Dermatology Transcribed Medical Transcription Sample Report

DATE OF VISIT:  MM/DD/YYYY

CHIEF COMPLAINT:  Worrisome lesion on the right leg.

HISTORY OF PRESENT ILLNESS:  The patient is a well-appearing (XX)-year-old female new to Dermatology.  She comes today at the request of Dr. Doe.  The patient states that her primary care physician noted a lesion on her right medial tibia that had been present for some time, but otherwise asymptomatic.  Otherwise, she feels generally well today and has no additional skin concerns. 

ALLERGIES TO MEDICATIONS:  None.

CURRENT MEDICATIONS:  Warfarin, atenolol, Diovan, furosemide, Klor-Con and glyburide.

PAST MEDICAL HISTORY:
1.  Diabetes.
2.  Hemochromatosis.
3.  Hypertension.

Negative for melanoma.  Positive for skin cancer on the right hand, 3rd finger, dorsal surface that was excised approximately 5 or 6 years ago.

FAMILY MEDICAL HISTORY:  Positive for a spouse who has had skin cancer and allergies in a daughter who has eczema, negative for melanoma.

Pain on the scale of 1 to 10:  The patient rates pain at a level of 7 or 8 when standing on her ankle.  Her primary care physician Dr. Doe is aware of this problem and she has an upcoming appointment to address this issue.

PERSONAL SAFETY:  Negative.

REVIEW OF SYSTEMS:  Updated and reviewed, placed in the chart.

PERTINENT FINDINGS:
1.  Right medial anterior tibia, an 8.5 mm red, erythematous, rough plaque with gritty scale.
2.  On the right upper back, solitary erythematous macule with hyperkeratotic protuberant rough scale.
3.  Right upper lateral arm, 4.5 mm erythematous plaque with scale.
4.  Multiple white, rough, gritty papules on the lower extremities.
5.  On the bilateral forearms and dorsal surface of the hands, multiple erythematous macules with gritty scale.
6.  Multiple coalescing ephelides and lentigines on all sun exposed surfaces.

ASSESSMENT:
1.  Neoplasm of uncertain behavior.  Hypertrophic actinic keratoses versus squamous cell carcinoma on the right upper back and right upper arm.  Hypertrophic actinic keratosis versus squamous cell carcinoma versus inflamed seborrheic keratosis on the right medial tibia. 
2.  Stucco keratoses and seborrheic keratoses.  
3.  Actinic keratosis on the forearms and dorsal surface of the hands.
4.  Actinic damage.

PLAN:  Regarding the 3 neoplasms of uncertain behavior, after the patient identified her name, date of birth, site and procedure , an appropriate time-out was taken.  Written consent was obtained.  Plain lidocaine was injected into each of the 3 sites and a shave biopsy utilizing a DermaBlade with Drysol solution for hemostasis was employed x3.  The patient received appropriate topical wound care and the 3 biopsies were sent to pathology.  Regarding her stucco and seborrheic keratoses, she was reassured of the benign findings.  For her actinic keratoses on the forearms and dorsal hands, liquid nitrogen was applied x12.  For her actinic damage, photo precautions were encouraged.  Skin self-examination was reviewed.

Endoscopic Ethmoidectomy / Maxillary Antrostomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Chronic sinusitis.

POSTOPERATIVE DIAGNOSIS:  Chronic sinusitis.

OPERATIONS PERFORMED:
1.  Bilateral endoscopic ethmoidectomy.
2.  Bilateral endoscopic maxillary antrostomy with removal of maxillary sinus contents, right.
3.  Right endoscopic frontal sinusotomy.
4.  Right endoscopic sphenoidotomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  200 mL.

IV FLUIDS:  900 mL of crystalloid.

INDICATIONS FOR OPERATION:  The patient is a pleasant (XX)-year-old female with history of chronic sinusitis. She has had persistent disease despite antibiotics, steroids and topical decongestants. A CT scan was obtained recently and found to be significant for complete opacification of the right maxillary ethmoid and frontal sinuses with mucosal thickening in the right sphenoid sinus. Although the left sinuses appeared clear, the patient has had an upper respiratory tract infection for the past week and asked to have the left sinuses addressed and cleared out if necessary.

OPERATIVE FINDINGS:
1.  Greenish-blackish pasty material within the right maxillary sinus with copious purulent drainage.
2.  Purulent drainage involving the right ethmoid and frontal sinuses as well. The sphenoid sinus had mucosal thickening. All sinuses had evidence of chronic inflammatory disease. In regards to the left sinus cavity, the anterior ethmoid sinus had evidence of acute mucosal thickening with obstruction of the ostiomeatal complex.

DESCRIPTION OF OPERATION:  The patient was orally intubated and placed under general anesthesia. Clindamycin 600 mg and Decadron 10 mg were given intravenously. The nasal and septal mucosa injected with 1% lidocaine with 1:100,000 epinephrine and cottonoids soaked in it were inserted into the nasal cavities bilaterally. The patient was then prepped and draped using sterile technique. The right side was addressed first. The caudal elevator was used to medialize the right middle turbinate. The uncinate bone and mucosa were then incised using the caudal elevator. The uncinate bones and mucosa were removed using the handheld microdebrider. The right maxillary sinus was emanating purulent drainage after removal of the uncinate process. The handheld microdebrider was used to remove the mucosal disease from the ostiomeatal complex. The maxillary sinus was then cleared using the curved suction tip and maxillary sinus forceps. As stated above, there was a large amount of greenish-blackish pasty material within the maxillary sinus and copious purulent drainage. A culture was taken and sent for cultures and sensitivities, including anaerobic, aerobic and fungal cultures.

The ethmoid sinus was addressed next. The handheld microdebrider was used to remove the diseased tissues from the ethmoid sinus. There was a small area of dehiscence of the right lamina papyracea, measuring approximately 2 to 3 mm. On reinspection of the preoperative scan, this dehiscence was also noted. Care was taken to avoid any injury to the orbital fat and there was none. The right sinus cavities were then packed with cottonoids soaked in 1:100,000 epinephrine and the left side was addressed.
The caudal elevator was used again to medialize the middle turbinate. The uncinate process bone and mucosa were then removed using the handheld microdebrider. As stated previously, due to her recent upper respiratory tract infection, there was obstruction of the ostiomeatal complex on the left. The ethmoidectomy was performed using a handheld microdebrider. There was no evidence of bone dehiscence of the lamina papyracea on the left side. An anterior ethmoidectomy was only required on the left. The frontal recess appeared fairly patent; this was left untouched as well on the left hand side. The left maxillary sinus was then cannulated using the curved suction tip. A small amount of purulent drainage was suctioned clear from the left maxillary sinus. The maxillary sinus cavities on the left were then irrigated with copious normal saline mixed with Betadine and hydrogen peroxide.

