Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF CATHETERIZATION:  MM/DD/YYYY

PROCEDURES PERFORMED:  Left heart catheterization, left ventriculography.

REASON FOR PROCEDURE:  Unstable angina and abnormal stress test.

FINDINGS:

1.  The left main coronary artery was short and patent.
2.  The left anterior descending coronary artery had total occlusion in the proximal and mid portion.
3.  The circumflex coronary artery had 95% lesion in the proximal portion.
4.  The right coronary artery had 90% proximal and 100% total occlusion in the mid.

GRAFTS:  The left internal mammary artery graft to the left anterior descending coronary artery was patent.  The saphenous vein graft to the diagonal vessel was also patent.  The saphenous vein graft to the obtuse marginal was not located and was not selectively engaged.

COLLATERALS:  There were collaterals noted from the left anterior descending, septal and obtuse marginal to the right side.

Left ventriculography revealed an overall ejection fraction of around 40% with inferobasal akinesis and mid anterior and septal hypokinesis.  End-diastolic pressure was normal at 13 mmHg.  There was no gradient across aortic valve on pullback.

At the end of the procedure, the decision to proceed with angioplasty and stent placement of the critical circumflex lesion was made.

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Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF PROCEDURE:  MM/DD/YYYY

PREPROCEDURE DIAGNOSES:1.  Nonsustained ventricular tachycardia.
2.  Normal left ventricular ejection fraction.
3.  History of coronary disease.  Status post coronary artery bypass graft with patent bypass grafts on cardia cath.
PROCEDURE:  Electrophysiology study.
DETAILS OF PROCEDURE:  The patient was brought to the electrophysiology lab where ECG and vital signs were continuously monitored.  The right groin was meticulously prepared with Betadine solution and was draped in the usual sterile fashion.  Lidocaine 1% was administered subcutaneously for local anesthetic.  Using modified Seldinger technique, two #6 French introducer sheaths were inserted into the right femoral vein.  Two quadripolar EP catheters were inserted into the sheaths and advanced under fluoroscopic guidance.  One was positioned in the area of the high right atrium and one in the area of the His bundle.  The high right atrial catheter was later moved to the RV apex for ventricular stimulation.  Endocardial potentials were recorded and baseline measurements were performed.  The sinus cycle length was 1195 milliseconds.  The AH interval was 115 milliseconds.  The HV interval was 45 milliseconds with a pacing cycle length of 800 milliseconds.  The sinus node recovery time was 1430 milliseconds with the pacing cycle length of 700 milliseconds.  The sinus node recovery time was 1465 milliseconds with a pacing cycle length of 600 milliseconds.  The sinus node recovery time was 1570 milliseconds.  AV Wenckebach recorded an atrial pacing cycle length of 450 milliseconds.  The AV node effective refractory period was 320 milliseconds with the pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 600 milliseconds.  The pacing threshold from the right ventricular apex was 0.5 milliamps, 1:1 VA conduction was present at a ventricular pacing cycle length of 600 milliseconds.  The ventricular effective refractory period was 240 milliseconds with a pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 400 milliseconds.  After single, double and triple extrastimuli were performed at two pacing cycle lengths from the RV apex, Isuprel was started at 2 mcg per minute.  This was gradually increased to 4 mcg per minute in order to achieve a good heart rate response.  The ventricular effective refractory period was 220 milliseconds with the pacing cycle length of 400 milliseconds.  All ventricular pacing was performed from the RV apex.  After completion of programmed electrical stimulation, catheters were removed.  Good hemostasis was achieved using manual compression.  The patient was then transferred to the recovery room in good condition.
IMPRESSION:
1.  Mildly abnormal sinus node function.
2.  Normal atrioventricular node function without evidence of dual atrioventricular node physiology.
3.  Normal His-Purkinje function without evidence of infra-His block.
4.  Frequent nonsustained ventricular tachycardia with single, double and triple ventricular extrastimuli from the right ventricular apex.  The morphology of the nonsustained ventricular tachycardia varied between left bundle, left axis and left bundle right axis morphology.  Nonsustained ventricular tachycardia or prolonged nonsustained ventricular tachycardia was induced.

RECOMMENDATIONS:  The patient will be continued on beta blocker, which should be increased as tolerated.  If the patient has recurrent symptoms, despite medications, an ablation procedure may be considered.  However, given the differing morphologies of the nonsustained VT, this may make ablation difficult.

 

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History and Physical Sample Report (General)

HISTORY OF PRESENT ILLNESS:  This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills, and sweats.  He denies cough and diarrhea.  He has mild anorexia.  Past Medical History:  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.

MEDICATIONS:  Advil and Ibuprofen.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  He occasionally drinks.  He is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982, which he described as "very active." He denies intravenous drug use.  The patient is currently employed.

FAMILY HISTORY:  Unremarkable.

PHYSICAL EXAMINATION:
General:  This is a thin, black cachectic man speaking in full sentences with oxygen.
Vital Signs:  Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.
HEENT:  Funduscopic examination normal. He has oral thrush.
Lymph:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.
Neck:  No goiter, no jugular venous distention.
Chest:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.
Heart:  Regular rate and rhythm, no murmur, rub or gallop.
Abdomen:  Soft and nontender.
Genitourinary:  Normal.
Rectal:  Unremarkable.
Skin:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms.

