PEDIATRICIAN: Dr. Jane Doe

OBSTETRICIAN: Dr. Jeff Doe

CHIEF COMPLAINT: Prematurity, 35-week twin gestation, RDS.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gravida 2, para 1, full term 1, living 1, mother who presented with contractions and leg swelling. Her EDC was MM/DD/YYYY. She received prenatal care with Dr. (XX) for monochorionic diamniotic twin gestation. A primary C-section was done for maternal ITP. Twin B was footling breech and velamentous cord. The mother received spinal anesthesia. AROM was clear at delivery. Maternal blood type is O positive. The antibody screen is negative. HIV negative. Hep B negative. RPR nonreactive. She denies HSV. She is rubella immune. GBS unknown. Positive PPD with negative chest x-ray. Baby girl (XX) twin B was received by the ALS team, noted to have cyanosis with grunting and retracting. Please see ALS note. The infant was admitted to the NICU, placed on nasal CPAP of plus 5 and weaned to 25% FiO2. UAC and UVC catheter were placed by the ALS RN. Birth weight 2635 g, head circumference 39.5 cm, length 47.5 cm. Glucose was 42 and the followup was 51.

ADMISSION VITAL SIGNS: Axillary temp 36.1, heart rate 170, respiratory rate 60, BP was 46/40 with a mean of 44.

PHYSICAL EXAMINATION:
HEAD, EYES, EARS, NOSE, AND THROAT: Anterior fontanelle is soft and flat. Bilateral red reflex is seen. Palate is intact. Nares appear patent. Ears are grossly normal.
CARDIOVASCULAR: Heart rate is regular rate and rhythm with no murmur audible. Pulses are 2+ and equal in 4 extremities. Cap refill is 2 to 3 seconds. The infant is noted to be plethoric.
RESPIRATORY: Bilateral breath sounds are equal and coarse. Substernal retractions on nasal CPAP are noted.
GASTROINTESTINAL: Abdomen is soft, nondistended, with positive bowel sounds. There is a 3-vessel cord. No hepatosplenomegaly or masses are felt.
GENITOURINARY: Female genitalia. The anus is patent.
MUSCULOSKELETAL: The spine is intact. There are no hip clicks.

IMPRESSION:
1. A 35-week twin B female.
2. Respiratory distress syndrome (RDS).
3. Suspected sepsis.

PLAN:
1. Wean CPAP as tolerated. Obtain chest x-ray and follow up ABG.
2. CBC, blood culture on admission, AMP and CEF. Follow up CBC and CRP in a.m.
3. UAC half normal saline, 1 unit of heparin per mL at 1 mL an hour.
4. UVC 200 D10W with 200 mg of calcium gluconate per 100 and 0.5 units of heparin per mL at 8 mL an hour for total fluids of 80 mL per kilo per day.
5. BMP and bili in a.m.
6. The father of the baby was updated at the bedside on infant’s condition and plan of care.

The post RDS Pediatric Admission Sample Report appeared first on Medical Transcription Sample Reports.

POSTOPERATIVE DIAGNOSIS: Hard palate neoplasm.

PROCEDURES PERFORMED:
1. Wide local excision hard palate neoplasm.
2. Reconstruction with combination of buccal free graft and myomucosal advancement flap.

ATTENDING SURGEON: John Doe, MD

ANESTHESIA: General endotracheal tube.

ESTIMATED BLOOD LOSS: 20 mL.

FINDINGS: A 0.9 cm neoplasm of hard palate with a 1.5 cm defect following excision.

SPECIMENS: Hard palate neoplasm, sent to Pathology.

COMPLICATIONS: None.

DISPOSITION: To recovery room, stable.

INDICATIONS FOR OPERATION: A (XX)-year-old male with slowly growing hard palate neoplasm suspicious for neoplasm on clinical examination. Informed consent explaining the risks, benefits, and alternatives of the procedure was obtained from the patient.

OPERATION IN DETAIL: In the operating room under general endotracheal tube anesthesia, in the supine position, after appropriate surgical time-outs were called x2, the hard palate was injected with 0.25% Marcaine with 1:100,000 epinephrine. A McIvor gag retractor was inserted intraorally and used to reflect the tongue downwards. The hard palate neoplasm was outlined with the Colorado tip of the Bovie cautery with 3 mm margin surrounding circumferentially.

The needle tip of the electrocautery was then used to excise the hard palate neoplasm down to periosteum. Periosteum elevation was undertaken, and the neoplasm sent off to Pathology as a specimen. Incisions were made bilaterally in the soft palate and this was extensively undermined. The soft palate advancement flap was then advanced to partially close the full-thickness defect. This was sutured in place with 3 and 4-0 Vicryl.

