EGD and Colonoscopy with Cold Forceps Polypectomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic upper abdominal pain.
2.  Gas/bloating.
3.  Reflux.
4.  Change of bowel habits.

POSTOPERATIVE DIAGNOSES:
1.  Chronic upper abdominal pain.
2.  Gas/bloating.
3.  Reflux.
4.  Change of bowel habits.
5.  Grade 1 esophagitis.
6.  Mild erythematous gastropathy.
7.  Duodenitis.
8.  Rectal polyp.
9.  Hemorrhoids.

PROCEDURE PERFORMED:
1.  Esophagogastroduodenoscopy with biopsies.
2.  Colonoscopy with cold forceps polypectomy.

PHYSICIAN:  John Doe, MD

ANESTHESIA:  Fentanyl 75 mcg IV, Versed 7 mg IV, and topical benzocaine spray.

SPECIMENS:
1.  Duodenal and gastric biopsies.
2.  Rectal polyp.

COMPLICATIONS:  None.

BLOOD LOSS:  Minimal.

CONSENT:
Informed consent was obtained prior to the initiation of the procedure.  All questions were answered.

ESOPHAGOGASTRODUODENOSCOPY:
The esophagogastroduodenoscopy was the first procedure performed. The patient was given topical benzocaine spray and placed in the left lateral decubitus position. Following the administration of appropriate anesthesia, a diagnostic gastroscope was advanced under direct vision to the second portion of the duodenum without difficulty. Examination of the esophagus revealed a normal-appearing Z-line at approximately 35 cm from the incisors. There was patchy erythema consistent with a grade 1 esophagitis. Examination of the stomach revealed a normal gastric cardia, fundus and body. No ulcerations or erythema was appreciated. The patient's stomach was somewhat J-shaped in nature with some angulation at the region of the pylorus. However, it should be noted that there were no ulcerations present, though some patchy erythema was appreciated in the region of the distal stomach. Biopsies were obtained for histology. Examination of the duodenal bulb revealed patchy duodenitis without ulceration. The visualized second portion of the duodenum was normal. Duodenal biopsies were basically to look for other sources of abdominal discomfort including malabsorption syndrome such as celiac disease. The gastric biopsies were to evaluate for potential Helicobacter pylori.

IMPRESSION:
1.  Grade 1 esophagitis.
2.  Erythematous gastropathy.
3.  Duodenitis.

RECOMMENDATIONS:
1.  Await pathology results.
2.  Proceed with colonoscopy.

COLONOSCOPY:
The patient was repositioned and a digital rectal exam was performed. No significant masses or lesions were palpated. Following this, a variable stiffness pediatric colonoscope was advanced under direct vision to the cecum without difficulty. The patient did require some sigmoid pressure for deep cecal intubation. The patient's colon preparation was good with clear identification of the appendiceal orifice as well as the IC valve. The patient did have some residual material present, though this did not interfere with the examination. Careful examination of the colonic mucosa was then performed as the scope was slowly withdrawn. The exam of the cecum, ascending, transverse, descending, and sigmoid colon were otherwise endoscopically unremarkable. Retroflexed views in the rectum revealed a diminutive rectal polyp in addition to nonbleeding internal hemorrhoids. The rectal polyp was removed using cold forceps polypectomy technique and retrieved for pathology. Air and fluid were then aspirated. The scope was withdrawn and the procedure terminated.

IMPRESSION:
1.  Rectal polyp.
2.  Hemorrhoids.

RECOMMENDATIONS:
1.  Await pathology results.
2.  Written instructions were given to the patient to contact the office for followup visit in the next 3 weeks.

Newborn Discharge Summary Transcription Example / Sample

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

DISCHARGE DIAGNOSIS:
The patient is (XX)-day-old now, a (XX) and 3/7 weeks, on ad lib feedings, ruled out sepsis.

MATERNAL HISTORY:
Mother is a (XX)-year-old gravida 1, para 0, with EDC of MM/DD/YYYY. She is AB positive, GBS negative, RPR negative, hepatitis surface antigen B negative, rubella immune.

Maternal prenatal medication administered was prenatal vitamins. No complications during pregnancy.

Rupture of membranes was spontaneous 25 hours prior to delivery with clear fluid noted. Mother did run a temperature during labor of 101.8 and there was a nonreassuring tracing, baby. The mother did receive ampicillin x4 doses, delivered vertex, vaginal vacuum assist. Nuchal cord x1, tight.

Apgars assigned to the baby were 8 at one minute and 9 at five minutes. Spontaneous respirations noted. Only required tactile stimulation and oxygen blow-by and the baby was taken to the newborn nursery. The baby's birth weight was 3265 grams, which was 7 pounds 2 ounces. The baby was transferred to the neonatal care service on day 1 of life with increased respiratory rate.

CBC screen was done and we are ruling out sepsis.

HOSPITAL COURSE:
1.  Initially, the baby had respiratory distress, increased respiratory rate, questionable transient tachypnea of the newborn. Blood gas was within normal limits. Her chest x-ray had some slight hyperinflation noted. Distress was resolved within 12 to 24 hours and no further problems noted.
2.  Possible sepsis, rule out. The baby was initially put on ampicillin and gentamicin. A CRP initially was done at less than 24 hours of age which was 0.4; a followup was 2.4. Maternal histories involve a maternal temperature during delivery of 101.8. Repeat CRP on day of discharge was 1.3. Antibiotics were discontinued and 48-hour blood cultures were negative with no further problems.
3.  Nutrition. The baby initially was placed n.p.o. and put on some IV fluids of D10W. Feedings were initiated on day 1 of life and advanced to an ad lib schedule. Currently, the baby is on ad lib feedings of Enfamil with iron and tolerating feeds with no problems. Stooling and voiding. Advancing weight appropriately.

DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.2, heart rate 142, respiratory rate 58 and blood pressure 86/56.
GENERAL:  The infant was alert and active. Discharge weight was 3280 grams.
HEENT:  Eyes x2, ears x2, symmetrical. Nares pink. Palate intact.
NECK:  Without masses. Left parietal cephalohematoma noted.
RESPIRATORY:  Symmetrical.
CHEST:  Bilateral breath sounds, clear and equal with good aeration.
CARDIOVASCULAR:  Regular rate and rhythm. No murmur noted. Pulses +2 x4. Capillary refill less than 2 seconds.
ABDOMEN:  Soft and nondistended. Bowel sounds positive.
GENITOURINARY:  Female genitalia. Anus patent.
SPINE:  Intact and straight.
EXTREMITIES:  Ten fingers/ten toes, hips negative for click, moves extremities well and symmetrically.
SKIN:  Pink, slightly icteric, intact, warm to the touch.