LABORATORY:  Sodium 133, potassium 5.3, BUN 29, creatinine 1.8, hemoglobin 14, white count 7100, platelet count 515, total protein 10, albumin 3.1, AST 131, ALT 31, urinalysis shows 1+ protein, trace blood, total bilirubin 2.4, and direct bilirubin 0.1.

X-RAYS:  Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.

IMPRESSION:
1.   Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.
2.   Thrush.
3.   Elevated unconjugated bilirubin.
4.   Hepatitis.
5.   Elevated globulin fraction.
6.   Renal insufficiency.
7.   Subcutaneous nodules.
8.   Risky sexual behavior in 1982 in Haiti.
PLAN:
1.   Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.
2.   Begin intravenous Bactrim and erythromycin.
3.   Begin prednisone.
4.   Oxygen.
5.   Nystatin swish and swallow.
6.   Dermatologic biopsy of lesions.
7.   Check HIV and RPR.
8.   Administer Pneumovax, tetanus shot, and Heptavax if indicated.

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Hematology Oncology History and Physical Medical Transcription Sample Reports

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman with diffuse large B-cell lymphoma, complicated by spinal cord compression, right lower lobe pulmonary embolism, and bilateral leg deep venous thromboses. She began the R-CHOP chemotherapy regimen on MM/DD/YYYY. Cycle 2 started on MM/DD/YYYY and cycle 3 started on MM/DD/YYYY. The patient presented to my office today for a Neupogen injection. Today is cycle 3, day 10. In my office, the patient had a temperature of 101.5 degrees, and she was found to be neutropenic with WBC 0.4. She was admitted for treatment of neutropenic fever. Symptomatically, the patient reports subjective fevers, although she has no localizing symptoms suggestive of infection. She has no other complaints today. Regarding the lymphoma, the patient presented on MM/DD/YYYY with spinal cord compression. CT-guided needle biopsy of a lumbar mass on MM/DD/YYYY showed lymphocytes, which were positive for CD19, CD20, CD22, and lambda light chain, and negative for CD10. Cytology was consistent with large cell lymphoma. Bone marrow biopsy was negative. CT scans of the chest, abdomen, and pelvis showed lymphadenopathy in the left lower neck, supraclavicular areas, retroperitoneum, bilateral psoas muscles, and L1 vertebral body. LDH was mildly elevated at 276, and the patient did not have any significant symptoms. In summary, the patient has stage IV diffuse large B-cell lymphoma, based on extranodal involvement of the L1 vertebral body. On MM/DD/YYYY, the patient was admitted to the hospital with sinus tachycardia. Workup revealed pulmonary embolism and bilateral leg deep venous thromboses. The patient has been on anticoagulation. She should be taking Coumadin 2.5 mg alternating with 5 mg per day, although her compliance with this regimen has been questionable. Recently, she was found to be supratherapeutic with INR greater than 7. I instructed her to withhold Coumadin for two days, then resume at the prescribed dose. She did not have any significant hemorrhagic complications. 

PAST MEDICAL HISTORY:  Peptic ulcer disease and osteoporosis. 

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Coumadin 2.5 mg alternating with 5 mg per day and Protonix 40 mg per day. 

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient denies alcohol and tobacco use.

FAMILY HISTORY:  There is no known history of inherited hematologic or oncologic disorders. 

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  The patient reports subjective fevers x1 day. Otherwise, she denies night sweats, weight loss, fatigue or bleeding. GASTROINTESTINAL:  The patient has chronic dyspepsia, which is temporarily relieved with Mylanta or Maalox. All other systems in a 10-point review of systems were reviewed and were negative.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 110/56, heart rate 112, respiratory rate 22, and temperature 102.5.

GENERAL APPEARANCE:  The patient is alert and oriented, in no acute distress, ambulating slowly without assistance.

HEENT:  PERRL. EOMI. Sclerae anicteric. Oral mucosa clear.

PULMONARY:  Clear to auscultation bilaterally.

HEART:  Regular rate and rhythm. No murmurs.

ABDOMEN:  Soft, nontender, and nondistended. No palpable organomegaly.

EXTREMITIES:  No edema.

LYMPH NODES:  No palpable lymphadenopathy.

SKIN:  No rashes, petechiae or ecchymoses.

NEUROLOGIC:  No focal neurologic deficits, although, the patient ambulates slowly because of low back pain, which has been present since her initial presentation for spinal cord compression.

LABORATORY DATA:  WBC 0.4, hemoglobin 9.8, hematocrit 29.6, and platelets 172,000.

ASSESSMENT AND PLAN:  This is a (XX)-year-old woman with diffuse large B-cell lymphoma, pulmonary embolism, and bilateral leg deep venous thromboses, now on R-cyclophosphamide, hydroxydaunorubicin, Oncovin, prednisone cycle 3, day #10. She is now admitted with neutropenic fever without localizing signs or symptoms suggestive of infection. The patient will start empiric cefepime, and blood and urine cultures will be drawn. Neupogen 300 mcg per day will be continued. Antibiotic coverage will be adjusted based on culture findings and clinical examination. Regarding the anticoagulation for pulmonary embolism and deep venous thromboses, the patient will start Coumadin 2.5 mg per day tomorrow. Currently, she is likely to be supratherapeutic. For peptic ulcer disease, the patient will continue Protonix with the addition of p.r.n. Mylanta or Maalox.