The right frontal sinus was addressed next. The frontal sinus seeker was used to identify the area of the frontal recess as this was completely blocked with polyps. The polyps were removed using the giraffe and frontal sinus forceps. Upon entry into the right frontal sinus, there was a large amount of purulent drainage also noted. The frontal sinusotomy was enlarged using the frontal sinus punch. The right frontal sinus was then irrigated with the Betadine, saline and peroxide solution. The right sphenoid sinus was addressed lastly. The inferior aspect of the superior turbinate was resected using the handheld microdebrider. The sphenoid sinus was then entered using the Frazier suction tip. The sphenoidotomy was enlarged using the handheld microdebrider. The sinus cavities were reirrigated with Betadine, saline and peroxide mixture. Stammberger foam mixed with Kenalog was then injected into the sinus cavities bilaterally. Merocel sponges were then cut to size and placed as middle turbinate spacers to prevent synechia and lateralization in the early postoperative period. The patient was then suctioned free of blood and secretions prior to extubation. The patient was successfully extubated and transferred to the recovery room in stable condition.

Orthopedic SOAP Note Medical Transcription Sample Report

SUBJECTIVE:  The patient presents in followup regarding his right leg injury. He is post injury day #9, status post irrigation and debridement of type 1 open right segmental distal tibial fracture, as well as closed treatment of right lateral tibial plateau fracture and application of a joint spanning external fixator. He has been at a skilled nursing facility. He has maintained nonweightbearing status in the right lower extremity. He is taking Lovenox 40 mg once daily for venous thromboembolism prophylaxis. He reports no problems with the pins. His pain has been well controlled. He denies any calf pain or swelling. He denies any fevers or chills or any other constitutional symptoms.

OBJECTIVE:  On examination of the right lower extremity, the tibial and femoral pin sites are clean, dry and intact. There are no local signs of infection. On examination of the knee, there is minimal soft tissue swelling. There are no fracture blisters. There is wrinkling over both the medial and lateral aspects of the proximal tibia. There is no calf pain or tenderness to palpation. There is moderate soft tissue swelling the distal third of the tibia. The anteromedial fracture blister, which was serous in nature has decompressed itself and is in the process of re-epithelializing. The foot is warm and well perfused with brisk capillary refill. The calcaneal pin site has minimal serous drainage. There are no local signs of infection. The skin is intact over the heel. Sensation is intact to light touch in the distribution of the sural, saphenous, superficial peroneal, deep peroneal, and tibial nerves. He is able to actively flex and extend the toes against gravity. There is no pain with passive stretch of the leg muscle compartments. There is a lack of wrinkling over the medial aspect of the ankle. There is evidence of skin wrinkling over the lateral aspect of the ankle. The traumatic open wound, which has been closed loosely, primarily, demonstrates no local signs of infection. There is no warmth or erythema or drainage.

Radiographs of the right knee and tibia and fibula demonstrate no change in position of the fractures.

ASSESSMENT AND PLAN:  Postoperative day #9, status post irrigation and debridement of type 1 right segmental distal tibia fracture, as well as application of a joint spanning external fixator for closed right proximal lateral tibial plateau fracture and segmental type 1 open distal tibia fracture. The diagnosis was described in detail to the patient. At the present time, his pin sites remain stable. He is to continue on Lovenox for venous embolism prophylaxis 40 mg once daily.

With regard to the second stage of treatment, at the present time, his soft tissue swelling over the proximal tibia has resolved. I do feel this is fit for open surgical repair. However, distally, the soft tissue envelope remains swollen and the medial blister continues to re-epithelialize. I feel at the present time, the soft tissue envelope over the distal tibia is unfit for surgery. I explained that after stabilization of the tibial plateau fracture, one of three methods will be used to stabilize the distal tibial fracture; plate osteosynthesis, definitive external fixation, intramedullary nailing. At the present time, however, the soft tissue envelope precludes any open type of surgery.

We will tentatively plan for open reduction and internal fixation of the right tibial plateau fracture to be performed on MM/DD/YYYY. At that time, depending on the soft tissue envelope distally, he may or may not have definitive surgical repair. Either way, he will have the knee spanning external fixator removed at that point and most likely have an adjustment made to the distal tibial external fixator. He understands the treatment plan as outlined above. I have given instructions to the rehabilitation facility to place only a dry dressing over the medial fracture blister as Xeroform will potentially cause excess moisture and maceration. He understands the treatment plan as outlined above.

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SUBJECTIVE:  This is a pleasant male who has a history of low-grade pain in the shoulder that is about 2/10. He has no numbness, tingling, or weakness. He has done no formal therapy. He takes some anti-inflammatories. No injections or surgeries. He does have GERD.

OBJECTIVE:  The patient is 5 feet 8 inches, 238 pounds. Well nourished, well developed, in no acute distress. Normal affect. Skin is intact. He does have good symmetric range of motion, good external rotation bilaterally, even in the abducted position it was fully symmetric. He has a positive Neer sign, less so Hawkins. He has some pain with a dynamic labral shear. Really no pain with the O'Brien's. He has no instability, negative apprehension and Jobe’s. He has no pain with load and shift. He has good strength with 5/5 forward elevation, external rotation, internal rotation, abduction. He is otherwise grossly neurovascularly intact.

X-rays are negative. MR arthrogram shows possible tear of the posterior inferior labrum, small changes in the supraspinatus, but no full-thickness tears.

ASSESSMENT AND PLAN: We had a long discussion regarding options, including leaving it alone, consideration of formal therapy program, as well as surgical intervention. At this point, he is going to go forward with therapy program. Certainly, does not want to do anything from a surgical standpoint. It does not bother him that badly at this point. We will see him back in a couple of months and see how he is doing. Certainly, if he wants to leave things alone, even if it does not get better, he can live with it. If things do not improve, we certainly can consider an arthroscopic evaluation, possible debridement or repair. If things worsen in the interim, he will call and we will see him sooner.

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ORIF of Tarsometatarsal Dislocation Sample Operative Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Closed left tarsometatarsal dislocation.

POSTOPERATIVE DIAGNOSIS:  Closed left tarsometatarsal dislocation.

OPERATION PERFORMED:  Open reduction and internal fixation, left tarsometatarsal dislocation.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, PA-C

ANESTHESIA:  Spinal and LMA.

INTRAVENOUS FLUIDS:  2500 mL lactated Ringer's.

ESTIMATED BLOOD LOSS:  300 mL.

TOTAL TOURNIQUET TIME:  180 minutes.

DRAINS:  None.

PATHOLOGY:  None.

COMPLICATIONS: None.

DESCRIPTION OF OPERATION:  The patient was identified and the operative site was marked in the preoperative holding area. He was taken back to the operating room on the hospital bed and carefully transferred from the hospital bed to the operating room table. The attending anesthesiologist administered a spinal anesthetic without any difficulty. The patient was then placed in a supine position and secured to the table with a safety strap. A bump was placed under the left hip to encourage neutral rotation of the left lower extremity. A well-padded, thigh-high tourniquet was placed and set to 280 mmHg. Biplanar fluoroscopy was utilized to ensure unimpeded access to the left foot for intraoperative imaging. The left lower extremity was then prescrubbed with chlorhexidine gluconate scrub brushes and then completely dried. The patient received 1 gram of cefazolin prior to the surgical skin incision. The left lower extremity was then prepared and draped in usual sterile fashion with Betadine.