SCREENING:
Hearing screen done, passed both ears.

DISCHARGE INSTRUCTIONS:
Follow up with pediatrician after discharge.

Pediatric Discharge Summary Samples #1     Discharge Summary Sample Reports #2


Septoplasty, Rhinoplasty, Blepharoplasty Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Aging face.
2.  Blepharochalasis.
3.  Nasal deformity.
4.  Deviated nasal septum.

POSTOPERATIVE DIAGNOSES:
1.  Aging face.
2.  Blepharochalasis.
3.  Nasal deformity.
4.  Deviated nasal septum.

OPERATION PERFORMED:
1.  Septoplasty.
2.  Cosmetic rhinoplasty.
3.  Bilateral upper eyelid blepharoplasties.
4.  Bilateral lower eyelid blepharoplasties.
5.  Facelift.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient's face and upper eyelids were marked in the sitting position in the holding area.  The patient was then brought to the operating room and placed on the OR table in the supine position.  General anesthesia was induced and a Foley catheter was placed in the bladder.  The entire face was prepped and draped in aseptic fashion.  Lidocaine 1% with epinephrine was infiltrated into the upper and lower eyelids.  Later, the same local anesthetic was injected in the periauricular areas.  Upper eyelid blepharoplasties were performed by excising excess skin from each upper eyelid as marked, using a #15 blade.  A strip of orbicularis oculi muscle was resected with tenotomy scissors, thereby opening each orbital septum.  Excess fat from medial and central compartments was bipolar cauterized and resected.  Hemostasis was achieved in each upper lid with bipolar cautery and a 6-0 Prolene suture was used to close the upper eyelid incisions.  Attention was then turned to the lower eyelids.  A subciliary incision was made in each lower lid and skin muscle flap was elevated on each side.  Excess fat from the medial, central, and lateral compartments was bipolar cauterized and resected.  Excess skin and muscle was then resected with tenotomy scissors.  Hemostasis was achieved in each lower lid with bipolar cautery.  A 6-0 Prolene suture was used to close each lower lid incision.

Attention was then turned to the face.  A periauricular incision was made around each ear and a submental incision was made with a #15 blade.  A subcutaneous skin flap was elevated in the submental and submandibular area, thereby exposing each platysma muscle.  The medial border of the platysma muscles were sutured together with 3-0 Vicryl suture.  Distal to the hyoid bone, the medial border of each platysma muscle was incised with Metzenbaum scissors.  The skin flaps were then elevated across each cheek and each side of the neck using face-lift scissors.  Undermining was carried all the way across the underside of the neck until the submandibular pocket was reached.  A SMAS layer was elevated on each side to help correct the neck ptosis.  A 3-0 Mersilene suture was used to plicate the SMAS layer on each side.  Skin flaps at this point were retracted with Allis clamps and redundant skin around each ear was resected.  A layered closure was performed on each side of the neck over TLS drains using 4-0 Vicryl in the dermal layer and 5-0 and 6-0 Prolene in the periauricular skin layers.  The submental incision was closed in layers using 4-0 Vicryl and 5-0 PDS.

A face-lift dressing was applied at this point and attention was turned to the nose.  Lidocaine 1% with epinephrine was infiltrated intranasally, 5 mL was used.   A #15 blade was then used to make a columellar incision.  This was carried intranasally on each side of the rim incision.  The nasal skin was thereby elevated with tenotomy scissors, elevating skin from the lower lateral cartilages, upper lateral cartilages and nasal bones.  The septum was isolated by separating the 2 lower lateral cartilages from each other.  A Cottle elevator was used to elevate mucoperichondrial and mucoperiosteal flaps from either side of the septum.  Generous dorsal and caudal septum was preserved and intervening deviated cartilaginous septum was resected.  The perpendicular plate of the ethmoid bone which was also deviated was resected.  A portion of the maxillary crest was also resected.  When the septoplasty was completed, attention was turned once again to the nasal bones.  Medial osteotomies were performed using curved Neivert osteotomes and lateral osteotomies were then performed using a straight Neivert osteotome.  The nasal bones were then infractured.  Excess cartilage and some bony dorsum were taken down prior to the osteotomies.  The cephalic rim of each lower lateral cartilage was resected with a #15 blade and intradermal sutures using 4-0 Vicryl were placed.  The nose was then thoroughly irrigated and suctioned and the nasal skin flap was closed with 6-0 Prolene suture.  A 5-0 chromic was used to close intranasal incisions, and at this point, a Denver splint was placed on the nose.  The patient was transferred to PACU in stable condition.  No complications.

Blepharoplasty / Open Rhinoplasty Sample      Blepharoplasty and Facelift Sample

 Plastic Surgery Operative Sample Reports      Plastic Surgery Operative Sample Reports #2

 MT Word Help

Medical Transcription Samples

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Radical Axillary Dissection Operative Sample Report / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Malignant melanoma.
2.  Left axillary lymphadenopathy.

POSTOPERATIVE DIAGNOSES:
1.  Malignant melanoma.
2.  Left axillary lymphadenopathy.

OPERATION PERFORMED:  Left radical axillary dissection.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Laryngeal mask airway.

ESTIMATED BLOOD LOSS:  Less than 50 mL.

DRAINS:  A 10 mm Jackson-Pratt drain.

SPECIMEN:  Left axillary contents.

COMPLICATIONS:  None.

FINDINGS:  Multiple matted lymph nodes in the inferior aspect of the axilla along the latissimus dorsi muscle.

INDICATIONS:  The patient is a (XX)-year-old male who underwent a wide local excision of a Clark level IV malignant melanoma of the left scapular region with associated sentinel lymph node biopsy, which was negative at that time for axillary metastasis.  He presents with a 2-week history of a swollen lump in his left axilla, which on fine needle aspiration revealed poorly differentiated carcinoma.  The patient will now undergo a left radical axillary dissection to remove all the involved nodes in the left axilla, as well as all the lymph nodes well up into the apex of the axilla for therapeutic treatment.

