and platelet count 208,000.  Comprehensive metabolic panel is normal except glucose of 126, CK of 196.  Troponin and CK-MB normal.  Urine showed 3+ occult blood.

The patient had some laboratory workup done in the past.  Her ANA was negative.  Rheumatoid factor was negative.  Cholesterol was elevated at 208.  Protein C activity was normal.  Complement 3 level was normal.  Complement 4 level was normal.  Total complement level was normal.  RPR was nonreactive.  Rheumatoid factor was done again and that was normal.  B12 level was normal.  Folate level was normal.  Hepatitis panel for A, B and C was unremarkable.  Serum ferritin was normal.  Serum iron was normal.  Antiphospholipid antibody was negative.  DRVVT lupus anticoagulant was unremarkable.  Whole blood hemoglobin A1c was normal.  TSH was normal.  Free T4 was normal.  FSH was normal.  T3 was low and that was 70.  Thyroglobulin was 0.7.  Thyroid peroxidase antibody was negative.  Protein C activity was high 5 years ago at 142.  Protein S activity was high 5 years ago as well. Anti-DNA antibody was negative.  Kaolin clotting time was normal.  Lupus sensitive PTT was normal.  Estradiol level was normal.  RBC folate was normal.  Factor XIII assay was normal. Factor VIII assay was normal.  Thrombin time was normal.  Von Willebrand ristocetin cofactor was normal.  Old blood factor II gene mutation was negative.  No gene mutation was detected.  Hepatitis B surface antigen was negative.  Rubella IgG was positive.

The patient had an IVP done 10 years back and it showed minimal postvoid bladder residual.  Focal indentation of upper pole of the infundibulum of right kidney was reported.  CT scan of the brain was done 8 years ago and that was negative.  Upper GI series with air contrast was done 8 years ago and that was unremarkable.  Upper GI series was done 6 years ago and that was unremarkable.  Ultrasound of the gallbladder was done 5 years ago and that was normal.  MRI of the breast was done 4 years ago.  CT scan of brain was repeated 4 years ago and that was normal.  Gallbladder ejection fraction was done 4 years ago and that was unremarkable.  MRI of the lumbar spine was done and showed a mild facet arthropathy at L4 and L5.  At L5 and S1, dehydration, degenerative loss in disk height was reported.  Renal ultrasound was done 3 years ago and that was normal.  Thyroid ultrasound was done 3 years ago.  It showed a small hyperechoic nodule.  MR of the neck was unremarkable except for a 2.5 mm left lower pole nodule that was identified in the thyroid.  MR of the orbit and brain was normal.  MR of the hip was done and it showed greater trochanteric bursitis on the left side.  This was done 2 years ago.  MR of the lumbar spine was done 2 years ago and it showed disk degeneration, bulging and spur at L5-S1 with symmetrical foraminal stenosis and mild facet arthropathy at L4 and L5.  This was stable compared to previous examination.  A CT scan of the brain was done in April of this year and there was a small asymmetric vessel in the right parietal lobe, probably representing a small vascular malformation.  MR angiogram was done and that was unremarkable.  MRI of the brain was done and that was unremarkable.  CT scan of the brain was done in October of this year and that was unremarkable.

IMPRESSION:
1.  Left lower quadrant pain.
2.  History of irritable bowel syndrome.

PLAN:  The patient presents with the above-mentioned problems.  Symptomatic treatment is being given with pain management.  IV fluids are being given.  CT scan of the abdomen and pelvis are pending.  After that, I will determine further management.  I will continue to follow her and I will assess the need of colonoscopy after the CT scan result.