There was a residual defect measuring approximately 1 x 1 cm. A 1 x 1 cm full-thickness buccal mucosa free graft was then taken from the right buccal mucosa taking care to spare injury to Stensen duct. This area was closed with interrupted 3-0 Vicryl deeply and mucosally. The buccal graft was then used to fill the remaining hole in the hard palate and the buccal graft was sutured in place with interrupted 4-0 Vicryl. Tisseel fibrin sealant was then used to secure the graft further. Hemostasis was found to be excellent.

The wound was copiously irrigated, made meticulously hemostatic with bipolar cautery, and hemostasis found to be excellent. Of note, prior to the incision, the mouth was sterilized with dilute Betadine solution, and the patient was given intravenous clindamycin.

The post Wide Local Excision Hard Palate Neoplasm Procedure Description appeared first on Medical Transcription Sample Reports.

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing (XX) for retinal evaluation on MM/DD/YYYY. She is a pleasant (XX)-year-old who was poked in the eye 1 week ago. Several days after getting poked in the eye, she started noticing flashes and floaters. You had referred her for evaluation and management.

Clinical Findings:
Visual acuity, uncorrected, is 20/25 OU.

Intraocular pressure is 14 mmHg OU.

Anterior segment examination is unremarkable. There are no obvious puncture sites.

Dilated funduscopic examination of the right eye reveals macula, vessels, and periphery. There is no PVD or peripheral retinal pathology.

Examination of the left eye reveals a complete PVD. There are no events of any peripheral retinal pathology on careful scleral depression. The macula and vessels are within normal limits.

Assessment and Plan:
Acute posterior vitreous detachment, left eye. I do not see any evidence of any puncture sites related to the needle stick. I also do not see any evidence of any retinal tears, holes or detachments. We did review signs and symptoms of retinal tears and detachment, and I have asked her to call me immediately if she does notice any changes. I have asked her to return in 2 weeks for close followup.

Thank you very much for allowing me to share in the care of this very pleasant patient. Please feel free to call me at your convenience for any questions.

Sincerely,

Ophthalmological Letter Sample Report #2

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing Mr. (XX) on followup today on MM/DD/YYYY. He is a pleasant (XX)-year-old with a history of retinal tear, status post laser in the past. He reports stable vision. He is still noticing floaters.

Clinical Findings:
Visual acuity with correction is 20/70, pinhole 20/60 OD, 20/40 OS.

Intraocular pressure is 20 mmHg OD, 19 mmHg OS.

Anterior segment examination reveals 1-2+ NS, OU.

Dilated funduscopic examination reveals peripheral laser retinopexy OU. There are no new retinal tears, holes or detachments.

Assessment and Plan:
Retinal tear, status post laser retinopexy in the past, both eyes. I do not see any evidence of any new retinal tears, holes or detachments. We did review signs and symptoms of these, and I have asked him to call me immediately if he does notice any changes. I have asked him to return in 1 year for followup.

Sincerely,

Ophthalmological Letter Sample Report #3

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing Ms. (XX) in followup today on MM/DD/YYYY. She is a pleasant (XX)-year-old with a history of moderate dry macular degeneration. She reports some slight blurring of vision at near.

Clinical Findings:
Visual acuity, uncorrected, is 20/30-2 OD, 20/50 pinhole, 20/40 OS.

Intraocular pressure is 19 mmHg OU.

Anterior segment examination reveals 2+ NS, OD and a PCIOL OS.

Dilated funduscopic examination reveals macular drusen, OU. There is a large drusenoid pigment epithelial detachment in the left eye. There is no evidence of any macular edema, hemorrhage or subretinal fluid.

Assessment and Plan:
Moderate dry macular degeneration, both eyes, with drusenoid pigment epithelial detachment, left eye. Ms. (XX) appears stable from a retinal standpoint. I do not see any evidence of choroidal neovascularization, macular edema or hemorrhage. We did review signs and symptoms of these, and she does know to call immediately if she does have any distortion or vision changes. I have asked her to return in 6 months for a followup but to contact me immediately with any changes.

Sincerely,

Ophthalmological Letter Sample Report #4

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing Mr. (XX) for retinal consultation on MM/DD/YYYY. He is a pleasant (XX)-year-old who has been noting floaters in his left eye for the last month. You had referred him for evaluation and management.

Clinical Findings:
Visual acuity with correction is 20/25 OD, 20/30 OS.

Intraocular pressure is 16 mmHg OD, 14 mmHg OS.

Anterior segment examination is unremarkable.

Dilated funduscopic examination of the right eye reveals normal macula, vessels, and periphery.

Examination of the left eye reveals a complete PVD. There are 2 small horseshoe-shaped tears inferonasally and 1 small horseshoe-shaped tear superotemporally. There is a pigmented tear temporally. There is no significant subretinal fluid.

