Rheumatology Consult Medical Transcription Sample / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

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

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

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

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

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

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

SOCIAL HISTORY:  The patient is divorced.

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

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

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

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

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

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

Rheumatology Consult Sample Report

Metatarsal Cheilectomy / Decompressive Osteotomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left hallux rigidus.

POSTOPERATIVE DIAGNOSIS:  Left hallux rigidus.

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

SURGEON:  John Doe, DPM 

ANESTHESIA:  Local/MAC.

HEMOSTASIS:  Pneumatic ankle tourniquet at 250 mmHg.

ESTIMATED BLOOD LOSS:  Less than 20 mL.

COMPLICATIONS:  None.

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

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

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

Laparoscopic Appendectomy Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Acute appendicitis.

POSTOPERATIVE DIAGNOSIS:  Acute appendicitis.

OPERATION PERFORMED:  Laparoscopic appendectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

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

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

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



Exercise Stress Test Sample Report / Transcription Example

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR EXAMINATION:  Chest pain, shortness of breath and cardiomyopathy.

DESCRIPTION OF PROCEDURE:
The patient exercised on Bruce protocol for 8 minutes and 4 seconds, achieving a heart rate of 142, which is 81% of his age-predicted maximum heart rate. Resting heart rate was 80 with resting blood pressure of 134/92. With exercise, the blood pressure increased to 169/94 and the heart rate increased to 142. Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left ventricular hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain.

IMPRESSION:
1.  Average exercise capacity.
2.  Somewhat blunted heart rate response secondary to beta-blocker use.
3.  Normal blood pressure response.
4.  No clinical or electrocardiographic changes consistent with myocardial ischemia noted during this exercise stress test.
5.  Sestamibi imaging results will be reported separately.

Thank you for this kind referral.

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

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR EXAMINATION:  Chest pain.

DESCRIPTION OF PROCEDURE:  Cardiolite stress testing was performed for evaluation of chest pain. Informed consent was obtained from the patient.  First, the patient had resting perfusion images with Cardiolite.  The patient was brought to the stress test laboratory and was exercised on regular Bruce protocol. Resting EKG showed normal sinus rhythm, rightward axis.  There was also poor R-wave progression noted over the precordial lead.  The EKG was also of low voltage, especially in chest leads. The patient exercised on regular Bruce protocol for 4 minutes and 6 seconds.  He achieved a heart rate of 126 beats per minute, which is 81% of the maximal predicted heart rate.  Maximum blood pressure response was 192/106.  Maximum workload attained was 5.5 METS.  Reason for termination of stress testing was shortness of breath, tiredness and especially leg fatigue.  One minute before termination of stress testing, Cardiolite was reinjected per protocol. Review of the stress EKG and recovery EKG did not demonstrate ischemic ST depression or elevation.

CONCLUSION:
Negative exercise electrocardiogram for ischemia at a workload of 5.5 METS.

Thank you for this kind referral.

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Pulmonary Consult Medical Transcription Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Pleural effusions and hypoxemia.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male with a complicated past medical history, who has been on peritoneal dialysis since many years. The patient has a history of diabetes mellitus and coronary artery disease. He was recently admitted and was found to have a pelvic abscess secondary to sigmoid diverticular rupture. He was found to have an infected hemodialysis catheter. He underwent sigmoid resection and cholecystectomy, and after that, peritoneal dialysis could not be re-formed and he was switched over to hemodialysis and he has a right internal jugular dialysis catheter for this. The patient, however, during that time period states that he had at least 3 or perhaps 4 thoracenteses performed and we were asked to see him for the finding of pleural effusion, still persistent on chest x-ray, and also the need for increasing supplemental oxygen. The patient denies any shortness of breath at rest and only has minimal shortness of breath with exertion. He has engaged in physical therapy activities without difficulty.

CURRENT MEDICATIONS:  Digoxin 0.125 mg daily, Zocor 20 mg daily, Protonix 40 mg daily, folic acid 5 mg, B complex 1 capsule daily, Colace 100 mg b.i.d., vitamin B12 1000 mcg every 30 days, nystatin 15 grams of powder topically, Panafil ointment daily, Accuzyme spray daily, Xenaderm ointment b.i.d., iron sulfate 325 mg daily, Epogen 10,000 units 3 times per week, ProAmatine 10 mg on dialysis days 1 tablet hour before and 1 tablet after the first hour of each hemodialysis. He is on Lotrimin 1% cream b.i.d. He is on Lantus insulin 12 units daily and regular insulin sliding scale, Cardizem 120 mg daily, Levaquin 250 mg daily, Coreg 12.5 mg b.i.d., Cozaar 50 mg b.i.d., Flagyl 250 mg t.i.d. He is also on Coumadin.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY: The patient is a former smoker having quit about 20 years ago, but he did smoke 1 to 2 packs per day for 8 years. There is also significant recent alcohol use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: He has no headache, fevers, chills or sore throat. He denies any neck pain or stiffness. He denies any chest pain. He has no purulent sputum production. He denies any abdominal pain, nausea or vomiting. He denies any diarrhea but did have some loose stools in the past. He has been getting his physical therapy and is ambulating with a walker. He does still have some lower extremity edema. He denies any specific muscle weakness. He has no hot or cold intolerance. He denies any known history of thromboembolic disease.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 126/84, pulse 92, respirations 22, temperature is 96.8.
HEENT:  Oropharynx clear. Nasopharynx clear. No sinus tenderness.
NECK:  No increased jugular venous distention seen but there is a hemodialysis catheter in place, which limits the examination in the right internal jugular area. There is no obvious thyromegaly. Trachea is midline.
CARDIOVASCULAR:  Regular rate and rhythm. S1 and S2 are normal. There is no murmur, gallop or rub.
LUNGS:  Significant for decreased breath sounds at both bases approximately one-quater way up, but there is only mild egophony present, mostly at the right base.
CHEST:  Expansion is symmetric. No accessory muscle use.
ABDOMEN:  Soft and nontender. No palpable organomegaly, no masses. Bowel sounds present.
EXTREMITIES:  Difficult to palpate but there does appear to be significant 1 to 2+ edema present in both lower extremities palpated through the patient's devices on his lower extremities. Unable to palpate distal pulses in the lower extremities. Radial pulses are 2+.
NEUROLOGIC:  The patient is alert and oriented x3. Motor examination was not able to be done completely. The patient's face appears symmetric and he does move all extremities well.

DIAGNOSTIC/LABORATORY DATA:  Chest x-ray was personally reviewed and shows bilateral pleural effusions and increased pulmonary and vascular congestion. Hemodialysis catheter is in place. CT of the abdomen shows cuts at the lower lung fields showing bilateral pleural effusions and associated atelectases.

INR from yesterday is 2.34 with a prothrombin time of 23.2. CBC:  Hemoglobin 13.6, hematocrit 41.2, white cell count 11.2, and platelets 164,000. C-reactive protein from yesterday is 4.94, elevated. Chemistries; sodium 136, potassium 4.6, chloride 102, bicarbonate 30, BUN 32, creatinine 3.6, glucose 142. Sedimentation rate was mildly elevated at 24.

ASSESSMENT:
1.  Bilateral pleural effusions, likely secondary to congestive heart failure.
2.  Respiratory insufficiency.
3.  Hypoxemia.
4.  Atelectasis.
5.  End-stage renal disease.

