Neuro Consult Medical Transcription Dictation Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Evaluation and management of abnormal MRI of the cervical spine.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old African-American female who drove herself to the emergency department yesterday after left arm and left leg numbness. The patient reported that when she got up yesterday morning, she just did not feel right. The patient drove to work and on the way her left arm felt numb and heavy from the shoulder to fingertips, according to her. These symptoms lasted about 30 minutes. The patient’s left leg also became numb from her foot up to her knee. At that time, she drove herself to the emergency department. She denies any associated weakness. The symptoms resolved yesterday afternoon and she feels back to her baseline now. She denies any difficulty with speech or swallowing, headaches, chest pain, shortness of breath, visual disturbances, gait difficulties, or other associated symptoms. The patient did have an episode of dizziness many months ago. She was also worked up by Neurology and ENT for this dizziness, and those workups were unremarkable. The patient also reports some intermittent right facial numbness after a fall she sustained 4 years ago. She also has occasional neck pain for the past 2 or 3 weeks, which has now resolved after using alternating heat and ice.

PAST MEDICAL HISTORY:  Right femoral fracture, status post internal fixation, as a result of a motor vehicle accident, right facial numbness, status post fall. Otherwise, past medical history is noncontributory.

MEDICATIONS:  None.

ALLERGIES:  IV DYE.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient denies alcohol, tobacco, or illicit drug use. She is divorced.

REVIEW OF SYSTEMS:  As above.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 104/70, pulse 86, respirations 18, and temperature 98.6.
GENERAL:  This is a moderately obese (XX)-year-old woman, sitting up in the chair, in no acute distress. She is alert and oriented to person, place, and time.
NEUROLOGIC:  Her speech is fluent. Language is intact. Attention, memory, and concentration are normal at the bedside examination. Cranial Nerve Evaluation:  Pupils are equal and reactive, 3 mm bilaterally and brisk. Extraocular movements are intact. Visual fields are full to confrontation, intact. Corneal reflex is intact. Hearing is present to finger rub. Tongue is midline with good palate elevation. No facial asymmetry noted. Motor examination reveals power, 5/5, in all extremities with normal bulk and tone. Fine motor coordination is intact with finger-to-nose testing. She has good sensation in all extremities laterally and medially to pinprick and temperature. Deep tendon reflexes are symmetric. Babinski is negative. There is no pronator drift. Her gait is with significant right limp due to the right femoral fracture she sustained from a motor vehicle accident.

LABORATORY DATA:  CBC and CMP are unremarkable. Triglycerides 56, total cholesterol 174, HDL 52, LDL 110. Cardiac enzymes, first 2 sets were negative.

DIAGNOSTIC STUDIES:  CT of the brain reveals no acute abnormality. MRI of the brain reveals partially empty sella, mild right cerebellar tonsillar ectopia of the cerebellar tonsils, at the lower limits of normal. Intracranial ischemia not appreciated. MRI of the cervical spine revealed mild C6-7 stenosis with diffuse posterior protrusion and left foraminal spur. Shallow diffuse C5-6 posterior protrusion with asymmetric left foraminal narrowing due to uncinate process spurring, multilevel left facet arthropathy, asymmetric left C2-3 foraminal narrowing. Cerebellar tonsillar herniation through the foramen magnum 7.6 mm on the right and 4.4 mm on the left.

IMPRESSION:  Left arm and left leg paresthesias, which have now resolved after approximately 10 hours. At this time, her symptoms are unlikely an acute neurological event.

RECOMMENDATIONS:  Cardiac workup is in progress, and given her possible cardiac abnormality, this might be causing her symptoms. If her paresthesias do recur, we can see the patient as an outpatient for EMG and nerve conduction studies.

Thank you, Dr. Doe, for including us in the care of this patient. We will follow along with you.


MRI Stealth Guided Suboccipital Craniotomy Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Brainstem cavernous malformation.

POSTOPERATIVE DIAGNOSIS:
Brainstem cavernous malformation.