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

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Infectious Disease (ID) Consultation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION:  Abscess in the left upper chest.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old woman who reportedly has prior history of right upper extremity DVT. She states that she presented to the hospital emergency department because of problems with pain and swelling in the left axillary area and left lateral adjacent chest; also, apparently, was having pain in the back. The patient reports that about a week or so prior to that, she developed a small lesion in the right axilla, contralateral side, which appeared to be consistent with a boil. She states that there was spontaneous drainage from this and the area seemed to be healing. Then, about 3 or 4 days before admission, she developed a similar abnormality in the left axillary area, on the anterior wall of the axilla, which continued to enlarge and become painful. She states that she actually was unable to move the shoulder because of the pain. She had pain towards the back of the shoulder and also in the anterior chest laterally and, apparently, in the lateral prepectoral area. She actually had spontaneous drainage of purulent material at home. She was having some feverishness at home as well.

She presented to the emergency department. At that time, initial temperature was 98.6, pulse 66, blood pressure 134/90, and O2 saturation 99%. She did have cultures taken, which were positive for polymicrobial growth, currently consisting of Enterococcus faecalis, Serratia marcescens, and Proteus species. Enterococcus was susceptible to ampicillin, penicillin and vancomycin. The Serratia was susceptible to aztreonam, ceftazidime, cefepime, Cipro, ceftriaxone, cefotetan, ertapenem, gentamicin, imipenem, Septra and resistant to cefazolin. Proteus susceptibilities are reportedly pending at this time. The patient has been on antibiotics including Zosyn and vancomycin. She underwent evaluation by Dr. Bradford Doe and was taken to surgery, undergoing incision and drainage and possibly biopsy as well of the left axillary abscess. Pathology is reportedly pending at this time. Infectious Disease consultation is requested today for assistance with evaluation and management.

PAST MEDICAL HISTORY:  Reportedly positive for right upper extremity DVT about 5 years ago, for which the patient does continue on chronic anticoagulation with Coumadin. She has had previous cesarean section x2 reportedly. She is not aware of any history of any prior skin and soft tissue infections other than the recent lesions as described above. She does occasionally develop some similar lesions in the axilla, but none of which had ever resulted in any major problems.

MEDICATIONS:  Reportedly are stated as Coumadin, Lovenox, Zosyn 3.375 grams IV q.6 h., and vancomycin 1 gram IV q.24 h.

SOCIAL HISTORY:  The patient states that she lives with her mother, a brother and sister, and the patient has 2 children who all live at home with her. She is a cigarette smoker, usually smoking about 2 packs of cigarettes about every 3 to 4 days. She reports only occasional use of alcohol. She denied any utilization of any illicit drugs and also denied any utilization of any injectable drugs.

FAMILY HISTORY:  Positive for diabetes.

REVIEW OF SYSTEMS:  The patient denied any known trauma to the left axilla or chest wall area. No animal bites or scratches. She has no history of stroke or seizure disorder. No dysphagia. No history of thyroid disease or goiter. No history of diabetes mellitus. No history of myocardial infarction or rheumatic heart disease. No history of asthma or emphysema. No history of tuberculosis. No abdominal pain. No vomiting. No diarrhea. No dysuria or hematuria. No personal history of cancer. No severe arthralgia or myalgia at this time.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 97.6, pulse 74, and blood pressure 139/91. The patient has been afebrile in the hospital with the exception of a temperature of 99.6 degrees at midnight.
GENERAL:  The patient is overweight. She is awake and alert and in no acute distress at this time.
HEENT:  Pupils are round and reactive. Sclerae anicteric. Conjunctivae noninjected. Oral mucosa moist. No thrush. No pharyngitis.
NECK:  Supple. Trachea midline. No palpable thyromegaly. No frank cervical or supraclavicular adenopathy.
CHEST:  Symmetrical excursion. Lungs are clear to auscultation without wheezes.
HEART: Regular rate and rhythm without rub.
ABDOMEN:  Nondistended. Normoactive bowel sounds. No guarding or rebound tenderness. No palpable hepatomegaly.
EXTREMITIES:  No clubbing or cyanosis. No palpable cords. No calf tenderness to palpation. In the left upper extremity, the patient has surgical dressing in the axilla. There is still some induration palpable and some serosanguineous drainage noted on the dressing. Previously, the patient had edema around the anterior wall of the axilla in the lateral prepectoral area, but that appears to be improving now. She also is having some improving range of motion of the shoulder. No crepitance is evident. No foul odor.
SKIN:  Otherwise, without diffuse rash. No vesicles or bullae. No Janeway lesion or Osler nodes.

