MT

Samples of Transcribed Medical Documents

Google

COMPLETE OFFICE PHYSICAL
S: The patient presents for a physical. His main problem has been some pains in the neck, elbows and lower back. The back pain has been present for just a few days and is slightly worse with movement. He has had pains in his elbows for approximately four months. It is relatively constant, no extreme. It does tend to hurt when he supinates his forearm fully. He has also had some mild pain in the back. At one time, he was thought to possibly have cervical disc disease; however, a CT scan of the cervical spine was unremarkable. He has no other significant history. Social: He is a nonsmoker. Family history: His father does have some mild arthritis and also has hypertension and heart disease.

O: HEENT: Tympanic membranes are clear bilaterally. Nose and throat are clear. Neck is supple without lymphadenopathy or bruits. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft, flat, nontender, and nondistended. Bowel sound are active. He has some minimal tenderness in the right lower quadrant. Back: There is trigger-point tenderness. Lower extremities are normal to exam. He has negative straight leg raising in the supine position.

Laboratory studies were within normal limits, with the exception of his cholesterol which was 236 and his triglycerides which were 320. He is not watching his diet at all.

A: Strain of the lower back. I think this may well be due to his work as a clerk. He spends a lot of time at a computer keyboard.

P: He is to take the strain off of his elbows and lower back. I also gave him an instruction sheet on a low-cholesterol diet. He will try to follow this for six months, and we will recheck his cholesterol then. He asked if I would recommend taking niacin. I told him that it might have some beneficial effect and was probably relatively safe for him to take.


TYPICAL SOAP NOTE (subjective, objective, assessment and plan)
S: This is a 78-year-old white female with multiple complaints. She has a history of chronic sinusitis, esophagitis, a fibromyalgia-type syndrome, and depression. She complains today of continued problems with pain in the left cheek and preauricular area, especially in the morning. The pain gets very intense at times. She also has a great deal of postnasal drainage which gives her a sour feeling in her stomach. She also complains of some dizzy spells over the last few months, usually when she is working around the house. These are associated with some sweating and nausea. She has not ever had any loss of consciousness. She also complains of recurrent problems with constipation, especially over the last three months. She has been using Correctol. This tends to give her runny stools for a day and then she has constipation again the next day. She has tried taking Colace. This was not helpful.

O: General: She is a well-nourished, well-developed, elderly white female in no acute distress. She appears somewhat sad and tearful. HEENT: Tympanic membranes were clear bilaterally. Nose had some pale mucosa, otherwise clear. She had tenderness along the left maxillary and left preauricular areas, and some mild temporomandibular joint tenderness. Throat was clear. Neck was supple. Lungs: Clear to auscultation. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft and diffusely tender to a mild degree. Bowel sounds were active.

A: 1. Depression.
2. Recurrent sinus pain.
3. Constipation.
4. Esophagitis.

P: 1. She has been off Zoloft for a while, so we will have her resume that. There is no record in the chart of her ever having an adverse reaction to it.
2. Beconase AQ 2 puffs b.i.d.
3. For her constipation, I recommended using Metamucil or some other type of similar fiber, and increasing her fluid intake. She is going to make an appointment with Dr. Suess at his next opening, so that he can follow up on how she is doing with these changes. If she continues to have the sinus pain, we may need to refer her to an otolaryngologist.


PATIENT CARE PLAN LETTER TO HEMATOLOGIST
RE: Prince Charming

Dear Dr. Doolittle:

I am sending Prince Charming to you in regards to some leukopenia and thrombocytopenia. He was a previous patient of The Wicked Witch and evidently had some low platelets and white counts in the past. In February, he had a white count of 4100 with essentially a normal differential. His platelet count was 130,000.

We repeated his complete blood count recently. He continues to have no anemia, but his white count is now 2800 and platelet count is 109,000. Antinuclear antibody was negative. His blood chemistry profile did show a mildly low globulin at 1.7. Uric acid was slightly elevated at 8.7. Bilirubin was at 2. His retic count was 3 with an absolute reticulocyte count of 139.5, which is about double normal.