PLAN:  We will recheck chest x-ray and suggest as much as possible fluid removal with hemodialysis. If the patient needs thoracentesis, we will send the patient across the street for ultrasound guidance. We will add nebulizers with Xopenex and Atrovent and continue oxygen therapy. Because of the patient's elevated INR, if a decision to do a thoracentesis is done, the patient's Coumadin will have to be held and INR will have to be followed to less than 1.5 range.

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Oncology Consult Medical Transcription Sample / Example Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  IgG kappa monoclonal gammopathy of undetermined significance.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who apparently had a 4-week history of at least 4 falls. The patient apparently had a right shoulder degenerative rotator cuff tear but improved at physical therapy. In addition, the patient was found to have a left inferior pubic ramus fracture and bilateral sacral chronic and acute insufficiency fractures. The patient was brought here for further evaluation and treatment. Workup including a serum protein electrophoresis was performed, which did show evidence of an IgG kappa monoclonal gammopathy of undetermined significance. We were asked to see the patient because of this finding. In general, the patient is doing well and rehab is actually going well.

PAST MEDICAL HISTORY: Significant for diabetes mellitus, coronary artery disease, osteoporosis, hypertension, osteoarthritis with a history of bilateral total knee arthroplasties with urinary incontinence, hypothyroidism and a history of a total abdominal hysterectomy. The patient also has had problems with recurrent falls in the past.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

MEDICATIONS:  Nitroglycerin, calcium carbonate with vitamin D, Lipitor, Glucophage, Catapres, Detrol LA, Zanaflex, Actonel, aspirin, multivitamin, Synthroid, Zestril, Lasix, Norvasc, K-Dur, Micronase, labetalol, sliding scale insulin, Lidoderm patch, Celebrex, insulin 70/30 and Senokot.

PHYSICAL EXAMINATION: 
GENERAL:  The patient is alert and oriented x3, in no distress.
VITAL SIGNS:  Stable. Afebrile.

LABORATORY DATA:  Lab work most recently performed showed a white count of 8.2, hemoglobin of 11.2, platelet count 372,000 with an MCV 87.6. Sodium 138, potassium 4.2, chloride 104, bicarbonate 26, BUN 26, creatinine 0.9, AST 16, ALT 34, alkaline phosphatase 233, total bilirubin 0.4, calcium of 9.9. Vitamin B12 was 507, folate 17.4. IgG 1032, IgA 162, IgM 46.

ASSESSMENT:
1. IgG kappa monoclonal gammopathy of undetermined significance.
2. Compression fracture of T12.
3. Osteoporosis.

PLAN:  At this time, I feel this likely is a monoclonal gammopathy of unknown significance. At this point in time, I do not see any evidence of myeloma. However, I would like to check a 24-hour urine for immunoelectrophoresis and a beta-2 microglobulin. This patient likely should be followed with quantitative immunoglobulin checks 1 to 2 times a year just to assure that things are not progressing.

Thank you for allowing us to participate in this patient's care. We will follow along closely in consultation.

Medical Transcription History and Physical Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS:  The patient is an (XX)-year-old female with history of TIAs, hypertension, hyperlipidemia, IBS and hypothyroidism, who was admitted yesterday after syncopal episode at home. The patient reports sitting outside for a while and then when she got up to walk into the house, she felt faint, slightly lightheaded and, when she got to the door, apparently fainted but seemed to recover within a few minutes. Her niece was there and witnessed the episode. There was some very short-lived confusion after the patient recovered, but then she felt better right away. There was no seizure activity, incontinence or postictal state. The patient denied any chest pain or palpitations prior to the syncopal episode. She does report that it was similar to a syncopal episode after having a bowel movement several years ago. Of note, the patient was most recently admitted to the hospital about two weeks ago for left facial numbness and TIA, which she has had multiple times in the past. At that time, workup included a negative EEG, a normal 2-D echocardiogram, carotid MRAs and Doppler studies as well as a brain MRI, which did not reveal any acute bleeds or ischemia, but did demonstrate the patient's known AV malformation. The patient had been evaluated by the neurology service, and once her workup was completed, she was discharged home in stable condition. She was seen in the office last week and was doing quite well until this event yesterday. This morning, she is doing well. She looks fine. There are no other complaints. Of note, she does report having a negative stress test 4 years ago.

PAST MEDICAL HISTORY:  TIAs, hypertension, hyperlipidemia, hypothyroidism, history of AV malformation and IBS.

MEDICATIONS:  Aspirin 81 mg daily, levothyroxine 25 mcg daily, Zocor 10 mg daily and lisinopril 40 mg daily.

ALLERGIES:  SULFA.

SOCIAL HISTORY:  No smoking, alcohol or drug use.

FAMILY HISTORY:  Mother died of colon cancer. Father had heart disease.

PHYSICAL EXAMINATION:  
VITAL SIGNS:  Blood pressure 144/74, pulse 72, respirations 18.
GENERAL:  The patient is alert and oriented x3. No acute distress. Nontoxic appearing.
HEENT:  Negative.
NECK:  Supple. No lymphadenopathy.
LUNGS:  Clear.
HEART:  Regular rate and rhythm with a faint holosystolic murmur consistent with the patient's mild mitral valve insufficiency seen on recent echocardiogram.
ABDOMEN:  Soft, nontender and nondistended. No hepatosplenomegaly. No masses.
EXTREMITIES:  No edema.
NEUROLOGIC:  Nonfocal.
SKIN:  Warm and dry. No rashes.

LABORATORY DATA:  On admission, white blood cell count was 6.6, hemoglobin 14.4, hematocrit 41.6, platelets 169,000. Glucose 104, BUN 21, creatinine 0.9. Sodium 134, potassium 3.6, chloride 101, CO2 of 28. LFTs were normal. Troponin was less than 0.4. Calcium was 9.3. D-dimer was 774. BNP was 23.

CT scan of the chest in the emergency room was negative for PE.

ASSESSMENT:
1.  Syncope, likely due to orthostatic hypotension.
2.  Hypertension.
3.  History of transient ischemic attacks.
4.  Hyperlipidemia.
5.  Hypothyroidism.
6.  History of arteriovenous malformation.
7.  History of irritable bowel syndrome.

PLAN:  We will repeat troponin this morning and check orthostatic blood pressures. If troponin is negative, we will obtain an adenosine stress thallium and await further neurology input and reevaluation.


Endoscopic Thoracic Sympathectomy Transcribed Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hyperhidrosis involving the face, hands and underarms.

POSTOPERATIVE DIAGNOSIS:  Hyperhidrosis involving the face, hands and underarms.

OPERATION PERFORMED:  Bilateral endoscopic thoracic sympathectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room. After the establishment of general endotracheal anesthesia, the patient was prepped with Betadine and sterile drapes. The left side was approached first. The patient was placed in a reverse Trendelenburg position and rotated to the right. The patient's breast was retracted medially and a small incision was made alongside the breast in the fourth intercostal space. The internal intercostal nerve block was first administered. Hemostat was then used to puncture in the thoracic cavity. An operating trocar and thoracoscope were passed in the thorax. Once we had assured access to the chest, CO2 insufflation was begun to displace the lung. Additional Marcaine was administered in the axilla and a second trocar was inserted at this level. Thoracic trunk was readily identifiable. Because of the patient's symptoms, we felt that at T2-T3, sympathectomy was warranted. The pleura adjacent to the sympathetic trunk was incised overlying the second and third ribs. The pleura was mobilized free from the underlying sympathetic trunk. The nerve was then gently manipulated with an L-hook. Two clips were placed at each level without difficulty. We looked before but did not identify any accessory nerves. Once, the clips were applied, CO2 insufflation was stopped. Additional 5 mL of Marcaine solution was instilled in the thoracic cavity. The lung was then re-expanded and the gas vented from the trocars. The trocars were removed as the lung expanded. Once the trocar was removed, the skin was closed with subcuticular suture of 4-0 Monocryl.