LABORATORY DATA:  White blood count on day of admission to the emergency department was 15,500. Three days prior to admission, it was 18,500. Hemoglobin on day of admission was 11.3. PT 18.4 and INR 1.50 today. Sodium on day of admission to the emergency department was 133, creatinine 0.9 and BUN 6. Pregnancy screen was negative. Troponin less than 0.02. CPK 38.

Chest x-ray reportedly showed no acute pulmonary infiltrates.

IMPRESSION:
1.  The patient is status post surgical incision and drainage of left axillary abscess.
2.  Previous wound cultures, as described above, with polymicrobial growth. Of note, surgical wound cultures showing progress at this time and no growth so far.
3.  The patient is overweight.
4.  Leukocytosis.
5.  History of right upper extremity deep venous thrombosis approximately 5 years ago.
6.  Cesarean section x2.
7.  Tobacco abuse.

RECOMMENDATIONS:  We will follow up pending surgical cultures with regards to antibiotic coverage. We will continue for now on IV Zosyn. We will go ahead and discontinue vancomycin at this time. No resistant gram-positives have been identified. We will await Proteus susceptibilities. Hopefully, further adjust antibiotics when additional culture information is available. Also, we will recheck the patient's CBC in a.m.

Thank you very much for allowing me to participate in the care of your patient.

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Neuropsychology Consultation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  To evaluate the patient's current cognitive and emotional function following central nervous system compromise. 

DIAGNOSIS ON PRESENTATION:  Stroke. 

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old gentleman who was transferred from an outside hospital with right-sided weakness and aphasia.  The patient reportedly had a nonhemorrhagic CVA.  The patient was also noted to have a right homonymous hemianopsia to confrontation with a left gaze preference and right central facial weakness along with right hemiplegia.  The patient also had increased reflexes on the right compared to the left and aggressive upgoing plantar response.  The patient was noted to have a left carotid bruit.  The patient also had an elevated blood pressure prior to onset.  The patient was evaluated on the acute floor and then transferred to the rehabilitation unit for further evaluation and treatment.

PAST MEDICAL HISTORY:  Hypertension, but no significant history of diabetes or cardiologic abnormalities.

PAST SURGICAL HISTORY:  As noted above. 

ALLERGIES:  NONE NOTED. 

MEDICATIONS UPON ADMISSION:  See chart. 

FAMILY MEDICAL HISTORY:  Diabetes. 

PAST PSYCHIATRIC HISTORY:  Reportedly unremarkable. 

SOCIAL HISTORY:  The patient lives with his wife of 40 years.  They live in an older home with no air conditioning or heat.  The patient has a son and daughter who also live in that area.  Educationally, the patient completed high school.  Occupationally, the patient worked in the (XX).  Prior to this stroke, there was no history of reported disability.

SUBSTANCE ABUSE HISTORY:  Positive for remote tobacco history, but negative for alcohol and illegal substance use. 