DESCRIPTION OF OPERATION:  After adequate preparation, the patient was taken to the operating room where an LMA was inserted.  He was then positioned in the standard fashion for left axillary dissection.  The area was shaved, prepped and draped in the standard fashion.  The arm was draped within the field.  A transverse incision extending up along the pectoralis muscle and down posteriorly along the latissimus dorsi was made, incising through skin and subcutaneous tissue.  The flap was developed over the pectoralis major muscle.  The edge of the pectoralis major muscle was identified and it was used to dissect up to the axillary vein.  Dissection then occurred just slightly cephalad to the axillary vein pulling down as much of the axillary contents as possible.  The entire dissection was carried up to the undersurface of the pectoralis minor right at the very apex.  Lymph-bearing tissue was peeled down from just above the axillary vein inferiorly.  The branches of the axillary vein were divided either with silk ligatures or clips.  The entire axillary contents were peeled off the vein and posterior to the vein down to the thoracodorsal vessels and nerve, which were clearly identified and preserved throughout the entire procedure, as well as the long thoracic nerve.

Dissection continued in a caudal manner pulling the axillary contents with the specimen.  The highest axillary nodes were removed separately and sent to pathology.  Further dissection continued.  The largest mass of lymph nodes were matted along the posterior edge of the latissimus dorsi and inferiorly.  They appeared to have some skin involvement; therefore, an ellipse of skin was taken with the specimen in order to not cut into tumor.  There was some traction on the long thoracic nerve at its most inferior aspect, being pulled by tumor fibrosis, but not involved by tumor.  The long thoracic nerve was dissected free from the entire axillary contents and was preserved as well.  All the palpable lymph nodes were removed.  The entire specimen was ultimately removed.  Inspection of the axilla revealed the thoracodorsal nerve and the long thoracic nerve, both of which were functioning with compression.  There was no other lymph-bearing tissue left in the axilla.

The area was then irrigated with sterile water.  A 10 mm Jackson-Pratt drain was placed in the axilla and brought out through a separate stab incision.  The incision was then closed with 2-0 nylon in a vertical mattress interrupted fashion.  A pressure dressing was then applied and the patient was then awoken from anesthesia and transported to the recovery room in satisfactory and stable condition.  The patient will be on 23-hour observation.

General Surgery Operative Sample Reports      Plastic Surgery Operative Sample Reports

MT Word Help

Medical Transcription Samples

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Physical Examination Transcribed Medical Transcription Samples

PHYSICAL EXAMINATION:
GENERAL:  The patient is a super-morbidly obese male, in no apparent distress.
VITAL SIGNS:  Pulse 76, respirations 14, blood pressure 132/72. Height 5 feet 8 inches, weight 355 pounds, BMI 54.
HEENT:  PERRLA. Sclerae anicteric. Oral cavity:  Moist, pink, 1+ tonsillar hypertrophy without exudate, erythema, crypts or obstruction.
NECK:  Supple. No JVD, adenopathy or thyromegaly.
LUNGS:  Clear to bases bilaterally.
HEART:  RRR. No S3, S4, murmur or carotid bruits.
ABDOMEN:  Centrally obese with positive bowel sounds in all quadrants. Organomegaly not appreciated secondary to body habitus. No tenderness, masses or rebound.
RECTAL:  Exam deferred.
PERIPHERAL VASCULAR:  Extremities warm and dry, 1+ pitting edema from mid shin to ankles bilaterally with early brawny hyperpigmentation about the ankle areas. No varicosities or cords.
MUSCULOSKELETAL:  Full ROM of all the major joints.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a pleasant young woman in no acute distress.  She is alert and oriented x3.
HEENT:  No scleral icterus.
NECK:  Trachea is midline.
LUNGS:  Clear to IPPA.
HEART:  Heart sounds are normal.
LYMPH NODES:  There is no cervical, supraclavicular or axillary adenopathy.
BREASTS:  Both breasts are normal.  No masses are palpable.
ABDOMEN:  There is no hepatosplenomegaly, inguinal adenopathy or other abdominal pathology noted.

PHYSICAL EXAMINATION:  Blood pressure 144/70, pulse 76 and regular, respiratory rate 16.  The patient is oriented to place and time.  She had some attentional problems.  Mild memory difficulty; she was able to remember 2/4, she did not recall the other two.  There is a hint of apraxia.  She can conceptualize multi-step commands.  She is rather inattentive and has some word finding difficulties and difficulties naming uncommon objects. Funduscopic examination is normal.  Visual fields, extraocular eye movements are full.  There is no nystagmus.  There is a profound hearing loss on the right and somewhat on the left.  There is no ptosis.  Facial movements are normal.  Tongue and palate are normal.  There is no evidence of motor weakness or drift.  Deep tendon reflexes +2 in the upper extremities and at the knees, absent at the ankles.  Fine/coarse motor movements are normal.  There is no limb dysmetria.  She has an ankle foot orthotic.  There is no evidence of ocular or cervical bruits.  There is no temporal tenderness. 

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 142/90, pulse 86, respiratory rate 18. Pain level 0/10.
GENERAL:  The patient is a pleasant woman, well developed, in no acute distress.
NECK:  Supple, no bruits.
HEART:  Regular rhythm.
EXTREMITIES:  No edema was noted.
NEUROLOGIC:  Alert and oriented x3. Normal attention and language. No neglect or apraxia was noted. Pupils about 4 mm, both reactive to light. Full visual fields to confrontation. No visual extinction to double simultaneous stimulation. Disks sharp bilaterally. Extraocular movements intact with no nystagmus. Facial sensation and strength normal. Normal hearing bilaterally. Normal shoulder shrug. Tongue midline. Motor strength 5/5 throughout without any pronator drift. Normal muscle tone. No abnormal movements noted. No dysmetria on finger-to-nose or heel-to-shin test. She had initially some mild tremors bilaterally but that did improve. Sensation:  She felt pinprick throughout, even though she felt some tingling sensation in both big toes. Vibration was decreased in both toes. Normal position sense. Reflexes were +2 throughout. Toes were downgoing. Gait was normal based. Had some difficulties with tandem gait and mild positive Romberg.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 102/72, pulse 74, respirations 18 and temperature 98.6.
HEENT:  Pupils are equal and reactive. There are some surgical changes noted over the left pupil. Sclerae are clear. TMs are clear bilaterally. Oropharynx is well hydrated. No lesions. No erythema.
NECK:  No lymphadenopathy or thyromegaly. Carotids are +2.
HEART:  Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear with no wheezing, rales or rhonchi.
BREASTS: Symmetrical. There is no tenderness. No discrete masses. No nipple discharge. No skin changes.
ABDOMEN: Obese. Positive bowel sounds. Some minimal right upper quadrant tenderness is noted. No rebound or guarding.
GENITOURINARY:  Normal external genitalia. Cervix is without lesions or discharge.
PELVIC:  Exam reveals normal-sized uterus and ovaries. No CMT.
EXTREMITIES:  Without cyanosis, clubbing or edema. Good range of motion. There is no discomfort over the hips bilaterally with palpation.
NEUROLOGIC:  Deep tendon reflexes are +2 and symmetrical. Gait is normal. Cranial nerves II through XII are grossly intact. Motor and sensation are grossly intact.
PSYCHIATRIC:  Normal mood and affect. Alert and oriented x3. Pleasant and cooperative.
SKIN:  No notable lesions or atypical moles.