We then directed attention to the right side. The patient was rotated to the left. Mirror image incisions were made on the right side. Access to the thorax was achieved in the similar fashion. On this side, the sympathetic trunk was very difficult to identify. We thought we could notice something beneath the pleurae overlying T2 and in fact the pleurae were incised and we were not able to identify the sympathetic trunk at this level. We placed traction on the nerve but still could not identify at T3. Further dissection was then undertaken at T4 and again, based more on hunch and the anticipated anatomic location, we were able to incise the pleura and identify the nerve at T4. Dissecting superiorly and inferiorly from T2 and T4, we were then unable to trace the nerve in a location posterior to azygos vessel. At the T3 level then, we were able to incise the pleura laterally and mobilize it in a lateral to medial fashion. In so doing, we were then able to get behind the azygos vessel and hook the nerve with a hook. In so doing, we were able to mobilize it and pull it medially; however, we did not feel we safely applied clips without likely injury to the azygos vessel. Accordingly, we opted not to put clips at this level.

At this point, we applied 2 clips at the T2 level; this being the most important level in this patient. We then again hooked the nerve with an L-hook and then cauterized the nerve until it was divided. No significant bleeding was encountered. Once the nerve had been clipped and cauterized and there was no bleeding, we stopped CO2 insufflation. Additional 5 mL of Marcaine was instilled in the thoracic cavity. The gas was vented from the chest without difficulty. The trocars were removed as the lung was re-inflated. Skin was closed with subcuticular sutures of 4-0 Monocryl reinforced with Steri-Strips. The patient was then awoken from anesthesia and sent to recovery in satisfactory condition.

Type I Aortic Dissection Medical Transcription Transcribed Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Status post surgical revascularization of heart with left internal mammary artery graft, left anterior descending coronary artery and aortocoronary bypass x4. Now, presents with chest pain. CT scan demonstrates type I aortic dissection.

POSTOPERATIVE DIAGNOSIS:  Type I aortic dissection involving the ascending aorta.

OPERATION PERFORMED:  Type I aortic dissection, resection and reconstruction with 26 mm Hemashield graft and reimplantation of saphenous vein grafts, utilizing cardiopulmonary bypass.

SURGEON:  John Doe, MD

DESCRIPTION OF OPERATION:  After general endotracheal anesthesia was established, a femoral heart line was placed in the right common femoral artery for hemodynamic monitoring purposes. The patient had the left common femoral artery exposed and vessel loops placed around it. The chest was reopened, sternal wire was removed and the heart was dissected from the adhesions. Systemic heparinization was given through right atrial appendage and cardiopulmonary bypass was established through the femoral artery and the two-stage cannula in the right atrium. The patient was cooled, aortic cross-clamps applied and retrograde cardioplegia was injected as well as antegrade cardioplegia. 

With the heart arrested, the aorta was opened and the dissection was found to be just proximal to the area of cannulation and involving vein graft take-off sites. Thus, the aorta was resected and the vein grafts were preserved and the proximal anastomosis was able to be created with an outer rim of Teflon reinforcement and a 26 mm Hemashield graft and 3-0 Prolene suture. This was completed. The anastomosis was tested, felt to be hemostatic and reinforced as needed. Additional cardioplegia was given throughout the procedure. The proximal anastomosis was then constructed just above the sinuses of Valsalva in the coronary artery take-offs, and this was again done with 3-0 Prolene suture with Hemashield graft and Teflon reinforcement. This was checked for hemostasis and additional cardioplegia was given. Antegrade cardioplegia catheter was placed into the graft and then the 3 vein grafts were individually anastomosed to the segment of Hemashield graft utilizing Concept cautery to create the ostomies and then 6-0 Prolene suture to construct the anastomoses.  

Warm infusion of cardioplegia was given and the heart returned to sinus rhythm spontaneously, and the patient was ultimately able to be weaned from cardiopulmonary bypass. Total pump time was 75 minutes. Cross-clamp time was 95 minutes. The cannula was removed, the cannula sites were reinforced and protamine was utilized to reverse the effects of heparin. The femoral artery was repaired with 6-0 Prolene suture in a running continuous fashion. The temporary pacing wires were placed into the right ventricle and two 36 French chest tubes were placed. Hemostasis was gained. The patient was stabilized after weaning from cardiopulmonary bypass, hemostasis was retained and the chest was then closed with a #7 sternal wire. There was prior fracture in the sternum on the right side, which was repaired with a lateral sternal wire. The wound and subcutaneous tissues were closed with absorbable suture. The patient was then transferred to the intensive care unit hemodynamically stable, having received blood with the procedure, as well as platelets and fresh frozen plasma, cryoprecipitate. The patient had sinus rhythm, good cardiac output and no active bleeding.

Laboratory Data Medical Transcription Transcribed Examples

LABORATORY/DIAGNOSTIC DATA:  CBC normal. Chemistry showed sodium 152, potassium 4.2, chloride 102, bicarbonate 26, BUN 19, creatinine 0.9, glucose 92. Upon discharge, sodium 134, potassium 4.3, chloride 102, bicarbonate 24, BUN 19, creatinine 0.7, glucose 88. Liver function is normal. Troponin less than 0.5. Magnesium 1.9, calcium 8.8. Urinalysis unremarkable. Urine culture negative. Sedimentation rate 10. CRP 0.3. TSH 5.7. CK-MB normal. 

Left shoulder x-ray showed degenerative changes, mild intracapsular effusion. Adenosine Cardiolite stress test showed moderate size reversible ischemia in the inferolateral wall, ejection fraction 50%. Chest x-ray showed cardiomegaly, no infiltrates. Urinalysis unremarkable. CT angiogram showed left ventricular ejection fraction of 55%, left main artery 40% stenosis in the distal LAD. All grafts were patent. LAD occluded in the distal portion. First diagonal also occluded. Left circumflex, nondominant diffuse small vessel distal disease as well as moderate disease in ostium. Moderate biatrial enlargement. Pulmonary artery dilatation of 3.7 cm. EKG showed normal sinus rhythm, right bundle branch and new T-wave inversion in V3 to V6 leads. Left ribs, no fracture or dislocation. 

LABORATORY/DIAGNOSTIC DATA:  CBC: WBC 8.8, hemoglobin 13.2, hematocrit 39.4, MCV 93.4, platelets 128,000. Protime 10.6, INR 1.04, aPTT 27.7. Heparin antibody was negative. Chemistry profile, through the emergency room, glucose 132, BUN 18, creatinine 1.2, sodium 142, potassium 4.6, chloride 106, CO2 of 26, calcium 8.7, total protein 6.8, and albumin 4.1. SGOT 38, SGPT 72, alkaline phosphatase 89, total bilirubin 0.7, and magnesium 2.2. Troponin was less than 0.5 x2; one troponin was 0.67. BNP was 118. Homocysteine level was 12. ANA was negative. Cardiolipin antibodies were all negative. Urinalysis was within normal limits. Stool for occult blood was negative x2. Protein S was 128, antithrombin III was 60, protein C was 109. Anticardiolipin antibodies were negative. Prothrombin G mutation was unremarkable. Factor V Leiden mutation was negative.