EXAMINATION RESULTS:  The patient was alert and oriented to self, but further evaluation of orientation could not be established at this time secondary to aphasia.  Interaction with the examiner was pleasant, but eye contact was limited secondary to the deficits noted above in the history.  Attention span and processing was extremely brief.  Attention span was brief partly because the patient appeared fatigued and was also unable to respond appropriately.  Information processing is substantially impaired as well as memory secondary to severe language dysfunction, aphasia.  No assessment of apraxia was completed at this time.  Please see speech therapy's review.  According to the patient's wife, he is normally a very quiet person with limited expression, but no disability was noted.  Upon review of comprehension, the patient was inconsistent for one-step commands and following at approximately 50% for yes or no response type format.  Fluency as well as repetition severely impaired.  Verbal processing again was severely impaired.  Further language as well as cognitive testing would be indicated after the patient demonstrates considerable improvement from this point forward.  Thought process and thought content could not be fully evaluated at this time.  There was no history of any deficit in this area.  The patient does not appear to be experiencing any overt signs of things like hallucinations or delusions.  Regarding behavioral activity, the patient is restless at times and does require safety devices to be in place.  The wife indicates concern about him falling.  Regarding affect and mood, the patient's affective expressions were very limited.  The patient's wife has indicated that he does get frustrated and aggravated with his deficit profile as well as language impairment.  A formal assessment cannot be evaluated at this time secondary to the level of impairment noted.  Regarding vegetative features, according to the patient's wife, he was very restless upon the acute floor, but since being on rehab, he has been showing increasing abilities.  The patient's appetite has been improving, but following at approximately 50% of normal.  According to the patient's wife, he has lost weight.  Energy level is significantly decreased.  He fatigues quickly and naps often.  Overall awareness of current deficits cannot be fully assessed at this time.  The patient does have some recognition of deficits secondary to becoming frustrated, but it is difficult to say as to what his current level of insight is.  Overall adjustment to the rehabilitation unit appears adequate, in that he is beginning to show changes associated with therapies.  Also, some of the vegetative features are beginning to improve, which should also help his overall adjustment to the rehabilitation process.  The patient's wife indicated that overall he has been cooperative and seems motivated for treatments.  She also indicated that he is a person who normally has significant drive and will provide his best efforts. 

IMPRESSION:  At this time, neuropsychological impression is consistent with the effects of a large middle cerebral artery distribution infarct with associated right hemiplegia as well as language impairment.  There was an issue of visual fields being deficient.  This will be further evaluated as the patient's language skills improve.  Overall adjustment appears consistent with level of frustration secondary to deficits that would be expected as part of the recovery process. 

Axis I:  Cognitive disorder, not otherwise specified, with associated language impairment as well as adjustment reaction, not otherwise specified, mild. 

Axis II:  Deferred. 

Axis III:  See history above including a left middle cerebral artery distribution nonhemorrhagic stroke. 

Axis IV:  Current psychosocial stressors include current level of disability as well as loss of home in this past year as well as economic change. 

Axis V:  Current global assessment of functioning equals approximately 35 secondary to severe communication deficit, and past year would equal approximately 85 to 90. 

RECOMMENDATIONS:  At this time, further intervention by Neuropsychology.  Will be working with the patient's wife for educational purposes, as well as helping her to understand cognitive and linguistic deficits following this type of stroke.  In addition, the patient will be discussed during neurobehavioral rounds as appropriate, and finally, followup intervention for cognitive as well as adjustment issues will be provided on an as-needed basis providing that the patient is able to tolerate this form of treatment.  Neuropsychological assessment will likely not be able to be completed during the time of the inpatient rehabilitation stay secondary to language impairment.  However, if the patient demonstrates enough comprehension, then neuropsychological assessment would be attempted.  Thank you for this consultation.

Neuropsych Testing Sample Report

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Colonoscopy and ERBE Argon Laser Cautery Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hemoccult-positive stools, melena and acute blood loss anemia, on anticoagulation therapy with aspirin, Plavix and heparin, not explained by upper endoscopic findings.

POSTOPERATIVE DIAGNOSES:
1.  Large, extensive rectal prolapse, ischemic-type ulcerations with visible vessel and active bleeding, photocoagulated with ERBE argon laser for hemorrhage control.
2.  Severe rectal prolapse.
3.  Several benign-appearing colon polyps, the largest measuring 1.6 cm.
4.  Moderate sigmoid diverticulosis with no acute diverticulitis.

PROCEDURES PERFORMED:
1.  Colonoscopy to cecum.
2.  ERBE argon laser photocoagulative ablation of a bleeding rectal ulcer visible vessel for hemorrhage control.