Rehab Consultation Medical Transcription Sample Note / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Stroke.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed male without significant past medical history, who was admitted with chest pain, cognitive changes and slurred speech. His blood pressure was 121/47. Troponins were positive. CPK-MB fraction was positive. The patient did rule in for a myocardial infarction. CT scan of the brain demonstrated periventricular small vessel disease. A followup MRI examination revealed periventricular small vessel disease, atrophy and a left temporal infarct. Carotid studies were unremarkable. Echocardiogram was unremarkable, except for moderate mitral regurgitation. The patient was placed on aspirin and is now on heparin and Coumadin. His liver function tests have been elevated. Right upper quadrant ultrasound was negative. A videofluoroscopic swallowing study is pending. The patient was started on pureed diet with honey-thick liquids after a bedside speech and language pathology swallow evaluation. The patient denies any pain. He is not sleeping well. He has chronic insomnia and has been on Ambien 5 mg at bedtime for at least a couple of years. His appetite is good. He did fall 6 days prior to admission but declined transfer to the hospital after the paramedics evaluated him at his home.

PAST MEDICAL HISTORY:  None.

PAST SURGICAL HISTORY:  Status post right cataract surgery and prostate surgery.

ALLERGIES:  None.

MEDICATIONS:  Heparin infusion, Lopressor 25 mg b.i.d., lisinopril 2.5 mg daily, Ecotrin 325 mg daily, Coumadin 5 mg and Xenaderm b.i.d.

MEDICATIONS PRIOR TO ADMISSION:  Ambien 5 mg at bedtime p.r.n.

DIET:  Pureed with honey-thick liquids. He is receiving D5 half normal saline at 60 mL/hour.

FUNCTIONAL STATUS:  The patient requires mild to maximal assistance for self-care. He requires moderate assistance for bed mobility and transfers. He is ambulating 20 feet with minimal assistance on a rolling walker. He was independent with a rolling walker prior to admission. He was not driving.

SOCIAL HISTORY:  The patient is a widower. He has 3 children.  The patient lives alone with 2 steps to the entrance. He was a 2-pack-per-day smoker for 30 years. He quit 20 years ago. He drinks occasionally. He was made DNR during this hospital admission.

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:  Per the HPI and PMH. Benign prostatic hypertrophy. Chronic insomnia. He wears glasses. No glaucoma. No hearing difficulties.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 97.6, pulse 68, respirations 22, blood pressure 110/42, and oxygen saturation is 97% on 2 liters of oxygen. Height 5 feet 8 inches, weight 158 pounds, and BMI is 24.
GENERAL APPEARANCE:  Well-developed, well-nourished gentleman, in no acute distress. His affect was normal.
NECK:  There were no carotid bruits.
LUNGS:  Clear to auscultation and percussion.
HEART:  Regular rate and rhythm.
ABDOMEN:  Soft. Bowel sounds are positive. Nontender and nondistended.
EXTREMITIES:  No clubbing, cyanosis or edema. No calf erythema, warmth or tenderness. Peripheral pulses were strong and symmetrical. Passive range of motion was within functional limits throughout.
NEUROMUSCULAR:  The patient was alert and oriented x3. Immediate recall was 3/3 and 3/3 after 5 minutes. His speech was fluent with a moderate to severe dysarthria. Naming and repetition were intact. Basic problem solving and reasoning were intact. Attention and concentration were intact. Visual fields were full. There was a loss of left nasolabial fold. Hearing was intact to whisper bilaterally. Shoulder shrug was diminished on the right. His tongue protruded in the midline with good lateral movement. Motor: There was normal tone in all 4 extremities. No atrophy was noted. Strength was normal in the left upper and lower extremities. Strength was normal in the right lower extremity, except for 3/5 to 4/5 hip strength. He did have a pronator drift on the right. Right upper extremity strength was 5/5 proximally and 4/5 distally. Muscle stretch reflexes, absent ankle jerks and knee jerks bilaterally. Toe response was downgoing on the left and equivocal on the right. Coordination intact on the left, somewhat ataxic on the right. Sensory: Localization was intact. He did not extinguish to double simultaneous stimulation. Gait not tested at this time.

LABORATORY DATA:  Hemoglobin 11.6, white blood cell count 12,700, and platelet count 392,000. ESR was 49. INR 1.14 and PTT 34.6. Sodium 142, potassium 3.8, chloride 102, bicarbonate 24, BUN 18, creatinine 1.2, glucose 117, calcium 7.7, albumin 2.7, total protein 5.8, AST elevated at 69, ALT 52, alkaline phosphatase 64 and total bilirubin elevated at 1.4. TSH was normal at 2.08. Cholesterol 101, HDL 26, LDL 54 and triglycerides 94. Urine culture was negative. MRSA screen was negative.

ASSESSMENT:
1.  Left cerebrovascular accident.
2.  Right hemiparesis, dysarthria and dysphagia.
3.  Impaired mobility and self-care.
4.  Coronary artery disease, status post myocardial infarction.
5.  Moderate mitral regurgitation.
6.  Dyslipidemia with low HDL.
7.  Leukocytosis.
8.  Benign prostatic hypertrophy.
9.  Chronic insomnia.