OPERATION PERFORMED:
1.  MRI stealth-guided suboccipital craniotomy.
2.  Gross total resection of brainstem cavernous malformation.
3.  Microscope use for nerve root microdissection.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  50 mL.

COMPLICATIONS:  None.

DISPOSITION:  To the recovery room.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, induced and intubated without difficulty.  A MRI stealth scan had been completed the night before.  This was registered as the patient had a Mayfield headholder attached to the head.  The patient was rolled prone on an operating room table with his head flexed.  The occipital and suboccipital regions were shaved and scrubbed with a Betadine scrub brush, registration.  This area was prepped and draped in sterile fashion.  It was infiltrated with 1% Xylocaine with epinephrine and opened with a 10 blade.  Bovie cautery to superficial fascial layers led down to the nuchal fascia.  Staying in the midline, the dissection continued down to the occipital bone and the arch of C1.  Dissection laterally was followed with placement of deep retractors in the field.

At this point, curettes were used to free up the posterior margin of the foramen magnum and the superior arch of C1.  The Midas Rex and the AM-35 drill bit was used to drill a trough in a suboccipital craniotomy position.  Once the bone was thinned, a #3 Kerrison was used to complete this craniotomy.  The bone was removed en bloc at this time.  The fascia superior to the C1 arch was removed, as was a small portion of the superior edge of C1.  The bony edges were waxed.  Copious irrigation was followed with placement of a stitch in the midline.  The dura was then opened, leaving the arachnoid intact.  Three dural tacking sutures were placed on either side.

At this point, the microscope was brought in.  Under microscopic guidance, the arachnoid was opened.  The underlying cervicomedullary junction was identified, as were the cerebellar tonsils.  Retraction of the cerebellar tonsils laterally led to identification of the obex and the inferior portion of the floor of the fourth ventricle.  On the right-hand side, as expected, a hemosiderin-stained bulge was seen.  A thin film of medullary tissue was seen with obvious cavernous malformation beneath.  A Beaver blade was used to make a linear incision overlying this abnormality and vascular sacs were immediately seen.  Tedious dissection with suction bipolar cautery, microscissors, and dissecting instruments to remove portions of the cavernous malformation piece by piece without injuring the surrounding tissue was carried out.  Slowly, the margins of the cavernous malformation were defined medially and laterally, inferiorly and superiorly.  Near the end of the resection, significant venous bleeding was seen from the depths of the resection bed.  This was controlled with Gelfoam.

Once the cavernous malformation had been completely removed, returning to this area, careful cautery of the floor of the resection area led to identification of a vein, which was subsequently cauterized.  The pressure was raised 20 points and no bleeding was identified.  This was returned to around a systolic of 100.  FloSeal was placed over the floor of the cavernous malformation resection area.

At this point, closure began.  The deep retractors were removed.  The Greenberg retractor system had been used to hold the cerebellar tonsils away from the midline.  The dura was closed with running 4-0 silk suture.  Tisseel was placed over the dural closure.  DuraGen was placed over that.  The bone flap was reattached with Synthes cranial plates.  The nuchal musculature and fascia were closed with interrupted 0 Vicryl sutures.  Superficial fascial layers were closed with interrupted 2-0 Vicryl sutures.  The skin was closed with a 3-0 nylon suture.  Betadine ointment and a Telfa dressing were applied.  The patient was returned to the supine position and taken to the recovery room intubated.

Neurosurgical Operative Samples #1        Neurosurgery Operative Sample Reports #2

Annual Physical Exam Medical Transcription Sample Report

REASON FOR VISIT:  Annual physical exam and followup of several medical problems.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic male who presented to the office for annual physical exam.  He has hyperlipidemia.  Unfortunately, he is intolerant to Lipitor and Zocor, which causes joint aches.  Currently, he is not on any medications.  He had repeat fasting lipids checked, which showed that his cholesterol is still significantly high.  The patient does watch his diet and also has some exercise.  The patient also has a family history of breast cancer.  His sister has breast cancer.  Last year, his mother also was diagnosed with breast cancer.  The patient has not noticed any breast lump.  At this visit, the patient has several other complaints. He feels general fatigue more significant in the morning.  No fever.  No night sweating.  Appetite has been fine.  No diarrhea or abdominal pain.  Also, notes constipation.  He would like to check it out.  Another complaint is right thumb pain for the past 3 months.  He did not notice any swelling, and he would like it checked out.

