Swallowing Evaluation Medical Transcription Sample Report

The patient had been seen by this department for a clinical swallowing evaluation. At that time, he had reported 3 to 4 months of coughing with liquids, approximately one time per week. He had a barium swallow, which showed one episode of aspiration with appropriate cough response. Given the patient’s complaints of coughing with thin liquids and possible reflux related symptoms, an objective swallowing evaluation was recommended. However, the patient chose not to follow up for further objective testing at that time. The patient returns today reporting that dysphagia has persisted, and now, he feels as though he can cough or choke several times a day with either liquids or solids. He is on a regular diet. He takes his pills with water without difficulty. He has a reported 5 to 10 pound weight loss over the past several months that has been unexplained. His physician has asked him to gain some weight to improve his nutritional status. He has no recent history of pneumonia. The patient does complain of feeling as though he has sluggish passage of his meals and sometimes this will cause him to stop eating early. He has a feeling of increased mucus with frequent throat clearing throughout the day, and he complains of frequent heartburn. He is not on any proton pump inhibitor regimen at this time.

PAST MEDICAL HISTORY:  Coronary artery disease requiring LAD stent placement, hypertension, hyperlipidemia, asymptomatic right carotid stenosis, chronic anemia due to renal disease, chronic renal insufficiency that is stable.

CLINICAL OBSERVATIONS:  The patient arrives to today's session with his daughter. He uses a walker due to knee trouble. He is fully alert and oriented, slightly hard of hearing. He is able to provide a comprehensive history. Good speech intelligibility. Vocal quality is slightly raspy, although otherwise within normal limits for age and gender.

ORAL PERIPHERAL EXAM:  The patient has naturally present dentition, in poor condition. There is bilateral palatal elevation, good lingual and labial strength and range of motion, and good ability to maintain intraoral pressure. Cough is strong and unproductive. There is good hyolaryngeal elevation and excursion to palpation.

SWALLOWING EVALUATION:  Administered p.o. trials of ice chips, thin puree, and particulate solid.

ORAL PHASE:  The patient is able to self-feed appropriately. He has good bolus containment and timely anterior to posterior transit with mildly delayed trigger of pharyngeal swallow overall. Question premature spillage with multiple sips of thin liquids.

PHARYNGEAL PHASE:  Audible and question slightly discoordinated swallowing pattern for multiple sips of thin liquids. One swallow required for single sips of thin, puree, and particulate solids. No overt clinical signs or symptoms of aspiration after any p.o. trial; although, the patient reports that he had slight difficulty with the initial sip of water, feeling like it might head down the wrong pipe.

SUMMARY AND IMPRESSION:  The patient is a (XX)-year-old male with a several year history of reported dysphagia to solids and liquids. This can happen several times per day. Clinically, he does not show significant overt clinical signs of aspiration, although question discoordinated swallowing pattern for thin liquids, especially when given larger quantities. This is likely consistent with the one incidence of symptomatic aspiration on a barium swallow in the past. The patient also complains of multiple symptoms that appear consistent with laryngopharyngeal reflux, and these include increased mucus, throat clearing, and globus sensation. He reports frequent heartburn and sensation of slow esophageal passage. At this time, would recommend objective testing to further evaluate oropharyngeal swallowing mechanism to determine if coordination of swallowing pattern has been affected over time. Further differential diagnosis would be considerable reflux in current complaints. The patient may benefit from a proton pump inhibitor regimen if deemed appropriate by his physicians. At today’s session, discussed aspiration precautions, especially given that the patient self-reported drinks multiple sips at a time. In addition, reflux precautions were recommended, including sitting upright 90 degrees with all p.o. and for one hour after meals. The patient was also counseled to monitor his nutritional intake. If he is indeed shortening meals due to sensation of sluggish passage, would recommend multiple smaller meals a day rather than three large ones to allow for adequate nutritional intake. The patient understands all given recommendations and is in agreement for a followup with an objective swallowing test.

RECOMMENDATIONS:
1.  Regular diet with thin liquids.
2.  Medications one at a time with water.
3.  Further objective testing via modified barium swallow.
4.  Upright 90 degrees with all p.o. and for one hour after meals.
5.  Decrease bolus size and rate of presentation.
6.  Single bites and single sips.
7.  Consideration of proton pump inhibitor regimen if reflux is deemed by the patient's physicians to be playing a role in the patient's current symptoms.
8.  Further recommendations will be made pending outcome of objective study.

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Speech Language Pathology Swallow Evaluation Sample Report

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Tonsillectomy Medical Transcription Sample Reports

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Chronic tonsillitis and tonsillar hypertrophy.

POSTOPERATIVE DIAGNOSIS:  Chronic tonsillitis and tonsillar hypertrophy.

PROCEDURE PERFORMED:  Tonsillectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

FINDINGS:  Absence of adenoid tissue and 3+, very smooth tonsils.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old with a history of recurrent strep infections of the tonsils with newly developed sleep-disordered breathing from tonsillar hypertrophy, who presents for removal of tissue.

DESCRIPTION OF PROCEDURE:  After informed consent was reviewed with the patient, the patient was brought to the operating room and placed on the table in the supine position. Once a suitable plane of anesthesia was obtained, the Anesthesia personnel performed endotracheal intubation. Next, the patient was draped in standard fashion. A Crowe-Davis mouth gag was inserted to exposed the oral cavity. Tonsils were palpated and were normal. The patient was placed in suspension. The Crowe-Davis was then suspended from the Mayo stand. The right tonsil was grasped and retracted medially and Bovie cautery was used to dissect the tonsil from the tonsillar fossa. This procedure was repeated on the left side. Hemostasis was achieved with suction Bovie. Next, a red rubber catheter was passed through the nasal cavity and into the mouth to provide retraction on the palate. The adenoid bed was inspected with a laryngeal mirror and was found to be normal. At this point, the tonsils were reinspected and irrigated. There were no signs of active bleeding. An nasogastric tube was passed into the stomach. The stomach contents were suctioned. At this point, the red rubber catheter and Crowe-Davis mouth gag were removed and care was turned over to Anesthesia for extubation. The patient was extubated in the OR and was stable upon transport to the PACU.

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

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Chronic tonsillitis.