A longitudinal incision was marked with a marking pen in the first web space as well as in line with the fourth metatarsal. A time-out was performed. A soft rubber Esmarch bandage was used to exsanguinate the left lower extremity and the tourniquet was inflated to 280 mmHg.  Attention was first directed towards the medial incision. A skin incision was made with a 15 blade scalpel. Hemostasis was obtained with Bovie electrocautery. Blunt dissection was carried down to the fascia. The EHL was identified, preserved, and protected throughout the case. Dissection was carried down to the first tarsometatarsal joint capsule. The joint capsule was tagged for later repair. A subperiosteal dissection was utilized to expose the first and second tarsometatarsal joints. Care was taken to protect the dorsalis pedis and the neurovascular bundle. The joints were explored. There were no visual surface abrasions or full-thickness cartilage lesions noted. There was no bony debris.

Next, attention was directed towards open reduction of the first tarsometatarsal joint. Care was taken to ensure that the joint was concentrically reduced in both AP and sagittal planes. A 1.6 mm K-wire was used for provisional stabilization. Biplanar fluoroscopy confirmed appropriate joint reduction. Next, a high-speed bur was used to remove the upper part of the dorsal cortex of the first metatarsal approximately 15 mm distal to the joint. This was done to allow the screw head to be less prominent. A 2.5 mm drill bit was used to drill a path for the screw in a distal-to-proximal direction. A 3.5 mm fully-threaded cortical screw of appropriate length was then placed obtaining good purchase. Next, a second screw was placed from the medial cuneiform into the first metatarsal. A 2.0 mm drill bit was used to drill a path for the screw and a 2.7 mm fully-threaded cortical screw was placed obtaining good purchase.

Next, care was taken to ensure that the second tarsometatarsal joint was reduced. A 2.5 mm fully-threaded cortical screw was placed in a distal-to-proximal direction from the base of the second metatarsal from the proximal third of the second metatarsal into the middle cuneiform. Good purchase was obtained. An additional 2.7 mm fully-threaded cortical screw was placed from proximal-to-distal from the medial cuneiform into the proximal second metatarsal. Visual reduction was confirmed as well as with biplanar fluoroscopy. At this point, the tourniquet was deflated. Hemostasis was obtained with Bovie electrocautery. At this point, there was an increase in the amount of soft tissue swelling. Therefore, we felt that the risks of an additional incision outweighed the potential benefits. Therefore, the plan was for percutaneous pinning of the third tarsometatarsal joint as well as pin stabilization of the fourth and fifth tarsometatarsal joints. A closed reduction was obtained and verified with biplanar fluoroscopy. A 1.6 mm K-wire was placed from the distal aspect of the third metatarsal into the base of the lateral cuneiform. Biplanar fluoroscopy confirmed appropriate pin placement across the joint and into the lateral cuneiform. Next, the fourth and fifth tarsometatarsal joints were stabilized with a 1.6 mm K-wire as well. Biplanar fluoroscopy confirmed appropriate reduction of the tarsometatarsal joints and appropriate implant placement. Intraoperative plain radiographs were taken and demonstrated appropriate joint reduction and implant placement. The K-wires were cut short with a wire cutter, bent and protected with pin covers.

The wound was irrigated with sterile saline solution. The capsule was closed with 0 Vicryl in a figure-of-eight interrupted fashion. The deep fascia was closed with 0 Vicryl in a figure-of-eight interrupted fashion. The subcutaneous tissue was closed with a 2-0 Vicryl in a simple interrupted fashion. The skin was closed in a tension-free manner using 3-0 nylon with an Allgower modification of the Donati technique suture pattern. A sterile compressive dressing consisting of Xeroform, 4 x 4 gauze, ABDs, and sterile Webril were placed over the wounds. The patient was then placed into a well-padded, 3-sided, AO-type plaster splint with the ankle in neutral and dorsiflexion. LMA was required for the procedure and the patient was extubated without difficulty. He was taken to the postanesthesia care unit in stable condition.

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Voice Evaluation and Therapy Medical Transcription Sample

The patient is a (XX)-year-old man with a history of intracranial hemorrhage who presents with generalized weakness, nausea and vomiting. He also had some prior deficits on his left side secondary to a prior pontine infarct. During the prior hospital stay, the patient required intubation and subsequent extubation. He was noted to have an aphonic vocal quality. He was seen by Dr. Doe of otolaryngology in February of this year with findings of a left vocal fold paralysis either secondary to intubation or as a result of his CVA. He was followed clinically, however, continued with near aphonic vocal quality. Dr. Doe performed a thyroplasty for vocal fold medialization. At his most recent office visit, flexible laryngoscopy revealed left vocal fold in a more medial position, allowing for good glottic closure. The patient continued with breathy weak voice, however, and he was subsequently referred for voice therapy.

The patient has an extensive medical history including hypertension, diabetes, dyslipidemia, prior lacunar stroke, and intracranial hemorrhage. A reported fall at rehabilitation resulted in a left hip fracture with an ORIF performed for repair of femur fracture. He has a heavy history of smoking. There is reported heroin abuse. However, the patient denies this. At the current time, he is frustrated by his weak and breathy voice. He reports that voicing is effortful and is exacerbated with use. Of note, the patient appears disheveled and emotionally labile at today's visit. Within home safety screen, the patient reported that he feels safe at home. The patient also reports that he is frustrated regarding ongoing pain and becomes emotional discussing this. When asked to elaborate further, he reports that he has had a level 8 pain each time he swallowed for the past week. For this reason, Dr. Doe was contacted for further evaluation given history of recent thyroplasty and high level of reported pain.

VOICE HANDICAP INDEX:  The voice handicap index (VHI) was administered to capture a subjective measure of the patient's perceived voice. Scores are as follows: Functional 26/32 (severely perceived functional handicap), physical 22/36 (severely perceived physical handicap), and emotional 19/40 (moderate to severe emotional handicap). Overall, the patient reports a total score of 67/100 correlating to a severely perceived voice handicap overall.

ACOUSTIC PARAMETERS:  The patient has a breathy vocal quality with low intensity. He is variably able to achieve improved voicing; although, this is inconsistent and negatively affected by emotional state. Maximum phonation time for sustained /a/ equals 4 seconds, although question the patient’s comprehension regarding appropriate initiating breath with prolonged production.

The perceptual analysis of dysphonia (GRBAS) was administered to qualify the patient's current vocal quality. This is a subjective clinician rated scale from 0 to 3 with 0 equaling normal and 3 equaling severe. Scores are as follows:
Grade - severe (3) indicative of an overall severe dysphonia.
Roughness/harshness - severe (3) as noted through persistent voice breaks and vocal fry.
Breathiness - severe (3) noted through audible air leakage and short aphonic segments.
Asthenia - severe (3) notable in the presence of hypofunctional voice use and weakness.
Strain - normal (0) he is not noted to have severe strain.