I have included the laboratory studies for you to review. His vitamin B12 level was normal at 282. He is somewhat reluctant to see a hematologist. I told him that you may recommend a bone marrow exam. At this point, he is feeling well and does not understand why he would nee to see another physician.

I appreciate your evaluation.

Sincerely,

Dr. Suess


FLEXIBLE SIGMOIDOSCOPY
PROCEDURE: The Olympus-60 scope was passed to 40 cm. On withdrawal, two polyps, about 3-4 mm, were noted. One was at 35 cm and the other at 20 cm. Multiple diverticula were noted in the sigmoid colon. Scope was not advanced past 60 cm, due to sharp flexures of the sigmoid colon and redundancy. Patient tolerated procedure well. Preparation was excellent. Mucosa was otherwise normal.

ASSESSMENT:
Two polyps that appear benign, at 20 and 35 cm.

PLAN
Referral for colonoscopy.


HISTORY AND PHYSICAL (Hospital)
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: None.

Allergies: No known drug allergies.

Social History: He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." 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 and X-Ray Data: 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, direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room air. 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 bilirubins.
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.


OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Right foot infection.
POSTOPERATIVE DIAGNOSIS: Right foot infection.
PROCEDURE: Right below-knee amputation.
SURGEON: Save A. Life, M.D.
ANESTHESIA: Spinal.
FLUIDS: 300 cc Ringer's lactate.
ESTIMATED BLOOD LOSS: 250 cc.
INDICATIONS FOR SURGERY: This is a 70-year-old male with a history of insulin-dependent diabetes mellitus, coronary artery disease, chronic renal failure and heart failure who was initially admitted for congestive heart failure and nonhealing bilateral foot ulcers treated for years with debridement and whirlpool. The patient was readmitted for acute diabetic right foot. Recently his foot had been worsening. He had been using dry dressings. He was admitted and taken to the operating room for incision and drainage of his right foot and first ray amputation. The patient's infection could not be eradicated from the foot; therefore, it was decided to take him for right below-knee amputation.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the operating room table in the right lateral decubitus position. After placement of intravenous lines and electrocardiogram leads, spinal anesthesia was induced. The patient was placed supine and the patient's right lower limb was sterilely scrubbed with Betadine and prepared with Betadine paint in a sterile fashion. The patient's right lower limb was draped in a sterile fashion after the application of a tourniquet to th right upper thigh. The tourniquet was not inflated during the case.

We first turned our attention to the foot and made a transmetatarsal incision with a 10-blade scalpel around the foot. We performed a transmetatarsal amputation at first. There did not seem to be bleeding or viable tissue at this amputation site, especially posteriorly on the foot. Therefore it was decided to carry the amputation up to a below-knee amputation. A fish-mouth incision was made at the midtibia, leaving more posterior tissue to form a lip for closure. Using the 10-blade scalpel, we cut circumferentially the soft tissue around the tibia and fibula, being careful to clamp bleeding vessels which appeared along the way. We cut through all the soft tissue muscle tendons and were careful to identify the peroneal nerve and the tibial nerve, and to stretch these as far down as possible and cut them as far proximally as possible so they would retract and not form neuromas. We tied off the major vessels, the tibial and peroneal arteries. After the soft tissue was removed, the tibia was cut with the oscillating hand saw approximately 3 cm proximal to the skin incision. The end was rasped away so there would be smooth edges. The fibula was cut with the hand saw 2 cm above this, and the end was rasped off as well to a smooth dry point. Hemostasis was obtained with the cautery, and also with Vicryl suture used to tie off some bleeding vessels.

The fascial tissue layer was closed with 0-Vicryl figure-of-eight sutures. After this, 0-Vicryl was used to bring the skin together by bringing the subcutaneous tissue above the fascia. The last layer of skin was closed with 4-0 nylon interrupted sutures. A sterile dressing and Ace wrap were placed over the wound. We also inserted a small drain into the wound. The patient tolerated the procedure well and was returned to the recovery room in stable condition.


DISCHARGE SUMMARY
DIAGNOSES:
1. Cerebrovascular accident.
2. Schizophrenia.
3. Recurrent transient ischemic attacks.

PROCEDURES:
1. Echocardiogram.
2. Holter monitor.