CT scan of the chest revealed resolution of the pulmonary emboli previously seen. Bullous emphysema was present. Portable chest x-ray at the time of admission revealed stable chest findings with no active pulmonary disease. Venous duplex scan of the bilateral lower extremities reveal bilateral deep venous thrombosis. Echocardiogram revealed no significant pericardial effusion. There was normal left ventricular size with uniformly normal left ventricular wall motion. Left ventricular ejection fraction was greater than 55%. The mitral and tricuspid valves appeared to open well. The aortic valve was trileaflet and opened well. The pulmonic valve was not seen. There were no intracardiac masses present. There was trivial tricuspid regurgitation. Normal left ventricular systolic function without any evidence of right ventricular enlargement or pulmonary hypertension. The aortic root was upper limits of normal at 3.7 cm. A preliminary report from the CT scan of the chest revealed bilateral pulmonary embolism.

LABORATORY DATA:  CBC:  WBC 5.5, hemoglobin 14.6, hematocrit 43.2, MCV 95.4, platelets 182,000, polys 59, bands 6, lymphs 28, monocytes 6, eosinophils 1. Atypical lymphs were seen. Prothrombin time 10, INR 0.94, aPTT 27.2, D-dimer 0.76. Chemistry profile:  Sodium 141, potassium 4.3, chloride 104, CO2 of 26, BUN 13, creatinine 0.7, glucose 96, calcium 8.6, magnesium 1.9. Total bilirubin 0.3, SGOT 25, SGPT 37. Troponin less than 0.4. Total protein 7.5, albumin 3.7, globulin 3.8. Alkaline phosphatase 74. Carbamazepine level was 10.2 initially and later 11.5, normal range reported 12.

Chest x-ray in the emergency room revealed no significant change. The cardiac silhouette was stable and no focal consolidation or pleural effusion was appreciated. Head CT scan revealed no intracranial hemorrhage, mass effect, extraaxial fluid collections or fracture. The visualized sinuses and the mastoid air cells were aerated. Pulmonary CT angiogram with the pulmonary embolism protocol revealed a left upper lobe mass suspicious for neoplasia. It was associated with mediastinal and bilateral hilar adenopathy. Also noted was a bilateral lower lobe atelectasis and interstitial change. Brain MRI was unremarkable. Cervical spine MRI revealed intervertebral disk degenerative changes present within the cervical spine. Maxillofacial CT in the axial plane with coronal reconstruction views revealed no acute abnormality. There was a deviated nasal septum.

LABORATORY STUDIES:  The patient has a myoglobin level of 484, which is elevated. White count is 10.8, hemoglobin is 9.8, platelets are 192,000. BUN 66 and creatinine 2.8. Sodium 137 and potassium 5.4. Total bilirubin is 2.3. Urinalysis shows rbc's 206 in high power field and wbc's of 142 per high power field.  Leukocyte esterase large.

CT scan of the head shows a small to moderate subdural hemorrhage on the right, greatest along the tentorium but also extending laterally along the posterior temporal and parietal lobes.  Chest x-ray shows possible early pneumonia adjacent to the left heart border, pulmonary nodule in the right upper lobe medially.  He has a urine culture, which shows Klebsiella, Enterococcus and Serratia greater than 100,000 colony-forming units.

LABORATORY DATA:  CBC:  WBC 7.9, hemoglobin 13.4, hematocrit 40.8, MCV 97.8, platelets 134,000, lymphs 11.5, polys 79.6, monocytes 6.5, eosinophils 1.9, basophils 0.5.  Protime 11.8, INR 1.13, aPTT 28.4, repeat was 42.8. Chemistry profile through the emergency room revealed glucose 132, BUN 37, creatinine 1.6, sodium 142, potassium 3.9, chloride 110, CO2 of 26, calcium 9.4, total protein 6.6, albumin 3.8, SGOT 36, SGPT 41, alkaline phosphatase 56, total bilirubin 1.6, magnesium 2.1. Troponin less than 0.5 x4, myoglobin 67. Cholesterol 88, triglyceride 126, HDL cholesterol 30, LDL cholesterol 33. BNP was 729. Hemoglobin A1c was 5.9. Urinalysis was within normal limits. Stool for occult blood was negative.

Myocardial perfusion imaging with Cardiolite revealed irreversible perfusion defect in the inferior wall, presumably due to underlying infarct. The left ventricle was markedly dilated. Ejection fraction of the left ventricle was 25%. Portable chest x-ray at the time of admission revealed bilateral infiltrates and mild vascular congestion, most likely representing congestive heart failure. EKG revealed an electronic ventricular pacemaker with premature ventricular complexes. When compared with a previous EKG, ventricular rate had decreased by 18 beats per minute. There was limited echocardiographic study and Optison was used to improve endocardial visualization. Mild left atrial enlargement with normal right atrial size. Mild left ventricular chamber enlargement with decreased left ventricular contractility. Estimated ejection fraction was in the 40% range. There was global hypokinesia; however, the inferior wall did appear more hypokinetic than the remainder of the ventricle, as does the posterior wall. There was a small pleural effusion. Normal aortic root dimension. Mild thickening of the mitral valve with normal opening and closure. Mild thickening of the aortic valve with normal opening and closure. Normal appearance of the tricuspid valve. Doppler exam showed mild tricuspid regurgitation with no tricuspid stenosis. There was moderate pulmonary hypertension and estimated pulmonary pressures of approximately 50 to 55. Normal function of the aortic valve with no regurgitation or stenosis. Normal function of the pulmonic valve. Trace mitral regurgitation with no mitral stenosis.


Operative Hysteroscopy and Bartholin's Gland Cystectomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic menometrorrhagia.
2.  Uterine leiomyomata with submucous mass, probable submucous myoma.
3.  Desires conservation of fertility.
4.  Left Bartholin's gland cyst.

POSTOPERATIVE DIAGNOSES:
1.  Chronic menometrorrhagia.
2.  Uterine leiomyomata with submucous mass, probable submucous myoma.
3.  Desires conservation of fertility.
4.  Left Bartholin's gland cyst.

OPERATIONS PERFORMED:
1.  Operative hysteroscopy with resection of submucous myomas and curettage.
2.  Left Bartholin's gland cystectomy.

SURGEON:  John Doe, MD 

ANESTHESIA:  General with LMA.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS: 40 mL.

DRAINS:  Foley catheter to the bladder intraoperatively.

SPECIMENS TO PATHOLOGY:  Submucous fibroids in shavings and left Bartholin's gland cyst.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite in stable condition. Intravenous prophylactic antibiotics had been administered. Informed consent had been obtained. The patient was aware of options. She strongly desired a conservative procedure with conservation of fertility. The risks had been outlined including embolus, stroke, pain, phlebitis, infection, hemorrhage, laceration of the cervix, certainly perforation of the uterine wall. The patient had received intravenous prophylactic antibiotics. She was placed under general anesthesia with LMA and then positioned in the lithotomy position. The perineum, vagina and lower abdomen were all prepped and draped in the standard fashion for surgery. The bladder was catheterized. Pelvic examination was performed. Attention was then turned to performing the operative hysteroscopy.