RECOMMENDATIONS:  Physical, occupational and speech therapies should continue. The patient is appropriate for rehabilitation when he is stable. The patient may require 24-hour supervision at home. His bowels needed to be watched. His Ambien should be resumed. He should receive Tylenol as needed for general aches and pains.

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


Percutaneous Nephrolithotomy Medical Transcription Op Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left renal calculi.
2.  Left ureteral calculi.
3.  Left calcified indwelling stent.

POSTOPERATIVE DIAGNOSES:
1.  Left renal calculi.
2.  Left ureteral calculi.
3.  Left calcified indwelling stent.

OPERATION PERFORMED:
1.  Left percutaneous nephrolithotomy.
2.  Left ureteral stent exchange.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

SPECIMENS:  Kidney stones.

ESTIMATED BLOOD LOSS:  100 mL.

DRAINS:  A 16-French Foley catheter and 18-French nephrostomy tube.

INDICATIONS:  The patient is a (XX)-year-old male with a history of bilateral kidney stones. The patient had an obstructing left proximal ureteral stone at the proximal ureter and ureteropelvic junction and some calculi in the lower pole of the kidney. He had undergone previous extracorporeal shock-wave lithotripsies and ureteroscopies without success. The patient had an indwelling stent and attempts previously to remove this had been unsuccessful due to calcification of the stent. The patient had a nephrostomy tube placed and is now here for definitive management of his stones with percutaneous nephrolithotripsy.

DESCRIPTION OF OPERATION:  The patient was brought to the procedure room and placed on the table in the supine position. He was given general anesthetic and intubated. He was then placed in the prone position. All pressure points were padded. Through the nephrostomy tube, which was in place, we passed a 0.035 guidewire. This guidewire was then looped as many times as possible from the renal pelvis. At this time, the nephrostomy tube was removed over the wire. I then passed double introducer over this wire, and then once this was in the renal pelvis, I advanced a 0.035 sensor guidewire into the renal pelvis and again curled this as many times as possible. At this time, I passed a NephroMax balloon dilator over the sensor guidewire. This was passed to what I felt was the level of the renal pelvis. This was inflated to 14 cm of water, held for 3 minutes. I then passed the access sheath over the balloon without difficulty.

At this time, I used rigid nephroscope to enter the collecting system. There was no active bleeding noted. At this point, I could see the large impacted stones at the level of the UPJ. A calcified stent was also seen in the renal pelvis, which was calcified along its entire length within the renal pelvis. I then used the ultrasonic lithotriptor to begin ablating the stone. A three-prong grasper was used to grasp the larger and smaller pieces and pull them free. I was able to clear the entire stone after a period of time, down several centimeters of the ureter, which was significantly dilated allowing access to the nephroscope. Once I had access to the ureter, I passed a sensor guidewire down the ureter to the level of the bladder and then removed the previous two wires, which had been placed within the renal pelvis. There were some stones within the lower pole as well, and these were visualized and removed with a three-prong grasper.

There was another calcification, which was in the mid calyceal system. I was able to use the flexible cystoscope, which I passed in this area, and using a Zero Tip Nitinol basket, I was able to basket this and pull this free. I was also able to pass the flexible cystoscope down the ureter and there were no calcifications noted down the ureter. There were also no significant strictures at this point; although, there was significant edema where this stone had been impacted within the ureter. Due to the significant edema of the proximal ureter, I felt it safest to place an indwelling stent. Therefore, over the wire, which was down the ureter, I passed an antegrade 6 x 24 French double-J stent. This could be seen curling in the bladder from below and the renal pelvis above, once the wire was removed. At this point, since there was no bleeding noted, I passed an 18 French Foley catheter. Balloon was filled with 2.5 mL of water. I performed a nephrostogram and this was noted to be in good position within the renal pelvis. The access sheath was then cut away from the nephrostomy tube and removed from the patient. Nephrostomy tube was then sutured to the skin with 2-0 silk. The patient was then transferred to the postop care unit in stable condition.

Urology Operative Sample Reports #1     Urology Operative Sample Reports #2

 MT Word Help

 Medical Transcription Samples

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Pediatric Discharge Summary Sample Transcribed Report

DISCHARGE DIAGNOSES:
1.  Term female infant, newborn.
2.  Transient tachypnea of the newborn, resolved.
3.  Jaundice.

CONSULTANTS:  None.

HISTORY OF PRESENT ILLNESS:  This is a female infant born on MM/DD/YYYY at XXXX hours. Mother is gravida 2, para 1, AB 1, blood type B positive, GBS negative, hepatitis B surface antigen negative, rubella immune, VDRL nonreactive. Mother had a history of abnormal quad screen during this pregnancy. Amniocentesis was normal. Membranes ruptured artificially 10 hours prior to delivery with clear fluid. Infant delivered via C-section for failure to descend. Mother did receive ampicillin, gentamicin, and clindamycin prior to delivery for elevated maternal temperature. Apgar scores were 8 and 8 at one and five minutes respectively. The infant was given mask CPAP with oxygen for positive pressure ventilation due to respiratory distress with subcostal retractions and persistent cyanosis. The infant was admitted to special care nursery due to persistent retractions and mild hypoxia.

PHYSICAL EXAMINATION:
VITAL SIGNS:  On admission, weight 3760 grams, length 51 cm, head circumference 33.6 cm. Temperature 99.2, pulse 140, respiratory rate 44, blood pressure 68/40 with a mean of 50.
GENERAL:  Nutrition status good. Term infant.
HEENT:  Anterior fontanelle soft. Mucosa moist and pink. Caput noted.
NECK:  No masses.
LUNGS:  Normal AP chest diameter and expansion. No asymmetry. Clear auscultation. Subcostal retractions.
HEART:  Normal S1 and S2. No murmur.
ABDOMEN:  No masses. No hepatosplenomegaly. Normal bowel sounds. Normal umbilical cord.
GENITOURINARY:  Normal female external genitalia.
MUSCULOSKELETAL:  Normal strength and tone for age.
EXTREMITIES:  Warm.  No edema.
NEUROLOGIC:  Normal behavior for age and condition. No abnormal movements.
SKIN:  No lesions.