RESPIRATORY PARAMETERS:  The patient has very shallow breath support, was limited. Breath replenishment at the conversational level. He speaks in short utterances only during today's evaluation and breath support is inadequate even for his short 4 to 8 word utterances. S/z ratio is unable to be obtained at this session due to the patient's emotional state and need for followup with Dr. Doe. This can be done at a future session to gauge glottic valving in a rudimentary fashion. This, however, may not be the most reliable measure with question of the patient's ability to accurately replicate desired phonemes.

OBJECTIVE MEASURES:  Objective measures obtained using the CSL. The first set is from a vowel prolongation.
1.  Highest fundamental frequency: 195.56, norm 150.08.
2.  Lowest fundamental frequency: 112.76, norm 140.4.
3.  Absolute jitter 472.088, norm 41.663.
4.  Shimmer percent 19.264%, norm 2.523%.
5.  Noise to harmonic ratio: 0.416, norm 0.122.
6.  Soft phonation index 3.598, norm 6.770.
7.  Degree of voice breaks: Zero, norm 0.2%.
8.  Degree of voiceless 95.488%, norm 0.2%.

The following measurements are obtained via a speaking sample.
1.  Minimum pitch 146.64.
2.  Maximum pitch 154.82.
3.  VFO 0.01.
4.  RAP 0.56.

The patient's lower than average lowest fundamental frequency and soft phonation index may be correlated to loosely adducted vocal folds. He may have inconsistent glottic valving despite improved medial positioning of the left vocal fold. The patient also appears to have a hypofunctional component to voicing so he may not be consistently and strongly achieving vocal fold adduction.

The patient's notably elevated degree of voiceless is supported by clinical findings of persistent voice breaks and near aphonia with breathy vocal quality.

HEARING AND ORAL MOTOR STATUS:  The patient has seemingly normal hearing acuity for a quiet one-on-one setting. Strength and range of motion of the articulators is judged to be generally within normal limits for conversational speech tasks. The patient is edentulous.

VOCAL HYGIENE AND DEMANDS:  The patient drinks 3 glasses of water per day. He drinks 3 cups of caffeinated coffee. He states he does not drink alcoholic beverages, but smokes a half pack of cigarettes a day. He lives at home with his mother. He does not work. He avoids using the telephone because people have difficulty hearing him.

SUMMARY AND IMPRESSION:  The patient is a (XX)-year-old male with a history of left vocal fold paralysis status post CVA and required intubation in the past after his CVA. The patient is approximately 3 weeks status post a thyroplasty procedure with improved positioning of paralyzed left vocal fold allowing for glottic contact. The patient continues with breathy vocal quality and reduced intensity indicative of hypofunctional voice use and it is further supported by objective measures during today's evaluation.
He may benefit from voice therapy optimizing functional voice use through coordination of respiration and phonation. However, question the patient's insight into problem and compliance with program. At this time, he states he is willing to try some exercises so he was provided with initial breath support and vocal energy exercises at the short phrase level. He had some slight success with this in today's session; although, it is unclear if the patient is able to discriminate between accurate and inaccurate productions.

He is scheduled for followup in one week's time. Until then, he is following up with Dr. Doe, later today, for reported odynophagia for the past week. Therapeutic intervention will be reassessed at each session pending the patient's success with home practice and insight into use of vocal techniques. The case was discussed with Dr. Doe who is in agreement.

RECOMMENDATIONS:
1.  Trial course of voice therapy.
2.  Follow up with Dr. Doe in clinic today for odynophagia.
3.  Intensive work with breath initiation and replenishment in order to optimize intensity and limit undue effort associated with voicing.
4.  Use of neck stretches and laryngeal massage once the patient has slightly more healing from thyroplasty procedure.
5.  Use of partially occluded vocal tract exercises for coordination of respiration and phonation.
6.  Further recommendations to be made pending therapeutic process.

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ENT Consult Medical Transcription Transcribed Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  Jane Doe, MD

CONSULTING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Chronic rhinosinusitis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who has cystic fibrosis.  He has been recently admitted due to cystic fibrosis exacerbation with gram-positive bacteremia and fevers. The patient's history is notable for recently being seen for shortness of breath and desaturation.  The patient underwent a blood culture in the emergency department showing gram-positive cocci in clusters and was subsequently admitted.  He has been on cefepime, aztreonam, voriconazole, Flonase and nasal saline.  In terms of his pulmonary complaints, his symptoms are improving and he is scheduled for a followup bronchoscopy tomorrow.  I have been asked to see him in terms of his chronic sinus complaints.  He has a history of endoscopic sinus surgery at the age of 8 and states that this immensely improved his breathing.  However, over the past year, he has developed worsening nasal congestion, facial pain and pressure over the ethmoid and infraorbital regions as well as thick green rhinorrhea.  He also has chronic cough with intermittent productive sputum and intermittent fevers and chills.  Some of this is due to his underlying pulmonary state as well.  He is chronically on Flonase and nasal saline and has been on a prolonged course of intravenous antibiotics as described.  He recently underwent a CT scan of the paranasal sinuses.

PAST MEDICAL HISTORY:  Cystic fibrosis related diabetes, pancreatic insufficiency, bipolar disorder, deep venous thrombosis in the superior vena cava, and he is chronically on Coumadin.

Past surgical history, medications, allergies, family history, social history, and review of systems per the patient's admitting history and physical.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6 degrees and T-max 99.6 degrees, heart rate 104, respiratory rate 21, oxygen saturation 98% on room air, blood pressure 114/66.
GENERAL:  Age-appropriate male, in no apparent distress.  Voice is slightly hyponasal.
HEENT:  Overall, face is symmetric.  No sinus tenderness.  Facial strength intact bilaterally.  Ears:  Bilateral lobes and pinnae without deformity.  External auditory canals patent.  Tympanic membranes pearly gray, mobile and intact.  Nose:  Pale boggy mucosa.  There are some prominent small blood vessels along Kiesselbach plexus along the right anterior septum.  No active bleeding currently, although the patient has been having some intermittent epistaxis.  Anterior rhinoscopy reveals no gross evidence of masses, polyps or purulence.  Oral Cavity/Oropharynx:  Moist mucous membranes and do not show lesions.
NECK:  No palpable lymphadenopathy or thyromegaly.  Trachea is midline.
NEUROLOGIC:  Cranial nerves II through XII are grossly intact bilaterally.

PROCEDURES PERFORMED:
1.  Bilateral flexible nasal endoscopy.
2.  Cauterization of right septum.

INDICATIONS:  Epistaxis and chronic rhinosinusitis.

