Scalp Injury ER Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

 CHIEF COMPLAINT:  Scalp injury.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who apparently was at a party tonight when he slipped on something on the floor, fell down, hit the back of his head, noted some blood, and came in complaining of some mild sharp scalp pain since.

The patient denies any loss of consciousness. The patient denies any neck pain and denies any chest pain or trouble breathing.

PAST MEDICAL HISTORY:  History of hernia repair.

ALLERGIES:  None.

MEDICATIONS:  None.

SOCIAL HISTORY:  The patient reports drinking one to two beers daily. The patient denies tobacco or illicit drug use.

 REVIEW OF SYSTEMS:  As above in HPI. The patient denies any other recent illness. All other systems are negative.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a pleasant, well-nourished young male. The patient does not appear to be in any distress.
VITAL SIGNS:  Blood pressure 120/76, pulse 72, respirations 18, temperature 98, and O2 sat is 97% on room air.
HEENT:  Head is normocephalic. He is noted to have a small posterior scalp laceration that is approximately 1 cm. This is a relatively superficial scalp laceration. Pupils are equal and reactive. Extraocular muscles are intact. Oropharynx is clear.
NECK:  Supple.
LUNGS:  Clear to auscultation.
HEART:  Regular rhythm.
ABDOMEN:  Soft, nontender.
EXTREMITIES:  There is no edema.
NEUROLOGIC:  The patient is awake, alert, and oriented x4. Gait is within normal limits. Exam is nonfocal.

EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING:  The patient was seen and examined as above. His wound was copiously irrigated. We used three staples to reapproximate the wound after using some lidocaine for topical anesthesia. The patient tolerated the procedure well. He was given a tetanus shot here today.

The patient will be discharged home with instructions to have his staples removed in 7 to 10 days and otherwise return as needed.

DISCHARGE DIAGNOSIS:  Scalp laceration.

PLAN:  The patient is discharged home with instructions as above.

DISPOSITION:  To home.

DISCHARGE CONDITION:  Good.

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Pancreatic Cancer Consultation Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Pancreatic cancer.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old lady whom we have been following for metastatic pancreatic cancer. We saw the patient last in the office in August, and we felt that her clinical condition was deteriorating and she was not strong enough for chemotherapy. We ordered a restaging CT of the chest and abdomen and the plan was to follow up with us after the scans to make a decision about whether to continue with further systemic therapy or to be enrolled in hospice.

Over the course of the two weeks since we saw her, she went to see Dr. Jane Doe where she was placed on the macrobiotic diet and was started back on gemcitabine. She immediately developed the same skin blotchiness that she had developed previously and had progressive upper abdominal back pain and came back to the hospital for evaluation.

PAST MEDICAL HISTORY:  Positive for hypertension and positive for depression.

MEDICATIONS:  As an outpatient are Lipitor, Zetia, Fosamax, lisinopril, Zoloft, Xanax, vitamin B12, Os-Cal, vitamin C, Neurontin, and since she has been in the hospital, she has been started on a morphine infusion at 3 mg an hour and continues on the Duragesic patch at 75 mcg an hour that she had been on.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  Tobacco:  She does not smoke. Ethanol:  She does not drink.

FAMILY HISTORY:  Positive for cancer. Her sister has gastric cancer.

REVIEW OF SYSTEMS:  GENERAL:  The patient's activity level has been declining. Her Karnofsky performance status is still only 40 and precludes her from doing anything outside the house. PULMONARY:  No shortness of breath, no cough. CARDIOVASCULAR:  The patient has the midline pain that she attributes to gastroesophageal reflux disease. GASTROINTESTINAL:  The patient has no constipation or diarrhea. See history of present illness for remainder. RHEUMATOLOGIC:  No bone pain or arthritis. DERMATOLOGIC:  Skin rash, see history of present illness. NEUROLOGIC:  No headaches, no focal neurologic symptoms.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure is 118/66, pulse 76, respirations 16, and temperature 97.6.
GENERAL:  The patient is a well-developed, well-nourished female who is in moderate discomfort from lower abdominal pain, which she now describes as having gone from her epigastrium down to the lower abdomen and is bilateral.
LUNGS:  Clear to auscultation and percussion.
HEART:  Regular rhythm and rate without murmur, gallop or rub.
ABDOMEN:  Mildly tender. She does have hepatomegaly. There is no splenomegaly.
EXTREMITIES:  No clubbing, cyanosis or edema.
LYMPH NODES:  Negative for cervical, supraclavicular or infraclavicular lymphadenopathy.

LABORATORY DATA:  CBC: White blood count 6.4, hemoglobin 10.6, platelets of 188,000. Sodium 138, glucose 114, creatinine 0.8, albumin 3.2, globulin 2.9, calcium 8.4, bilirubin 0.5, AST is 40, alkaline phosphatase is 268.

