Cough and Congestion ER Medical Transcription Sample

DATE OF ADMISSION:  MM/DD/YYYY

MODE OF ARRIVAL:  Private vehicle.

CHIEF COMPLAINT:  Cough and congestion.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male with a history of coronary artery disease, hypertension, and hypercholesterolemia, who presents with 3 days of sore throat, nasal congestion and cough. The patient stated that he began to become a little bit short of breath and had some tactile fevers at home. He has pain in his chest associated with cough. There is no exertional chest pain noted. There is no nausea, vomiting or diarrhea. No headache. The patient also states that his wife is sick right now with the same symptoms, although much less significant.

PAST MEDICAL HISTORY:  Myocardial infarction 1 year ago with a stent placed, hypertension, hypercholesterolemia.

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Over-the-counter cough medications, Plavix, lisinopril, aspirin and Zocor.

ALLERGIES:  NKDA.

SOCIAL HISTORY:  Noncontributory.

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:  As per HPI, otherwise unremarkable. All systems reviewed and are negative.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE:  The patient is alert and oriented, nontoxic-appearing male.
VITAL SIGNS:  Blood pressure 152/102, pulse 94, respiratory rate 20, temperature 98.6, pulse oximetry 95% on room air, interpreted as normal. Pain is 6/10.
HEENT:  Normocephalic and atraumatic. Pupils are equally round and reactive to light. Tympanic membranes are normal. Nasal mucosa is boggy. Turbinates with clear nasal discharge and postnasal drip. Oral mucosa is moist. There is some mild oropharyngeal erythema. There is no exudate noted.
NECK:  Supple. Full range of motion. There is no thyromegaly.
LYMPHATICS:  Increased anterior cervical lymphadenopathy.
HEART:  Regular rate. No murmur, 2+ pulses x4 extremities.
LUNGS:  Normal respiratory effort. There are bilateral coarse breath sounds. There is no rhonchi noted. No wheezes appreciated.
ABDOMEN:  Soft, nontender, nondistended. Positive bowel sounds.
EXTREMITIES:  No clubbing, cyanosis, or edema. Full range of motion of all extremities.
NEUROLOGIC:  Cranial nerves II through XII are grossly intact. No focal motor or sensory deficits were appreciated.
PSYCHIATRIC:  Normal mood and mentation. Alert and oriented x4.
SKIN:  Warm and dry with no rashes or lesions noted. No petechiae or bruising noted diffusely.

LABORATORY AND DIAGNOSTIC DATA:
EKG:  Normal sinus rhythm with a ventricular rate of 88 with incomplete right bundle branch block with no ST or T-wave changes.
Chest x-ray:  Normal cardiac silhouette. No infiltrate. No effusion. No bony abnormalities.
CPK 72, troponin less than 0.01. WBC 10.6, hemoglobin 14.8. INR is 1.0. LFTs are normal. Chemistry is normal.

EMERGENCY DEPARTMENT COURSE:  The patient was given IV hydration in the emergency department as well as Levaquin 750 mg p.o. The patient remained afebrile, normotensive. No tachycardia, no hypoxia in the emergency department and remained stable throughout the emergency department stay.

ASSESSMENT:
1.  Bronchitis.
2.  Chest wall pain.

PLAN:
1.  Return to the emergency department immediately for worsening symptoms.
2.  The patient was given a list of providers in the area for followup as soon as possible.
3.  The patient was given Z-Pak as directed, Phenergan with Codeine and Motrin 800.
4.  The patient was stable and improved at the time of discharge.

DISPOSITION:  Discharged to home.

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Laboratory Data Medical Transcription Words and Samples

LABORATORY DATA:  Sodium 126, potassium 3.8, chloride 94, CO2 is 26, glucose is 146, BUN 18, creatinine 1.0, anion gap is 14. CPK and troponin are negative. Chest x-ray, PA and lateral, no acute disease. White count 13.2, H and H 12.2 and 36.6, platelet count 236 with 90 segs, 2 lymphocytes. Urinalysis:  Occasional budding yeast, white blood cell clumps many, bacteria many, moderate leukocyte esterase, positive nitrite, large blood, 10-20 reds, 10-20 whites. Cardiac enzymes, second set, negative.