HOSPITAL COURSE AND TREATMENT:
1.  Term female infant. Hepatitis B vaccine deferred. Hearing screen OAE passed bilaterally. Newborn screen drawn after 24 hours of age. Infant breast and bottle feeding with adequate output.
2.  Transient tachypnea of the newborn, resolved. The infant presented with persistent retractions and mild hypoxia after C-section delivery. Chest x-ray consistent with retained fluid. The infant was placed on nasal cannula oxygen. Oxygen weaned to room air within 24 hours. Respiratory status also normalized within 24 hours. CBC was done on initial presentation. White count of 40,100, normal differential, H and H of 19.2 and 56.4, platelet count 354,000. Blood culture drawn, negative for 48 hours.
3.  Jaundice.  The infant was noted to be mildly jaundiced on the day of discharge. Bilirubin level was 6.6 at approximately 60 hours of life, which is in the low risk zone.

DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS:  Discharge weight 3545 grams.
GENERAL:  Nutrition status good.
HEENT:  Anterior fontanelle soft. Mucous membranes moist and pink. Mild molding, gradually resolving. Still with mild facial edema, gradually resolving. Red reflex present bilaterally.
NECK:  No masses.
LUNGS:  Breath sounds are clear. Good aeration. No retractions.
CARDIOVASCULAR:  Regular rate and rhythm. No murmur.
ABDOMEN:  No masses. No hepatosplenomegaly. Normal bowel sounds. Umbilical cord drying.
GENITOURINARY:  Normal female external genitalia.
EXTREMITIES:  Warm without edema. No hip clicks.
SKIN:  No lesions. Mild jaundice of the face and chest. A few Mongolian spots over the buttock areas.
NEUROLOGIC:  Normal behavior for age and condition. No abnormal movements. Normal tone and strength for age.

DISCHARGE INSTRUCTIONS:
1.  Follow up within 48 hours.
2.  Ad lib feeding by breast and bottle. Monitor output, supplement as needed.
3.  Monitor jaundice, mother counseled.
4.  Consider hepatitis B vaccine series.

Pediatric Discharge Summary Samples #1     Discharge Summary Sample Reports #2

MT Word Help

Medical Transcription Samples

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Excision of Papules Procedure Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Cervicofacial papules.

POSTOPERATIVE DIAGNOSIS:  Cervicofacial papules.

PROCEDURE PERFORMED:  Excision of cervicofacial papules with primary closure.

SURGEON:  John Doe, MD

ANESTHESIA:  Local.

ESTIMATED BLOOD LOSS:  Scant.

DESCRIPTION OF PROCEDURE:  The patient was placed on the operating table in the semi supine position. Each site was prepped and draped separately.  The right neck was treated first. A 2-layer Betadine swab prep was employed. A blue drape with a central cut-out was placed over the papule. The papule measured approximately 6.5 mm. It had an irregular surface that was not truly papillomatous. A marking pen was used to map out the elliptical incision plane. Lidocaine 1% with 1:100,000 units of epinephrine was used as the anesthetic agent. The site was injected with approximately 2 mL of fluid, one from the medial and one from the lateral aspect. A 27 gauge needle was used. Gentle massage then followed to facilitate uptake of the medication by the tissues. A 15 blade was used to make the incision surrounding the papule. It followed the delineation of the marking pen. The edges laterally and medially were approximated. Forceps was used to grasp the normal skin, allowing the 15 blade to dissect into the subcutaneous tissue plane. The patient tolerated the excision without additional need for anesthetic.  Once the subcuticular tissue plane was reached, the excision continued from medial to lateral with tension held on the specimen to be removed. There was no gross evidence of extension of the disease to the undersurface of the excised tissue. The specimen was removed from the field in its entirety and placed in formalin. This was delivered to the laboratory for analysis. Grossly, the skin margins were free of disease. Given the benign nature of the condition, approximately 2 mm was used as a superior-inferior margin. Hemostasis was achieved with a needle-tip cautery at 5 watts of coag power. The device had an overlying protector to avoid any inadvertent injury to other skin areas. Due to the elliptical nature of the excision and its small vertical dimension, easy primary approximation was achievable. This was performed using 4-0 Prolene suture. A midline dissecting suture and 2 subsequent sutures were placed.

The left cervical papule was next addressed. It was prepped and draped. Again, the marking pen was used to establish an elliptical and horizontal incision. The anesthetic was injected. An additional 1.5-2 mL was used. The same technique was employed to excise the papule and to close the tissue bed.  Attention was next directed to the right temporal region. Again, a 2-layer Betadine prep was performed followed by placement of a sterile towel. The same method was employed with use of a marking pen to delineate the intended elliptical incision by injection of the anesthetic. This papule was nonpigmented on gross appearance. The excision was performed in a manner similarly described as above. Incision was brought down through the cutaneous region to the subcutaneous tissue plane. No nerve trunks or vessels were noted that warranted isolation or ligature. Following removal, the wound was again closed with interrupted 4-0 Prolene suture.

The final site to be addressed was the right nasal alar mass. This was firm and did not have the same rugae surface as the other sites. Following use of the marking pen, the upper lip and right nostril region were injected with anesthetic. The nurse’s report contains total use of the anesthetic throughout the procedure. More significantly, the incision was not elliptical, but curvilinear, to follow the contour of the ala.  A fresh 15 blade was used. This papule had more of a fibromatous component. It was also embedded deeper than the other specimens. Once the lower curvilinear incision was made, the superior one, contouring the inferior aspect of the ala was performed. The incision was again brought down through the skin to the subcutaneous tissue plane. This was then dissected from the underlying soft tissues. Although benign in appearance, on palpation, the superficial mass had deep extension. The base was transected below this plane. The remaining soft tissue attachments were transected to allow for removal of the specimen from the field. It too was placed in formalin.

Electrocautery was used for hemostasis. Pressure was also applied. Due to the degree of dead space, a single buried 4-0 chromic suture was placed. This allowed for 4 separate 4-0 Prolene sutures to be placed with the intent to achieve eversion. This was satisfactorily achieved.  The patient's face and neck were cleaned with a wet and dry gauze at each surgical site. Bacitracin ointment was applied. The procedure was deemed complete. After a suitable period of observation, the patient was discharged home.