HISTORY OF PRESENT ILLNESS:
This is a 59-year-old, right-handed woman with a history of hypertension, schizophrenia, and a fallopian ovarian tumor resecte surgically and with radiotherapy treatment, who presented to the emergency room with a four-hour history of difficulty talking, and numbness and weakness on the right side. She was in her usual state of health until early the morning of admission when she woke up and noted numbness on her right side. Her numbness was associated with weakness as well as difficulty speaking, with no associated headache, chest pain, fever, chills, double vision difficulty swallowing or palpitations. She reported having a similar incident about one month prior to admission when she was seen in the emergency room, but at that time, her symptoms resolve while in the emergency room. CT scan at that time showed bilateral basal ganglion infarcts. Carotid duplex then showed minimal plaque, rig ht greater than left, with no hemodynamic stenosis. At that time, she was sent home on aspirin 1 q.d. which she has been taking except for the day prior to admission when she missed her dose.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature of 37.1, blood pressure of 164/100 in both arms.
HEENT: Clear.
NECK: Mild right bruit.
HEART: Regular rate and rhythm with no murmurs.
LUNGS: Clear.
ABDOMEN: Obese with a surgical scar. Bowel sounds were present.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: She was alert and oriented times three. She had difficulty with speech, mostly lingual sounds. No aphasic symptoms. Normal flow, normal rate and normal content. No breathlessness noted. Cranial nerves showed right fundi with sharp discs, pupils reactive 3 to 2 bilaterally, full extraocular movements and full visual fields. Corneal reflexes were present bilaterally. Decreased V1 through V3 pinprick on the face. Masticatory muscles were normal. Face was symmetric. Eye closure, puffed cheeks and smile were symmetric. Uvula and tongue were midline. Her gag was present bilaterally, left greater than right. Motor examination showed increased tone in the left arm. Strength was 4/4 in the right upper and lower extremities and 5/5 in the left upper and lower extremities. Reflexes were 2+ throughout with downgoing toes. Sensory examination showed decreased pinprick on the right side. There was decreased vibration bilaterally in upper and lower extremities. Normal stereognosis and graphesthesia. Gait: She was able to bear weight on the left with some difficulty.

LABORATORY DATA: Unremarkable. Head CT scan at the time of admission showed bilateral lacunae of the anterior internal capsule with basal ganglion involvement; no change from prior CT scan. Electrocardiogram showed normal sinus rhythm at 81 with Q-waves in leads I and aVL, and small Q-waves in V1 and V6.

HOSPITAL COURSE: The patient was admitted to the neurology service with concern for an embolic versus ischemic event in the face of aspirin therapy. As an inpatient, she had an echocardiogram which was reported to show mild, concentric, left ventricular hypertrophy with normal left ventricular function, no segmental wall abnormalities, no mitral regurgitation, no aortic regurgitation and no tricuspid regurgitation. No evidence of coral thrombus. Carotids were not repeated, since she had a carotid study one mont prior to admission that showed an occlusion of her carotids. RPR was nonreactive. Blood pressure remained under control during hospitalization. Her psychiatric symptoms were stable during this time. She was seen by physical therapy and occupational therap who helped her with ambulation, and by discharge she was making good progress, ambulating and using her arms, although she remained with weakness on the right more marked than the left. She was discharged in good health.

DISCHARGE MEDICATIONS:
1. Nortriptyline 25 mg p.o. q.h.s.
2. Benadryl 50 mg p.o. q.h.s.
3. Navane 5 mg p.o. q.h.s.
4. Aspirin 2 p.o. b.i.d.

DISCHARGE INSTRUCTIONS:
1. Diet: Low-cholesterol, low-fat diet.
2. Activity: As tolerated.

FOLLOW-UP CARE:
1. Followup with physical therapy and occupational therapy.
2. Return to the neurology clinic about one month after discharge.


PATTERN SHIFT VISUAL EVOKED POTENTIAL STUDY
Visual acuity left eye 20/200, right eye 20/25 with glasses. After full field stimulation of each eye, waves N1, P1, and N2 are identified. The P1 absolute latencies are left eye 95.5, right eye 98.0. The P1 difference is 2.5 msec. The amplitude ratio is 86.2%.