ENDOSCOPIST:  John Doe, MD

PREP:  Combination of Fleet Phospho-soda with GoLYTELY, generally very poor, requiring extensive and copious irrigation and lavage, markedly prolonging the patient's procedure.

ANESTHESIA:  Monitored anesthesia care.

PROCEDURE IN DETAIL:  After informed consent had been obtained prior to sedation for upper endoscopy, the patient was kept in the semirecumbent position. Colonoscopy was performed with the patient on his back. Digital rectal examination revealed some narrowing of the anal sphincter, with tenderness. The finger was used as a guide to insert the Olympus video colonoscope through the anus into the rectum. A small amount of air was insufflated to distend the lumen. The scope was then advanced with moderate difficulty, proximally, due to the presence of extreme spasticity in the left colon area with moderate diverticulosis. There was no evidence of any diverticulitis noted within this area. The prep was poor throughout with large pools of liquid stool that required copious irrigation and lavage with aspiration. Using a push-pull technique, the cecum was finally reached, where the ileocecal valve and appendiceal orifice were both identified to verify location. The mucosa was inspected upon insertion of the scope and carefully re-inspected upon withdrawal of the scope. Retroflexion was not performed in the rectum due to extreme rectal spasticity and the presence of decreased rectal chamber size due to essentially circumferential, patchy, exudative, ischemic-type ulcerations that were seen in the context of rather severe rectal prolapse. One of these ulcerations, which was more distally located in the rectum and measured 1.6 cm, had a visible vessel and was actively bleeding. This ulceration was cauterized with an ERBE argon laser cautery unit at a setting of 40 watts of power, 1 liter per minute argon flow. There was cessation of bleeding. Also noted within the colon were several polyps. In the cecum was a sessile 1.6 cm polyp, which was not removed. Another 3 mm sessile benign-appearing polyp was seen in the fold in the hepatic flexure. Within the sigmoid colon, at approximately 30 cm, two sessile 4 to 6 mm benign-appearing polyps were seen. Another larger broad-based polyp, measuring between 1.5 cm and possibly 2 cm, was seen in the rectum at 15 cm. None of these polyps were removed due to the patient having been actively on aspirin, Plavix, heparin and requiring these. No biopsies were taken throughout the colon, as noted. Prior to withdrawal of the scope from the patient, air was removed from the colon. The patient tolerated the procedure well with no evidence of immediate complications. The patient was stable on transfer to the recovery area.

IMPRESSION:
1.  The patient has Hemoccult-positive stools, melena, as well as blood loss anemia. They very well can be explained by the extensive rectal prolapse, ischemic-type ulcerations, one of which had a visible vessel and was actively bleeding requiring photocoagulation for bleeding cessation. These are chronic-appearing ulcers and they may very well be exacerbated by diarrhea with rectal prolapse.
2.  Several adenomatous-appearing polyps, two of which were of substantial size, one measuring 1.6 cm in the cecum and second one of 1.5 or possibly 2 cm in rectosigmoid colon that has a significant risk of containing or developing into a malignancy. These were not removed or biopsied secondary to the patient being actively on aspirin, Plavix and heparin.
3.  Moderate uncomplicated sigmoid diverticulosis.

RECOMMENDATIONS:
1.  Bowel regimen for the patient's rectal prolapse and ulcerations. Anticholinergic, antispasmodic therapy as well as fiber supplements and stool softeners will be initiated.
2.  Possibly discontinue the Zosyn due to the patient's recent diarrhea, which may be antibiotic associated, particularly in the absence of any pseudomembranes to suggest pseudomembranous colitis.
3.  Careful monitoring for any continued significant bleeding in the context of continued aspirin, Plavix and heparin therapy.
4.  Anticipate the colonoscopy to be rescheduled along with upper endoscopy for biopsies and polypectomies within approximately 6 months or sooner when the patient can be safely taken off his anticoagulation therapy.

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Corpectomy / Decompression of Spinal Canal Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Cervical spinal stenosis with myelopathy.
2.  Severe cervical congenital abnormality and scoliosis.