POSTOPERATIVE DIAGNOSIS:  Chronic tonsillitis.

PROCEDURE PERFORMED:  Tonsillectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

SPECIMENS:  Bilateral tonsils.

BRIEF HISTORY:  The patient is a (XX)-year-old gentleman with a history of chronic tonsillitis, tonsilloliths and halitosis. The patient elected to undergo a tonsillectomy. The risks and benefits of the procedure were explained to the patient, and he agreed to proceed.

FINDINGS:  The patient had large cryptic tonsils with retained food products bilaterally.

DESCRIPTION OF PROCEDURE:  The patient came to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was turned, and the patient was draped in routine fashion. A Crowe-Davis mouth gag was used to visualize the oral cavity and the oropharynx. The right tonsil was grasped with a tonsil clamp and medialized. Bovie cautery was then used to dissect the tonsil free from the tonsillar fossa. There was no bleeding during the removal. The tonsil was then sent for routine pathological diagnosis. Attention was then turned towards the left tonsil. This was grabbed with a tonsil clamp and medialized. Bovie cautery was then used to excise the tonsil from the tonsillar fossa. Again, there was no bleeding during this part of the procedure. The tonsil was removed and sent for permanent pathology. The oropharynx was then thoroughly irrigated with normal saline. Suction Bovie cautery on a low setting was used to cauterize superficial vessels, which were identified on inspection bilaterally. After hemostasis with the suction Bovie cautery, the oropharynx was again thoroughly irrigated with normal saline. There was no evidence of bleeding at the end of the case. At that point, the Crowe-Davis mouth gag was removed. The patient was then awoken from general anesthesia, extubated and sent to the postanesthesia care unit in stable condition without any immediate apparent complications.

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Loop Electrosurgical Excision Procedure LEEP Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  High-grade squamous intraepithelial lesion of the cervix.

POSTOPERATIVE DIAGNOSIS:  High-grade squamous intraepithelial lesion of the cervix.

PROCEDURE PERFORMED:  Loop electrosurgical excision procedure of the transformation zone.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

FINDINGS:  White epithelium at the transformation zone in the cervix.

ESTIMATED BLOOD LOSS:  Negligible.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and placed in the supine position on the operating table where general anesthesia was administered. She was then placed in the dorsal lithotomy position where exam under anesthesia was performed. She was prepped and draped in the usual manner. An insulated bivalve speculum was then inserted into the vagina to expose the cervix. The cervix was prepped with Betadine under direct visualization. It was then swabbed with acetic acid and visualized with the colposcope to delineate the abnormal area of the transformation zone. The cervix was infiltrated with diluted Pitressin solution, 5 units of Pitressin in 50 mL of sterile saline. Approximately 15 mL of this solution was utilized as the cervix was injected at several points around the periphery of the cervical os until the cervix was blanched, indicating vessel spasm. A 10 x 15 mm loop electrode was then obtained, and a cone biopsy was carried out using a blended current of 45 watts cutting and 45 watts coag. There was basically no bleeding encountered. After excision of the cone biopsy specimen, an additional area of surrounding epithelium was cauterized with the ball electrode. Small endocervical curettage was also taken with a Kevorkian curette. All instruments were removed. The patient was returned to the supine position. She was awakened from anesthesia without difficulty and transferred to the recovery room in good condition. She tolerated the procedure well with no complications.

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Persistent cervical intraepithelial neoplasia.

POSTOPERATIVE DIAGNOSIS:  Persistent cervical intraepithelial neoplasia.

PROCEDURES PERFORMED:
1.  Exam under anesthesia.
2.  LEEP of the transformation zone.
3.  Endocervical curettage.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

FINDINGS:  Normal size uterus with no adnexal masses. There is white epithelium of the transformation zone surrounding the os.

 ESTIMATED BLOOD LOSS:  Negligible.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room and placed in the supine position on the operating table where general anesthesia was administered. She was then placed in the dorsal lithotomy position where examination under anesthesia was performed. She was prepped and draped in usual manner for surgery. An insulated bivalve speculum was inserted into the vagina to expose the cervix. This was fitted with an evacuation system to remove any resultant smoke from the procedure. The cervix was prepped with Betadine, and it was then swabbed with acetic acid and viewed colposcopically to delineate the abnormal transformation zone. The cervix was then infiltrated with diluted Pitressin solution, 5 units in 50 mL of sterile saline. Approximately 12 mL of this solution were infiltrated at multiple points around the periphery of the cervix and the cervix was blanched nicely. A blue electrode was obtained and fitted with the guard at a setting of 45 watts cutting, 45 watts coag blend. It was used to excise the cone biopsy specimen. There was no bleeding encountered. The ball electrode was used to cauterize an additional peripheral area of epithelium. An endocervical curettage was taken. Again, no bleeding was encountered. After the endocervical curettage, the speculum was withdrawn. The procedure was terminated. The patient was returned to supine position, awakened from anesthesia without any difficulty and transferred back to same day surgery in good condition. She tolerated the procedure well with no complications.

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Thoracic Arch Aortogram Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Severe recurrent left carotid stenosis, 4 years status post left carotid endarterectomy.

POSTOPERATIVE DIAGNOSIS:
Carotid ectasia with no evidence of hemodynamically significant stenosis.

PROCEDURES PERFORMED:
1.  Thoracic arch aortogram.
2.  Selective right carotid arteriography.
3.  Selective left carotid arteriography.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

COMPLICATIONS:
None.

ESTIMATED BLOOD LOSS:
Minimal.

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old who is 4 years status post a left carotid endarterectomy performed at an outside institution. Followup carotid duplex studies revealed evidence of a critically severe, apparent recurrent carotid stenosis based on flow velocities. The patient was brought to the endovascular suite for carotid arteriography for evaluation for possible carotid angioplasty and stenting, if a hemodynamically significant recurrent stenosis was confirmed.

FINDINGS:
1.  Normal thoracic arch with mild calcification at the origin of innominate, left common carotid arteries.
2.  Patent vertebral arteries with no evidence of vertebral artery stenosis.
3.  Mild, less than 15%, stenosis of the right carotid artery with no intracranial tandem carotid lesions.
4.  Ectasia of the internal carotid artery just beyond the carotid bifurcation with no evidence of any hemodynamically significant internal carotid artery stenosis.
5.  No evidence of tandem intracranial internal carotid artery lesions.
6.  Normal intracranial internal carotid artery with normal bifurcation of the anterior cerebral artery and middle cerebral artery.
7.  Normal M1, M2, M3 segments of the middle cerebral artery.