SUMMARY
Decreased visual acuity, left eye. Pattern shift visual evoked potential study within normal limits.


BRAIN STEM AUDITORY EVOKED POTENTIAL STUDY
Auditory Threshold: Left ear 20 db, right ear 20 db. After stimulating each ear, waves 1, 3, and 5 are identified. The absolute latencies, interwave latencies, and interear, interwave differences are normal. The amplitudes of waves 1 and 5 are normal. The 1/5 amplitude ratios are normal.

SUMMARY
Normal brain stem auditory evoked potential study.


ELECTRONYSTAGMOGRAPHY REPORT (ENG)
CLINICAL HISTORY
This is a 43 year old with seizure disorder and recent imbalance with stair climbing.

The following examinations are performed with horizontal and vertical electrodes.

Saccadic eye movements are well organized in the horizontal and in the vertical directions. Gaze and fixation testing, including straight gaze, gaze to the left, gaze to the right, and gaze upward and downward, produces no nystagmus. The oscillating tracking test reveals well-organized horizontal pursuit movements to each side.

Bidirectional opticokinetic testing with peripheral stimulation produces horizontal nystagmus of appropriate direction with the targets moving to each side. The torsion swing test with the eyes closed produces normal direction-changing horizontal nystagmus. Positional head testing with the eyes closed and the patient in the head hanging, left lateral, right lateral, and sitting positions produces no nystagmus. Cold and warm water caloric testing of each ear produces horizontal nystagmus of appropriate direction.

SUMMARY
Electronystagmography within normal limits.


ELECTROENCEPHALOGRAM REPORT (EEG)
Age: 62. Patient is on Neurontin, phenobarbital, and Dilantin.

ANALYSIS OF PATTERN
There is a bioccipital rhythm, which is organized, of about 8 Hz. Frontal activity is a mixture of rapid and slow activity. Bifrontal spike and slow wave activities are noted, which have been noted in previous EEGs. High voltage delta slow waves are also noted intermittently in the frontal areas. The spike activity noted does not generalize but spreads occipitally. Interictally, the EEG has some slow theta activity in the 5-6 Hz range. The spike and slow activity is not frequent but intermittently increases in frequency. Tow episodes of every 1 second, lasting 4 seconds, are recorded. Otherwise, the spike activity appears between 2 minutes to 3 minutes in the EEG. The high-frequency delta waves are not as frequent. One episode lasting up to 5 seconds is also noted. No clinical correlation was noted with this EEG by the EEG tech or by the patient. The patient is not photosensitive.

IMPRESSION
Compared to the previous EEG, it is either unchanged or slightly better.


ELECTROMYOGRAPHY (EMG)
NEUROLOGICAL AND ELECTRODIAGNOSTIC CONSULTATION
This is a 44-year-old white female with left lower extremity pain. Approximately one month ago, the patient, while descending stairs, was almost tripped by her cat. The patient put her left leg out in front of her to prevent a fall. She felt "a shock" in the center of the left knee. She subsequently had numbness of the entire left knee. Subsequently, the left knee pain radiated into the quadriceps muscle and into the lower leg and ankle. "The whole leg felt terrible." Because of pains in the knee, the leg would jump at night. She had X-rays of the knee, which she understands were "fine." The knee was immobilized by a splint. She had a orthopedic evaluation. She subsequently had physical therapy. The patient noticed increased left knee pain after the use of a Hydrocollator pack. She continues to complain of left knee pain. Now she cannot sit for longer than 1-1/2 hours because she develop a burning sensation in the left knee. The burning radiates to the posterior lower leg and subsequently also radiates into the posterior thigh. If she stands for a prolonged period of time, she has pins and needles sensations in the anterior left knee. With prolonged standing, the left knee seems to give out from underneath her. When she keeps her left leg dependent, the left knee tends to burn, and she has burnin g sensations at the back of the left lower leg and in the heel.

The patient also complains of some back discomfort in the middle of the low back for approximately one month. She describes this sensation, "It feels like muscles." There are no right leg symptoms and no bladder or bowel symptoms.