Assessment and Plan:
Acute posterior vitreous detachment with retinal tears, left eye. We discussed treatment options, and I recommended proceeding with laser retinopexy to the tears. This will be scheduled for him first thing tomorrow morning. We will monitor him closely post laser.

Sincerely,

Ophthalmological Letter Sample Report #5

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing Ms. (XX) in followup today. She is a pleasant (XX)-year-old with a history of a branch retinal vein occlusion in the left eye. She reports stable vision.

Of note, she was switched from Combigan to Travatan recently.

Clinical Findings:
Visual acuity with correction is 20/40 OD, 20/30 OS.

Intraocular pressure is 14 mmHg OU.

Anterior segment examination reveals 1+ NS, OU.

Dilated funduscopic examination reveals a cup-to-disc ratio of 0.8 OU. In the right eye, the macula, vessels, and periphery are within normal limits. In the left eye, there are intraretinal hemorrhages and telangiectasias in the superotemporal macula. There is no macular edema or neovascularization.

Fluorescein angiography did reveal areas of capillary nonperfusion but no significant macular edema or neovascularization.

Assessment:
1. Branch retinal vein occlusion, left eye.
2. Retinal ischemia, left eye.

Plan:
Ms. (XX) is stable from a retinal standpoint. I do not see any evidence of any macular edema or neovascularization. We did discuss that Travatan does have a small risk of macular edema, so we will monitor for this. I have asked her to return in 6 months or sooner if symptoms warrant.

Sincerely,

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CHIEF COMPLAINT: Back pain.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who presents with a somewhat long history of low back pain. She states that she has a chronic type of nagging pain in her back. She is a restaurant server. She just came off 2 double shifts and states that this seems to have worsened her back pain. She does stand for most of her shift. She tells me that she does not wear comfortable shoes. She has no symptoms down either leg. She has no bowel or bladder symptoms. She denies numbness or tingling.

PAST MEDICAL HISTORY:
1. Cholecystectomy.
2. Back pain, as mentioned.

SOCIAL HISTORY: She denies alcohol, tobacco, illicit drug use.

FAMILY HISTORY: Noncontributory.

MEDICATIONS: None.

ALLERGIES: None.

REVIEW OF SYSTEMS: As mentioned. Otherwise, negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 116/76, pulse 80, respirations 20, temperature 98.6.
GENERAL: She is awake, alert, and oriented. No acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales, or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft. Nontender. Nondistended. Good bowel sounds with no organomegaly.
MUSCULOSKELETAL: She does have some tenderness to palpation in the paraspinous musculature of her lumbar spine. She has negative straight leg raise. She has no midline tenderness. Sensation is grossly intact distally. She has good reflexes and good peripheral pulses bilaterally.

EMERGENCY DEPARTMENT COURSE: This patient was seen and evaluated for exacerbation of low back pain. This seems to be a subacute issue with frequent exacerbations due to her work. There is no need to x-ray at this time as there are no neurological symptoms. No tenderness to palpation midline. She does need to follow up with a primary care doctor. She states that she does not have one she sees routinely. We did give her a clinic list and advised her to follow up as she may require physical therapy, MRI, etc. She voiced understanding, is acceptable, and is agreeable of this.

DISCHARGE DIAGNOSIS: Acute back pain on chronic back pain.

PLAN:
1. We will treat her with Naprosyn 500 mg twice daily.
2. Flexeril 10 mg 3 times daily, to take for the back pain.
3. Advised moist heat.
4. Rest.
5. No heavy lifting greater than 10 pounds.
6. She should follow up, as mentioned, with primary care doctor.

DISPOSITION: She is discharged to home.

CONDITION: Stable.

Back Pain ER Admission Evaluation and Treatment Sample #2

CHIEF COMPLAINT: Back pain.

HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old female with a history of epilepsy who presents to the ER after having 2 grand mal seizures yesterday, which were witnessed by both her husband and her daughter. She states she ran out of her Tegretol, which she usually takes and believes this is why she had her seizures overnight.

She states she had increasing back pain, which she rates as a 9/10 starting in her lower back in the middle of spine moving up her back, has a cramping sensation, and it is sharp in nature. Better with sitting still, worse with moving, again, starting in her lower spine up into the middle of her spine and otherwise is nonradiating. No associated shortness of breath or chest pain, no abdominal pain, no nausea, vomiting, diarrhea. No associated bowel or bladder incontinence.

It does not radiate into her buttocks or legs. She has no difficulty with walking. No weakness, numbness, tingling in her extremities. She denies any trauma. She was sitting on the couch at the time of her seizure. She did not fall to the floor. She did not sustain any trauma to her spine, but per her husband, who did witness the seizure, she was writhing back and forth on the couch during them.

PAST MEDICAL HISTORY:
1. Asthma.
2. Seizures.

MEDICATIONS:
1. Depakote.
2. Tegretol.
3. Topamax.