A weighted speculum was placed and the cervix was visualized. The anterior lip of the cervix was grasped with a tenaculum. The uterine cavity was sounded to 10 cm. The endocervical canal was then carefully and gently dilated to a #20 Pratt dilator. Initially, the 6.5 mm hysteroscope and sleeve were advanced into the uterine cavity and diagnostic hysteroscopy was performed, utilizing sterile saline as a distending medium with a suction apparatus attached. The submucous myomas were identified. Attention was then turned to proceeding with operative hysteroscopy. The VersaPoint bipolar electrocautery operative hysteroscopic system was utilized. The introducer was placed into the endocervical canal and then the operating hysteroscope was placed. We had attached a loop electrode to the operating hysteroscope to allow us to shave the fibroids out of the uterine cavity. Standard settings on the power generator were established and bipolar electrocautery was utilized. Normal saline was utilized as a distending medium.

The procedure was carried out until the larger submucous myoma had been totally resected and the other smaller one had been shaved down to the level of the surrounding uterine cavity. Curettage had been performed initially to sample the endometrial lining. We utilized the coagulation as needed, but there really was not any major bleeding from the resectoscope procedure, which had been utilizing bipolar electrocautery. Several times, the instruments were removed so that we could remove shavings, which had diminished visualization. At the end of the procedure, uterine cavity was flushed and inspected and all specimens had been noted to be removed. Hemostasis was noted in the operative areas as well. Representative photographs were obtained, pre and postprocedure. At this point, the instruments were removed. Inspection revealed minimal bleeding coming from the endocervical canal with a hemostatic tenaculum site. Bimanual pelvic examination was performed and was unremarkable. Calibration of inflow and outflow was obtained, and although we had lost some fluid into the drapes and onto the floor, we estimated at most the patient had 100 to 200 mL of saline passed through her tubes. Most likely, the amount was much less than this.

Attention was turned to performing a left Bartholin's gland cystectomy. The operative area was infiltrated with Marcaine and epinephrine solution. With a #15 scalpel blade, incision was made over the cyst on the labia minora on the left. The cyst had been stabilized between the operator’s left thumb and forefinger. Dissection was then carried bluntly and sharply around the cyst. The cyst was totally excised. The base was clamped with hemostats prior to removal. These pedicles were suture ligated with 3-0 Vicryl sutures. Defect in the operative area was then closed with 3-0 Vicryl sutures in layers. Electrocautery was utilized to maintain hemostasis. The area was copiously irrigated. The cyst contained a very viscid brownish fluid and there was scarring around it during its dissection. This always raises the possibility of endometriosis pending final pathology. The epithelium of the labia minora was closed with subcuticular sutures of 3-0 Vicryl. The area was, at this point, carefully inspected for several minutes and there was no significant bleeding or swelling within the vulva. At this point, the operative procedure was ended. The patient was awakened and returned to recovery in stable condition. The instrument, sponge and needle counts were reported as correct. Estimated blood loss was 40 mL. There were no complications.

Podiatry Consultation MT Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  This (XX)-year-old male was admitted for a pulmonary embolism. The patient's daughter is present and relates most of the history. The patient apparently was at an outside facility, undergoing a mesenteric artery bypass, where it was noted in the recovery room that his feet and legs were turning blue. It was decided at that time to watch the feet, as he was in no condition for any further surgery. After 2 weeks, he was transferred to this facility, where he has had much improvement in the color and pain in his feet. This past Wednesday, however, it was noted that he had a couple of red spots on his left heel. The patient states that the left heel is only slightly sore when compared to the right. He has been wearing PRAFO boots for the past 12 days while at the rehab center, and therefore, every attempt was made to keep pressure off of his heels. He states that the right second toe has been about the same over the last few weeks; however, the left second toe has fluctuated quite a bit. He has been using Lidoderm patches for pain, which again he states is improving.

PAST MEDICAL HISTORY:  Significant for hypertension, chronic obstructive pulmonary disease, hyperlipidemia, history of lung cancer, right thigh wound with MRSA, peripheral arterial disease, recent aortomesenteric bypass, and a history of prostate cancer.

MEDICATIONS:  See nursing intake sheet.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Stable. The patient is noted to have a 101-degree temperature, which is the T-max. 
INTEGUMENT:  Reveals cyanotic, pre-gangrenous changes to the distal tip of the right second digit from the distal interphalangeal joint out. There is a small wound on the dorsum of the right second digit, which is healthy. There are no signs of infection or any drainage or odor. There is peeling of the epidermis to the right second digit with healthy skin beneath this. There are patchy cyanotic ischemic changes to the distal tip of the left hallux, left second and third digit, and dorsal left fifth digit just proximal to the nail. There is a larger patchy area posterolaterally on the left heel. The skin is intact, however, with no drainage or gross signs of infection noted.
VASCULAR:  Examination reveals nonpalpable dorsalis pedis and posterior tibial pulses, bilateral feet. Hair growth is absent with cool, shiny, atrophic skin. Moderate nonpitting edema is noted bilaterally.
NEUROLOGIC:  Examination is intact to light touch.
MUSCULOSKELETAL:  Examination reveals tenderness to palpation, posterolateral left heel and distal right second digit. The lesser digits on both feet are mildly contracted in a semirigid manner. There is no other obvious deformity noted.

LABORATORY DATA:  WBC 11.8, hemoglobin 10.6, hematocrit 33.4, and platelets 632,000. CRP 11.98. Sedimentation rate 86. Bilateral lower extremity duplex venous ultrasound is negative for lower extremity DVT. Arterial flow study of both lower extremities without exercise reveals probable right SFA occlusion with an ABI of 0.78 on the right side. There is a probable left SFA occlusion with an ABI of 0.46 on the left. Absent digital waveform is noted to the right second digit, suggesting thrombosis or embolic phenomenon.

IMPRESSION: 
1.  Ischemic/cyanotic digits, bilateral feet and left heel.
2.  Peripheral arterial disease, bilateral lower extremities.

RECOMMENDATION:  Following examination of both feet, light excisional debridement of all loose tissue was performed to the right second digit. I would recommend keeping the toes open to air and only cover with a Lidoderm patch p.r.n. pain. Ensure that both of his heels are off of the bed, as they are currently, on pillows or in a PRAFO. The patient is going for an angiogram and possible percutaneous transluminal angioplasty today per Interventional Cardiology. Hopefully, if they discover a blockage and it can be opened, the left heel and the toes will improve. I would allow them to demarcate and continue to monitor them, as they are not infected and the patient does not have severe intractable pain. Therefore, there is no immediate cause for debridement or amputation. I will follow this patient during his hospital stay.

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

Medical Oncology Sample Report / Transcription Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Newly diagnosed small cell lung cancer. 

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who gives an approximately 4-week history of malaise, anorexia, loss of weight, nausea and more recently very distressing upper abdominal pain. Recently, a CT scan showed evidence of mediastinal and perihilar lymphadenopathy, as well as liver lesions. Biopsy confirmed small cell carcinoma. A medical oncology consultation was therefore requested by the primary physician. The patient states that she has not had any overt vomiting. Denies fevers or chills. Her weight loss has been about 9 pounds over the past 2 to 3 weeks. She states that her breathing is clearly worse than her usual COPD, but she has not had any cough, sputum or hemoptysis. 

PAST MEDICAL HISTORY:  Hypertension, autoimmune hepatitis for about 8 years, COPD for many years, degenerative arthritis. Denies diabetes, heart disease or kidney disease.