REVIEW OF SYSTEMS:  Please see interview questionnaire.

PAST MEDICAL HISTORY:  Hyperlipidemia, eczema of left knee, right hip degenerative joint disease, external hemorrhoids, anxiety, seborrheic keratosis, melanocytic nevi, left cervical radiculopathy, and MRI of the C-spine consistent with degenerative disk disease.

SOCIAL HISTORY:  The patient is divorced.  Smoker and admits to having alcoholic beverages.

FAMILY HISTORY:  Significant for father and brother with skin cancer, grandmother with CAD, grandfather with diabetes, grandfather with colon cancer, and sister and mother with breast cancer.  Otherwise, no family history of prostate cancer or ovarian cancer.  No family history of hypertension.

ALLERGIES:  LIPITOR AND ZOCOR.

MEDICATIONS:  None.

PHYSICAL EXAMINATION:  Vital Signs:  Temperature 98.6, pulse 66, and blood pressure 164/74.  Height 5 feet 8 inches and weight 160 pounds.  General:  The patient is a Hispanic male, in no acute distress.  HEENT:  Unremarkable.  Neck:  Supple.  No JVD.  No thyromegaly.  No lymphadenopathy.  Heart:  Regular rhythm and rate.  No murmur, gallop, or rub.  Lungs:  Clear to auscultation bilaterally.  Breasts:  Bilateral breasts with no palpable mass.  No nipple discharge.  No skin retraction.  No axillary lymphadenopathy.  Back:  No spinal tenderness.  No CVA tenderness.  Abdomen:  Soft, nontender, and nondistended.  No hepatosplenomegaly.  Bowel sounds are present.  Genitourinary:  Unremarkable.  Rectal:  Normal sphincter tone.  No pedal mass.  Stool guaiac negative.  Extremities:  No clubbing, cyanosis, or edema.  Left side of face, there is  tenderness to palpation.  Full range of motion of the joints.  No joint fluid is detected.  No erythema.

LABORATORY DATA:  Normal CBC.  Normal BUN and creatinine.  Normal fasting blood sugar.  AST and ALT also within normal limits.  Fasting lipids, triglycerides 100, total cholesterol 214, HDL 64, and LDL 202.  UA also was within normal limits.

EKG last year showed normal sinus rhythm.  No acute ischemic changes.

ASSESSMENT AND PLAN:  This is a (XX)-year-old Hispanic male in good health.  However, the patient has hypercholesterolemia, not improved with diet control and exercise.  We discussed management and also discussed trying another statin. He agrees.  We gave him a prescription for Lescol 20 mg, instructed the patient to take every other day.  If he has no side effects noticed, he can increase to 20 mg daily.  We booked the patient for liver function at 2 months.  We will repeat his fasting lipid and liver function in 6 months.  Regarding his right thumb, most likely it is tendinitis.  No evidence to suggest a fracture.  The patient may take NSAID p.r.n. for symptom control.  He will let us know if his symptom does not improve by NSAIDs.

Regarding the patient’s strong family history of breast cancer, we discussed management and recommended gene screen for the family members.  We will continue annual breast exam.  The patient is instructed to call if he notices any breast lump.  Regarding his family history of colon cancer, at this visit, he has negative stool guaiac.  We will continue annual rectal exam.  We will go ahead and obtain colonoscopy for colon cancer screen.