POSTOPERATIVE DIAGNOSES:
1.  Cervical spinal stenosis with myelopathy.
2.  Severe cervical congenital abnormality and scoliosis.

OPERATION PERFORMED:  C4 corpectomy with decompression of the spinal canal and nerve elements with application of the titanium cage and local bone graft.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ASSISTANT:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  100 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room.  Preoperative antibiotics were given.  He was intubated and placed in the supine position.  Throughout the surgery, spinal cord monitoring was performed to ensure the integrity of the spinal cord.  All bony prominences were padded carefully.  Cervical spine was draped in the usual sterile fashion.  Incision was made on the right aspect of his neck.  Dissection was taken to the platysma muscle.  Platysma muscle was opened along its fibers.  He has significant rotation of the cervical spine with scoliosis, which make this approach challenging.  His carotid artery was significantly posterior to its normal position.  His anterior cervical spine was rotated significantly to the right side with scoliosis.  Full dissection was performed, deep cervical fascia was identified and it was opened bluntly.  Then, attention was directed to the next level.  Esophagus was identified, and the esophagus and trachea were removed medially.  The prevertebral fascia was identified.  This fascia was thickened and it was opened along its fibers.  As mentioned, his cervical spine was deformed and there was significant rotation and scoliosis.

The C-arm was brought in to identify the intended corpectomy level.  At this point, the retractors were placed and colli longus muscle was detached and retractors were placed in.  Corpectomy was performed by performing diskectomy at the level above C4 and below the C4.  The C4 level, which was being corpectomized, had significant rotation to the right.  Rongeur was used to remove the anterior aspect of the C4 vertebral body all the way posteriorly as much as possible.  Then, corpectomy was continued with high-speed drill all the way to the posterior cortex.  Attention was given to perform a wide cord decompression.  The uncovertebral joints were used as reference to determine the width of the corpectomy.  The corpectomy was performed all the way to the posterior cortex.  At this point, Kerrison was used to gently remove the bone.  There was significant pressure that was brought on the superior aspect, particularly on the left side.  Meticulously, with the combination of small Kerrison and high-speed drill, corpectomy was performed all the way.  Posterior longitudinal ligament was identified.  At the end of the decompression, the neural foramen, superiorly and inferiorly, was completely free.  Spinal cord was widely exposed and decompressed.  To control hemostasis, FloSeal was used.  Endplates were cleaned up of any remaining disk material and decorticated with good bleeding bone.

At this point, the width of the corpectomy was measured, appropriate size cage was assembled and it was packed with the bone graft taken from the corpectomy site as well as from allograft.  The cage was gently placed in the interspace once the traction was applied to the cranium.  The cage was gently tapped in place.  It had a very nice fit and it was very solid.  The plate was bent and it was placed on top of the cage.  The screws were placed in C3 and C5.  We had a very strong construct.  Radiographs were taken that demonstrated the cage in appropriate position.  Interpretation of plain radiographs is difficult and challenging at times due to the fact there is significant scoliosis and rotation.  However, the C-arm was used in different angles and rotation and these showed that we had excellent placement of the cage, both radiographically and clinically.  At the end of the case, he had excellent hemostasis.  A drain was placed in.

Fascia closed in layers with 3-0 Vicryl.  Final closure was done with a 2-0 Vicryl followed by 4-0 Vicryl.  Steri-Strips were applied.  The patient was awakened and taken to the recovery room.  He was moving both upper extremities with no focal deficits.  Due to the fact that it was a prolonged surgery, to avoid any respiratory complications, the patient was kept intubated overnight.  There were no complications throughout this case.  Due to its complexity, the surgery was undertaken in a meticulous stepwise fashion.  All counts were correct at the end of the case.  The next day, the patient was extubated and he was moving both upper and lower extremities.  He had no focal deficit.  Of note, due to the fact that he has scoliosis and rotation, to further stabilize this construct, I have recommended for the patient to have posterior spine stabilization.

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