PROCEDURE:  We passed the flexible nasal endoscope through the right nasal cavity.  There appeared to be some prominent blood vessels along the anterior septum as described.  The middle turbinate appeared to be somewhat edematous with synechial band between the middle turbinate and lateral nasal wall that was mildly obstructing in nature.  There appeared to be polypoid disease within the ethmoid cleft as well as the maxillary sinus on the right side that was obstructing in nature.  No gross evidence of purulent rhinorrhea.  I then passed the flexible nasal endoscope through the left nasal cavity.  The left maxillary antrostomy appeared to be open itself, but there was a significant amount of mucosal thickening in the left maxillary sinus filling nearly the entire cavity.  There was also significant mucosal thickening with polypoid disease in the ethmoid itself.  There were some thick green secretions noted as well.  We then cauterized the right anterior septum using silver nitrate and there was no further evidence of bleeding.  The patient tolerated the procedure well.

CT scan of the paranasal sinuses was personally reviewed.  There were multiple abnormal findings including complete opacification of bilateral frontal sinuses.  There was evidence of prior sinus surgery with maxillary antrostomy and ethmoidectomies noted.  There was complete opacification or near complete opacification of bilateral ethmoid sinuses, particularly on the right side.  There was complete opacification of the left maxillary sinus and partial mucosal thickening of the right maxillary sinus.  There was left sphenoid sinus mucosal thickening.  The right sphenoid sinus was well aerated.  No air-fluid level throughout the paranasal sinuses.

IMPRESSION:
1.  Symptomatic chronic rhinosinusitis.
2.  Cystic fibrosis.

PLAN:  The patient has been on multiple intravenous antibiotic therapies and continues to have evidence of persistent chronic rhinosinusitis seen on flexible nasal endoscopy and CT scan of the paranasal sinuses.  Given the fact that he continues to have persistent symptoms, I do believe that he would benefit from endoscopic sinus surgery and this will be set up as an outpatient.  Otherwise, he should continue his current medications including Flonase 2 sprays each nostril once daily and nasal saline irrigations twice daily.

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


Renal Consult Medical Transcription Transcribed Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

CONSULTING PHYSICIAN:  John Doe, MD

REQUESTING PHYSICIAN:  Jane Doe, MD

REASON FOR CONSULTATION:  To evaluate the patient for acute renal failure.

SOURCE AND RELIABILITY:  History obtained from medical records. Unable to obtain history from the patient because he is intubated.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with history of coronary artery disease, hypertension, history of bypass surgery, chronic anemia with 3-month history of shortness of breath with exertion. The patient denied associated chest pain. He had worsening symptoms over the past week prior to admission. He underwent an outpatient dobutamine stress test. This was negative for reversible ischemia. Left ventricular ejection fraction was 35% and heart rhythm was irregular. The patient was admitted for further cardiac workup of atrial fibrillation. He was in congestive heart failure and required IV diuretics. BUN and creatinine on admission was 8.5 and 0.8 and H and H was 8.8 and 27.4. The patient underwent EGD and colonoscopy for evaluation of chronic anemia. EGD showed multiple antral erosions with chronic gastritis and colonoscopy revealed an ascending colon mass, 75% occlusion. Pathology is positive for moderately differentiated adenocarcinoma. The patient also had problems with bradyarrhythmias, which required pacemaker placement. He developed a brief episode of acute encephalopathy, which resolved on its own. EEG did not show any seizures. The patient was being optimized for right colectomy. He is having problems with elevated LFTs and coagulopathy, which is being corrected with FFP. Yesterday, the patient developed acute onset of shortness of breath requiring intubation. He became hypotensive post medications. The patient developed acute renal failure with baseline creatinine of 0.8, yesterday 1.8. Today, creatinine is 2.8. Therefore, renal consult has been obtained. The patient did receive boluses of IV fluids, and despite that, urine output has been marginal. Lasix drip was started overnight with no improvement today. The patient is anuric. He is currently on norepinephrine drip. The patient does not have any evidence of prior kidney disease. CT scan of the abdomen with IV contrast was performed and this revealed nonobstructive, right-sided renal stones.

PAST MEDICAL HISTORY:  Hypertension; coronary artery disease status post CABG, negative recent dobutamine stress test for ischemia; atrial fibrillation/sick sinus syndrome status post dual chamber pacemaker; hyperlipidemia; chronic anemia; right colon moderately differentiated adenocarcinoma diagnosed during this hospitalization; chronic gastritis, EGD performed during this hospitalization; right renal stones diagnosed this hospitalization by CT scan; borderline diabetes, which has been diet controlled; glaucoma of the right eye; status post appendectomy.

MEDICATIONS PRIOR TO ADMISSION:  Lopid 600 mg p.o. b.i.d.; Crestor 10 mg p.o. daily; diltiazem 120 mg slow release one daily; enalapril 10 mg p.o. b.i.d.; aspirin 325 mg daily; Lumigan 0.03% ophthalmic drops both eyes at bedtime; Timolol 1 drop, right eye, q.a.m.; Alphagan 1 drop, right eye, b.i.d.; Aleve p.r.n. pain. and Tylenol p.r.n. pain.

CURRENT MEDICATIONS:  Norepinephrine drip at 26.6 mcg per minute; propofol drip; fentanyl drip; Lasix drip at 40 mg per hour; insulin drip; Combivent puff MDI; amiodarone 400 mg p.o. b.i.d.; Lumigan 1 drop, both eyes, at bedtime; Alphagan 0.15% ophthalmic drop b.i.d., right eye; Celebrex 200 mg p.o. daily; TPN at 70 mL per hour; gemfibrozil 600 mg p.o. b.i.d.; Prevacid 30 mg NG b.i.d.; lisinopril 10 mg p.o. daily, last dose given yesterday; Zosyn 2.25 grams IV q.6 h., started yesterday; Diprivan drip; Crestor 10 mg p.o. daily; Timolol 0.5% ophthalmic solution, right eye, one drop daily and Vancomycin 1 gram IV q.24 h.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY:  Mother is alive at age 89. Father deceased at age 76. Four siblings; one brother passed away from some type of cancer, another sister passed away from heart disease. The patient has one son and one daughter, both are in generally good health. There is no family history of chronic kidney disease.

SOCIAL HISTORY:  The patient is currently married. The patient is a prior smoker. Drinks socially.

REVIEW OF SYSTEMS:  Unable to obtain review of systems from the patient because he is intubated.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.8, temperature up to 100.8 yesterday; pulse 102; respiratory rate 18; blood pressure 114/52; saturating at 97%. The patient is intubated. Weight on admission 68 kilos. Current weight is 82 kilos. I's and O's; 3735 in, 1490 out. Urine output is 0. Swan-Ganz catheter reading; CVP 14 to 17, wedge 18. Cardiac index 2 to 3, up to 4.2.
GENERAL APPEARANCE:  The patient is a well-developed male, intubated.
HEENT:  Normocephalic, atraumatic. Pupils are reactive. Nose clear. Mouth; ET tube and NG tube present.
NECK:  Supple. No obvious carotid bruits. Jugular venous distention is present.
BACK:  Unable to examine. The patient is intubated.
LUNGS:  Anterior is clear.
HEART:  Irregularly irregular, healed median sternotomy scar.
ABDOMEN:  Distended with decreased bowel sounds, right lower quadrant appendectomy scar.
EXTREMITIES:  2+ edema with some scrotal edema.
GENITOURINARY:  Foley catheter is in place.
JOINTS:  No synovitis.
MUSCULOSKELETAL:  Normal tone.
SKIN:  No systemic rash. Peripheral pulses are intact.
NEUROLOGIC:  The patient is intubated and sedated.