Regarding his general fatigue, unclear etiology.  We will check his TSH to rule out any possible steroid dysfunction.  We will encourage the patient to abstain from smoking, limit alcohol intake.  Also encouraged he avoid sun overexposure, use sunscreen at least 30 SPF.  The patient will follow up p.r.n.

PE Sample 1      PE Sample 2       PE Sample 3     PE Sample 4      Infant PE Sample 5 

Laparoscopic Cholecystectomy Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Cholecystitis with cholelithiasis.

POSTOPERATIVE DIAGNOSIS:
Cholecystitis with cholelithiasis.

OPERATION PERFORMED:
Laparoscopic cholecystectomy with operative cholangiogram.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:
General endotracheal anesthesia.

ANESTHESIOLOGIST:  John Doe Jr., MD

ESTIMATED BLOOD LOSS:
Less than 100 mL.

DRAINS:
No drains were used.

DISPOSITION:
To the recovery room.

DESCRIPTION OF OPERATION:
Under general endotracheal anesthesia, the patient was put in the supine position.  The abdomen was prepped with Betadine and draped in a standard fashion.  A subumbilical incision was made.  The incision was deepened through the fascia.  The peritoneal cavity was entered.  Digital palpation was done.  Stay sutures were placed in the fascia.

A blunt cannula was inserted into the peritoneal cavity under direct vision and anchored with stay sutures.  Pneumoperitoneum was produced and maintained at 14 mmHg.  The patient was put in reverse Trendelenburg position.  A #10 Surgiport was introduced in the epigastric region.  Under direct vision, two 5 mm ports, one in midclavicular and another in anterior clavicular line, were placed.  Through the 5 mm ports, grabbers were introduced to grab the fundus and Hartmann pouch.

Through the epigastric Surgiport, a microdissector was introduced with blunt and sharp dissection.  The omentum over the gallbladder was mobilized and released.  Then, the peritoneum over the porta hepatis was gently teased.  The cystic duct and artery were identified.  The whole triangle was visualized.  The cystic duct was clipped proximally, and a cystic duct cholangiogram was done with fluoroscopy, which shows the dye going freely into the duodenum and into the proximal duct.  No filling defects were seen.

After the cholangiogram was done, the catheter was removed, and the cystic duct was clipped distally and divided.  Then, the cystic artery was further mobilized and was clipped proximally, distally, and divided.  Then, the gallbladder was separated all the way from the neck to the fundus with Bovie, and hemostasis was established in the gallbladder bed with electrocoagulation.  After the gallbladder was completely separated, the patient was put in supine position.  The camera was introduced through the epigastric Surgiport and a grabber was introduced through the subumbilical port, and the gallbladder was removed containing multiple small stones.

Then, the subumbilical wound was approximated with 0 Vicryl.  The subcutaneous and subhepatic areas were irrigated with saline and aspirated, and after making sure there is good hemostasis, all the Surgiports were removed and the pneumoperitoneum was reversed, and the skin wounds were approximated with 4-0 Vicryl in a subcuticular fashion.  Marcaine 0.25% with epinephrine was infiltrated in the wounds.  A sterile dressing was applied.  The patient tolerated the procedure well and was brought to the recovery room in stable condition.

Laparoscopic Incisional Ventral Herniorrhaphy Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Symptomatic incisional ventral hernia, status post appendectomy.

POSTOPERATIVE DIAGNOSIS:
Symptomatic incisional ventral hernia, status post appendectomy.

OPERATION PERFORMED:
Laparoscopic incisional ventral herniorrhaphy with mesh.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General with endotracheal intubation.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  This (XX)-year-old female presents with a symptomatic incisional ventral hernia at the site of her previous appendectomy. The patient was evaluated and felt to be a candidate for general anesthesia for surgery. The plan is to proceed with a laparoscopic ventral hernia repair. The procedure, including risks and potential complications such as bleeding, infection, enterotomy, infection of the mesh, as well as a possibility of recurrence, was discussed with the patient. The possible need for further surgery was discussed with the patient. The patient understood and agreed with the plan.