DESCRIPTION OF OPERATION:
The patient was brought to the endovascular suite and placed in the supine position on the angio table. The right groin was sterilely prepped and draped in the usual fashion. The right groin was anesthetized with 1% lidocaine without epinephrine for local anesthetic. A single wall puncture of the right femoral artery was performed with micropuncture technique. A 5 French sheath was placed in the right femoral artery. A 5 French pigtail catheter was advanced over a wire to the ascending aorta.

Arteriogram was obtained with 40 mL of contrast injection, rate of 20 mL/sec for 2 seconds. The pigtail catheter was exchanged for a 3DRC catheter, which was selectively advanced over the wire into the left common carotid artery, and selective left cervical and cerebral carotid arteriograms obtained with hand injection. AP and lateral and oblique views were obtained. The 3DRC catheter was then brought down to the arch and advanced over a wire into the innominate artery and then selectively into the right carotid artery. Selective cervical and cerebral right carotid angiography was performed. The 3DRC catheter was removed over the wire.

Since the lesion was in fact found to be in ectatic left internal carotid artery with no evidence of hemodynamically significant kink or stenosis associated with that ectasia, no intervention was pursued. The catheter was removed. A femoral arteriogram was obtained, which suggested the patient was a good candidate for Angio-Seal closure. The Angio-Seal was used. A pressure dressing was then applied for some mild bleeding, which quickly resolved with 5 minutes of pressure. The patient was then returned to the recovery room in excellent condition with no immediate complications apparent.


Selective Coronary Angiography Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURES PERFORMED:
1.  Selective coronary angiography.
2.  Left heart catheterization.
3.  Left ventriculography.
4.  Percutaneous intervention to the right coronary artery via 2 Cypher drug-eluting stents.

INDICATION FOR PROCEDURE:
Acute coronary sinus syndrome with unstable angina.

INTERVENTIONAL CARDIOLOGIST:  John Doe, MD

COMPLICATIONS:
None.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained prior to presentation to the cardiac catheterization lab. The patient was brought to the cardiac catheterization lab in a fasting state and prepped and draped in sterile fashion. The right groin was then anesthetized via 20 mL of 2% lidocaine, and the right common femoral artery was accessed via single wall puncture technique. A 6-French femoral arterial sheath was advanced over a guidewire using modified Seldinger technique.

Next, a 6-French JL4 catheter was advanced over the guidewire to the level of the ascending aorta. This catheter was used to selectively engage the left main coronary artery. The left main coronary artery and its branches were then imaged in multiple planes and views. The JL4 catheter was subsequently withdrawn over the guidewire.

Next, a 6-French JR4 catheter was advanced over the guidewire to the level of the ascending aorta. This catheter was used to selectively engage the right coronary artery, which was then imaged in multiple planes and views. The JR4 catheter was then withdrawn over the guidewire.

Next, a 6-French angled pigtail catheter was advanced over the guidewire to the level of the ascending aorta. This catheter was used to cross the aortic valve and enter the left ventricle where hemodynamic measurements were obtained and left ventriculography was performed in the RAO projection via hand injection. The pigtail catheter was then used to obtain hemodynamic measurement upon pullback across the aortic valve into the ascending aorta. The pigtail catheter was subsequently withdrawn over the guidewire.

At the termination of diagnostic coronary angiography, the patient was referred for percutaneous intervention.

PROCEDURE FINDINGS:

SELECTIVE CORONARY ANGIOGRAPHY:
1.  Left main:  The left main is long and bifurcates into left anterior descending and circumflex coronary arteries. The left main is angiographically free of significant stenosis.
2.  Left anterior descending:  The left anterior descending has mild to moderate luminal irregularities and is noted to be angiographically free of significant disease. The left anterior descending provides 2 medium caliber, medium length diagonal branches in its proximal and mid segments.
3.  Circumflex:  The circumflex coronary artery is noted to be moderately, diffusely diseased without focal significant stenosis and provides 3 obtuse marginal branches prior to terminating in the AV groove. The circumflex coronary artery and its branches are, otherwise, free of angiographically significant stenosis.
4.  Right coronary artery:  The right coronary artery is dominant and is noted to have a proximal 90% ulcerated plaque. The rest of the right coronary artery is noted to have moderate diffuse luminal irregularities with multiple segments of ectasia.
5.  Left heart catheterization and left ventriculography:  Left ventricular end-diastolic pressure 20. No gradient noted upon pullback. Visually estimated ejection fraction of 60-65%.

FINAL DIAGNOSIS:
Severe coronary artery disease involving the right coronary artery.

PLAN:
The patient underwent successful percutaneous intervention to the proximal right coronary artery via 3.5 x 13 mm and 3.5 x 8 mm Cypher drug-eluting stents. These stents were placed in an overlapping fashion and were postdilated with excellent angiographic results with 0% residual stenosis.


Corneal Transplant Penetrating Keratoplasty MT Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Keratoconus, left eye.
2.  Pellucid marginal degeneration, left eye.

OPERATION PERFORMED:
Corneal transplant (penetrating keratoplasty), left eye.

SURGEON:  John Doe, MD

ANESTHESIA:
General endotracheal.

COMPLICATIONS:
None.

ESTIMATED BLOOD LOSS:
Less than 5 mL.

DESCRIPTION OF OPERATION:
After informed consent had been obtained, the patient was taken back to the operating room where cardiac and blood pressure monitoring devices were applied. The patient underwent general anesthesia and then was prepped and draped in the usual sterile fashion for a penetrating keratoplasty of the left eye.

A lid speculum was inserted and the cornea was inspected. There appeared to be an ectatic central protuberance of the cornea with inferior steepening, thinnest approximately 2 mm below the corneal anatomic center. The corneal dome was elevated from approximately normal depth of 4 mm to approximately 6 mm. The corneal central was marked with a sterile marking pen and an 8.5 mm trephine was used to pick a proposed location for the corneal transplant.