ALLERGIES: Sulfa, Motrin, tetracycline.

PRIMARY CARE PHYSICIAN: Dr. John Doe.

NEUROLOGIST: She has a primary neurologist who she sees, who already refilled her Tegretol for her, which she was previously out of and she started taking this again yesterday.

SOCIAL HISTORY: She is menopausal. Denies tobacco, alcohol or drug use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: As in HPI, all other systems reviewed and otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 138/74, pulse of 82, respirations 18, temperature 96.8.
GENERAL: This is a pleasant, middle-aged female who appears in no acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, reactive to light and accommodation. Extraocular movements are intact.
NECK: Supple.
LUNGS: Clear.
ABDOMEN: Soft, nontender, nondistended, no CVA tenderness.
BACK: She does have midline thoracic spine tenderness from T8-T12 and also L4-L5. There is evidence of paraspinal muscle spasm as well.
EXTREMITIES: There is no cyanosis, clubbing or edema.
NEUROLOGIC: Alert and oriented x4. Cranial nerves II through XII grossly intact. Strength is 5/5 throughout. She has equal plantar dorsiflexion bilaterally with no weakness, numbness, tingling in her distal extremities. She has equal bilateral grip strength. No evidence of ataxia. She has a negative leg raise bilaterally.

X-RAY: T spine and L spine x-rays were obtained and were read as negative by the resident radiologist for any evidence of acute fracture, malalignment.

EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. History and physical was obtained. She was given 2 Percocets here for her pain as she is allergic to Motrin. This did help improve her pain considerably. X-rays were obtained, which were negative. She had normal neurologic exam. We did feel like her pain was likely due to deep musculoskeletal pain due to her twisting and writhing motions during her grand mal seizures.

She has, again, no neurologic deficits here. We feel this would be best treated as an outpatient with Vicodin as needed for pain as well as Flexeril for spasms. She already has refilled her Tegretol with her primary neurologist and is taking this again; therefore, we feel this will likely alleviate the initial cause of her seizures, which was a decreased Tegretol dose due to the medication running out.

She has no bowel or bladder problems, no saddle anesthesia, nothing to suggest central cord syndrome. She is otherwise afebrile, and we think this is just an abscess or an infection. We believe this is mechanical in nature secondary to seizures, and she will be discharged home safely in the company of her daughter.

DIAGNOSES:
1. Musculoskeletal back pain.
2. Seizures.

DISPOSITION: Home in good condition.

PLAN:
1. Vicodin as needed for pain, #15.
2. Flexeril 3 times daily as needed for spasms, #15.
3. Follow up with primary neurologist.
4. Follow up with primary care physician.
5. She is advised to return to light activity but not to lift anything greater than 10 pounds for at least 1 week.
6. Return for worsening symptoms.

Back Pain ER Admission Evaluation and Treatment Sample #3

CHIEF COMPLAINT: Back pain.

HISTORY OF PRESENT ILLNESS: This is (XX)-year-old female with right flank/back pain. It has been going on for about 2 weeks, getting progressively worse and associated with a little bit of nausea and 1 episode of vomiting. She has no abdominal pain. It does not radiate. It is a severity of about 5/10, relieved with Toradol in the ER. Nothing seems to make it worse. She has had some intermittent fevers as well; she is not sure how high. The patient thinks that she has got pyelonephritis. She has been having symptoms of urgency, no burning. She has no other lower abdominal symptoms.

PAST MEDICAL HISTORY:
1. Questionable history of lupus, being worked up.
2. History of kidney infections before, in the past.
3. Scoliosis.

ALLERGIES: Dilaudid.

MEDICATIONS: None currently.

SOCIAL HISTORY: A remote history of IV drug abuse 12 years ago. No alcohol or other problems.

REVIEW OF SYSTEMS: CARDIOVASCULAR: No chest pain. PULMONARY: No shortness of breath. GI: Positive for CVA pain. NEUROLOGIC: No headaches. MUSCULOSKELETAL: No aches or pains. CONSTITUTIONAL: Positive for fevers. SKIN: No rashes. PSYCHIATRIC: No suicidal or homicidal ideation. All other review of systems per HPI, otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: See nurse’s note.
GENERAL: The patient appeared well and in no distress.
HEENT: Head: No signs of trauma. Eyes: Pupils are 4-2. Ears, nose throat: TMs clear. Oropharynx clear.
NECK: Nontender to palpation.
PULMONARY: Lungs are clear to auscultation bilaterally.
CARDIOVASCULAR: S1, S2, regular rate and rhythm.
ABDOMEN: Soft, nontender, positive bowel sounds.
NEUROLOGIC: Cranial nerves intact. Motor is intact. Gait was normal.
SKIN No lesions.
GU: The patient had right CVA tenderness.
MUSCULOSKELETAL: No CT or L-spine tenderness.
PSYCHIATRIC: Normal mood and affect.