 

 

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CONSULTATION (Pulmo case)

CONSULTATION

This is a 32-year-old white male, lifelong nonsmoker, referred to me. He complains of a less than 2-weeks history of dry cough associated with dull substernal discomfort and dyspnea, particularly on exertion. Otherwise, he has been remarkably free of any other associated symptoms. In particular, he denies any preceding cold or flu or allergic exposure, and denies any associated fevers, chills, sweats, or weight loss. He does admit to having childhood asthma but felt he grew out this by the time he was a teenager. He was traveled extensively outside the U.S., including travel to the California deserts and Central Valley. He has not had pneumonia vaccine. He did have TB skin test 10 years ago and did have flue vaccine 3 years ago.

PAST MEDICAL HISTORY: Past medical history is remarkably negative.

PHYSICAL EXAMINATION: Blood pressure 140/80, pulse 85, respiratory rate 22, temperature 99.3.Chest exam is complete normal. There are no rales, wheezes, rhonchi, rubs. Even on forced exhalation, there was no cough or prolongation. Cardiac exam showed a regular rate and rhythm with no murmur or gallop.

LABORATORY DATA: PA chest x-ray is striking for a new interstitial infiltrate seen on both midlung zones with some shagging of the cardiac borders, indicating involvement of the lingual and right middle lobe. Surprisingly, the lowest part of the lung fields and the apices appear to be spared. Spirometry before and after bronchodilator performed in my office show a vital capacity of 3.79 or 69% after an 11% improvement with bronchodilator. FEV-1 achieves 3.24 L or 72% of predicted after 12% improvement wih bronchodilator. FEV-1/FVC ratio was mildly increased at 85 instead of predicted 82.

ASSESSMENT AND PLAN: Differential diagnosis includes the following:
1. Hypersensitivity pneumonitis.
2. Mycoplasma pneumonia.
3. Less likely candidates appear to be Wegener’s granulomatosis, Goodpasture’s syndrome, sarcoidosis, alveolar proteinosis, and allergic bronchopulmonary aspergillosis.

RECOMMENDATIONS:
1. CBC, differential, chemistry-20, Wintrobe sed rate, angiotensin converting enzyme, urinalysis, and Mycoplasma titers.
2. Full pulmonary function test within 2 weeks
3. Vibramycin 100 mg q. day for 14 days. If he still has significant symptoms and restriction on PFTs within 2 weeks, he will have to be evaluated for one of the more chronic diagnoses, which may ultimately require open lung biopsy. Otherwise we should hope that within 2 weeks the patient will be improved and his x-ray will have cleared.

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EMERGENCY ROOM REPORT (Pulmonary case)

EMERGENCY ROOM REPORT

HISTORY OF PRESENT ILLNESS: Patient is a one-year-old female that has been congested for several days. The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago. Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin, cough syrup, and Slo-bid 100 mg b.i.d. but is not improving. Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

PHYSICAL EXAMINATION
GENERAL: Physical exam in the ER showed an alert child in moderate respirator distress.
VITAL SIGNS: Respiratory rate was 40, pulse 20, temperature 99.6.
HEENT: Within normal limits.
NECK: Positive for mild to moderate stridor.
CHEST: Chest showed a diffuse inspirator and expiratory wheezing. No rales were noted. Viewing the chest wall, patient had subcostal-intercostal retractions.
HEART: Regular rhythm without murmur, gallop, or rub.
ABDOMEN: Soft, nontender, bowel sounds normal.
EXTREMITIES: Within normal limits.

The child was sent for a PA and lateral chest x-rays to rule out pneumonia. No pneumonia was seen on the films.
It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3 h. The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.

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History and Physical Sample Report (Optha case)

HISTORY AND PHYSICAL EXAMINATION


PREOPERATIVE DIAGNOSIS:
1. Cataract of left eye.
2. Pseudophakia of the right eye.
3. Dermatomyositis.
4. Rheumatoid arthritis.

HISTORY OF PRESENT ILLNESS: Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function. She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye. She has had dry eyes and uses artificial tears frequently. She had had ectropion repair of the right lower lid. She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this. She is presently taking Persantine twice daily and Inderal 40 mg twice daily. She is allergic to penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.

PHYSICAL FINDINGS:
VITAL SIGNS: Blood pressure 110/80, pulse 76 and regular.
HEENT: Eyes; Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left. Pupils and extraocular motility were normal. Intraocular pressures where 18. Slit-lamp exam showed the eyelids in good position with weakness of the orbicularis and facial muscles. There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left. Fundus examination in each eye was normal.
EARS, NOSE, AND THROAT: Tympanic membranes are normal. The oral cavity showed dentures in place, and the pharynx had no lesions.
NECK: The neck showed a slight right carotid bruit, and the left was normal.
CHEST: The chest was clear to auscultation.
HEART: Heart had a regular sinus rhythm without murmur.
EXTREMITIES: Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.

PLAN: Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient. The risks of the procedure, including possible loss of the eye, were discussed.

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PREOPERATIVE DIAGNOSIS
By-lateral subdural hematomas.

POST OPERATIVE DIAGNOSIS
By-lateral subdural hematomas.

PROCEDURES:
By-lateral burr holes frontal and parietal for drainage of subdural hematomas.

ANESTHESIA
General Endotracheal.

ANESTHESIOLOGIST 

X, M.D.