Dermatology Sample Transcribed Note     More Derm SOAP Note Samples

MT Word Help    Medical Transcription Samples

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Lab Data Common Medical Transcription Words and Phrases

LABORATORY DATA:  CBC:  White blood cell count 6800 with 54% neutrophils, 31% lymphocytes, hemoglobin and hematocrit 13.9 and 41.8 respectively with low MCV of 81.9, normal MCH of 27.2, and MCHC of 33.2. Platelet count was 229,000. Coagulation profile:  PT 13.3, PTT 28.2. Chemistry profile:  Sodium 141, potassium 4.2, chloride 104, CO2 of 26, calcium 8.6, and hemoglobin A1c 5.9. Lipid profile:  Cholesterol 137, triglycerides 122, HDL low at 35, LDL 78, cholesterol HDL ratio is 3.9. Hepatic profile was completely within normal limits. Urinalysis:  Specific gravity 1.020, pH 6 with trace blood, otherwise normal. TSH 2.24. Arterial blood gas:  pH 7.38, PaCO2 41, pO2 87, base excess 0, bicarbonate 25.3, and saturation 97%.

A chest x-ray was normal. EKG demonstrated normal sinus rhythm with leftward axis and prolonged QT interval. Colon screening Hemoccult cards were negative x3. A 2-hour oral glucose tolerance test included fasting glucose of 106, which was mildly elevated, and a significantly elevated 2-hour glucose of 212.

LABORATORY DATA:  White count 7400, hemoglobin 9.8, hematocrit 28.4, BUN 33, creatinine 3.2, potassium 4.2, CO2 of 24, calcium 8.2, glucose 106. Albumin was low at 1.8. Liver function tests normal. Lipase normal at 26. Urinalysis:  pH of 6.0, protein 300 mg/dL, large blood, negative leukocyte esterase, positive nitrite. Microscopic exam showed many epithelial cells, 2 to 5 white cells, 20 to 50 red cells, and many bacteria. Urine culture was sent and to date is growing greater than 100,000 multiple non-predominating organisms. Blood cultures are negative to date. Renal ultrasound showed normal-sized kidneys with diffusely increased echogenic parenchyma. No obstruction. Intake and output yesterday was 1800 in and 1500 out. A CAT scan of the abdomen and pelvis was done and showed a 1 mm nonobstructing calculus at the lower pole of the right kidney. No obstruction. There were post cholecystectomy changes in the right upper quadrant. 

LABORATORY DATA:  Chemistry:  Sodium 146, potassium 3.9, chloride 88, bicarbonate 37, BUN 27, creatinine 7.5, and blood sugar 198. CBC shows WBC 17.2 with 4% bandemia and 78 segs. Hemoglobin 11.8, hematocrit 34.4, and platelets 298. Coagulation:  PT is 16, INR 1.3, PTT 36.8. Liver functions:  Total protein 7.3, albumin 3.7, AST 18, ALT 14, alkaline phosphatase 66, total bilirubin 1.3, direct bilirubin 0.4, indirect bilirubin 0.9, lipase 19. Ionized calcium 0.92. ABG showed pH 7.6, PCO2 of 41, PO2 of 49. CK total 169. Imaging:  CT of the abdomen with contrast showed polycystic kidney disease, normal appendix. Chest x-ray showed increased pulmonary vasculature and cardiomegaly. Abdominal x-ray showed mild nonspecific small bowel dilatation on the left side but no obstruction. EKG showed normal sinus rhythm, rate of 94, PR interval 209 msec, T-wave inversion in V5 and V6.

LABORATORY DATA:  BUN and creatinine upon transfer were 14.2 and 0.7. Sodium 141, potassium 3.4, CK-MB 5.1, CK-MB index 3.9, troponin 0.06, BNP 96.  White blood cell count was 16, had improved to 6.2 at the time of transfer. Hemoglobin and hematocrit on transfer were 11.4 and 33.6. Platelets were 260 and declined subsequently to 145. D-dimer was 0.82. ABG; pH 7.34, pCO2 of 43, pO2 of 50, base excess -1, bicarbonate 23, O2 saturation 83% on non-rebreather mask. AFB smear from bronchoscopy was negative for acid-fast bacilli. Sputum culture from bronchoscopy showed reduced growth of upper respiratory tract flora. MRSA culture screen was negative for MRSA. Blood cultures showed no growth. X-ray of the chest showed complete opacification of the left hemithorax, residual opacities throughout the left lung and the right lower lung. Chest x-ray subsequently showed improvement in left hemithorax infiltrate as well as the right base infiltrate. Echocardiogram showed vigorous left ventricular systolic function with an EF of 65-70%, mild LV diastolic dysfunction, grade 1/4 mild to moderate tricuspid regurgitation, trace pulmonic regurgitation, severe pulmonary artery systolic hypertension.


Urodynamics and Cystometrogram Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Benign prostatic hypertrophy.

POSTOPERATIVE DIAGNOSES:
1.  Benign prostatic hypertrophy.
2.  Bladder hypotonia.

PROCEDURE PERFORMED:  Complex urodynamics including sphincter EMG, cystometrogram, uroflow and abdominal manometry.

SURGEON:  John Doe, MD

ANESTHESIA:  None.

DESCRIPTION OF PROCEDURE:  The patient attempted to void and voided intermittently a total of 215 mL of yellow urine. Average flow rate was 5.5 mL per sec with maximum flow rate of 13.4 mL per sec. The patient's genital area was prepped with Betadine solution and a 7 French dual-lumen urethral catheter was inserted into the bladder without difficulty and 50 mL of postvoid residual urine was drained. A 9 French abdominal pressure catheter was inserted into the rectum. Pediatric EMG skin patches were placed perianally at 3 and 9 o'clock positions. The bladder was filled with sterile water, an infusion rate of 40 mL per minute. In the filling phase, there was evidence of uninhibited bladder contractions with pressures in the 10 to 17 cmH2O range. At 240 mL of bladder volume, the patient began to express a sense of urgency. Infusion was stopped at 260 mL and the patient voided. He voided 450 mL of fluid around the catheter at an average flow rate of 8.6 mL per sec and a maximum flow rate of 13.5 mL per sec. Detrusor pressure was estimated to be 5 to 8 cmH2O. There was no postvoid residual urine and there was good EMG relaxation during micturition.