Next, a radial keratotomy marker was used to mark the quadrants in 12 meridians. Next, a Flieringa ring was sewn to the sclera with 5-0 Dacron suture. Next, the corneal donor button was prepared with a vacuum punch measuring 8.5 mm. This was covered in viscoelastic and placed aside for the time being. Sample of the fluid that the donor cornea arrived in and the remainder of the donor tissue was sent for microbiology. Next, the vacuum trephine was applied to the patient's cornea. This was an 8.5 mm vacuum trephine, and it was advanced until a small gush of aqueous came inferiorly.

Next, Healon was used to restore the anterior chamber depth and to provide space between the iris and the cornea. The patient's cornea was removed using an eye knife to make a vertical paracentesis incision and then continued with corneal scleral scissors to remove the host button. The host button was then sent for pathology. The donor button was then carefully placed. The cardinal sutures were placed at 12, 3, 6, and 9 o'clock with 10-0 nylon sutures. After the cardinals were secured, additional sutures were placed in each clock hour for a total of 12 interrupted sutures.

Because of the lack of thickness in the host cornea inferiorly, as well as to reduce postoperative myopia, decision was made to use a 24 interrupted suture technique and 12 additional sutures were placed between the original clock hours. Once all 24 sutures were placed, the anterior chamber was reinflated with Healon and tension on each suture was tested. All loose sutures were removed and replaced. All nonradial sutures were removed and replaced. Once all 24 sutures had been successfully placed, the Healon was irrigated from the anterior chamber using BSS on a 27-gauge cannula. The cornea was then dried with a Weck-cel sponge and fluorescein testing demonstrated a small leak between the 6 and 6:30 sutures. The 10-0 nylon was used to create one more additional pass at 6:15, which stopped the leak. The Flieringa ring had been removed prior to removing the Healon.

Once the wounds were all deemed to be Seidel negative, the surface was irrigated and the patient was given an additional injection of 0.1 mL of 10 mg/mL vancomycin sterile solution and BSS. The lid speculum was removed and a drop of Alphagan, timolol, and Pilopine gel were all applied to the left eye, which was patched and covered with an eye shield, which was taped in place. The patient was then extubated and taken to the recovery area in good condition without any immediate apparent complications.

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Back Pain Emergency Room ER Transcription Sample

CHIEF COMPLAINT:  Back pain.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Asian male who complains of left lower back pain since last evening. The patient states the pain does radiate to his left testicle. He did have two episodes of the pain overnight and one earlier today. He denies any known injury. He denies any hematuria, fevers or chills. He has had a previous history of kidney stones in the past but states that this does not feel typical of his kidney stone pain. He has not been taking anything at home for the pain. The patient denies any penile discharge.

PAST MEDICAL HISTORY:
1.  Vasectomy.
2.  History of kidney stones.

MEDICATIONS:  None.

ALLERGIES:  None.

FAMILY HISTORY:  Noncontributory.

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

REVIEW OF SYSTEMS:  As above, otherwise, negative per the patient.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 138/90, pulse 72, respirations 18, temperature 98.6, O2 sat is 97% on room air.
GENERAL:  This is a well-developed, well-nourished male, in no acute distress.
HEENT:  Normocephalic, atraumatic. PERRLA. EOMI. Posterior oropharynx is pink and moist without erythema or exudate.
NECK:  Supple. No lymphadenopathy.
HEART:  Regular rate and rhythm. No murmurs, gallops, rubs.
LUNGS:  Clear to auscultation bilaterally.
ABDOMEN:  Soft, nontender, nondistended. Bowel sounds x4.
BACK:  The patient does have slight tenderness to palpation in his left flank area. There is no muscular spasm noted. There is no CVA tenderness.
GENITOURINARY:  The patient does have normal circumcised external genitalia. There is diffuse testicular tenderness to palpation on the left, but there is no erythema or edema. There is no scrotal swelling. The testicles have a normal lie. There is no hernia noted.

EMERGENCY DEPARTMENT COURSE:  The patient's nursing notes were reviewed. He did have urinalysis, which showed 30 protein, many bacteria, negative leukocyte esterase and nitrites, moderate blood, 5-10 wbc’s and 0-3 squamous epithelial cells. Urine was, otherwise, negative. He did have a CT scan of the abdomen and pelvis without contrast, which showed a fatty liver in the right lobe, uncomplicated mild sigmoid diverticulosis, no collecting system calculi, a small left inguinal hernia with fat only. However, upon our read, it did appear that the patient did have a small stone in the left UVJ. There also appeared to be a stone further down, either in the bladder or the urethra.

The patient was given 10 mg of morphine IM and 12.5 mg of Phenergan IM, which did not provide any relief of his pain but did relieve his nausea. He was then given 60 mg of Toradol IM after which he was resting comfortably and stated that his pain was significantly improved.

MEDICAL DECISION MAKING:  It does appear that the patient's pain is related to a renal stone. He has had a history of these in the past, and his symptoms are suggestive of this. The patient also has a moderate amount of blood in his urine, which is also highly suggestive of this. Upon the review of the CAT scan, it did appear that the patient does have a renal stone. We will, therefore, encourage him to follow up with his urologist, and we will give him something to control his pain and nausea at home. There is no evidence of any hydronephrosis or any obstructing stone, and therefore, the patient can be managed on an outpatient basis.

DIAGNOSIS:  Nephrolithiasis.

PLAN:
1.  The patient can take ibuprofen over the counter for pain.
2.  The patient is given Vicodin, #20, for severe pain.
3.  The patient is given Phenergan.
4.  The patient is to drink plenty of fluids.
5.  The patient is to follow up with his urologist.
6.  The patient is to return to the ER for any increased pain, uncontrolled vomiting, fever or any other concerns.

DISPOSITION:  The patient was discharged to home in good condition.

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Chest Pain Emergency Room ER Transcription Sample

CHIEF COMPLAINT:  Chest pain.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male who presented to the emergency department with chest pain. He stated that he had congestion and heartburn since 9 p.m., which was 3 hours ago. The patient states it feels like heartburn. It is present in his left chest and occasionally radiates into his back. He has taken some Advil without any improvement in his symptoms. No fever, chills, or cough. He has had some shortness of breath for approximately a minute and it resolved. He used to get this frequently after eating spicy food.