LABORATORY AND DIAGNOSTIC STUDIES:  He had an EKG for an indication of lightheadedness. This showed normal sinus rhythm, 68 beats per minute. PR 168, QRS of 86, QTc 396. He had a leftward axis, normal intervals. No ST elevation or depression. No T-wave inversions. He had some flattened Ts in lead III and with R-wave progression in his inferior leads, but it was no change from a previous EKG. He had labs drawn including a normal CBC, normal renal panel. Glucose is slightly elevated. He had 3 sets of cardiac enzymes over 3 hours, which were normal. UA was normal and a BNP was normal. He had a chest x-ray read by the radiologist as normal.

LABORATORY AND DIAGNOSTIC STUDIES:  Initial laboratory studies are remarkable for glucose 750, osmolality 330, acetone was negative, white blood cell count 5.2, SGOT 26, SGPT 146, sodium was 134, INR 0.9.  EEG was reviewed and found to demonstrate minimal diffuse slowing.

LABORATORY AND DIAGNOSTIC STUDIES:  EKG showed a paced rhythm with an underlying rhythm, likely to be atrial fibrillation and premature complexes. There is some ST segment depression in lead II. The EKG is essentially nondiagnostic, otherwise. The patient had a chest x-ray, which revealed no acute abnormalities. Cardiac enzymes were negative. Digoxin level 1.6. AST, ALT, and alkaline phosphatase are all normal. INR is 2.2. Lipase 34. White blood count of 5, hemoglobin 12.8, platelets 170, sodium 139, potassium 3.2, chloride 108, bicarbonate 26, glucose 98. BUN 14 and creatinine 0.9.

LABORATORY AND DIAGNOSTIC STUDIES:  A CBC was obtained, which revealed a white count of 5.8, H and H of 13.9 and 41.8 and platelet count of 326,000. She had 53% neutrophils, 38% lymphocytes and 8% monocytes. Renal panel revealed a sodium of 140, potassium of 3.8, chloride 108, total CO2 of 30, BUN of 18, creatinine 1.1 and glucose of 109. Coagulation times revealed PT of 13.6, INR of 1.1 and PTT of 28.2. A set of cardiac enzymes revealed CK-MB of 1.7 with troponin I of less than 0.05. A chest x-ray was unremarkable. EKG revealed a slightly prolonged QTc at 162 milliseconds, but was otherwise an unremarkable EKG. Urinalysis revealed specific gravity of 1.024, small bili, trace ketones, 30 of protein and urine hCG was negative.

LABORATORY AND DIAGNOSTIC STUDIES:  EKG showed sinus bradycardia at 56 beats per minute, normal axis, normal intervals. No evidence for acute ischemia. Otherwise, normal EKG. There is no old EKG for comparison. Noncontrast head CT was unremarkable. Chest x-ray was unremarkable. Sodium 138, potassium 3.8, BUN and creatinine 17 and 1.2 respectively with a glucose of 86. White count 6.6 with an H and H of 14.6 and 43.8, platelets 246,000. Cardiac enzymes are negative and normal x2. An LP was  performed. CSF findings came back consistent with viral meningitis with a glucose of 54 and protein of 44, which were both within normal limits. Tube 1: Somewhat of a traumatic tap with 3000 red blood cells, 104 whites with 87 lymphocytes and 12% monocytes. Tube 4:  Showed 3 red blood cells, still 100 white blood cells with 82% lymphocytes, 16% monocytes, and 1% eosinophil. Given this pattern, this is most likely viral meningitis.

LABORATORY AND DIAGNOSTIC STUDIES:  CBC:  White count 11.6, hemoglobin 17.2, hematocrit 51.4, platelets 139. Renal:  Sodium 134, potassium 3.8, chloride 102, bicarbonate 26, BUN 11, creatinine 1.4, glucose is 186. CK MB is 1.3. Troponin 0.06 and BNP is 37.2. Second set of cardiac enzymes, CK MB was 1.2, troponin was less than 0.05. AST was 362, ALT was 354, total bilirubin 7.9, direct bilirubin 2.9, protein 6.8, albumin 4.2, lipase is 8. Alkaline phosphatase 126. Protime 18.2, INR 1.6 and PTT is 33.8. Urinalysis showed 100 protein, 40 ketones, 100 bacteria, 100 sugar, moderate bacteria, 3-5 white blood cells, small blood, urobilinogen 8.1, large bilirubin and 3-5 white blood cells, 5-10 reds. EKG was done, which showed a normal sinus rhythm, heart rate is 66. No ST elevation or depression noted. No acute ischemic changes noted, normal axis. There is no old EKG to compare to at this time. Also did a CT scan of the abdomen and pelvis, which did show gallstones and acute cholecystitis.