LABORATORY DATA: Significant for a CBC with positive nitrites, 50-100 white blood cells. CBC that showed a white count of 5.0.

EMERGENCY DEPARTMENT COURSE: The patient was treated with 1 liter of normal saline for dehydration, Phenergan for nausea, Toradol for pain and Cipro antibiotic for pyelo.

MEDICAL DECISION MAKING: The patient is a (XX)-year-old female here with a history and physical exam consistent with pyelonephritis. She appears nontoxic and is tolerating p.o. in the ER. As such, we do not think that she has a perinephric gastric abscess that is going to require IV antibiotics as an inpatient. The patient appears, after a liter of fluid, to be hydrated and tolerating p.o. She will be sent home with ibuprofen for pain, Phenergan for nausea and Cipro antibiotic. We do not think there is any sort of intra-abdominal infection or other process such as right lower lobe pneumonia. We think her history and physical exam is clear for pyelonephritis.

CLINICAL IMPRESSION: Pyelonephritis.

PLAN:
1. Take Cipro.
2. Follow up with primary care doctor.
3. Return if symptoms worsen.

Back Pain ER Admission Evaluation and Treatment Sample #4

CHIEF COMPLAINT: Back pain.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who is otherwise healthy, who is presenting to the ER with complaints of low back pain that started 1 hour prior to arrival while she was walking. She denies any trauma or recent straining. She complains of a constant aching pain, which is occasionally sharp, worsened when she ambulates and when she bends over. She denies any bowel or bladder incontinence, urine retention or constipation. She denies UTI symptoms. She currently is rating her pain as a 9/10 in severity. It does not radiate. She denies paresthesias, numbness, coldness, loss of range of motion or weakness in the extremities. She has not taken any medicine prior to arrival to relieve her pain. She otherwise has no complaints.

PAST MEDICAL HISTORY: MVA in February of (XXXX) after which she had back pain, followed by a chiropractor for approximately 2 months.

MEDICATIONS: None.

ALLERGIES: Amoxicillin.

FAMILY HISTORY: Not elicited.

SOCIAL HISTORY: She works in (XX).

REVIEW OF SYSTEMS: As stated above in the HPI, significant for low back pain associated with positioning. She has otherwise been well without fevers, chills, nausea, vomiting, abdominal pain, changes in urinary or bowel habits, polyuria, polydipsia, heat or cold intolerance, fatigue, recent weight changes, rashes or lesions. Further review is otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/80, pulse 100, respirations 18, temperature 97.8, pulse ox on room air is 97%.
GENERAL: This is a well-developed, well-nourished female in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist.
NECK: Supple without lymphadenopathy.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Soft, nondistended, nontender.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: Warm, dry and intact.
MUSCULOSKELETAL: The patient has minimal tenderness with palpation to the paralumbar musculature, right greater than left, without palpable spasm. She has full range of motion of the back with increased pain on extreme flexion. She ambulates without difficulty. She has good movement in all 4 extremities.
NEUROLOGIC: Patellar and Achilles tendon reflexes are symmetric bilaterally. She has full 5/5 strength with resisted movement in all muscle groups of the lower extremities bilaterally. Sensation is intact throughout to light touch. There is no saddle anesthesia as reported by the patient. She has a negative straight leg raise. There are no focal neurologic deficits.

EMERGENCY DEPARTMENT COURSE: The patient was given ibuprofen here in the department for her pain. Dr. John Doe saw the patient and agrees with the assessment and plan.

DIAGNOSIS: Lumbar strain.

PLAN:
1. She is given prescriptions for Naprosyn and Flexeril to take as directed for pain.
2. She is to follow up with local clinic of choice if there is no improvement in the next 4 to 5 days.
3. Apply ice as needed for pain or heat for stiffness.
4. Return to the ER for any worsening symptoms.
5. She is to avoid bending at the waist or lifting anything greater than 20 pounds for the next week.

DISPOSITION: She is discharged home in good condition and ambulated out of the department without difficulty.

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CHIEF COMPLAINT: Headache.

HISTORY OF PRESENT ILLNESS: This gentleman was involved in a fight and was hit in the head with a steel chair. This happened last Friday, which is 6 days from now. He did go to the emergency room initially. Apparently, he had x-rays done that were negative. He followed up the following day, and the x-rays were done at that time; he states were negative. He has continued swelling and pain.

He has a feeling of pressure behind his eyes, which is most concerning to him. He does not have any visual disturbances however. He has not been nauseated or vomiting. He is coughing up a bit of blood; however, he has no dizziness, no lightheadedness or change in mentation.

PAST MEDICAL HISTORY: Benign. No chronic diseases.

SOCIAL HISTORY: He denies alcohol, tobacco, illicit drug use.