PAST MEDICAL HISTORY:  Unremarkable.

ALLERGIES:  None.

FAMILY HISTORY:  Negative for coronary artery disease.

SOCIAL HISTORY:  Denies tobacco use.

REVIEW OF SYSTEMS:  All systems reviewed and otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  BP 110/78, temperature 97.4, pulse 86, respirations 18, O2 sat 100% on room air.
GENERAL:  The patient is a well-developed male, in no distress.
HEENT:  Moist mucous membranes.
HEART:  Regular rate and rhythm, S1, S2. No murmurs, rubs, or gallops.
LUNGS:  Clear to auscultation bilaterally.
CHEST: Chest is nontender with palpation.
ABDOMEN:  Soft, nontender, and no masses.
EXTREMITIES:  No clubbing, cyanosis, or edema.

DIAGNOSTIC STUDIES:  EKG shows a normal sinus rhythm with a rate of 72. No acute findings seen. Chest x-ray shows no infiltrates by my reading.

EMERGENCY DEPARTMENT COURSE:  The patient was seen and examined. He underwent workup. He was given a GI cocktail with resolution of his symptoms. He was re-examined and was discharged in good condition.

MEDICAL DECISION MAKING:  The patient is a (XX)-year-old male with chest pain. The patient will be discharged home on Protonix 40 mg, #30. He was to follow up with his primary care physician. He will be given referrals. The patient is to return if his symptoms worsen.

DISPOSITION:  Home.

DIAGNOSIS:  Acute chest pain, probably secondary to gastroesophageal reflux disease.

-----------------------------------------------------------------------------------

CHIEF COMPLAINT:  Chest pain.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old man who has been experiencing exertional chest pain with shortness of breath for 3 weeks. At 6 a.m. this morning, it occurred spontaneously, and he asked his wife to drive him to the emergency department. Cardiac enzymes were noted to be elevated, and he was transferred to this facility for angiography. He had a stress test 4 days ago.

PAST MEDICAL HISTORY:
1.  Hypertension for 8 years, treated with Monopril.
2.  Hypercholesterolemia for 2 years, on simvastatin 80 mg every day.

SOCIAL HISTORY:  The patient is married and lives with his wife. He does not smoke cigarettes. He used some alcohol.

FAMILY HISTORY:  Negative for coronary disease.

REVIEW OF SYSTEMS:  Except as mentioned above, review of system is negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 126/72, pulse 96 and regular.
GENERAL:  The patient is well nourished and well developed, in no acute distress.
EYES:  No scleral icterus, xanthelasma.
MOUTH:  No oral pallor or cyanosis.
NECK:  There is a right carotid bruit.
CHEST:  Clear to auscultation and percussion.
HEART:  There are no murmurs or gallops.
ABDOMEN:  Soft, nontender. No abdominal masses.
EXTREMITIES:  Peripheral pulses full. No edema. No varicose veins.
SKIN:  Warm and dry.
PSYCHIATRIC:  Oriented x3.
NEUROLOGIC:  Nonfocal.

DIAGNOSTIC STUDIES:  The electrocardiogram showed normal sinus rhythm, and it was within normal limits.

LABORATORY DATA:  Glucose 108, BUN 14, creatine 1.2, GFR 56, sodium 134, potassium 3.6, chloride 98. Troponin 0.34, myoglobin normal, BNP 22. PT 12.6, INR 1.2. Hemoglobin 14.6, hematocrit 43.8, white count 6.4 with a normal differential.

EMERGENCY DEPARTMENT COURSE:  The patient was given Plavix 300 mg by mouth, aspirin, and started on heparin. He was pain-free shortly after arriving to the emergency department.

IMPRESSION:
1.  Acute non-ST-segment elevation myocardial infarction.
2.  Hyperlipidemia.
3.  Hypertension.

PLAN:  Left heart catheterization with a view to primary angioplasty.

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Closure of Loop Ileostomy Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
History of pelvic abscess following a Delorme procedure, status post fecal diversion with a loop ileostomy laparoscopically.

POSTOPERATIVE DIAGNOSES:
1.  History of pelvic abscess following a Delorme procedure, status post fecal diversion with a loop ileostomy laparoscopically.
2.  Anastomotic stricture.

PROCEDURES PERFORMED:
1.  Closure of loop ileostomy.
2.  Rigid proctoscopy with dilation of anastomotic stricture.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

POSTPROCEDURE CONDITION:  Good.

SPECIMENS:  None.

INDICATIONS FOR OPERATION:  This patient has had rectal prolapse with adenomatous change. We performed a Delorme, and the patient developed a pelvic abscess with a fistulous communication to the anastomosis. The pelvic abscess was drained and then she had to be diverted. The patient now is over 3 months out and presents for elective closure. Preoperative CT scan with rectal contrast did not demonstrate any residual pelvic abscess or any fistulous communication. We discussed the risks of the procedure, which included anastomotic complications, wound complications, recurrent abscess formation, as well as alternatives. The patient noted understanding and elected to proceed.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed supine on the operating room table. The patient previously received preoperative antibiotics as well as heparin. After induction of general endotracheal anesthesia, the patient was frog-legged, and a gentle digital rectal exam was performed. The patient had a stricture at the previous anastomotic site, which was gently dilated with a fifth digit and then to the proximal interphalangeal joint of the first digit.

A rigid proctoscopic examination was then performed, and we were able to get past the anastomotic area. There was no mucosal abnormality, and the anastomosis was noted to be intact. Therefore, the patient was placed back on the operating room table in the supine position.

The patient’s abdomen was prepped and draped in a sterile fashion, and then using the cautery, a circumferential incision was made around the mucocutaneous junction of her ileostomy. Dissection was carried down to the fascia circumferentially, and then the small bowel was detached from the fascia. There were absolutely no adhesions below the fascia, and we were able to easily deliver the two limbs of the loop ileostomy. The adhesions between the two limbs were then taken down sharply, and the edges were trimmed.