PAST SURGICAL HISTORY:  Denies any prior surgeries.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

CURRENT MEDICATIONS:  Vicodin, prednisone, 6-mercaptopurine, losartan, Klonopin, potassium chloride, Lasix, calcitonin, albuterol and MiraLax.

SOCIAL HISTORY:  The patient states that she smoked 3 packs a day for about 30 years, but quit approximately 8 years ago. She states she has never had any history of heavy alcohol abuse. Denies any drug abuse.

FAMILY HISTORY:  There are no clear familial illnesses. The patient's half-sister was treated for a fibrous histiocytoma with surgery. Her mother was treated for colon cancer.

REVIEW OF SYSTEMS:  GENERAL:  Please see HPI.  HEENT:  No mouth sores, gum bleeds or difficulty swallowing. CARDIOVASCULAR:  No chest pressure. No palpitations. RESPIRATORY:  See HPI.  GASTROINTESTINAL:  See HPI.  GENITOURINARY:  No blood or burning with urination. MUSCULOSKELETAL:  Denies any new or unusual back, bone or muscle pains. SKIN:  No unusual new skin spots or rashes. HEMATOLOGIC:  No history of blood clots. No abnormal hemorrhaging.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6, blood pressure 136/78, heart rate 104, respiration rate 22 with mild dyspnea at rest. 
GENERAL:  The patient is a chronically ill, pleasant lady, in no acute distress, although has dyspnea at rest.
SKIN:  Clear, warm and dry. 
NODES:  Not palpable in cervical, supraclavicular and axillary regions.
HEENT:  Normocephalic and atraumatic. Sclerae and conjunctivae are clear without icterus or watery discharge. Oropharynx shows candida plaques on the palate, no ulcers or bleeding. Extraocular movements and visual fields are intact. Pupils are equal, round and reactive to light.
NECK:  Supple.
BACK:  No point spine or CVA tenderness.
LUNGS:  Breath sounds are decreased throughout both lung fields, except in the extreme bases. No rales or rhonchi.
HEART:  Distant S1, S2, without murmur or gallop.
ABDOMEN:  Distended with tender liver edge palpable about 10 cm below the right costal margin. No other masses. 
EXTREMITIES:  There is no clubbing, cyanosis or edema and no calf tenderness.
NEUROLOGIC:  The patient is alert and oriented x3. Cranial nerves II through XII are intact. Motor strength is 5/5 in both upper and both lower extremities. Deep tendon reflexes are 1+ and bilaterally symmetric in both upper and lower extremities. No Babinski sign is noted. 

LABORATORY DATA:  Pathology report from liver biopsy confirms differentiated small cell carcinoma. WBC 9.8, hemoglobin 12.6, platelets 502. Basic metabolic panel was unremarkable. INR 1.12, PTT 26.2, AST 118, ALT 88, total bilirubin 0.9, alkaline phosphatase 242, albumin 2.6, and calcium 10.6. CT chest report read and images reviewed; bulky mediastinal and perihilar lymph node masses are identified, as are lucent lesions in the liver compatible with metastatic disease. Bone scan report showed there is some concern about osseous metastasis, although degenerative changes are also possible.

IMPRESSION:
1.  Extensive stage small cell lung cancer.
2.  Liver metastasis due to extensive stage small cell lung cancer.
3.  Hypercalcemia, likely in part due to metastatic small cell lung cancer.
4.  Underlying chronic obstructive pulmonary disease.
5.  Underlying hypertension.
6.  History of autoimmune hepatitis.

RECOMMENDATIONS:  This was discussed at length with the patient. Her half-sister and her significant other were at the bedside during the discussion. As I explained to the patient, median survival without treatment for patients with small cell lung cancer is in the order of 2 to 3 months. This is raised to around 10 to 12 months with systemic chemotherapy. Several regimens are possible. Cisplatin and Camptosar is one such useful regimen. We discussed the schedule as well as anticipated risks and side effects, which include hearing loss, kidney damage, numbness and tingling from neuropathy, infection or bleeding from marrow toxicity. There is even a small risk of death. There is a chance of diarrhea from Camptosar. Despite these risks and potential toxicity, patients who receive chemotherapy have an improved survival and quality of life than patients who refuse treatment. At this point, the patient is still undecided and wishes to think things over overnight. We will write pretreatment hydration for overnight administration along with allopurinol to reduce the risk of tumor lysis syndrome and related nephropathy. Chemotherapy orders will be placed on the chart to be administered only after the patient consents. We will also request that patient materials about small cell lung cancer as well as the drugs just described are provided to the patient.

Thank you very much for this consultation. We will follow the patient with you. 

Hem-Onc Consult Sample                        Hem-Onc Consult Sample # 2

Rehab Consultation Sample Report / Transcription Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD  

REASON FOR CONSULTATION:  Spinal cord compression.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed woman who was recently diagnosed with multiple myeloma, currently on thalidomide and Decadron treatment, who was admitted after having suffered a compression fracture 1 week prior to admission. She was complaining of increased low back pain, lower extremity paresthesias and weakness. She was very fatigued. Her hemoglobin was 8.2. She was transfused. She was found to have a right middle and lower lobe infiltrate and/or effusion. Chest CT scan revealed a large right pleural effusion and a small left pleural effusion. A lesion in the left liver lobe was seen. Lumbosacral MRI examination was unremarkable except for spondylosis. A thoracic MRI examination revealed a T6 paraspinous lesion with spinal cord compression. The patient was transferred to this facility and was started on increased steroids and radiation therapy. It was felt that she was not a surgical candidate due to the risks outweighing the benefits. The patient did undergo a right thoracentesis and 1300 mL of fluid was removed. Final pathology is pending. She has 2 radiation treatments left. She has not had any significant return of lower extremity movement. PICC line placement is pending for tomorrow. The patient states that she is not having any significant pain. She is sleeping fairly well. She has not had any good bowel movements. Appetite is fair.

PAST MEDICAL HISTORY:  Hypertension, depression and hypercholesterolemia. She is status post cholecystectomy, tubal ligation, toe surgery and right breast cyst removal.

ALLERGIES:  CODEINE.

MEDICATIONS:  Heparin 5000 units subcutaneously q.12 h., oxygen 2 liters per nasal cannula, hydrochlorothiazide 25 mg daily, Zetia 10 mg daily, Levaquin 500 mg daily, Decadron 4 mg q.i.d., Zoloft 25 mg daily, thalidomide 200 mg daily, Colace 100 mg b.i.d., Inderal 10 mg b.i.d., Procrit 40,000 units subcutaneously, Darvocet-N 100 one to two tablets q.3-4 h. p.r.n. for pain and lactulose 30 mL p.o. p.r.n.

HOME MEDICATIONS:  Hydrochloride 25 mg daily, Inderal 10 mg daily, Zetia 10 mg daily, Zoloft 25 mg daily, thalidomide 200 mg daily and Decadron.

DIET:  Regular. 

FUNCTIONAL STATUS:  The patient has a Foley catheter. She was in urinary retention with high residuals. She has been incontinent of a few small bowel movements. She requires maximal assistance for bed mobility and she is dependent for transfers. She is not ambulatory. She requires setup for feeding. She requires assistance for grooming. She is dependent for other self-care. She was independent prior to admission.

SOCIAL HISTORY:  The patient is married. She has 3 sons and 2 daughters. The family is very supportive. She lives in a home with 2 steps to the entrance. There is a bathroom and living area on the first level. There are 9 stairs up to where her main bedroom and bathroom are located. The patient does not smoke. She does not drink. She is retired.