OPERATIVE FINDINGS:  The patient had extensive adhesions in the right lower quadrant associated with the right lower quadrant fascial defect. This was at the site of her previous appendectomy. There was approximately a 4 x 3 cm fascial defect.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and laid in a supine position. Appropriate monitors were applied, and the patient was intubated and general anesthesia was achieved. The patient's abdomen was prepped and draped in a sterile fashion.

An incision was made in the left upper quadrant. Veress needle was placed. Then, using a 12 mm bladeless trocar with the laparoscope in place, the abdomen was entered with the laparoscope visualizing the entrance. This was done without difficulty. Diagnostic laparoscopy was performed. An additional 5 mm bladeless trocar was placed in the left lower quadrant. An additional 10/11 bladeless trocar was placed in the right upper quadrant.

The patient was placed in Trendelenburg position with the patient tilted with her left side down, right side up. Adhesiolysis was performed, taking omental adhesions off the abdominal wall in the midline. There were no fascial defects noted in the midline incision. Once these adhesions were taken down, the areas were inspected. There was no dissection or any visceral structures. The hernia sac had some adherent small bowel associated with the previous appendectomy as well as some omentum. The hernia sac was reduced into the abdominal cavity, and the hernia sac grasped. These structures were dissected off the hernia sac on the adhesions with care taken not to dissect directly on the visceral structures. The entire area was freed up. The adhesions to the sac were freed up circumferentially. The fascial defect was cleared of tissue. Pictures were taken. It was measured to be approximately a 4 x 3 cm fascial defect. A piece of Bard composite mesh, approximately 10 x 15 cm, was chosen. It was laid on the proper longitudinal axis. This overlapped the fascial defect circumferentially, adequately.

Next, 0 Vicryl sutures were placed on the mesh. The mesh was placed into the abdomen, and Vicryl sutures were used to pull the mesh up against the abdomen wall taught. Then, the mesh was tacked to the abdominal wall circumferentially using the Onyx tacker. This was done at approximately 1 cm intervals on the outer ring and then internally as well. The mesh overlapped the fascial defect adequately throughout the entire area.

Satisfied with the repair of the area, a diagnostic laparoscopy was performed. There was no abnormal fluid collection or any active bleeding noted. Satisfied with the repair, the procedure was then completed. Pneumoperitoneum was released. The skin was closed using 4-0 Vicryl in subcuticular fashion. Port sites were infiltrated with 0.5% Marcaine with epinephrine. Steri-Strips were applied and sterile dressing. The patient tolerated the procedure well without any complications.

Tesio Catheter Insertion Sample Transcription Medical Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Renal failure with need for long-term dialysis access.

POSTOPERATIVE DIAGNOSIS:
Renal failure with need for long-term dialysis access.

OPERATION PERFORMED:
Placement of Tesio permanent catheter via right internal jugular vein.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:
Local with monitored anesthesia care.

COMPLICATIONS:
None.

INDICATIONS FOR OPERATION:
The patient is a (XX)-year-old patient who has renal insufficiency. This may be secondary to drug overdose. The patient will need to have a dialysis catheter placed. The patient does not yet know whether her need for dialysis will be permanent. I have recommended to her that she have a Tesio catheter placed. The risks of bleeding, infection, vascular injury, pneumothorax, and thrombosis were all carefully discussed and the patient's questions were answered.  The patient appeared to understand and agreed to proceed with the aforementioned procedure.

DESCRIPTION OF PROCEDURE AND FINDINGS:
The patient had a previous right internal jugular vein catheter, which was removed about 3 days ago. The area appeared clean. There were good jugular venous pulses noted both on the left and right side. We prepped both the right and left sides, neck, and chest and draped with sterile towels and drapes. The head was turned left, and then the patient was placed in Trendelenburg.