At this point, we chose to place the GIA-45 blue load down both limbs and anastomosis created using a functional end-to-end, side-to-side anastomotic technique, and the enterotomies were closed with a TLH-60 stapler. The anastomosis was then delivered back into the abdomen, and we irrigated the abdomen and aspirated it. Then, we closed the fascia with interrupted 0 Vicryl figure-of-eight sutures after clearing it of its fatty attachments using the cautery.

The whole wound was then thoroughly irrigated with Kantrex saline, and then we undermined the skin and trimmed it so that it would come together without dog ears and then loosely closed it with interrupted 3-0 Vicryls. Kantrex-soaked Nu-Gauze was then placed in the ileostomy closure site loosely. This was to serve as wicks. Dry dressing was applied. The patient was then taken to the recovery room, where she was noted to be good condition without apparent immediate complications.

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Vein Radiofrequency Ablation Stab Phlebectomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Symptomatic chronic superficial venous insufficiency, left leg, with varicose veins.

POSTOPERATIVE DIAGNOSIS:
Symptomatic chronic superficial venous insufficiency, left leg, with varicose veins.

PROCEDURES PERFORMED:
1.  Radiofrequency ablation, left greater saphenous vein.
2.  Ligation division, left saphenofemoral junction.
3.  Stab phlebectomies, left leg.

SURGEON:  John Doe, MD

ANESTHESIA:
General endotracheal.

INDICATION FOR OPERATION:
The patient is a (XX)-year-old lady who presented to the office complaining of left leg pain. She was found to have large varicosities around her left proximal thigh and calf. It was recommended the patient undergo venous duplex scan, which demonstrated reflux throughout the left greater saphenous vein as well as a large anterolateral branch off the saphenofemoral junction feeding her lateral thigh varicosities.

It was recommended she undergo radiofrequency ablation of the left greater saphenous vein as well as ligation and division of the saphenofemoral junction to treat the large feeding branches to the varicose veins of the thigh. It was also recommended she undergo stab phlebectomies. The patient expressed understanding of the risks, benefits and agreed to proceed.

DESCRIPTION OF OPERATION:
The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia, the left groin and leg were prepped and draped in a sterile fashion. The procedure was begun by making an oblique incision in the left groin crease overlying the femoral pulse. The subcutaneous tissue was divided down to the greater saphenous vein, which was then dissected up to the saphenofemoral junction.

The saphenofemoral junction was then skeletonized, ligating branches with 3-0 silk and clips. Following completion of this, the wound was packed with saline-soaked gauze. The patient was placed in reverse Trendelenburg. The ultrasound scanner was sterilely passed onto the field. The greater saphenous vein was identified just below the knee using ultrasound. A needle was used to percutaneously puncture the greater saphenous vein. A wire was passed without difficulty followed by a 6-French sheath, which was secured in place using a 2-0 silk suture.

A 6-French radiofrequency ablation catheter was inserted and advanced up to the saphenofemoral junction without difficulty. Its location was confirmed by visualization and palpation, and it was withdrawn approximately 1 cm below the saphenofemoral junction. Using ultrasound, tumescent fluid was injected into the perivenous sheath throughout the length of the thigh and proximal calf. The patient was placed in Trendelenburg, and the greater saphenous vein was ablated using a standard pullback technique heating the vein to 85 to 90 degrees centigrade.

The sheath and catheter were then pulled out after completion of the pullback. Saphenofemoral junction was then clamped proximally and distally and divided. It was oversewn with 2-0 silk suture ligatures. The groin was then closed using 3-0 Vicryl in two layers deep and subcuticular stitch of 4-0 Vicryl. The marked varicosities throughout the thigh and calf were then removed using a stab phlebectomy technique using Oesch hooks. Following completion of this, the stab puncture sites were closed using Steri-Strips only. A clean, sterile, dry compressive dressing was placed, and the patient was transferred to the recovery room in stable condition having tolerated the procedure well.

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Below the Knee Amputation Sample Transcription Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Ischemic gangrene and rest pain, right foot, with nonreconstructable arterial occlusive disease.

POSTOPERATIVE DIAGNOSIS:
Ischemic gangrene and rest pain, right foot, with nonreconstructable arterial occlusive disease.

OPERATION PERFORMED:
Right below-the-knee amputation with immediate fit prosthesis.

SURGEON:  John Doe, MD

ANESTHESIA:
General endotracheal.

COMPLICATIONS:
None.

INDICATIONS FOR OPERATION:
This is a patient on chronic hemodialysis, who presented with a right great toe gangrene and underwent a right great toe amputation, which was felt to have the possibility of healing despite mildly abnormal transcutaneous oxygen measurements. This was attempted because of her severe inframalleolar arterial occlusive disease identified on angiography.

Despite attempts at conservative management, the wound did not heal. She also developed progressive rest pain and developed ulcerations on the ball of her foot and lateral foot as well as other toes. The patient no longer was manageable with conservative care, and it was recommended she undergo below-knee amputation. The patient understood the risks, benefits, and agreed to proceed.

DESCRIPTION OF OPERATION:
The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia and placement of a nonsterile tourniquet on the thigh, the right leg was prepped and draped in a sterile fashion. The intended level of amputation was chosen approximately a hand's breadth or more below the level of the tibial plateau.

A skin incision was mapped out for the long posterior flap. Skin incision was then made after inflation of the tourniquet to 350 mmHg. The skin was incised along the course of the marked incision down through the fascia of the compartments. The muscles of the anterior compartment were then divided using scalpel to identify the anterior tibial vascular structures. These were clamped and divided and then oversewn with 3-0 Prolene. The entire anterior compartment was opened. The tibia was then mobilized using a periosteal elevator. It was then divided using the oscillating saw. The fibula was then mobilized and was divided with a hand bone cutter approximately 1 cm above the level of the tibial transection. An amputation knife was then used to complete the amputation through the muscles of the lateral and posterior compartment.

The posterior tibial and peroneal arteries and veins were identified, dissected and clamped. They were then oversewn with 3-0 Prolene. The tibial nerve was mobilized and suture ligated with 3-0 chromic. Other bleeding points were controlled with limited electrocautery as well as 3-0 chromic suture ligations. At this point, the tourniquet was deflated. Other bleeding points were identified and once again controlled with limited electrocautery and 3-0 chromic sutures. The anterior surface of the tibia was then beveled.