PROCEDURE IN DETAIL
The patient was brought into the operating room and after induction of general endotracheal anesthesia. The head was completely shaved, prepped and draped in the usual manner. An incision was made over the frontal areas approximately 3.0 cm from the midline on both sides. The incision was carried down through the scalp, rainy clips where applied for homeostasis, self retaining retractor were placed, burr holes has been made with common perforator. Bleeding from bone was then controlled with bone wax. The left flexed of bone where taken out with a curette and the dura underneath was coagulated in a cruciate fashion. The dura was open widely and copuis amount of all the crankcase colored blood should form. This was irrigated copiously on both side and blake 7millimitter drain where advance under the scalp and into this hole and to this subdural space. Both wounds where close then with zero vicruse who close the gailio layer and 30 nylon to close the skin. Zero form dressing where applied and both drain where secured with 20 silk The patient was recovered from anesthesia and taken to the recovery room in satisfactory condition.

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EMERGENCY ROOM REPORT (Pulmonary case)

HISTORY OF PRESENT ILLNESS: Patient is a one-year-old female that has been congested for several days. The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago. Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin, cough syrup, and Slo-bid 100 mg b.i.d. but is not improving. Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

PHYSICAL EXAMINATION
GENERAL: Physical exam in the ER showed an alert child in moderate respirator distress.
VITAL SIGNS: Respiratory rate was 40, pulse 20, temperature 99.6.
HEENT: Within normal limits.
NECK: Positive for mild to moderate stridor.
CHEST: Chest showed a diffuse inspirator and expiratory wheezing. No rales were noted. Viewing the chest wall, patient had subcostal-intercostal retractions.
HEART: Regular rhythm without murmur, gallop, or rub.
ABDOMEN: Soft, nontender, bowel sounds normal.
EXTREMITIES: Within normal limits.

The child was sent for a PA and lateral chest x-rays to rule out pneumonia. No pneumonia was seen on the films.
It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3 h. The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.

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Lab Data and Diagnostic Medical Transcription Terms

NOTE:  Always refer to your normal lab value sheet for normal ranges. The values indicated in this webpage are unique to each patient's specific disease/condition!! 

LABORATORY DATA:  White count on admission 9700, hemoglobin 14.4, hematocrit 44.6, and platelets 225,000.  Sodium 140, potassium 4.2, chloride 101, CO2 30, BUN 14, creatinine 1.2, glucose 103, calcium 9.2, total bilirubin 0.7, and total protein 8.1.  AST 195, ALT 116, alkaline phosphatase 120, albumin 4.1, lipase 241, and troponin I is less than 0.1.  Urinalysis shows trace protein, 1+ occult blood, negative nitrites, negative leukocyte esterase, 5-10 red blood cells and less than 2 wbc's, trace bacteria, trace mucus, and rare epithelial cells.  Valproic acid level is 61.6.

EKG showed no ST changes.  Abdominal x-ray showed a possible bezoar and distended loop of bowel.  Chest x-ray showed no acute pulmonary process with a positive gastric air bubble.

LABORATORY DATA:  On admission labs, white blood cell count 6.5, H&H 13.5 and 39.1, platelets 251,000, sodium is 134, potassium 4.1, chloride 102, bicarbonate 25, BUN and creatinine 13 and 1.2, and platelet 364,000.  PT 12.2, INR 0.8, PTT 29, D-dimer is 0.43.  Alkaline phosphatase 103, AST was 35, ALT 497.  cardiac enzymes x3 were negative.

LABORATORY DATA:  White blood count 5500, hemoglobin 14.4, hematocrit 40.6, and platelets 234,000.  Sodium 135, potassium 3.7, chloride 103, bicarbonate 25, BUN 5, creatinine 1.2, glucose 107, calcium 8.8, and albumin 4.3.  Alkaline phosphatase 83, AST 65, ALT 68, total bilirubin 0.6.  UA revealed trace blood.  Chest x-ray was normal.

LABORATORY DATA:  Laboratories on admission; blood gases show pH 7.39; pCO2 40.5, normal; pO2 60.2, decreased.  O2 saturation 90.8.  Urine drug screening came back positive for benzodiazepines and cannabinoids.  CK, myoglobin elevated.  Troponin was normal.  CBC shows WBC 6800, H&H 12.3 and 39.  Platelets normal at 262,000.  Chemistry profile on admission showed sodium 146.  Rest of the electrolytes are normal.  BUN, creatinine, and blood sugar were normal.  Liver profile was unremarkable.  Dilantin level on admission was 4.3.

LABORATORY DATA:  Laboratory workup showed hemoglobin of 10.5, hematocrit 31.8, WBC count of 7900, and platelet count of 92,000, bands 16 and polys 73.  Chemistry showed BUN of 13.9, creatinine of 2.8, glucose 148, calcium 9.5, albumin of 3.3, SGOT 46, SGPT 56, alkaline phosphatase 202, and anion gap of 10.

X-ray of the chest showed evidence of congestive heart failure.  EKG showed sinus rhythm and left ventricular hypertrophy with ischemia.

LABORATORY DATA:  Chest x-ray done in the ER showed a right lower lobe infiltrate, questionable infiltrate in left lower lobe.  CMP showed sodium 139, potassium 3.6, chloride 102, bicarbonate 22, BUN 11, creatinine 0.8, and blood glucose of 243.  Her CBC showed white blood cell count of 13,900, hemoglobin 13.2, hematocrit of 39.7, and platelets of 234,000.  The poly count was 90.5% and the lymphocytes were 6.4.  Also, the patient's amylase was 74 and lipase 29.  Albumin 4.3.  Calcium 9.3.  AST, ALT, and alkaline phosphatase were within normal limits.