FAMILY HISTORY:  Noncontributory. 

REVIEW OF SYSTEMS:  Per the HPI and PMH. She wears glasses. No cataracts or glaucoma. No hearing difficulties. No GI or GU difficulties. No other neurological problems. No other musculoskeletal problems. No endocrine disorders.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6, pulse 84, respirations 22, blood pressure 114/64. Height 5 feet 4 inches, weight 165 pounds. Her oxygen saturation is 98% on 2 liters of oxygen per nasal cannula.
GENERAL APPEARANCE:  A well-developed, well-nourished, overweight woman, in no acute distress. Her affect was somewhat flat. Multiple family members were present during the interview and examination.
HEENT:  NC/AT. Nasal cannula was in place.
NECK:  Without bruits.
LUNGS:  Clear except for some decreased breath sounds in the right base.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Obese. Bowel sounds are positive, soft, nontender and slightly distended. 
EXTREMITIES:  No clubbing, cyanosis or edema. No calf erythema, warmth or tenderness. Peripheral pluses strong and symmetric. Passive range of motion within functional limits throughout.
SKIN:  Intact.
RECTAL:  The patient declined at this time.
NEUROLOGIC:  Mental Status:  The patient was alert and oriented x3. She did not demonstrate any gross cognitive or language deficits. Cranial nerves II through XII intact. Motor:  There was decreased tone in the lower extremities. There was normal tone in the upper extremities. No atrophy was noted. Strength was normal in the upper extremities. Movement was absent in the bilateral lower extremities except for trace right ankle movements. Muscle Stretch Reflexes:  Absent ankle jerks and knee jerks bilaterally. The upper extremities were 2+ throughout. Toe response was equivocal bilaterally. Hoffmann sign was negative bilaterally. Coordination:  Intact in the upper extremities. Not applicable in the lower extremities. Sensory:  Sensation was decreased from the T7 dermatome and distally. Sensation was intact proximal to the T7 dermatome. She had decreased pinprick. Gait:  Not applicable.

LABORATORY DATA:  Echocardiogram showed that there was abnormal septal motion, probably secondary to intraventricular conduction delay. She had stage I diastolic dysfunction. Hemoglobin 9.8, white blood cell count 2800 and platelet count 84,000. Sodium 133, potassium 3.5, chloride 88, bicarbonate 24, BUN 15, creatinine 0.9, glucose 134, calcium 7.8 and albumin of 1.9.

ASSESSMENT:
  1. Incomplete paraplegia.
  2. Multiple myeloma with spinal cord compression.
  3. Neurogenic bladder and bowel.
  4. Right pleural effusion, status post thoracentesis with final pathology pending.
  5. Hypoxia.
  6. Anemia, status post transfusion.
  7. Pancytopenia.
  8. Left liver lobe lesion.
  9. Hypertension.
  10. Hypercholesterolemia.
  11. Hyponatremia.
  12. Decreased nutrition.
  13. Depression.
RECOMMENDATIONS:  Physical therapy will continue. Occupational therapy will be added. The patient is appropriate for rehabilitation to work on mobility and self-care, as well as patient and family education and training. I would estimate a length of stay of 2 to 3 weeks. This would be followed by home health services. The patient will be placed on a bowel program. The importance of this was discussed with the patient and her family. Her Zoloft could be increased to 50 mg daily due to her depression. Her skin needs to be monitored closely and she needs to be turned frequently. I would recommend adding protein shakes to improve her nutritional status. The assessment and recommendations were discussed with the patient and her family.

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


Radiation Oncology Consultation Transcription Sample / Example

DATE OF CONSULTATION:  MM/DD/YYYY 

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Renal cell carcinoma, metastatic to bone, now with progression of disease in the thoracic spine with spinal cord compression.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with known history of renal cell cancer, metastatic to bone.  He has previously undergone palliative radiation treatment to multiple sites including the left humerus, right forearm and the upper thoracic spine, as well as mid thoracic spine.  Specifically, he has received prior radiation treatment in the thoracic spine down to the level of thoracic vertebral body 8.  At this time, he is admitted here for evaluation and management of shortness of breath.  CT scans of the chest evaluated the possibility of a pulmonary embolus but were negative.  The patient’s shortness of breath has been attributed to an exacerbation of asthma and has responded well to aggressive treatment.  He has also noticed, however, progression of severe mid back pain.  He describes pain in the vertebral region and paravertebral area of the midthoracic spine.  An MRI scan of the spine was obtained and was reviewed with the radiologist.  There is significant evidence for metastatic disease in the spine with extensive disease noted in vertebral bodies T7, T9 and T11.  Disease is most significant in T7 with evidence of spinal cord compression.  The patient is seen at this time for an opinion regarding further management.  On further questioning, the patient notes difficulty in moving his legs, more because of back pain rather than true weakness.  He notes no paraesthesias.  There are no other symptoms of spinal cord compression.  He is on prednisone 60 mg daily because of his asthma/COPD.

PHYSICAL EXAMINATION:
GENERAL:  On physical examination, he appears chronically ill but stable, in no acute distress.  Lymph node survey is unremarkable.
CHEST:  Clear.
HEART:  Regular in rate and rhythm.
ABDOMEN:  Soft and nontender.  There is no gross mass or hepatosplenomegaly.
EXTREMITIES:  Without edema.  There is tenderness to palpation over the mid back consistent with the MRI findings.

IMPRESSION:  Renal cell carcinoma, widely metastatic to bone, symptomatic with mid back pain with radiographic evidence of spinal cord compression in a previously treated site.

RECOMMENDATIONS:  I plan to initiate radiation treatment to the spine in hopes of optimizing pain management and prevention/delay of neurologic compromise.  I recommend a dose of approximately 3000 centigray in 10 treatments to an area including T7 through T12.  Vertebral body T7 has previously been included in radiation treatment to the upper spine, and additional radiation treatment to this site will be limited.  Unfortunately, this also is currently the most extensive area of disease.  One could, therefore, consider neurosurgical evaluation regarding disease at the T7 level.  I have discussed the results of the imaging, as well as plans for radiation treatment with the patient.  He understands the overall status of his disease.  We did discuss the risks of a re-irradiation to the spine.  At the time of the initial consultation, the patient was not interested in neurosurgical evaluation and we shall, therefore, initiate radiation treatment.

Thank you for allowing us to participate in the care of this patient.