IMPRESSION:
1.  Pancreatic cancer.
2.  Liver metastases.
3.  Hypertension.
4.  Abdominal pain secondary to pancreatic cancer, liver metastasis, and constipation.
5.  Constipation.

PLAN:
1.  PCA pump. Increase the infusion rate to 4 mg an hour and allow the patient to give herself up to 5 mg an hour.
2.  If this is not effective after 24 hours, will have Anesthesia assess the patient for possible epidural pump for narcotic infusion.

Femur Fracture Intramedullary Nailing Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right femur fracture.
2.  Right patella fracture.
3.  Left base of fifth metacarpal fracture.

POSTOPERATIVE DIAGNOSES:
1.  Right femur fracture.
2.  Right patella fracture.
3.  Left base of fifth metacarpal fracture.

OPERATIONS PERFORMED:
1.  Intramedullary nailing, right femur fracture.
2.  Open reduction internal fixation, right patellar fracture, with cerclage wiring.
3.  Closed treatment of left fifth metacarpal fracture.

 SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

SPECIMENS REMOVED:  None.

ESTIMATED BLOOD LOSS:  350 mL.

TOURNIQUET TIME:  Not used.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female involved in a motor vehicle accident, who was seen and evaluated the day before surgery and noted to have the above new orthopedic injuries. Informed consent was obtained for surgery, and she was brought to the operating room at the earliest convenience for fixation of these fractures.

DESCRIPTION OF OPERATION:  The patient was brought back to the operating room and placed supine on the operating table. The right hip was bumped up. Anesthesia was induced by the anesthesia team. Informed consent was obtained prior to the procedure. A time-out was performed, and the patient's name, medical record number, operative site and operation to be performed were verified by the entire operative team. The patient was then prepped with ChloraPrep and draped in the usual standard sterile fashion. Preoperative antibiotics in the form of one gram of Ancef was given prior to the procedure being performed.

An incision was carried down in the midline, over the knee, from the tibial tubercle, approximately 12 cm long. The incision was carried down sharply through skin and subcutaneous tissues until the fascia above the patella and prepatellar bursa was identified. It was noted to be markedly hemorrhagic.

A median parapatellar arthrotomy was then performed from the level of the tibial tubercle up proximal to the pole of the patella. The patella was then brought laterally and inspected and noted to have a nondisplaced fracture through the mid part of the patellar articular surface, and alignment was noted to be excellent.

Attention was turned to the femur fracture. A guidewire was placed under direct visualization and fluoroscopic guidance up through the notch. Using biplane fluoroscopy, there was noted to be bone in both views. The starting reamer was then utilized to penetrate the subchondral bone. The long guidewire and ball-tipped guidewire were threaded up through the canal. The fracture was reduced and the guidewire was passed without complication. It was checked under biplanar fluoroscopy as well, and the alignment was noted to be acceptable.

Reaming was begun starting at 8, then 9, 10, 10.5, 11, 11.5 and 12. A 11 x 380 retrograde intramedullary Stryker nail was placed without complication and threaded up through the fracture up to proximally. Once this was done, the distal locking guide was placed and the distal locking screws were placed without complication.

The fracture rotation was then checked, and it was noted to be acceptable with adequate rotation and angulation. The proximal locking screws were then placed, one dynamically and one statically, without complication. The wounds were irrigated and attention was turned to the patella.

A 16 gauge wire was utilized to make a cerclage around the patella through the subcutaneous cuff. This was revised several times until x-rays and visual inspection noted it to be in excellent position without any wire in the joint or displacement of the fracture. This was tightened down and wounds irrigated copiously.

X-rays were obtained, biplane fluoroscopy, noting that patellar alignment was excellent and all screw lengths were adequate. The wounds were sutured closed. The median parapatellar arthrotomy was closed with interrupted 0 Vicryl sutures and the skin closed with 2-0 Vicryl sutures and staples.

The locking screw holes were covered with 2-0 Vicryl sutures and staples. The patient's leg was washed and dried. Bacitracin, Adaptic gauze and dry gauze dressings were placed. Drapes were removed and x-rays were taken while the patient was still asleep. A well-padded splint was placed for the patient's ankle and calcaneus fractures.

Attention was turned to the left hand and x-ray showed the base of the fifth metacarpal fracture was minimally placed. It was checked under fluoroscopy and noted to be adequate. The splint was replaced. The patient was awakened from anesthesia and taken to the PACU in stable condition.

PLAN:  The patient will convalesce in the hospital and will likely return to the operating room for definitive operative fixation of the calcaneus and lateral malleolus fractures once the soft tissues have improved.


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