The bladder was filled a second time. The infusion rate was 40 mL per minute. Again, there was evidence of uninhibited bladder contractions at 10 to 13 cmH2O pressure range. At 360 mL of bladder volume, the patient felt and expressed a sense of urgency. Infusion was stopped at 375 mL. The patient then voided 400 mL of fluid around the catheter. There was appropriate EMG relaxation during micturition. The detrusor pressure was estimated to be 6 to 10 cmH2O. Flow rate was 7.5 mL per sec. On average, maximum flow rate was 11 mL per sec. There was no evidence of postvoid residual urine.

The bladder was filled a third and last time at a 40 mL per minute rate. Again, there were uninhibited bladder contractions during filling ranging 13 to 16 cmH2O. The bladder was filled to 480 mL when the patient expressed an urge to void. He subsequently voided 460 mL of fluid with a sustained bladder pressure of 6 to 9 cmH2O. Average urinary flow rate was 6.8 mL per sec with maximum flow rate of 11 mL per sec. Postvoid residual was 10 mL.

The catheters and EMG skin patches were removed and the patient was discharged in satisfactory condition.

CONCLUSIONS:  The above study indicates evidence of uninhibited bladder contractions with relative bladder hypotonia. Despite this fact, there was good bladder emptying and flow rates that were somewhat diminished. Appropriate urologic management such as TURP will be discussed with the patient.

MT Word Help

Medical Transcription Samples

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Review of Systems Template Sample Words and Phrases

REVIEW OF SYSTEMS:
CONSTITUTIONAL: No weight loss, fever, weakness or fatigue.
HEENT:  No vision loss or blurred vision. The patient does wear glasses. No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure, chest discomfort, palpitations or edema.
RESPIRATORY: No shortness of breath or cough.
GASTROINTESTINAL: Has had nausea, vomiting, diarrhea as described above. Abdominal cramping as described above. No blood.
GENITOURINARY: No dysuria, frequency or hematuria.
NEUROLOGIC: Complains of headache as described above. No dizziness, no syncope, no paralysis and no ataxia. Denies loss of control of bowels or bladder.
MUSCULOSKELETAL: No joint pain or stiffness.
HEMATOLOGIC: No history of anemia or bleeding.
LYMPHATICS: No enlarged nodes or splenectomy.
SKIN: No rash or itching.

REVIEW OF SYSTEMS:  CONSTITUTIONAL: No weight loss, fever, weakness or fatigue. HEENT:  No visual loss, blurred vision, double vision or yellow sclerae. No hearing loss, sneezing, congestion, runny nose or sore throat. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: Shortness of breath. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: No dysuria, frequency or hematuria. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES:  No history of asthma, hives, eczema or rhinitis. SKIN: No rash or itching.

REVIEW OF SYSTEMS:  The patient denies headache, dizziness or loss of consciousness.  Denies changes in vision or loss of vision.  Denies ringing or buzzing in the ear.  Denies nasal congestion or epistaxis.  Denies sore throat, dysphagia or odynophagia.  Denies cough or hemoptysis.  Denies chest pain, shortness of breath, orthopnea or paroxysmal nocturnal dyspnea.  Denies abdominal pain, diarrhea or constipation.  Her right foot is not painful at this time.  Her surgical site is slightly sore.  She denies seizures.  Denies melena or bright red blood per rectum.

REVIEW OF SYSTEMS:  No fever, chills or night sweats. No headaches, visual disturbances, mouth pain, bleeding gums, tooth pain, tongue swelling or dysphagia. The patient is experiencing difficulty masticating certain food textures. Neck muscles are sore but without significant stiffness. Skin has no gross discolorations, rashes or itching. No pain, shortness of breath, palpitations, PND, orthopnea or edema. No nausea, vomiting or diarrhea. No bleeding or hematochezia. No dysuria, pyuria or hematuria. No flank pain. No seizure, syncope, headache, diplopia, dysarthria or worsening paresthesias.

REVIEW OF SYSTEMS: CONSTITUTIONAL:  The patient has gained some weight.  Denies any fever, chills or sweats. HEENT:  No visual change, no eye pain or diplopia.  No rhinorrhea, ear pain or sore throat.  Has some difficulty swallowing. CARDIOVASCULAR:  Denies chest pain or palpitation.  No history of heart attack. PULMONARY:  Has mild shortness of breath, no pneumonia, no TB. GASTROINTESTINAL:  Denies diarrhea or blood in the stool.  No stomach ache. GENITOURINARY:  Has no dysuria, flank pain, discharge or rash. NEUROLOGY:  Had multiple falls over the last couple of months, but no seizure or syncope. ENDOCRINE:  Has history of diabetes. MUSCULOSKELETAL:  Has arthritis. PSYCHIATRIC:  Looks depressed. HEMATOLOGY:  No history of anemia.

REVIEW OF SYSTEMS:  No CHF or palpitations.  No history of heart attack.  Normal nuclear stress test.  No complaints of asthma, emphysema or cough.  No shortness of breath.  Mild dyspnea on exertion, relieved by rest.  No history of ulcer, abdominal pain, nausea or vomiting.  No melena, hematochezia, hematemesis, ulcers, colitis, liver disease, pancreas problems or gallbladder problems.  No complaints of dysuria, hematuria or flank pain.  No claudication, peripheral edema or phlebitis issues.  Minor arthritic complaints at the hips and knees.  Hearing, speech and vision grossly normal.  No history of thyroid disease or carotid blockage.  No history of stroke.  Memory has been good.  No Alzheimer's history.

REVIEW OF SYSTEMS:  No TIA, blackout spells or seizure disorder.  No history of amaurosis.  Has had some lightheadedness.  No recent history of fever, chills or diaphoresis.  No headache but he has had a slight tremor.  No history of sputum production.  No hemoptysis.  No shortness of breath.  No orthopnea.  No dyspnea.  No recent chest pain or chest pressure.  No claudication.  No history of heart murmur.  Has never had veins stripped out of the legs.  Has got no nausea, vomiting or diarrhea.  No change in bowel or bladder habits.  No melena.  No pain with urination.  No blood in his urine and no hesitancy.  Does not have any skin bruisability or bleeding tendency.  Has had no history of neurologic or psychiatric disorders and had no history of endocrine disorders and no history of skin rash.

ROS Examples      ROS Examples # 1      ROS Examples # 2     ROS Words & Phrases
Subscribe to: Posts (Atom)