LABORATORY STUDIES:  Initial white count of 6600 with hemoglobin of 13.8 gm%, segs of 78%.  Another white count was 7130 and 7370 and hemoglobin ranging from 13 to 14.7, segs remained increased at 85% and 78%.  Urinalysis showed presence of sugar and a small amount of blood, protein.  No leukocyte esterase, wbc's negative, and bacteria trace.  Subsequent urine was negative.  Admission electrolytes showed sodium 142, chloride 99, blood sugar 156, creatinine 1.4, BUN 14, subsequent BUN was 11 and creatinine of 1.3.  LFTs showed normal studies and the magnesium initially was only 1.21, improving to 1.9 and 2.2.  TSH was 1.33, troponin I was 0.  Urine culture was negative.

A 12-lead EKG showed functioning pacemaker.  CAT scan of the pelvis without contrast was unremarkable.  CAT scan of the abdomen was also unremarkable except for punctate granuloma at the base of the lung.  No ascites.  Abdominal ultrasound showed a tiny 3 mm left renal calculus, which was nonobstructing.  HIDA scan was negative.  Chest x-ray showed low lung volume without any acute disease.

PERTINENT LABORATORY DATA:  On admission, CBC was 13.1.  Hemoglobin and WBC were fine.  Then, followup of the hemoglobin was down to 11.2.  Urinalysis was unremarkable.  BMP and electrolytes were normal.  BUN was a little bit high at 20.  Creatinine was a little bit high at 1.4.  Blood sugar was 172.  I did not do the followup.  The kidney function was done, back to normal.  Blood sugar was down to 72.  Electrolytes were unremarkable.  Magnesium level is low at 1.8.  The blood gases on admission; the pO2 was 76 with normal pH and pCO2.

We did a KUB on admission.  No change in position of the right ureteral stone at the level of the sacroiliac joint.  Chest x-ray:  The heart is normal, no active infiltrate.  EKG showed regular sinus rhythm.  No fascicular block or evidence of any acute changes.  Cardiac enzymes were unremarkable.

TEST RESULTS:

1.  Chest x-ray:  Cardiomegaly, otherwise unremarkable.
2.  CT of the abdomen and pelvis revealed circumferential diffuse wall thickening of the colon, most likely Clostridium difficile colitis and prominent cardiomegaly, otherwise unremarkable.
3.  CT, pelvis part; diverticulosis of sigmoid, thickening of the entire colon and rectosigmoid, Clostridium difficile colitis.
4.  White blood cells on hospital discharge down to 7400, hemoglobin 12.1, and platelets 275,000.  Sodium 135, potassium 4, creatinine 0.5.  Digoxin level is 0.9.  ALT is 31-39, normal.

LABORATORY AND X-RAY DATA:  At the time of admission, the patient had leukocytosis.  At discharge, her white blood count was normal.  Her hemoglobin had gone from 10.1 on admission to 9.5 at discharge.  Diagnosis of probable iron-deficiency anemia had been made.  The patient was found to have elevated fasting glucoses.  Her electrolytes were normal.  Admission urinalysis showed a trace of glucose, large ketones, and trace leukocyte esterase.

Chest x-ray showed some right minor fissure thickening with no acute cardiopulmonary disease.  Final pathology showed a portion of the cecum and appendix with gangrenous appendicitis, perforation, formation of periappendiceal abscess, and a portion of the large bowel with submucosal edema, mural and subserosal, acute inflammation without any evidence of malignancy.

LABORATORY STUDIES:  Electrolytes were normal.  BUN 17, creatinine 1.2, and blood sugar 99 mg%.  Magnesium 1.8, troponin 0, digoxin level was 0.69, subsequent troponin level remained 0.  PT was 12.6 with INR of 1.1.  White count was 9880 with 76% segs.  Urinalysis was unremarkable.

A 12-lead EKG showed functioning pacemaker.

LABORATORY STUDIES:  Sodium 133, potassium 4.2, and BUN 24.  Random blood sugar was 147 mg%.  Troponin I was 0.  Blood sugar 144.  T4 was 6.4.  TSH was 1.57, which is normal.  Initial white count was 20,000 with hemoglobin 17.9 mg%, hematocrit 53 mg%, 85 segs.  Repeat white count 2 days later was 11,400 and later this came down to 8400.  Urinalysis was negative.  Subsequent BUN went up to 36 mg% with creatinine of 1.3.  His PSA level was 3.2.  A repeat ABG showed pH of 7.37, pCO2 of 44, and pO2 of 114 on 36% of oxygen.  The urine culture did not grow any organism.

A 12-lead EKG on admission showed supraventricular tachycardia.  Followup EKG showed sinus rhythm with heart rate down to 83 per minute without any acute changes.  Chest x-ray showed chronic obstructive pulmonary disease with granulomatous lung disease and a tiny, small pleural effusion.  No definite pneumonia.  Renal ultrasound showed no evidence of hydronephrosis.  There was a 5.7 simple cyst in the right kidney.  Bladder ultrasound showed postvoid of 340 mL, which is very significant.