Using a 22 gauge needle, the skin posterior to the sternocleidomastoid muscle at the base of the neck was infiltrated. The needle was advanced towards the internal jugular vein. The intermediate soft tissues were anesthetized, and the position of the vein was noted. Successful venipuncture was then accomplished with 2 single Cook needles and 2 guidewires were passed into it. The catheter exit sites were then selected on the chest wall. The tunnels were anesthetized, and the catheter was passed through the tunnels, flushed with heparinized saline and then locked. The vein dilator peel-away sheath was then passed over each of the guidewires into the central circulation.

The dilators and wires were removed. The sheath was then immediately clamped to prevent bleeding aspiration and each catheter was then passed through its respective sheath into the central circulation while the sheath was peeled away.

Using C-arm fluoroscopy, the position of the catheters was adjusted so that the venous catheter was approximately 3 cm distal to the arterial catheter tip in the mid atrium to supine from Trendelenburg position. It was easy to aspirate and infuse both catheters. Both catheters were then fully flushed with heparinized saline and locked. The venipuncture site was closed with 4-0 Vicryl suture, and the catheter exit site closed with 4-0 Vicryl suture. Sterile bandages were applied.

The patient tolerated the procedure without complications. The final sponge, needle, and instrument counts were correct. The patient left the operating room in satisfactory condition.

Abdominal Pain Nausea Consult Transcription Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CHIEF COMPLAINT:  Abdominal pain with nausea and vomiting.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with a history of coronary artery disease, congestive heart failure, and diabetes who presents to the emergency room with acute onset of abdominal pain, which initially began 18 hours ago and was found to have acute cholecystitis in need of urgent surgery. Preoperative clearance is requested on this patient at this time. Currently, she denies precordial pain as well as shortness of breath and dyspnea on exertion; although, she is complaining of abdominal pain. She has had lower extremity edema but cannot recall any significant weight gain.

PAST MEDICAL HISTORY:  As described above.

MEDICATIONS:  Pepcid, Lopressor, Lasix, glipizide, Singulair, lovastatin, nitroglycerin patch, Lidoderm patch, insulin, and aspirin.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  Negative for tobacco and alcohol use.

REVIEW OF SYSTEMS:  All other review of systems noncontributory and is otherwise as stated above in the history of present illness.

PHYSICAL EXAMINATION:
GENERAL:  The patient is well developed, well nourished, in mild distress secondary to abdominal pain.
VITAL SIGNS:  Blood pressure was 180/100 mmHg, pulse regular at 82 beats per minute, respirations unlabored at 18 breaths per minute, and temperature currently afebrile.
HEENT:  Extraocular movements are intact. Conjunctivae are pink. Mucous membranes are moist.
NECK:  There is no jugular venous distention. Carotid upstrokes are normal bilaterally without bruits. Trachea is midline. No thyromegaly.
HEART:  PMI is displaced. First and second heart sounds are regular and of normal intensity. There is grade 1/6 systolic murmur heard over the left sternal border and apex; otherwise, no rubs or gallops are present.
LUNGS:  Decreased breath sounds appreciated bilaterally.
ABDOMEN:  Soft, nontender, and somewhat nondistended with decreased bowel sounds. There is no hepatosplenomegaly. Pulsatile mass is not appreciated.
EXTREMITIES:  Negative for cyanosis, clubbing with +1 edema of the lower extremities bilaterally. Peripheral pulses are +2.
NEUROLOGIC:  Grossly intact and no focal deficits.

LABORATORY DATA:  EKG performed demonstrates sinus rhythm, borderline left ventricular hypertrophy with nonspecific repolarization abnormalities. Troponin I less than 0.4.

IMPRESSION:
1.  Preoperative clearance for surgical intervention in treating acute cholecystitis.
2.  Coronary artery disease.
3.  Congestive heart failure.
4.  Hypertension.
5.  Diabetes.