LABORATORY DATA AND DIAGNOSTIC DATA:  Sodium 133, potassium 3.9, chloride 104, bicarbonate 22, BUN 74, creatinine 2.8, creatinine yesterday 1.8. On admission, BUN 8, creatinine 0.8. Phosphorus 4.4, magnesium 2.3, calcium 8.3, albumin 2.9, total CK 105, BNP 445. Lactic acid 2.5. Total bilirubin 2.2, direct bilirubin 0.8, alkaline phosphatase normal at 77. LFT elevated at 346, peaked at 966, AST 169 which peaked at 1198. Hemoglobin 10.8, hematocrit 32.6, white blood cell count 33.4, yesterday 40; neutrophils 89, bands 8, lymphocyte 1, monocytes 2, platelet count 52. INR 1.8, PT 19.8. TSH is normal at 1.8. Blood gas; pH 7.34, PCO2 35, PO2 112, bicarbonate 19, saturating at 98%. Urinalysis; pH 5.6, protein 100, large blood and large leukocyte esterase, positive nitrite, greater than 100 rbc’s, white blood cells 510 and a few bacteria. Urine culture showed greater than 100,000 of E. coli; it is sensitive to Zosyn. Blood cultures later on showed no growth to date. TIBC is 514, total iron is 32, ferritin is 5, CEA is 18.2.

Chest x-ray performed today and reviewed by me showed cardiomegaly with right upper chest wall pacemaker. Pulmonary edema is present with increasing right pleural effusion. Chest x-ray is worse compared to the prior x-ray. Also, right lower infiltrate present. Echocardiogram performed during his hospitalization showed ejection fraction of 40% to 45% with mid inferoseptal, apical septal and apical anterior wall hypokinesis. Right atrial and left atrial enlargement mild to moderate. Mild to moderate mitral regurgitation and tricuspid regurgitation. Moderate pulmonary hypertension. EKG reviewed by me showed PR interval 166 milliseconds, QTc 384 milliseconds. Q-waves in inferior leads, poor R-wave progression. Inferolateral T-wave inversions. CT scan of the abdomen and pelvis with IV contrast showed fatty infiltration of liver and no evidence of metastatic disease. Right renal stones, 5 mm, nonobstructing calculus in upper pole of right kidney and second calculus in lower pole. Cardiomegaly and tiny right pleural effusion.

IMPRESSION:
1.  Acute renal failure. This is due to prerenal sepsis, congestive heart failure in a patient newly diagnosed with right colon carcinoma. Renal function is worsening despite challenges with IV fluids. The patient remains anuric despite Lasix drip. The patient will need continuous hemodialysis. No evidence of obstruction. The patient is currently on broad spectrum antibiotics. The patient did receive IV contrast during this hospitalization; however, his creatinine remained stable. It is unlikely to be the primary cause of his current acute renal failure.
2.  Renal stone which is nonobstructive. This can be worked up as an outpatient when the patient stabilizes.
3.  Right colon carcinoma. The patient needs a colectomy once he is medically stable.
4.  Coronary artery disease with cardiomyopathy and new onset of atrial fibrillation.
5.  Elevated LFTs. This may be due to congestive heart failure and this is improving. We will rule out hepatitis.

RECOMMENDATIONS:
1.  We will initiate continuous hemodialysis today and remove fluid. Consent has been obtained over the phone from the patient's durable power of attorney, who is his son.
2.  We will check hepatitis B and C serologies.
3.  Continue IV antibiotics.
4.  Discontinue Celebrex.

We will follow along closely with you. Thank you for this referral.

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Neuro Critical Care Consultation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REASON FOR CONSULTATION:  Neuro critical care management.

HISTORY OF PRESENT ILLNESS:  I was asked to assist in the neuro critical care management of this (XX)-year-old male who was found at the bottom of a flight of stairs by bystanders. EMS was called, and at that time, EMS said the patient was oriented to self and was complaining of neck pain and headache. They did not report whether he was moving his arms and legs at that time, but apparently, then, he began having a seizure that lasted approximately 2 minutes. He was given Valium 5 mg. He was noted to have a right lateral gaze. His GCS was initially 7 to 8 and then dropped to 3. His blood pressure in the field was 138/86 with a pulse of 70. He was brought immediately to the emergency room. His blood pressure at that time was 162/82 with a pulse of 102. His temperature was 96.6. He was saturating at 94% and his GCS was 3. He was intubated with a rapid sequence intubation with 100 mg of lidocaine, fentanyl 50 mcg, vecuronium 1 mg, etomidate 20 mg and succinylcholine 200 mg. He was then given Versed 2 mg and another 9 mg of vecuronium thereafter. He also received Cerebyx 1 gram, Ancef 1 gram. He was taken for CT scan and MRI. He received a total of 3450 mL in the ER and 2450 mL out. His initial blood gases in the emergency room were venous 6.96/62/122. Sodium was 141, potassium was 3.8, ionized calcium was 1.15, H and H of 16.4 and 48.2.

PAST MEDICAL HISTORY:  Unknown.

MEDICATIONS AS OUTPATIENT:  Unknown.

ALLERGIES:  Unknown.

SOCIAL HISTORY:  Unknown.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 99.4 with blood pressure running between 120 to 160 over 70 to 90, cuff MAP at 88 to 110 with pulse of 72 to 84, saturating at 100% on SIMV mode, tidal volume of 700, rate of 12, pressure support of 10, PEEP of 5.
GENERAL APPEARANCE:  The patient is lying in bed unresponsive, orally intubated.
HEENT:  There is a large amount of blood coming from his head. There is a large laceration on the posterior aspect of his scalp. His sclerae are clear. He has no periorbital edema. There is no blood coming from his ear canal or his nostrils.
NECK:  The patient has a cervical collar in place.
HEART:  Regular rate and rhythm.
CHEST:  Without deformity or scars.
LUNGS:  Clear to auscultation bilaterally.
ABDOMEN:  Scaphoid, not distended. No bowel sounds present.
EXTREMITIES:  Some abrasions over the fingers, but no obvious limb deformities. Pulses are equal bilaterally and the radial DP and PT with good capillary refill. The patient has a laceration of his right knee.
NEUROLOGIC:  The patient is unresponsive to voice and pain. He does not blink to threat. His pupils are 3 mm and reactive bilaterally. Intermittently, the patient will have jerking movements of his arms and legs as though he was partially paralyzed. A train-of-four stimulation showed 1/4 stimulation with significant decrement. After waiting approximately a half hour, the patient began to move more. His left arm withdrew to pain, approximately 4-/5 strength, the right arm approximately 3-/5. The left leg withdrew, 3/5 strength in the lower extremity and the right was 2/5. His left toe was mute, the right toe was downgoing. His reflexes were 2 throughout. To deep pain, the patient had symmetric grimace.