FAMILY HISTORY: Noncontributory.

MEDICATIONS: None.

ALLERGIES: None.

REVIEW OF SYSTEMS: As mentioned. Otherwise, negative.

PHYSICAL EXAMINATION:

VITAL SIGNS: Blood pressure is 134/84, pulse 76, respirations 18, temperature 97.4.
GENERAL: He is awake, alert and oriented, in no acute distress.
HEENT: He has some tenderness to palpation in the left periorbital area, specifically in the maxillary area. He still has some bruising of note. He has no tenderness superiorly. He has some tenderness in bilateral temporomandibular joint areas. TMs are intact bilaterally. No evidence of septal hematoma.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. Active bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal.

EMERGENCY DEPARTMENT COURSE: He was given 2 Vicodin for the pain while here. Due to a continuance of symptoms, we did do a CT scan of his facial bones with some cuts for the orbital areas. These are still pending at time of dictation.

DISCHARGE DIAGNOSIS: Status post assault with cephalgia.

PLAN: Plan is pending at this time depending on the CT scan.

DISPOSITION: At this time, he remains stable in the emergency room. Final disposition is per the attending.

Headache ER Admission Medical Report Format #2

CHIEF COMPLAINT: Headache.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a headache. It is a dull occipital headache that radiates down his neck. He reports it is consistent with prior migraines. It is not the worst of his life. It was not sudden in onset. He reports it was relieved with ibuprofen. Nothing seems to make it better or worse. He reports some intermittent weight loss recently and some generalized malaise. The patient otherwise has no specific complaints.

PAST MEDICAL HISTORY:
1. Hypertension.
2. High cholesterol.
3. Migraine headaches.

ALLERGIES: Penicillin.

MEDICATIONS: None.

SOCIAL HISTORY: Positive for tobacco, occasional alcohol, no drugs.

REVIEW OF SYSTEMS: CONSTITUTIONAL: Positive for weight loss, no fevers or night sweats. CARDIOVASCULAR: No chest pain. PULMONARY: No shortness of breath. GI: No abdominal pain. NEUROLOGIC: No headaches or weakness. MUSCULOSKELETAL: No aches or pains. All other systems are per the history of present illness and are otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 158/86, pulse 62, respiratory rate 16, temperature 98.6 degrees, O2 saturation is 98%.
GENERAL: The patient appeared well and in no distress.
HEENT: Head: No signs of trauma. Pupils are 4-2. TMs are clear. Oropharynx is clear.
NECK: Nontender to palpation.
PULMONARY: Lungs are clear to auscultation bilaterally.
CARDIOVASCULAR: S1, S2, regular rate and rhythm.
ABDOMEN: Soft, nontender, positive bowel sounds. No rebound or guarding.
NEUROLOGIC: Cranial nerves are intact. Motor is intact. Gait was normal.

EKG, as read by us, showed sinus bradycardia, with a P-R interval of 196, QRS of 90, QTc of 366, normal axis. The patient had ST-wave inversions in leads V4 through V6, as well as II-III and aVF. The patient had LVH by criteria. As compared to a previous EKG, the patient has new T-wave inversions.

RADIOLOGY: Chest x-ray shows a pulmonary nodule. CT of the chest is currently pending.

MEDICAL DECISION MAKING: This is a (XX)-year-old male here with a headache. It is a nonspecific headache, primarily a mild type of headache, probably consistent with migraine. The patient was treated with ibuprofen, with relief of that. It is not the worst headache of his life. He reports he has had neck symptoms and occipital symptoms before in the past. As such, we do not think it is subarachnoid or meningitis. The patient does report some generalized malaise and axillary lymphadenopathy, so he had a chest x-ray done for screening and an EKG done for screening as well.

His EKG shows signs of LVH. He does have some new T waves, without active chest pain or shortness of breath. We do not think he is having an acute MI. The patient does have a chest x-ray that shows a pulmonary nodule. As such, that will be followed up considering he has no good social support and his CAT scan will be done as an emergency room patient. If the patient’s CAT scan shows just a granuloma, the patient will be able to be discharged to home. If shows signs of malignancy, we will arrange further workup at that point.

CLINICAL IMPRESSION: Headache.

DISPOSITION: Discharged to home.

PLAN:
1. Follow up with a regular doctor.
2. Return if symptoms worsen or any concerns.

Headache ER Admission Medical Report Format #3

CHIEF COMPLAINT: Headache.

HISTORY OF PRESENT ILLNESS: The patient complains of a headache in the frontal regions as well as the temporal regions, worse when she bends down. She states she has felt a little off balance. When it gets bad, she has trouble thinking. She has had emesis a couple times since she was prescribed Vicodin. She thinks it is the Vicodin as it is about a half an hour after she takes it for the headache that she has the vomiting. The light does not bother her eyes. She has not had neck stiffness. It is not the worst headache of her life; although, it is a severe one and it was non-thunderclap. She states no sinus drainage.