Physical Exam Normal Template Sample / Transcription Examples

PHYSICAL EXAMINATION:
GENERAL:  The patient is a well-nourished, middle-aged Caucasian female, not in any obvious distress.
VITAL SIGNS:  Temperature 98.6 degrees Fahrenheit, blood pressure 132/64, pulse 104 and respirations 22.
HEENT:  Remarkable for pallor. There is no icterus. Sclerae are clear. Pupils are equal and reactive to light. Mucous membranes are moist. There are no oropharyngeal lesions.
NECK:  Supple. No lymphadenopathy. Thyroid is not palpable.
CHEST:  Clear to auscultation.
HEART:  Regular rate and rhythm.
ABDOMEN:  Obese and soft with large infraumbilical oval wound measuring approximately about 5 cm to 7 cm in length and about 4 cm in broadest diameter with lobulated granulation tissue in the base. There is no discharge. There is no necrosis. There is undermining all around. There is no surrounding erythema or induration. The skin around the wound is minimally tender.
NEUROLOGIC:  Nonfocal.
EXTREMITIES:  Distal pulses are not felt.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.6 degrees, heart rate 102 beats per minute, respiratory rate 22 breaths per minute, blood pressure 146/52 mmHg and oxygen saturation 97% on 3 liters per nasal cannula.  Weight is 67.5 kilograms.
GENERAL:  The patient is alert, responsive, well developed and well nourished, resting comfortably in bed.  No acute respiratory distress is appreciated at this time.  Mild anxiousness is appreciated.
BACK:  No CVA or spinal tenderness.
LYMPH NODES:  No lymphadenopathy noted in the head and neck regions.
SKIN:  Warm, dry, no visible erythema, rashes or cyanosis.
NECK:  Supple.  Full range of motion.  No jugular venous distention.  No carotid bruits auscultated.  No tenderness.  No thyromegaly.
HEENT:  The patient's head is normocephalic to inspection.  Pupils are equally round and reactive to light and accommodation.  Extraocular movements are intact.  No conjunctival redness or scleral icterus appreciated.  Hearing acuity is grossly intact.  Nares are patent with dry nasal mucosa. Tongue is midline without fasciculations.
RESPIRATORY:   The patient's breath sounds are diminished but fairly clear throughout lung fields bilaterally.  No wheezing, crackles or rubs appreciated at this time.
CARDIOVASCULAR:  Regular rate and rhythm.  Normal S1, S2.  No S3 or S4 noted.  No murmurs or rubs are appreciated.
ABDOMEN:  Good bowel sounds, soft and nontender.  No appreciated hepatosplenomegaly.  No masses palpated.  No bruits auscultated. 
EXTREMITIES:  Good range of motion.  Good pulses.   Trace pedal edema is appreciated.  No calf tenderness.  No palpable cords. 
NEUROLOGIC:  The patient is alert and oriented to person, place and time.  Cranial nerves II through XII are grossly intact.  Sensation is normal.  Strength is 5/5, motor, in all extremities. Normal mood and normal affect is appreciated.  No focal neurological deficits are noted.

PHYSICAL EXAMINATION:  On examination, neurologically, the patient is conscious, alert and well oriented. Speech is normal. Mildly impaired recent memory. Other cognitive functions are normal. Cranial Nerves:  Pupils are equal, reacting to light and accommodation. Visual field is normal. Extraocular movements normal. No facial asymmetry. Normal movement of tongue, palate, jaw, uvula. The rest of the cranial nerves are normal. Speech is normal for age. No nominal aphasia. Motor Examination:  The patient has weakness of the distal muscles of the feet. The weakness is 4.5/5 and the left upper limb is normal. Right upper limb shows weakness of all muscles innervated by radial nerve sparing triceps muscle. The extensors of the wrist are 0/5. Intrinsic muscles of the hands and muscles innervated by median and ulnar nerves are normal. Sensory Examination:  Mildly decreased pinprick in the hand, in the distribution of the radial nerve. The sensory examination in the posterior antebrachial cutaneous nerve is normal. Triceps muscle is normal. Ankle jerks 1+ medial hamstring, 0 to 1+ patella. Left triceps is 1+, biceps is 1+, supinator absent. Right supinator and triceps are absent and biceps is 1+. Position and vibratory senses are normal for age. Cortical sensations are normal. Cerebellar exam is normal for finger-to-nose and heel-to-shin test. Gait not tested. Neck is supple. Carotid showed no bruits. HEENT:  Negative. S1, S2. No pedal edema. Bilateral inguinal hernia. Abdomen is soft, nontender. No organomegaly. 

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.4, pulse 80, respirations 21 and blood pressure 132/64. Oxygen saturation is 98% on 6 liters of oxygen. Height 5 feet 8 inches and weight 214 pounds.
GENERAL APPEARANCE:  A well-developed, well-nourished gentleman who was in no acute distress. His affect was normal.
NECK:  There were no carotid bruits.
LUNGS:  Had bibasilar rales. Had decreased respiratory effort.
HEART:  Regular rate and rhythm without murmur.
ABDOMEN:  Protuberant. Bowel sounds were positive. It was nontender.
EXTREMITIES:  Minimal ankle edema. No clubbing or cyanosis. No calf erythema, warmth or tenderness. Peripheral pulses were strong and symmetrical. Passive range of motion was within functional limits throughout. Vein graft harvest sites were clean, dry and intact.
NEUROLOGIC:  The patient was alert and oriented x3. Immediate recall was 3/3 and 2/3 after 5 minutes. His speech was fluent without dysarthria. His voice was dysphonic. He could follow instructions without difficulty. Basic problem solving, reasoning and attention were intact. Extraocular movements were intact. Visual fields were full. Smile was symmetric. Hearing was intact bilaterally. Shoulder shrug was symmetric. His tongue protruded in the midline with good lateral movement. Tone was normal. No atrophy was noted. Strength was generally 3/5 throughout without focal motor deficits. Ankle jerks and knee jerks were absent bilaterally. Toe response was downgoing bilaterally. Upper extremities were 1+ throughout. Finger-finger-nose and heel-knee-shin were slow, but intact. Localization was intact. Gait was not applicable at this time.

PHYSICAL EXAMINATION:  
GENERAL:  The patient is a well-developed, well-nourished female in no apparent distress.
VITAL SIGNS:  Temperature 98.6, pulse 88 and the blood pressure 124/56.
NECK:  Supple.
NEUROLOGIC:  The patient was alert and oriented to person, place and time. The speech was clear and the language was fluent with normal naming, repetition, comprehension and vocabulary. Examination of the cranial nerves revealed full visual fields, intact extraocular movements, equal, round and reactive pupils, and benign fundi. The facial sensation was full and the face was symmetric. The patient was able to hear a finger rub bilaterally. The palate rose symmetrically. Shoulder shrug was symmetric and the tongue protruded in the midline. On motor examination, the bulk and tone were normal. Motor strength was 5/5 throughout with the exception of left dorsiflexion, which was 3/5. There was no drift. Some tremor was present in the upper extremities. Deep tendon reflexes were 2+ throughout with the exception of the right ankle jerk, which was 1+. The right plantar response was flexor, and the left was questionably extensor. Sensations were intact to light touch, proprioception and vibration. Coordination was intact to finger-to-nose and heel-to-shin testing. The patient's gait was not evaluated.

PHYSICAL EXAMINATION:  
GENERAL:  The patient is alert and oriented x3.
VITAL SIGNS:  Temperature 97.6, blood pressure 127/69, pulse 72, respiratory rate 18. The patient is on nasal oxygen, 2 liters, with saturation more than 92%.
HEENT:  Overall unremarkable. Hearing deficit. 
LUNGS:  Air entry, basal, diminished.
HEART:  S1, S2, regular.
ABDOMEN:  Soft, nontender, morbid obesity. Bowel sounds present.
EXTREMITIES:  No calf tenderness. Clinically, no sign of DVT. Mild edema. Dorsalis pedis and posterior tibial pulses palpable.
NEUROMUSCULAR:  Good functional range of movement of the shoulders and overall no focal deficits. Reflexes are intact. Lower Extremities:  Right hip total hip arthroplasty. Operative wound covered with dressing. Right lower extremity:  Active SLR not possible, but good active ankle dorsiflexion. Left lower extremity:  Good active SLR, good active ankle dorsiflexion. Lower extremity reflexes difficult to elicit. Gross sensation is intact. No severe dysesthesias at this time. Plantars downgoing.  Proprioception is intact.


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