DIAGNOSTIC AND LABORATORY DATA:  CT scan of the head shows no intracerebral hemorrhages, no extra-axial fluid collection, but bilateral encephalomalacia of the frontal lobes that appear old. An MRI of the brain also shows the same findings. No evidence of hemorrhage. The CT of the cervical spine shows a C4 on 5 subluxation with a left facet jump. The MRI shows the cord is slightly impinged, but no obvious cord hematoma or cord change in signal. Anterior to the cord is either hemorrhage or possible calcification of OPLL. Chest x-ray shows right mainstem intubation with lung fields clear. The tube has subsequently been pulled back. Chest CT shows a questionable small pneumothorax on the right. There is also question of right upper lobe collapse. Otherwise, no acute intrathoracic abnormalities. The abdominal and pelvic CT negative except for old thoracic compression fracture. Lumbar spine was clear. FAST was negative.

Repeat ABG was 7.42/39/33.5. Sodium 141 with a potassium of 3.7, chloride of 104, bicarbonate 16, BUN 13, creatinine 1.3, glucose 115, calcium 1.15, and lactic acid 18. White count 13.4 with H and H 14.8 and 44 .8. MCV is 91.8, segs 46, lymphs 38, monos 14, eosinophil 1, basophil 1 with platelet count of 396. PT is 15.2 with INR 1.2, PTT is 31.5 with a ratio of 0.8. Toxicology screen is positive for cocaine as well as alcohol, 1.03, benzodiazepines are also positive. This is likely due to the Valium in the field.

IMPRESSION:  This is a (XX)-year-old male who is status post fall down a flight of stairs, who has had an episode of seizures that lasted approximately 2 minutes. It is unclear whether this was due to his old encephalomalacia or whether he has a known seizure disorder. An EEG will be performed and the patient will be loaded with fosphenytoin and continue at 100 mg q.8 h. and recheck a level in a.m. In addition, the patient is unresponsive and this may have been the postictal state as well as receiving Valium. There is no obvious intracranial abnormality at this time. It is not clear whether the patient had any hypoxic ischemic injury as he was awake in the field. The initial ABG was a venous ABG and cannot be relied on for his oxygenation status. The patient also has a C4 on 5 subluxation and Orthopedics has been consulted for evaluation. Since the patient is moving and although he cannot be fully evaluated for strength testing, he is at least moving his lower extremities, 3/5 strength on the left and 2 on the right. His arms are also moving better on the left than the right; it was 4 and 3 respectively. The orthopedist planned for tongs with attempt to reduce the subluxation initially by closed method, otherwise, will proceed to open reduction, internal fixation tomorrow per Dr. Doe, if they are unable to reduce the patient. After tongs and weight are placed, a repeat C-spine plain film will be obtained. The patient has respiratory failure due in part to his mental status and inability to protect his airway. His full cervical spine status is not clear. We will normalize his PCO2. Blood pressure is currently adequate.

PLAN:  To admit to the neuro intensive care unit for close neuro checks. Propofol for slight sedation. We will decrease the propofol later to assess his neurologic status. We will maintain MAP greater than 80, initially with fluids, to maintain good spinal cord perfusion. Solu-Medrol protocol for potential traumatic cervical myelopathy. Protonix for stomach prophylaxis. Venodyne for DVT prophylaxis. The patient will be n.p.o. for now. Central venous catheter as well as arterial lines were placed. Blood sugars will need to be obtained and may need an insulin drip if sugars are elevated. Tetanus toxoid needs to be given. IV fluids, normal saline, with 20 of potassium at 150 mL per hour. Serial lactic acids will be obtained, p.r.n. fentanyl if the patient has significant evidence of pain and an EEG.

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Followup Neuropsychological Evaluation Medical Transcription Example

DATE OF EVALUATION:  MM/DD/YYYY

REASON FOR REFERRAL:  The patient is a (XX)-year-old right-handed male who returns at this time for one-year followup neuropsychological evaluation. He was previously felt to have mild cognitive impairment and followup testing was suggested to determine any progression of his cognitive impairment to rule out dementia.

TESTS PERFORMED:
A.  Selected subtests of the Wechsler Adult Intelligence Scale-III and the Wechsler Memory Scale-III.
B.  California Verbal Learning Test-II.
C.  Rey-Osterrieth Complex Figure Test with recall and recognition trials.
D.  Clock drawing.
E.  Boston Naming Test.
F.  Semantic and Phonemic Verbal Fluency Test.
G.  Grooved Pegboard Test.
H.  Beck Depression Inventory and interview.

BRIEF HISTORY:  The patient stated that he thinks his memory is slightly worse than it was 1 year ago when he was previously tested. He continues to be independent in all of his activities of daily living including driving. He feels that his ability to recall people's names and come up with words and conversations has worsened. He said that he cannot do mental arithmetic as well as he used to. He cannot explain things as well. He said that he tends to avoid social situations so he does not have to express himself, but also said that he has always been anxious in social situations. He feels that the problems he is experiencing have made him depressed. He continues to see Dr. Doe for treatment of depression and is on Zoloft. His dose was recently raised to 200 mg per day. He is no longer on Aricept. He continues to drink 4 to 5 glasses of wine most days. He has not had any changes in his medical condition in the last year.

BEHAVIORAL EXAMINATION:  The patient presented as a very pleasant and cooperative man, neatly dressed and groomed, and appearing approximately his age. He answered questions with a normal degree of elaboration and his thought processes were logical, organized, and goal directed. His mood was somewhat anxious and his affect was slightly constricted in range and intensity. During the testing, he appeared to work to the best of his ability. He understood the instructions and the nature and purpose of the examination. The results are felt to accurately reflect his current level of function.