LABORATORY EXAMINATION:  Hemoglobin 12.3, hematocrit 35.5, white blood cell count 4070, and platelet count of 164,000.  Sedimentation rate of 5.  UA shows no blood, no protein, no nitrites.  Sodium 142, potassium 4.5, chloride 102, CO2 31.5, BUN 17, creatinine 1.1, glucose 88, protein 6.7, albumin 3.8, calcium 9.3.  Bilirubin 0.51, AST 14, ALT 31, alkaline phosphatase 85.  Amylase 48 and lipase 180.  Triglyceride 88, cholesterol 164, HDL 53, LDL 93.  PSA 1.78.  Iron 125, TIBC 344.  B12 of 247, folic acid of 14.  Herpes zoster IgG was 81, herpes zoster IgM was 15.  Serum protein electrophoresis was normal.  Urine culture was negative.

LABORATORY EXAMINATION:  Hemoglobin 10.3, hematocrit 32, white blood cell count 10,800, and platelet count 384,000.  UA showed no protein, no blood, and no glucose.  Sodium 142, potassium 3.2, chloride 103, CO2 of 25, BUN 9, creatinine 1.2, glucose 107, protein 6.1, albumin 2.9, calcium 8.2.  Bilirubin 0.4, AST 16, ALT 37, alkaline phosphatase 87.  Amylase 96, lipase 547, repeat lipase 494.  Magnesium 1.4.  Iron 24, TIBC 282.  C-reactive protein 16.  CEA 2.2.  RPR negative, rheumatoid factor negative, ANA negative, pH 7.35, pCO2 34, pO2 80, and bicarbonate of 19.  Urine negative.

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OR Report (Laparoscopic cholecystectomy)

PREOPERATIVE DIAGNOSIS:  Stage III gastric carcinoma requiring long-term intravenous access for chemotherapy treatment.

POSTOPERATIVE DIAGNOSIS:  Stage III gastric carcinoma requiring long-term intravenous access for chemotherapy treatment with poor peripheral venous access.

OPERATION PERFORMED:  Insertion of a 7.8 French pre-assembled Deltec ProPort via right subclavian.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  Local 0.25% Marcaine with MAC.

ANESTHESIOLOGIST:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Minimal.

BLOOD TRANSFUSED:  None.

DRAINS:  None.

SPECIMENS:  None. 

INDICATIONS:  The patient is a very pleasant (XX)-year-old female who is now one month status post subtotal gastrectomy for a stage III gastric carcinoma.  She was found to have positive node that is localized for which Dr. Doe has requested that we place a port for adjuvant chemotherapy.  The procedure risks, complications including but not limited to bleeding, infection, pneumothorax and underlying pneumothorax were explained to the patient and her daughter, who was present, and agreed to proceed.

DESCRIPTION OF OPERATION:  With the patient in the main operating room under adequate IV sedation and carefully monitored by anesthesia, Kefzol was given at the time of induction.  A small towel was placed in the intrascapular area.  Both arms were tucked at the side and adequately padded.  The entire upper chest, on both sides, including the neck and shoulder area were prepped with iodoform and draped in the usual sterile fashion.  The patient was placed in Trendelenburg position.  Attention was first directed to the left infraclavicular region.  This was anesthetized using 0.25 % Marcaine.  Here, using a standard percutaneous Seldinger technique, I was unable to identify the subclavian vein, and I opted to go on the right side. 

At this point, the right infraclavicular region was anesthetized using 0.25% Marcaine.  Here, using a standard percutaneous Seldinger technique, I was able to identify the right subclavian vein with no difficulty.  Blood was aspirated.  The guidewire was then placed through the needle, guided along the subclavian vein, superior vena cava at the atrium as confirmed by fluoroscopy.  Next, a small pocket was then fashioned just below the entrance of the guidewire.  Hemostasis was then obtained within this pocket where a 7.8 French pre-assembled Deltec ProPort was then placed within the pocket and secured.  A catheter was then tunneled up to the entrance of the guidewire.  The catheter was then cut to appropriate length and flushed using heparin saline.

At this point, a dilator with a peel-away sheath was placed over the guidewire.  The guidewire along with the dilator was subsequently removed.  The catheter tube was then placed with the peel-away sheath.  As the catheter was then guided down, the subclavian vein, superior vena cava-right atrial junction was confirmed by fluoroscopy.  Blood was aspirated from this catheter with no difficulty and this was then also flushed with heparin saline with no difficulty.  At this point, hemostasis was then obtained. 

The small incisions were approximated using #3-0 Vicryl.  The skin was approximated using running subcuticular #4-0 Monocryl.  Steri-Strips were applied to the wound.  Before placing the dressing, the catheter was accessed one more time with absolutely no difficulty, flushed again using heparin saline and sterile dressing was applied to the wound. 

The estimated blood loss was minimal and none was transfused.  No drains were placed.  Sponge and instrument counts were correct x2 at the end of the case.  The patient subsequently tolerated the procedure well and was then returned to her room in stable condition.