After hemostasis had been obtained, the wound was irrigated with antibiotic solution. The fascia of the posterior calf was then approximated to the fascia of the anterior calf using 2-0 Vicryl sutures in a buried fashion. After this was completed, the skin was approximated using staples. A light clean dressing was applied and an immediate prosthesis was placed. The patient was then extubated and transferred to the recovery room in stable condition with no apparent complications following the procedure.


Colon Resection with Colorectal Anastomosis Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Perforated viscus.

POSTOPERATIVE DIAGNOSES:
1.  Perforated descending colon diverticulitis.
2.  Purulent peritonitis.
3.  Obesity.

PROCEDURES PERFORMED:
1.  Left colon resection with colorectal anastomosis.
2.  Complete mobilization of the splenic flexure.
3.  On-table colonic lavage.
4.  Placement of On-Q pain control device.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  100 mL.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old man who presented to the emergency room with complaints of acute abdominal pain. CT scan of the abdomen and pelvis revealed evidence of a perforated viscus and suggestion of perforated diverticulitis. The patient was marked for a stoma preoperatively and planned to have a colon resection with construction of end colostomy.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, placed on the operating room table in the supine position. After adequate induction of general anesthesia with endotracheal intubation, a Foley catheter was placed without difficulty. The abdomen was then shaved, prepped and draped in the usual sterile fashion. A midline incision was made and carried out sharply down to the fascia, which was opened, taking care to avoid injury to underlying organs. Upon entering the abdomen, there was a small release of free air and cloudy fluid was seen. There was no evidence of gross fecal contamination.

Exploration revealed the small bowel to be normal. There appeared to be a walled inflammatory mass of the mid descending colon densely adherent to the left paracolic gutter that had broken free. There was no gross spillage of stool, but there was a dense inflammatory reaction around this part of the colon. In addition, the sigmoid colon was very hypertrophic. The patient's proximal and distal colon were full of solid stool.

Because of the patient's otherwise good health and hemodynamic stability, we decided to perform left colon resection with concurrent on-table colonic lavage and primary anastomosis. This required complete mobilization of both the hepatic and splenic flexure. Once this was done, an appendectomy was performed and a 24-French Foley was placed into the appendiceal orifice. This was secured with a pursestring suture. Sterile corrugated tubing was then placed into the proximal descending colon, just above the area of perforation. This too was secured with a pursestring suture. Three liters of warm saline were then used to lavage the colon until clear. The Foley catheter was removed from the appendiceal orifice and this was stapled closed. The staple line was oversewn with interrupted 3-0 Vicryl sutures.

Left colon resection was next performed. This was done by transecting the distal transverse colon between an automatic pursestring device and a Kocher clamp. The anvil of the 29 mm circular stapling device was placed in the proximal colon and the pursestring was secured. The sigmoid branches of the descending colon were then taken down, carefully preserving the inferior mesenteric artery. The rectosigmoid junction, where the taenia splayed out on the anterior wall of the rectum, was then divided with the TLH 60 stapling device. A tension-free, well-vascularized, end-to-end anastomosis was performed without difficulty. This anastomosis was reinforced with interrupted 3-0 Vicryl sutures. The pelvis was filled with saline and air insufflation was performed. There was no evidence of air leak.

Copious irrigation of the intra-abdominal cavity was performed with Kantrex in saline. The remainder of the bowel appeared completely healthy. Therefore, the small bowel was returned to the intra-abdominal cavity in gentle S-shaped curves and covered with omentum and Seprafilm. The sponge and needle counts were reported correct by the nurse in charge. The posterior sheath was closed with chromic, and the fascia of the abdominal wall was closed with two separate looped 0 Maxon sutures. Two separate long On-Q catheter devices were placed in the subcutaneous tissues lateral to the vertical incision. The incision was then closed with 3-0 Vicryl sutures and staples. The patient tolerated the procedure well without complications and was then awakened, extubated and returned to the PACU in stable condition.

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Chronic Kidney Disease Consult Transcription Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULT:  Chronic kidney disease.

HISTORY OF PRESENT ILLNESS:  This is a pleasant (XX)-year-old Caucasian male with history of hypertension, chronic kidney disease, cirrhosis of the liver, COPD, hypertension, DJD, gout, and esophagitis, who presented to the hospital with headaches and lower extremity swelling. The patient had a negative lumbar puncture, and headache has improved somewhat. The patient received 1 dose of 40 mg of IV Lasix, and his blood pressure is much better. The patient’s lower extremity swelling is much better at this time. In terms of the patient's kidney disease, his creatinine has been elevated for at least a year; although, I do not have the old records; it has been greater than 1.5. On admission, the patient's creatinine was 1.8, and this morning, it is 1.5. The patient feels well and has no complaints. He states that he has had hypertension, on medications for at least 2 years, and he takes for this metoprolol, Adalat, and Lasix. Otherwise, review of systems was reviewed, and it was negative. Specifically, denies any hematuria, frothy urine, family history of kidney disease or diabetes, or NSAID use.

ALLERGIES:  No known drug allergies.

PAST MEDICAL HISTORY:  As above.

FAMILY MEDICAL HISTORY:  No family history of kidney disease. Father has diabetes.

SOCIAL HISTORY:  The patient has been divorced.  He was a heavy drinker and smoker in the past and has not had anything to drink in about 8 years.

MEDICATIONS:  Augmentin, fluticasone, temazepam, Dilaudid, heparin subcutaneously, Lasix 40 mg IV daily and at home he takes 20 p.o. daily, pantoprazole 40 mg p.o. daily, Procardia XL 30 mg p.o. daily, Lopressor 50 mg p.o. daily, allopurinol 200 mg p.o. daily.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 122/78, pulse 76, respirations 22, O2 saturation 98%. I's and O's 600 in and 1200 out, all urine output.
GENERAL:  The patient is a pleasant Caucasian male, in no acute distress.
HEENT:  EOMI. Oropharynx is clear. Sclerae are anicteric. Conjunctivae are not pale.
NECK:  No carotid bruits. No thyromegaly.
CARDIAC:  RRR. No murmurs or rubs.
LUNGS:  CTA bilaterally with normal respirations.
ABDOMEN:  Positive bowel sounds, soft, nontender. No renal bruits. No HSM.
EXTREMITIES:  1+ pitting edema bilaterally.
SKIN:  Without rashes.
NEUROLOGIC:  Alert and oriented x3 and nonfocal exam.