The patient is using Advil, 3 tablets q.4-5h. She also tried Valium q.h.s., which is helpful.

PAST HISTORY: The patient has had a tonsillectomy and a tubal ligation. She has hayfever but no medication allergies. There have been no other significant prior illnesses.

SOCIAL HISTORY: Prior to the left leg problem, the patient was doing temporary office work. She now, however, is unable to work.

NEUROLOGICAL EXAMINATION: The neurological examination reveals the patient to be a well-developed, well-nourished white female. A single 1 x 2-inch cafe-au-lait spot is present over the dorsum of the left foot just proximal to the 4th and 5th toes. Bending forward with the knees extended, the patient misses her toes with her fingertips by 6 inches. Straight leg raising of the right leg is negative at 75 degrees; straight leg raising of the left leg at 75 degrees produces some discomfort only in the area of the left hip. Bent leg raising is negative. The patient complains of severe pain on compression of any part or side of the left knee.

All major muscle groups have strong symmetrical power. The patient complains of a great deal of left knee pain when she attempts to contract the extensors of the left knee strongly. There appears to be dullness to pin over the dorsum of the left large toe and over the lateral aspect of the left foot. Pin sensation is, otherwise, intact, including all of the other lumbar dermatomes. Position and vibratory sensations are normal. The deep tendon reflexes are 2+ and symmetrical. Both toes are down-going. The Romberg test is negative. There is no drift of the outstretched extremities. The pupils and fundi are normal.


ELECTROMYOGRAPHIC STUDY
The following muscles are examined in the lower extremities: extensor digitorum brevis, anterior tibial and peronei, quadriceps, gastrocnemius muscles, biceps femoris, and semitendinous muscles. The lumbosacral paraspinal muscles could not be examined because of poor needle electrode tolerance. In all of the muscles studied, the insertional activity was normal. There was no abnormal activity at rest. The motor units were of normal size and duration. The recruitment pattern was full.
NERVE CONDUCTION VELOCITY STUDY
(The patient's height is 5'2")
Left peroneal nerve: Terminal latency 3.20; NCV 45.5 mps.
Right peroneal nerve: Terminal latency 3.24; NCV 47.8 mps.
Left tibial nerve: Terminal latency 4.90; NCV 48.1 mps.
Right tibial nerve: Terminal latency 4.16; NCV 47.1 mps.

SENSORY RESULTS
Left superficial peroneal nerve: Terminal latency 3.16; NCV 47.5 mps.
Right superficial peroneal nerve: Terminal latency 3.08; NCV 47.2 mps.
Left sural nerve: Terminal latency 2.96; NCV 50.7 mps.
Right sural nerve: Terminal latency 2.94; NCV 51.0 mps.

LATE RESPONSES
F-wave latencies
Left peroneal nerve 46.0
Right peroneal nerve 45.8
Left tibial nerve 46.0
Right tibial nerve 46.4

H-reflex latencies
Left sciatic nerve 27.7
Right sciatic nerve 28.4

The amplitudes of the motor action potentials produced by stimulating the left and right peroneal nerves are low. The amplitudes of the other motor action potentials are normal.

SUMMARY
The most striking feature of the patient's neurological examination is the great deal of pain produced by compression or palpation of any part of the left knee. She appears to have dullness to pin over the left large toe and over the lateral aspect of the left foot.

The electromyographic study was limited by poor needle electrode tolerance. The muscles which were able to be examined, however, were normal.

The nerve conduction velocity study was mildly abnormal because of the low amplitude of the motor action potentials produced by stimulating the left and the right peroneal nerves. This was a very symmetrical finding. The rest of the nerve conduction velocity study is normal.

The etiology of the patient's left lower extremity symptoms remains unclear. Although the pin sensation findings suggest the possibility of a lumbar root problem, the finding is subjective in nature, and there are no other definite signs of nerve root injury. The pain on compression of the left knee suggests a primary knee problem.

I have administered Anaprox, 275 mg q.i.d. with food or milk. A bone scan is additionally requested. Also requested are a CBC, arthritis profile, and special chemistry profile.

Thank you very much for asking me to examine this patient.


MT Daily Homepage