OPERATION PERFORMED:  Laparoscopic cholecystectomy.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. Following induction of general anesthesia, the abdomen was prepped with Betadine and draped sterilely. This patient had received Zosyn preoperatively. A 1.5 cm incision was made at the lower border of the umbilicus, dissection carried down through the skin and subcutaneous tissue. The umbilical raphe was visualized and placed on upward traction. A transverse incision was then made at the base of the raphe and the abdomen thus directly entered. A Hasson trocar was introduced and the abdomen insufflated with carbon dioxide to about 12 to 13 mmHg pressure. The 0-degree laparoscope was then introduced and the gallbladder inspected. It was very distended and thick-walled with obvious acute cholecystitis changes about it. Additional trocars were then placed into position in the right lateral, the right subcostal, and the epigastric area. The gallbladder was unable to be grasped due to its distention; therefore, it was decompressed with a needle through the right subcostal port. Following this, the grasper in the right lateral port was used to close the opening where the aspiration had been performed and to place the gallbladder on upward traction. The infundibulum was then placed on outward traction and the edematous tissue about the tapering of the infundibulum was clearly teased away to identify the cystic duct. There appeared to be several stones impacted in the neck. The cystic duct was cleaned free of surrounding tissue and then triply clipped with the endoclips applier and divided. Likewise, the cystic artery which ran adjacent to this was triply clipped and divided. The gallbladder was then removed from the liver bed with the cautery device and blunt dissection. Once removed, it was placed in an EndoCatch bag and then retrieved and removed through the umbilical port under direct vision. Inspection of the operative area was then carried out again, and since there was some mild oozing in the gallbladder fossa, it was felt best to drain this area postoperatively. Therefore, a #10 Jackson-Pratt was placed into the abdomen in Morison pouch and brought out through the right lateral trocar site. All irrigant was removed and returns were clear. The patient was then placed back in the flat supine position instead of the head upward position and all returns were further aspirated from the irrigant. Carbon dioxide was evacuated and the ports removed under direct vision, with no evidence of any oozing. The fascia at the umbilical and epigastric areas was then closed with interrupted 2-0 Vicryl and all skin incisions with 5-0 subcuticular Monocryl and Steri-Strips. Sterile bandage was applied and the patient then awakened and returned to recovery in good condition.

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OB DISCHARGE SUMMARY

ADMITTING DIAGNOSIS: Cystocele with urinary incontinence.

FINAL DIAGNOSIS: Cystocele with urinary incontinence.

PROCEDURE: Anterior repair.

COMPLICATIONS: None

HISTORY: This is a 65-year-old woman who had had a previous hysterectomy, who developed urinary incontinence, and was found to have a large cystocele.

Physical examination was unremarkable except for the cycstocele.

Lab work, including a panel, CBC, EKG, and chest x-ray, was essentially within normal limits. Following surgery the patient has done well. The vaginal pack was removed this date and the Foley catheter. She will be checked for residual. IF the residual is over 150 cc, the Foley will be replaced and the patient taught to use the catheter plug, and she will be discharged. She will be seen in the office in approximately one week for follow-up.

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Emergency Room Report (OB-Ectopic pregnancy)

ADMITTING DIAGNOSIS: Ectopic pregnancy

CHIEF COMPLAINTS: The patient presents to the emergency room this morning complaining of lower abdominal pain.

HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she state that she is sexually active and using no birth control.

GYNECOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother.

PAST MEDICAL HISTORY: Positive for Hepatitis-B.

PAST SURGICAL HISTORY: Pilonidal cyst, remove in the remote past. Had plastic surgery on her ears as a child.

SOCIAL HISTORY: Married, has one daughter, patient works as a substitute teacher. Smokes one pack of cigarettes on a daily basis. Denies ETOH. Smoked marijuana last night. No IV drug abuse.

ALLERGIES: Tightness.

MEDICATION: None.

REVIEW OF SYSTEM
Patient complaints of a lower abdominal pain for the past week that apparently got much worst last night and by this morning was intolerable. The patient is also having some nausea and vomiting. Denies hematemesis, hematokesia and melena. The patient has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Denies arthralgias. Review of system is otherwise essentially negative.

PHYSICAL EXAMINATION
VITAL SIGNS: Shows temperature 97degrees, pulse 53, respirations 22, blood pressure 108/60.
GENERAL: Physical examination reveals a well developed, well-nourish, 35-year-old white female in a moderate amount of distress at the time of the examinations.
HEENT: Unremarkable except for poor dentition.
NECK: Soft and supple.
CHEST: Lungs are clear in all fields.
HEART: Regular rate and Rhythm.
ABDOMEN: Soft with positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexa are more tender than the right.
VAGINAL EXAMINATION: The cervix is close. A moderate amount of mucopurulent vaginal discharge is noted. The patient would not allow me to perform a bi-manual examination due to the patient pain. So the speculum was withdrawn.
EXTREMITIES: No clot. No edema.
NEUROLOGIC EXAMINATION: Intact. Oriented x3, No neurologic deficits.

DIAGNOSTIC DATA
ADMISSION: Hemoglobin 12.8 g and Hematocrit 36.6%.
URINALYSIS: Essentially Negative.
BETA HCG: Positive with WBC count of 23,278.

RADIOLOGY
Pelvic Ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 mg, and Phenergan 25 mg. IV for the pain after her report was obtained. The patient also given claperan 1g IV.

I page Dr. Gerard, patient’s GYN, physician, as soon as I receive the ultra-sound report at approximately 10a.m. He was not in North Miami office. I page the South Miami office and reach Dr. Gerard’s office at approximately 10:15a.m. His office personnel advice me that he is not on call, Dr. Bomback is on call. I spoke with Dr. Bomback at approximately 10:25a.m. and she will be here to take the patient to the operating room.

ADMITTING DIAGNOSIS: Left ectopic first trimester pregnancy.
Disposition: The patient receive and IV of lactated ringer upon arrival at the emergency room. This was switch to normal saline while we were awaiting Dr. Bomback’s arrival. The surgical procedure was explained to the patient and her husband. All risk and benefits were discussed. They understand the necessity for immediate surgery and informed consent was signed. No old records are available for review.