LABORATORY AND DIAGNOSTIC STUDIES:  CBC:  White count 4.7, hemoglobin 15.2, hematocrit 45.6, platelets 236. Renal:  Sodium 140, potassium 4.1, chloride 108, bicarbonate 28, BUN 10, creatinine 0.9, glucose is 108. CK-MB is less than 1, troponin is less than 0.05. AST is 22, ALT is 14, total bilirubin 0.6, direct bilirubin 0.1, protein 6.8, albumin 4.4, lipase is 14, alkaline phosphatase 74 and BNP was 19.8. A second set of cardiac enzymes was also negative. A chest x-ray showed mild hyperinflation; otherwise, no acute disease. EKG showed a normal sinus rhythm, heart rate of 74 with no ST elevation or depression noted. No acute ischemic changes were noted.

LABORATORY AND DIAGNOSTIC DATA:  CBC:  White count 11.6, hemoglobin 10.2, hematocrit 30.6, platelets 344. Renal panel showed sodium of 140, potassium 5.1, chloride 111, BUN 46, creatinine 1.9, which is up from her baseline of 1.2. She had a glucose of 120. Cardiac enzymes showed a CK-MB of 9.2 and a troponin of less than 0.05. She did have a total CK of 882. The patient had a BNP, which was 260 and protime and INR which were within normal limits. She had a chest x-ray which showed AICD, otherwise no acute process. She had an EKG which showed sinus tachycardia with a rate of 106, normal axis, normal intervals. She did have Q-waves in the inferior leads indicating an old MI. She also had LVH. She also had T waves in leads V4 through V6. There was no ST elevation or depression, no evidence of any acute ischemia.

LABORATORY AND DIAGNOSTIC DATA:  CBC: White count 12.2, hemoglobin 11.4, hematocrit 33.6, platelets were 228. Initial renal panel showed sodium of 131, potassium 3.2, chloride 102, BUN 32, creatinine 1.3. Glucose was 98. She had LFTs and lipase, which were within normal limits. Urinalysis showed 30 protein and was otherwise negative. She was typed and screened, which showed A positive with a negative antibody screen. She had acute abdominal series, which showed indeterminate for small bowel obstruction. Repeat renal panel showed a BUN of 28 and creatinine of 1.1. Her potassium also improved to 3.6. The patient did have a CT of abdomen and pelvis with IV and p.o. contrast with no acute abnormalities noted. EKG showed normal sinus rhythm with a rate of 88. She had a left bundle branch block, normal intervals. She did have one set of cardiac enzymes, which were negative.



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TrapEase IVC Filter Insertion Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left leg deep venous thrombosis.
2.  Contraindication to long-term anticoagulation.

POSTOPERATIVE DIAGNOSES:
1.  Left leg deep venous thrombosis.
2.  Contraindication to long-term anticoagulation.

PROCEDURE PERFORMED:
Insertion of TrapEase inferior vena cava filter.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIOLOGIST:  Jane Doe, MD

ANESTHESIA:
Local with monitored anesthesia care.

ESTIMATED BLOOD LOSS:
Less than 10 mL.

COMPLICATIONS:
None.

DISPOSITION:
To the recovery room.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed on the operating table in the supine position.  After induction of adequate IV sedation, the patient was prepped and draped in the usual sterile fashion.

The area in the right groin was infiltrated with 1% lidocaine.  The right femoral vein was percutaneously cannulated without difficulty and a Glidewire easily inserted.  This was carefully followed under fluoroscopy through the iliac vein into the inferior vena cava.  A small incision was made at the insertion of the wire.  The needle was removed and a dilator and sheath was then threaded over the Glidewire.  Again, this was followed under fluoroscopy into the inferior vena cava.  The level of L3 was identified.  The wire and dilator were removed.

A cavogram was performed through the sheath that noted patent inferior vena cava below the level of the renal veins.  The filter was placed into the sheath, and the pushing mechanism was used to place the filter to the appropriate level.  The sheath was then pulled back, fully deploying the filter at approximately the level of L3.  Again, this was completed expanded.  The sheath was removed and pressure was held on the groin for 5 minutes for hemostasis.  The small incision was closed with a Steri-Strip dressing, and gauze compressive dressings were applied.

The estimated blood loss was less than 10 mL.  The sponge and needle count was correct.  The patient tolerated the procedure well.  He was awakened in the operating room and taken to the recovery room in stable condition without any apparent complications.

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Pulse Generator Replacement Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Pacemaker battery at end-of-life.

POSTOPERATIVE DIAGNOSES:
1.  Pacemaker battery at end-of-life.
2.  Potential need for biventricular pacemaker.