Nursing notes reviewed.

REVIEW OF SYSTEMS: Negative for any melena, hematochezia, photophobia, neck stiffness, rash, fevers, weight loss, weight gain, difficulty with speech or swallowing, any weakness, any shortness of breath, chest pain, rash, diarrhea. Remainder of review of systems reviewed and negative.

PAST MEDICAL AND SURGICAL HISTORY: Diabetes.

MEDICATIONS:
1. Vicodin.
2. Aleve.

ALLERGIES:
1. Sulfa.
2. Penicillin.

SOCIAL HISTORY: No smoking.

FAMILY HISTORY: Noncontributory.

IMMUNIZATIONS: Noncontributory.

PHYSICAL EXAMINATION:
GENERAL: A well-lit room, does not appear acutely photophobic, resting comfortably.
VITAL SIGNS: Temperature is 97.8, pulse 86, respirations 16, blood pressure is 168/88, room air pulse ox 99%. It is within normal limits.
HEENT: Reveals nonicteric sclerae, PERRLA, EOMI. Oropharynx is clear. Moist mucous membranes. There is noted frontal and maxillary sinus tenderness bilaterally. There is no hemotympanum, no temporal artery tenderness, no meningismus.
MENTAL STATUS: Alert and oriented x3.
CHEST WALL: Nontender.
HEART: Regular rate and rhythm without murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly.
EXTREMITIES: No clubbing, cyanosis, edema.
SKIN: No rash, good turgor, warm and dry.
NEUROLOGIC: Cranial nerves II-XII intact without motor, sensory or cerebellar deficits. Reflexes 1+ and equal.

LABORATORY DATA: Electrolytes reveal the following abnormalities: Glucose 312, sodium 129, chloride of 92, has a normal potassium and CO2. Urinalysis shows glucosuria, ketonuria, trace protein, small blood, trace leukocyte esterase.

CT SCAN: A CAT scan of the head interpreted by the radiologist shows atrophy, no acute abnormality.

ADDITIONAL DATA: None.

EMERGENCY DEPARTMENT COURSE: Given inapsine here with symptomatic relief.

PROCEDURE: None.

CRITICAL CARE: None.

CONSULTATIONS: None.

MEDICAL DECISION MAKING: We do not feel we are dealing with entities to include, but not limited to, encephalitis, meningitis, intracranial bleed, temporal arteritis. We think we are dealing with acute sinusitis. The patient has been told that the only way to rule out a bleed is with a LP. This is something she does not want to have done. She understands and agrees the risks and benefits of her decision. Personally, we do not think it is something that is entirely necessary as the patient has been having these symptoms for 2 weeks. She has no meningismus symptoms over that period of time. We think she is dealing with a sinusitis. The vomiting may be secondary, not to an intracranial problem, but to intolerance to Vicodin so we will place her on Fioricet.

IMPRESSION:
1. Cephalgia.
2. Acute sinusitis.

PLAN:
1. Follow up with Dr. John Doe in 2 days.
2. Return to the ED if neck stiffness, photophobia, fever, trouble with speech or worse in any way.
3. Stop Vicodin.
4. Prescription for Fioricet and Z-Pak is given.

Headache ER Admission Medical Report Format #4

CHIEF COMPLAINT: Headache.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female, who is otherwise healthy, who presented to the ED with complaints of a 6-week history of diffuse headache and neck pain that has been constant. She states it is a constant aching pain, rates it as 7/10 in severity, worsened when she bends over and associated phonophobia.

She denies any change in her pain at different times of the day. It is not particularly worsened in the morning. Not thunderclap in its onset. She reports subjective fever and chills with nausea, no vomiting, has had no relief with ibuprofen at home as well as a migraine medication that her doctor prescribed for her.

She is currently rating her pain as 7/10 in severity. It does not radiate. She denies visual changes, dizziness or lightheadedness. The patient states that over the course of the last 6 weeks, she has seen her eye doctor and had a prescription change. This was approximately 1 month ago and has not noticed any change with this or with changing her monitor at work.

She had an MRI done yesterday as an outpatient by her primary care physician and also had blood work drawn at that time and was told she had elevated monocytes, was told that the MRI results were fine. She denies paresthesias, numbness, coldness, loss of range of motion or weakness in the extremities and otherwise has no complaints.

PAST MEDICAL HISTORY: Bladder sling approximately 3 years ago.

MEDICATIONS: None.

ALLERGIES: Multiple drug allergies listed in note.

FAMILY HISTORY: Breast cancer, coronary artery disease, and Hodgkin lymphoma.

SOCIAL HISTORY: She denies tobacco, alcohol or illicit drug abuse. Dr. Jane Doe is her primary care physician.