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History and Physical Sample Report

REASON FOR ADMISSION: Urinary tract infection and fever.

CHIEF COMPLAINT: "Problems with bladder."

HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old white male with a history of urinary frequency, burning, and recent fever. His urine was loaded with white cells in the office, and he is being admitted for intravenous antibiotics. Last night, he presented to the ER and had a temperature to 102.5 degrees, then subsequently developed worsening fever. His fever ultimately broke about 2:30 in the morning with a temperature that ended at approximately 103 degrees.

PAST MEDICAL HISTORY: Significant for oral agent diabetes mellitus and hypertension.

REGULAR MEDICATIONS: Include: (1) Glucovance. (2) Avandia. (3) Zantac. (4) Tricor. (5) Zestril.

ALLERGIES: PENICILLIN (he is unsure of the reaction - he thinks it has something to do with swelling).

FAMILY HISTORY: Significant for a father who died of myocardial infarction and mother died of a stroke. He has had a previous urinary tract infection, Escherichia coli type, in 1998, with admission to the hospital then. He has not had any other hospitalizations.

SOCIAL HISTORY: He is a truck driver. He is not an abuser of alcohol or tobacco.

REVIEW OF SYSTEMS: Significant for dysuria; PSA score of only 3.

PHYSICAL EXAMINATION:
VITAL SIGNS: Recorded in nursing notes: Temperature maximum of 101.5 degrees. He is slightly hypertensive at 145/75. His pulse oximetry is normal. His pulse rate is in the low 90s. His respiratory rate is 16.
GENERAL APPEARANCE: His mood and affect are normal. He is alert and oriented x 3. He is an excellent historian.
HEAD, EYES, EARS, NOSE, AND THROAT: Examination reveals he is normocephalic, atraumatic. Extraocular movements are intact.
NECK: Supple without jugular venous distention or thyromegaly.
CHEST: Grossly clear.
HEART: Rate is regular. Peripheral pulses appear to be normal.
LYMPHATICS: He has no abnormal adenopathy in the axillary, supraclavicular, cervical, or inguinal lymph node regions.
ABDOMINAL EXAMINATION: Soft, nontender, slightly protuberant. No evidence of inguinal, umbilical, or other fascial hernias are noted.
GENITOURINARY: The testes and phallus are normal. Prostate is about 20 g in size and significantly tender on the right hand side.

LABORATORY DATA: Indicative of a white blood cell count of 13.7. Hemoglobin and platelet count are well within normal limits. Comprehensive metabolic panel reveals a normal creatinine. Urinalysis reveals white cells present. Urine culture has been sent.

 DIAGNOSTIC IMPRESSION:
1. Probable prostatitis.
2. Urinary tract infection.

PLAN: Admission. Will do non-contrast CT scan to evaluate him for possible stone. No apparent prostate abscess is present and he will be treated with intravenous antibiotics.

Copyright 2005-2009 Copied with Permission from the web site,
"Patients and Medical Transcription" at http://www.mt-stuff.com

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Emergency Room Report

CHIEF COMPLAINT:
Colic.

 HISTORY OF PRESENT ILLNESS:
This 6-week-old enters with colicky pain and increasing flatus and crampy abdominal pain that she gets mostly at night. She is not constipated. She has had no blood in her stool and normal urine and normal intake and no nausea or vomiting. She has not had any fever. 

PAST MEDICAL HISTORY:
Other than the above, symptoms is negative. 

PAST SURGICAL HISTORY:
Negative.

SOCIAL HISTORY:
Negative. Both parents are present and appropriately concerned.

FAMILY HISTORY:
Negative.

REVIEW OF SYSTEMS:
The complete review of systems is essentially negative except for colicky abdominal pain and increased flatus. The patient is on formula with iron and does not use a gas decreasing bottle system. Has been on Gaviscon but has gotten only one dose a night apparently. The rest of the review of systems is negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.9. Pulse 130. Respirations 52. Pulse oximetry is 96% on room air.
GENERAL APPEARANCE: She is alert and is moving all extremities.
HEENT: The pharynx is wet. The tympanic membranes are normal. The fontanel is soft and ballotable.
NECK: Supple. There is no induration of the throat and there is no adenopathy.
LUNGS: Clear. There is no dyspnea.
HEART: Shows a regular rhythm without murmurs.
ABDOMEN: Somewhat distended. She had some flatus several times, I might add, and then it diminishes. It is totally nontender. She has good tone.
NEUROLOGIC: Intact for age including a positive Moro.
SKIN: She has no skin lesions, icterus, or jaundice, and the pulses are 2+ and equal.

DATABASE:
X-rays: Upright abdominal and chest combination is normal except for gas in the bowel, which shows no obstruction.

DISCUSSION:
I think this is colic. I have suggested the following: (1) To change to formula without iron. (2) To use soy based formula. (3) To increase the Gaviscon to 3 drops q.i.d. at least. (4) They should follow up with their own doctor.

CLINICAL IMPRESSION:
Colic.

PLAN:
Gaviscon, changing the formula, no iron, and see their doctor in 1-7 days.

CONDITION ON DISCHARGE:
Good


Copyright 2005-2008, Copied with Permission from the web site,
"Patients and Medical Transcription" at http://www.mt-stuff.com

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