PLAN:  The patient is currently in the telemetry unit for further observation. At this time, although the patient does not have any signs or symptoms suggestive of angina or congestive heart failure, she still represents at least moderate risk of major adverse cardiovascular event due to age and comorbidities. Nevertheless, given the urgency of the situation, surgery is clearly required without delay, and therefore, labetalol 20 mg IV push q. 6 hours will be administered for treatment of both hypertension and to decrease overall cardiovascular risk perioperatively. In addition, nitroglycerin paste 1 inch q. 6 hours is recommended. Postoperative EKG is recommended in addition to cardiac markers for 3 sets q. 8 hours. A 2-D echocardiogram with Doppler study will eventually be performed to assess for any heart abnormalities.

Thank you very much for allowing me to see your patient. Please do not feel hesitate to contact me with any questions regarding her cardiovascular care.


Renal Consult MT Sample Report                                      Cardiovascular Consultation MT Sample Report

Laparoscopic Cholecystectomy Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Gallstone pancreatitis.

POSTOPERATIVE DIAGNOSIS:
Gallstone pancreatitis.

OPERATION PERFORMED:
Laparoscopic cholecystectomy with intraoperative cholangiogram.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

SPECIMEN:  Gallbladder.

INDICATIONS FOR OPERATION:  The patient is an (XX)-year-old female who presented with signs and symptoms consistent with symptomatic cholelithiasis. The patient was confirmed on preoperative radiologic imaging and laboratory evaluation to have gallstone pancreatitis. After resolution of the patient’s pancreatitis, the decision was made to bring the patient to the operating room for laparoscopic removal of her gallbladder.

The risks and benefits of the procedure, including the possibility of bleeding, infection, bile duct injury, need for open operation, and worsening of her pancreatitis were reviewed in detail with the patient, and the patient agreed to proceed with surgery.

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was brought to the operating room and placed on the operating table in the supine position. After induction of a general anesthetic, the abdomen was prepped and draped in the usual sterile fashion.

A small stab incision was made in the left upper quadrant through which a Veress needle was inserted. After establishing pneumoperitoneum, a 5 mm trocar was then placed in the right upper abdomen using Visiport technique. Under direct visualization with the 5 mm camera, an additional 5 mm trocar was inserted in the left abdomen, and some adhesions involving the umbilical area were cleared to allow placement of an 11 mm trocar site through this space.

A 10 mm, 0-degree laparoscope was then inserted through the umbilicus, and with the patient in reverse Trendelenburg position, an additional 11 mm trocar was inserted in the epigastrium to the right of falciform ligament. The fundus of the gallbladder was grasped and extended cephalad above the liver. Dissection in the infundibular area of the gallbladder revealed normal cystic duct and cystic artery anatomy. The cystic duct was clipped on the gallbladder side, and a small incision was made through which a cholangiocatheter was inserted.

Cholangiogram was performed, which did reveal multiple small filling defects, and it was unclear even with positional changes whether these were small stones or air bubbles. There was a mildly dilated common bile duct, but no obstruction in the duodenum, and there was normal hepatobiliary anatomy.

At this point, the cholangiocatheter was removed. The cystic duct and cystic artery were both ligated between clips, and the gallbladder was then removed from the gallbladder fossa by electrocautery. After ensuring adequate hemostasis in the liver bed, the right upper quadrant was copiously irrigated and suctioned dry, and the gallbladder was placed in an EndoCatch bag and removed through the umbilical port site without difficulty.

All ports were removed under direct visualization. The umbilical and epigastric fascial defects were reapproximated with 0 Vicryl suture, and all skin incisions were anesthetized with local anesthetic, including the subcuticular fascia. The patient tolerated the procedure well, awoke from anesthetic in stable condition, and was brought to recovery without incident.

Anemia Consult Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:   John Doe, MD

REASON FOR CONSULTATION:  Normochromic, normocytic anemia.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with multiple medical issues.  He has been admitted with complaints of sensation of ill feeling in addition to discovery of right lower lobe pneumonia with his underlying immune deficiency syndrome, as a result of HIV infection.  The patient did have a history of anemia in normochromic, normocytic fashion, chronically.  The patient did have a bone marrow aspirate and biopsy evaluation for this.