TEST RESULTS:
1.  Attention, Concentration, and Processing Speed:  The patient could repeat 6 digits forwards and 5 backwards, which compares to 7 forwards and 5 backwards last year. Mental arithmetic was done at a slightly less proficient level, decreasing from the 91st percentile to the 75th percentile for his age. His performance on mental arithmetic tests was somewhat inconsistent and he was often heard incorrectly registering the information that was given, suggesting some attentional problems. Measures of visual and motor processing speed were essentially unchanged. The one exception was his performance on a test requiring visual search for target symbols. He made 4 or 5 errors on this particular test, which is a change from last year.
2.  Memory:  His performance on measures of verbal memory improved. Immediate memory for logically related verbal material improved from the 37th to the 75th percentile, with a similar improvement in delayed recall and retention. Similarly, he demonstrated slight improvement on a word list learning test. These improvements were seen on measures of immediate recall, delayed recall, and recognition memory. In contrast, he showed a slight decline on measure of visual memory, apparent both on immediate recall and delayed recall. Visual recognition memory remained unchanged, in the average range.
3.  Language:  Confrontational naming decreased slightly from a score of 60/60 on the Boston Naming Test to 56/60. Performance on measures of both phonemic and semantic verbal fluency also declined slightly, but remained well within the average range for his age and education.
4.  Visual spatial:  His ability to put together colored blocks to match a model was essentially unchanged. Copy of a complex figure was unchanged. His clock drawing was intact. There was a slight decline on a measure of attention to visual detail.
5.  Motor:  Fine motor speed and dexterity were essentially unchanged bilaterally.
6.  Problem solving, Reasoning, and Executive Functions:  His performance on the Trail Making Test Part B, which involves complex visual or motor tracking and mental flexibility was unchanged at the 54th percentile for his age and education. Verbal abstract concept formation was also unchanged, in the superior range. As mentioned, his clock drawing was good and showed normal spatial planning and conceptualization. His copy of a complex figure was adequately organized and planned.
7.  Emotional:  On the Beck Depression Inventory, he obtained a score of 15, which is in the mildly depressed range. He continues to have problems with self-esteem, indecisiveness, fatigue, poor concentration, and decreased interest. These symptoms were endorsed at a mild level. In the interview, he talked about some degree of social isolation. He moved here for a job and has given up some close friendships that he had on the west coast. He does have several acquaintances, but does not have a close circle of friends like he used to. This continues to be the source of some dysphoria for him.

EVALUATION CONCLUSIONS:  Neuropsychological reevaluation showed improvement on measures of verbal memory, but mild decline on measures of language and visual spatial skills including visual memory. None of the scores fell into the frankly impaired range, but rather showed declines from above average or superior levels to average levels in most cases. It is not clear whether these scores reflect true brain-related changes or simply chance of variations or regression to the mean. Because his memory test scores improved, the likelihood of underlying Alzheimer disease is negligible. However, there may have been some increase in cerebrovascular disease causing the focal changes noted on testing. He said that he had an MRI of the brain in the last year, but those results are not available at this time. The depression may also cause some fluctuations in cognition, both on a day-to-day basis and on formal testing.

DIAGNOSTIC IMPRESSION:
1.  Cognitive disorder, not otherwise specified.
2.  Adjustment disorder with depressed mood.

RECOMMENDATIONS:  The patient should continue to have treatment for the depression. He may need to be encouraged to develop friendships. Retesting should be done in 1 year, given the evidence of changes in specific cognitive skills. He has made an appointment for approximately 1 year from now.

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Oncology Consultation Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

CONSULTING PHYSICIAN:  John Doe, MD

REQUESTING PHYSICIAN:  Jane Doe, MD

Thank you for referring the patient for medical oncology consultation.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with noninvasive left breast cancer. The patient had a screening mammogram 4 months ago, which revealed a left upper outer breast abnormality. Stereotactic biopsy previously confirmed ductal carcinoma in situ. The patient underwent needle localization excision with pathology confirming ductal carcinoma in situ grade 2, ER positive, PR positive. She received ipsilateral breast radiation. Her course has been complicated by apparent incision site infection, which has resulted in persistent low-grade oozing of blood and occasional extrusion of pus. She has been treated with several courses of antibiotics. However, the scant bloody discharge continued. Over the past 1 week, she has noted increasing tenderness at the site of bleeding and apparent infection. She otherwise offers no complaints.

PAST MEDICAL HISTORY:  Remarkable for anemia attributed to iron deficiency for which she takes iron supplements. There is no hypertension, diabetes, hypercholesterolemia or prior cardiac, pulmonary or hepatic dysfunction. She maintains normal monthly cycles; however, the last cycle has been particularly prolonged at 12 days.

MEDICATIONS:  She takes no regular prescription medications.

ALLERGIES:  NO KNOWN ALLERGIES.

FAMILY HISTORY:  Remarkable for sister with diagnosis of breast cancer at age 40, presently 47, in remission. No other known family history of breast or ovary cancer. Father died at age 74 of cardiac disease, mother aged 76 with history of heart disease; 3 brothers, 2 sons, and 1 daughter are healthy.

SOCIAL HISTORY:  Married. No cigarettes or alcohol.

REVIEW OF SYSTEMS:  No fever, chills, sweats, headaches, seizures, syncope, blurred vision, dysphagia, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, hematochezia, dysuria, hematuria, flank pain, back pain, abnormal bleeding, bruising, lymph node swelling or focal paresthesias or weakness.

PHYSICAL EXAMINATION:
GENERAL:  The patient is well developed, well nourished, in no acute distress.
VITAL SIGNS:  Temperature 98.6, heart rate 64, blood pressure 102/62, weight 78.4 pounds, and height 64 inches.
SKIN:  Skin clear. No rash, ecchymosis or petechia.
HEENT:  Normocephalic. No scleral icterus. No mucosal lesions.
NECK:  Supple without thyromegaly.
LYMPH NODES:  No secondary neck, axillary or inguinal nodes.
BREASTS:  Without dominant mass bilaterally. There is moderate induration of approximately 3 cm across, underlying the left upper outer quadrant incision. There is no fluctuance, erythema and no significant tenderness to the area.
CHEST:  Clear to auscultation and percussion.
CARDIAC:  Regular rate and rhythm. No murmur, rub or gallop.
ABDOMEN:  Soft and nontender. No masses or hepatosplenomegaly.
RECTAL AND GENITAL:  Deferred.
EXTREMITIES:  No clubbing, cyanosis or edema.
MUSCULOSKELETAL:  No back tenderness. No bony or joint deformity.
NEUROLOGIC:  Alert and oriented. Cranial nerves, sensory and motor system and gait are normal.

IMPRESSION:  Ductal carcinoma in situ, left breast, stage 0 (Tis N0 M0), ER positive, PR positive, status post lumpectomy to negative surgical margins and has set up breast radiation. Overall prognosis is excellent with estimated risk of local recurrence in the 5% range. Risk of systemic metastasis is negligible. Thus, adjuvant systemic therapy is not warranted. She is of course at increased risk for second malignancy, thus tamoxifen chemoprevention would be a reasonable option.

RECOMMENDATIONS AND PLAN:  Diagnosis, prognosis, and management options were discussed in detail with the patient and questions were answered. Tamoxifen chemoprevention was discussed in detail and she at present appears agreeable to initiation of therapy. There is a prescription for tamoxifen 20 mg daily. On the assumption that she desires continuing oncologic followup, any followup appointment will be made in 6 months. Alternatively, if she should decline tamoxifen chemoprevention or if her primary care physician would be willing to prescribe tamoxifen and provide continuing oncologic followup, then medical oncology followup will be on an as needed basis. 

Thank you very much for asking me to see this patient in consultation.

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