PROCEDURE PERFORMED:
Pulse generator replacement, removal of a Medtronic unit and insertion of Biotronik Stratos LV with biventricular port.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:
Local anesthesia and general anesthesia.

COMPLICATIONS:
None.

DISPOSITION:
To the recovery room.

INDICATION FOR PROCEDURE:
The patient is a (XX)-year-old male who had previous aortic valve replacement. Later, the patient had insertion of a dual chamber pacemaker and now the pacemaker has shown signs of battery at the end-of-life. Therefore, the patient was brought in by Dr. Doe for pacemaker replacement, which was done as follows.

DESCRIPTION OF PROCEDURE:
The patient was placed in the supine position. Sedation was initially given and then it was converted to general anesthesia. The patient was positioned, then prepped and draped as usual for pulse generator pacemaker replacement.

The skin where the pacemaker was inserted in the left infraclavicular area was incised over the old scar, and the incision was carried down sharply all way to the pacemaker pocket. Attention was paid not to injure any of the structures going down to the pacemaker itself. Once that was found, the pocket incision was extended to allow removal of the pacemaker from the subcutaneous pocket. Once the pacemaker was at the surface, the leads were disconnected from the pulse generator and connected with an outside pacemaker. The patient has underlying rhythm, which is an atrial flutter. Hemostasis was done in the pocket with electrocautery. Then, the bottom of the pocket was incised to allow placement of the new pulse generator.

A Biotronik pulse generator Stratos LV was chosen, which has biventricular capabilities. At this point, we did not think the patient needed it, but the pulse generator can be connected to a third lead in the future if necessary. We checked both leads inserted several years ago. The atrial lead shows P-waves of 2.2 mV and the resistance was 480 ohms. The ventricular lead was tested as well and the threshold was 0.6 V at 0.4 msec. R-waves were 5.9 mV and the resistance was 520 ohms. Both leads were bipolar. The leads were then reconnected to the atrial and ventricular ports of the Biotronik pulse generator.

The pocket was irrigated with a large amount of antibiotic solution. The pulse generator was easily placed into the pocket and then pocket was closed in layers as usual. The patient was pacing normally once this was into the pocket. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.


Laparoscopic Ileocolic Resection Medical Dictation Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Terminal ileum carcinoid.

POSTOPERATIVE DIAGNOSIS:
Terminal ileum carcinoid.

OPERATION PERFORMED:
Laparoscopic ileocolic resection.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  50 mL.

DRAINS:  None.

SPECIMEN:  Terminal ileum, right colon.

CONDITION:  The patient tolerated the procedure well.  There were no complications.  He was extubated in the operating room and transferred to the PACU in stable condition.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and laid supine on the operating room table.  Once general endotracheal anesthesia was obtained, the patient was placed in the lithotomy position.  An infraumbilical midline incision was created in order to insert a 12 mm trocar infraumbilically.  Once this was passed into the abdominal cavity, insufflation was attached to the trocar and adequate pneumoperitoneum was obtained.

The laparoscope was then inserted into the abdomen, and there was a 12 mm trocar that was inserted in the left lower quadrant, a 5 mm trocar in the right lower quadrant, and a 5 mm trocar in the left upper quadrant.  With the use of the trocars, graspers and the Harmonic scalpel were used to mobilize the terminal ileum and the right colon off the white line of Toldt.  Once there was adequate medial mobilization, the Babcock grasped the cecum in the midline trocar to allow the ileocolic resection to be performed extracorporeally.  The pneumoperitoneum was then released and the infraumbilical incision was extended around the umbilicus and inferiorly.  The fascia and the peritoneum were also divided with electrocautery.

The terminal ileum was then grasped and delivered extracorporeally.  A portion of the terminal ileum was transected approximately 10 cm proximal to the ileocecal valve.   The ileocolic vessels were divided with electrocautery.  The ileocolic vessels were then grasped with a long Kelly.  They were transected and then they were tied with 2-0 silk sutures.  The mesentery of the right colon was also divided with Kelly clamps and 2-0 silk sutures.  The proximal transverse colon was then sutured with the terminal ileum in a side-to-side fashion.  A colotomy and enterotomy were created in order to accommodate a 75 mm GIA stapling device.  Once the stapler was introduced, it was secured, fastened, and fired.  This created a side-to-side and end-to-end functional anastomosis.  The colotomy was then stapled with a 55 mm TA stapling device.  A cross-suture was placed with a 3-0 silk suture.  The enterotomy that was transected with the TA was imbricated with multiple 3-0 silk sutures.  The mesentery was reapproximated with multiple 3-0 silk sutures.