At that time, bone marrow study showed evidence for normal cellular marrow with adequate megakaryocytes when he had a hemoglobin of 9.6 with MCV 88.2 and platelet count of 128,000.  The patient has had essentially chronic stable anemia with fluctuating results throughout this past year.

On this admission, the patient had hemoglobin of 7.4 initially, and today, his hemoglobin is 9.6 with MCV 89.8 while his white cell count is 2.7 and platelet count is 224,000.  Reticulocyte count yesterday was 3.26, and he did have sedimentation rate of 90.

PAST MEDICAL HISTORY:  The patient does have HIV infection in addition to hepatitis C infection.  Furthermore, he has history of cardiomegaly, congestive heart failure, hypertension, hyperlipidemia, diabetes mellitus, prior history of pneumonia, and prior history of polysubstance abuse.  There was also a history of Pneumocystis pneumonia in the past, and in addition, he has a history of chronic renal failure.

MEDICATIONS:  The patient has been on Levaquin, dapsone, insulin, clonidine, Procardia XL, enteric aspirin, Zocor, Sustiva, methadone, Vibramycin, vancomycin, Primaxin, Toprol-XL, Cancidas, heparin and Bumex.

ALLERGIES:  NKDA.

SOCIAL HISTORY:  The patient denies alcohol and smoking.  He did have a prior history of polysubstance drug abuse.

FAMILY HISTORY:  Significant for diabetes mellitus and cancer.  Otherwise, noncontributory.

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  No fever or chills previously.  He did have loss of appetite.  Unsure about weight loss, but he has been complaining of increased fatigue.  CARDIOVASCULAR:  No chest pain or orthopnea.  RESPIRATORY:  Some shortness of breath, particularly on exertion; cough, nonproductive.  GASTROINTESTINAL:  No nausea or emesis.  No GI bleed.  GENITOURINARY:  No dysuria, polyuria, or hematuria per patient.  NEUROLOGIC:  Nonfocal.  No history of TIA, CVA, or seizure activity.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 96.6, blood pressure 158/82, pulse 78, and respiratory rate 18.
GENERAL:  Alert, oriented, not in distress at this time.
HEENT:  Anicteric sclerae.  Pale conjunctivae.  Moist mucosa.
NECK:  Supple.
LYMPH:  No peripheral adenopathy in the cervical and supraclavicular areas.
LUNGS:  Coarse breath sounds with a few rhonchi in the right lower lobe area.
HEART:  S1 and S2 present.  Regular rhythm.
ABDOMEN:  Soft.  No organomegaly.
EXTREMITIES:  No edema.
NEUROLOGIC:  Nonfocal.

LABORATORY STUDIES:  CBC study is as noted above.  He did have erythropoietin value that was checked out previously, and the laboratory studies documented in the record show that these have been elevated; most recently this was at 64.  Previous evaluation with immunofixation showed no evidence of monoclonal band.

ASSESSMENT:
1.  Normochromic, normocytic anemia.
2.  Systemic infection with human immunodeficiency virus as well as hepatitis C.
3.  Multiple other comorbid medical issues as described above, including this current admission with right lower lobe pneumonia.

DISCUSSION:
1.  Differential diagnosis for anemia includes chronic systemic infection with probable underlying low-grade hemolysis as a result of it, and in addition chronic disease, for which the patient has multiple reasons.
2.  Drugs could also be the culprit, but the prior bone marrow study showed no evidence of decrease in erythropoiesis and now bone marrow, based on reticulocyte count, does not appear to be hypoplastic.

RECOMMENDATIONS:
1.  We would not proceed with bone marrow aspirate and biopsy at this time, as patients with advanced AIDS/HIV infection can have cytopenia, particularly secondary to the multiple drugs they take.
2.  The only course of action at this time should be a supportive one.
3.  There is no need to administer erythropoietin.

Thank you, Dr. Doe, for involving us in the care of this pleasant patient.  We will continue to follow with you, and further recommendations are to follow.

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