LABORATORY DATA:  CBC:  WBC 8.9, hemoglobin 12.4, hematocrit 37.4, and platelets 164.  BMP:  Sodium 138, potassium 3.4, chloride 102.  BUN 22 and creatinine 1.5.  Estimated GFR is 53 mL/minute.  Calcium 8.4, phosphorous 4.4, magnesium 1.9. Albumin 3.3. Alkaline phosphatase 119. BNP 68 yesterday.  UA:  Protein 30, negative for blood. Renal ultrasound shows left kidney 10.2 cm, right kidney 9.2 cm.  No renal artery stenosis noted.  No hydronephrosis. There are several bilateral renal cysts, largest in the left kidney, measuring 1.8 cm, and in the right kidney of 1.6 cm. No renal stones are noted.

IMPRESSION:  This is a patient with chronic kidney disease and hypertension. The patient has multiple bilateral renal cysts, although no evidence of family history of dialysis or kidney disease.

RECOMMENDATIONS:
1.  Chronic kidney disease with hypertension and bilateral renal cysts:  Although it is possible that the patient has acquired cystic disease from his renal insufficiency, it is also possible that the patient has polycystic kidney disease type 2. Further evidence for this would be if he has liver cysts and pancreatic cysts. He has had a prior CT scan done and will need to find this report to see if he does indeed have pancreatic and liver cysts. In addition, any family history of polycystic kidney disease would be helpful, but the patient has no known family history of polycystic kidney. Finally, given that the patient does have headache and that is why he was admitted, since there is a possibility of polycystic kidneys, I would like to obtain an MRA of his brain just to rule out berry aneurysm; although, this is unlikely based on his exam and symptoms. In terms of the chronic kidney disease, the patient's hematocrit is at goal currently. His phosphorous is also within normal limits but would also like to check parathyroid hormone level to evaluate for secondary hyperparathyroidism from chronic kidney disease.
2.  Hypertension:  The patient's blood pressure is under good control and we shall continue current regimen.
3.  Edema:  This could be related to his chronic kidney disease and increased salt intake. Also, Procardia XL could be causing some of his leg swelling. This has improved since admission. We will give him another dose of Lasix today to help with his lower extremity swelling. The patient states that he had an echocardiogram done in the past, so we need to check those results to look for his ejection fraction as well as mitral valve prolapse if indeed he has polycystic kidney disease.

Thank you, Dr. Doe, for consulting me on this patient. We will continue to follow closely as an inpatient and outpatient. Please do not hesitate to call with any questions.

Eye Injury Emergency Department HPI Medical Transcription Sample Report

CHIEF COMPLAINT:  Right eye injury.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic female who presents to the emergency department stating that she was in an altercation about 18 hours ago, and she was hit in the right eye. The patient thinks that the assailant's bracelet may have cut her eye, and she has had a foreign body sensation in that eye since that time. The patient denies any blurred vision. She denies significant pain within the eye itself. She denies any pain with extraocular movement. She denies any fevers or drainage from her eye. The patient denies any other injury and denies loss of consciousness. The patient describes her discomfort as a 9/10, worse with blinking, better with sleeping. It does not radiate. It is an achy pain.

PAST MEDICAL HISTORY:  History of coronary artery disease.

ALLERGIES:  None.

CURRENT MEDICATIONS:  Per medical reconciliation form.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  Positive for occasional alcohol ingestion. Negative for tobacco or drug use.

IMMUNIZATION STATUS:  Last tetanus shot was 3 years ago.

REVIEW OF SYSTEMS:  Negative for fevers, chills, nausea, vomiting, diarrhea or constipation, headache, chest pain, shortness of breath or abdominal pain. All other systems are negative, except as noted in the HPI.

PHYSICAL EXAMINATION:
GENERAL:  The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
VITAL SIGNS:  Blood pressure is 136/84, pulse 90, respiratory rate 18, temperature 98.6, pulse ox 100% on room air.
HEENT:  Head is atraumatic and normocephalic. Pupils are equal, round, reactive to light. Extraocular movements are intact. Sclerae are nonicteric. Conjunctiva on the left is clear. On the right, the patient has some conjunctival hemorrhage present, both medially and laterally with some conjunctival injection as well. The patient has on slit-lamp examination, a negative fluorescein exam. The patient has no evidence of hyphema and has no evidence of retained foreign body. Oropharynx is clear with pink, moist mucous membranes.
NECK:  Supple. There is no lymphadenopathy, no thyromegaly.  Trachea is midline.
LUNGS:  Clear to auscultation bilaterally.
NEUROLOGIC:  The patient is intact, moving all four extremities symmetrically and spontaneously and is following commands.
SKIN:  Warm and dry.  No evidence of rash.  The patient does have some periorbital ecchymosis around the right eye and a minimal amount of edema there as well, but there is no surrounding erythema, no crepitance.

LABORATORY AND RADIOLOGY RESULTS:  None.

EMERGENCY DEPARTMENT COURSE:  The patient was seen and evaluated. She had her visual acuity tested. In her right eye, it was 20/40; in her left eye, it was 20/50; and together, her eyes were actually 20/25. The patient had tetracaine topically applied and had a fluorescein exam performed by myself, which she tolerated well. The patient received ibuprofen for relief of her pain and eventually was discharged home.

MEDICAL DECISION MAKING:  The patient presents with evidence of right eye contusion and right subconjunctival hemorrhage. She has no evidence of penetration of her globe. She has no evidence of hyphema, no evidence of traumatic iritis. She has no evidence of corneal abrasion and no evidence of any periorbital fractures or entrapment. She is, otherwise, stable for discharge home.

IMPRESSION:
1.  Right eye contusion.
2.  Right subconjunctival hemorrhage.

PLAN:
1.  The patient is to take ibuprofen for pain.
2.  She is to apply cool and/or warm compresses for comfort.
3.  She is to return for loss of vision, difficulty seeing, fever, significant drainage from the eye or other concerns.

The patient verbalized understanding of the discharge instructions.

DISPOSITION:  Discharged home in good condition.

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