The newly anastomosed bowel was then reintroduced into the abdominal cavity.  The abdomen was copiously irrigated and dried.  There was adequate hemostasis.  A #0 Prolene suture was then used to reapproximate the fascia, one running from the inferior portion of the wound, one from the superior portion of the wound, meeting in the middle and being tied together.  The subcutaneous tissue was copiously irrigated and dried and the skin was reapproximated with skin staples.  The trocar sites were reapproximated with 4-0 Vicryl suture in a subcuticular fashion.  The 12 mm trocar site at the fascia was reapproximated with a 0 Vicryl suture.  The skin was also reapproximated with a 4-0 Vicryl suture in a subcuticular fashion. This completed the procedure.  Needle, lap, and instrument counts were correct at the end.  The patient tolerated the procedure well.  There were no complications.  The patient was then extubated in the operating room and transported to the PACU in stable condition.

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Venous Access Device Implantation Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Rectal cancer, status post resection.
2.  Need of adjuvant chemotherapy.

POSTOPERATIVE DIAGNOSES:
1.  Rectal cancer, status post resection.
2.  Need of adjuvant chemotherapy.

OPERATION PERFORMED:  Insertion of implantable venous access device.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with MAC

ESTIMATED BLOOD LOSS:  None.

IMPLANT:  MediPort.

SPECIMENS:  None.

COMPLICATIONS:  None.

OPERATIVE FINDINGS:   Three attempts were made in the right subclavian vein, ultimately, access was gained in two.  In one, the J wire progressed to the right internal jugular.  In the second one, a similar event happened; however, under fluoroscopy, it was guided down into the superior vena cava and through the heart to the inferior vena cava.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female recently diagnosed with rectal cancer, who underwent coloanal anastomosis with a protective ileostomy following neoadjuvant chemoradiation.  Now, her postoperative adjuvant chemotherapy has been delayed due to some cardiac issues, which have now been resolved.  The patient has elected at this time to proceed with adjuvant chemotherapy pending reversal of ileostomy.  She presents at this time for MediPort insertion to facilitate chemotherapy.

DESCRIPTION OF OPERATION:  After adequate preoperative preparation and counseling to include the risk of bleeding, pneumothorax, and catheter issues such as breakage and infection, the patient expressed understanding of all these risks and agreed to the procedure.  The patient was taken to the operating room and placed in the supine position, and IV sedation was given.  The right subclavian area was shaved, prepped, and draped in standard fashion.  A standard subclavian approach was used, which failed to gain access to the subclavian vein.  A second attempt was made on the right side, which did gain entry into the subclavian vein; however, the J wire, under fluoroscopy, was noted to be going up the internal jugular vein.  Attempts, while under fluoroscopy, to guide it down into the superior vena cava were unsuccessful.

Therefore, a third attempt was made.  Entry into the subclavian vein once again was attained, and once again, the J wire progressed up to the internal jugular vein.  However, at this time, we were able to successfully manipulate it down into the superior vena cava and through the heart into the inferior vena cava, under fluoroscopy.  At this point, then, additional local anesthesia was injected; this had been used prior to all 3 subclavian attempts.  

A pocket was then created in the right upper chest.  Incising through skin and subcutaneous tissue down to the fascia, a pocket was made just inferior to the J wire insertion.  At this point, the dilator with peel-away sheath was introduced over the J wire using Seldinger technique.  The dilator was then removed.  A catheter that had previously been fashioned was then placed over the J wire into the peel-away sheath.  The peel-away sheath was then peeled away and the J wire was then removed.  The catheter was then connected to the port.  

The port was then accessed.  Good easy return of blood was appreciated, and heparinized saline was then infused into the port and the catheter.  At this point, after establishing good hemostasis in the pocket, the port was then placed in the pocket and secured down to the fascia with the use of 2-0 Prolene to opposite sites.  Once this was done, under fluoroscopy, we viewed the tip of the catheter to be in the right atrium, which we felt was acceptable.

The incision was then closed using 3-0 Vicryl to approximate the platysma.  The skin was then closed with 4-0 Monocryl in a running subcuticular fashion.  The port was once again accessed through the skin with good easy return of blood and easy infusion of heparinized saline solution.  Benzoin and Steri-Strips were then applied to the incision.  Sterile dressing was then applied.  The patient was then transported back to recovery room in satisfactory condition.  Postoperative chest x-ray is still pending at this time.

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