REVIEW OF SYSTEMS: As stated above in the HPI significant for diffuse headache, associated neck pain, subjective fevers, chills, and nausea as well as phonophobia. She denies dizziness, lightheadedness, visual changes, chest pain, shortness of breath, polyuria, polydipsia, heat or cold intolerance, fatigue, recent weight changes, rashes or lesions. Further review is otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 108/72, pulse 70, respirations 18, temperature 99.0, and pulse ox on room air is 98%.
GENERAL: This is a well-developed, well-nourished female in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles intact. Mucous membranes are pink and moist. There is no tenderness with palpation over the temporal arteries.
NECK: Supple. There is no nuchal rigidity or meningismus.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Soft, nondistended, nontender. Bowel sounds normoactive in all 4 quadrants. There are no masses or hepatosplenomegaly appreciated.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: Warm, dry and intact.
NEUROLOGIC: Cranial nerves II through XII are tested and intact. She has good finger-to-nose-to-finger, rapid hand movement, and heel-to-shin movement. She has full 5/5 strength with resisted movement in all muscle groups of the upper and lower extremities bilaterally. Sensation is intact to light touch. There are no focal neurologic deficits.

EMERGENCY DEPARTMENT COURSE: The patient had IV access established. She was given 1 liter of normal saline, Toradol 30 mg IV, and Compazine 10 mg IV after which she reported significant improvement in her pain, rating her pain as a 2/10 in severity.

LABORATORY STUDIES: Include CBC with white blood cell count of 5.0, hemoglobin 13.2, hematocrit 39.4, and platelets 275. Sed rate is normal at 5.

EMERGENCY DEPARTMENT COURSE: MRI results were obtained from outside hospital. The impressions read as follows: No aneurysm is seen; however, is only sensitive in detecting aneurysm 3 mm larger. This examination is also limited by motion artifact. Irregularity of the internal carotid artery is present bilaterally. This is likely secondary to motion, but for confirmation of this, a CT angiogram could be done for better evaluation if clinically needed. A few scattered foci of increased FLAIR signal seen in the subcortical white matter. This is a nonspecific finding. Small foci of gliosis from prior trauma or prior infection can have a similar appearance. Migraines can cause similar abnormal lesions. They are not in a classic location for demyelinating disease. Sequelae of small vessel ischemic disease would be unusual given the patient’s young age unless a secondary diagnosis of diabetes or hypertension is present. No intracranial hemorrhage, mass or acute infarct. Dr. John Doe saw the patient and agreed with the assessment and plan.

DIAGNOSIS: Cephalgia.

PLAN:
1. She is given a prescription for Fioricet to take as directed for pain. She is told not to drive with this. She should also take Advil or Motrin as needed for pain as well.
2. Follow up with her primary care physician if there is no improvement in the next 2 to 3 days.
3. Return to the ED for vomiting or other worsening symptoms.
4. Increase her fluid intake.

DISPOSITION: She was discharged home in good condition and ambulated out of the department without difficulty.

The post Headache ER Admission Medical Report Template appeared first on Medical Transcription Sample Reports.

CHIEF COMPLAINT: Chest pain.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who states she has been feeling like something is in her chest every time she eats. For the last 2-1/2 to 3 weeks, she has had a sharp pain in the right chest with swallowing either liquids or solids. They do not feel like they get stuck. They pass fine and it only lasts a couple of seconds. She has been coughing a lot, as well with whitish sputum. She has a foul taste in mouth when she wakes up in the morning and a little bit of a sore throat.

She does use caffeine, nicotine and occasional alcohol. She takes ibuprofen on a regular basis secondary to a herniated disk. The patient denies any esophageal problems, either herself or in the family. She has never had surgery to the chest. She states it hurts as well to cough a little bit. She states the pain is sharp and is 2 to 6/10. Nursing notes were reviewed.

REVIEW OF SYSTEMS: Negative for any fever, chills, melena, hematochezia, vomiting, nausea, shortness of breath, weight loss, weight gain, leg swelling and abdominal pain. The remainder of her review of systems is reviewed and negative.

PAST MEDICAL/SURGICAL HISTORY: Recent UTI.

ALLERGIES: None.

MEDICATIONS: Recent antibiotic.

SOCIAL HISTORY: Positive smoker.

FAMILY HISTORY: Noncontributory.

IMMUNIZATION STATUS: Noncontributory.

PHYSICAL EXAMINATION:
GENERAL: Well-developed, nontoxic, polite and cooperative.
VITAL SIGNS: Temperature 98.4, pulse 98, respiratory rate 18, blood pressure 134/82, room air pulse ox is 96% and is within normal limits.
HEENT: Anicteric sclerae. Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear. Moist mucous membranes. No stridor. Bilateral TMs are clear.
CHEST WALL: Nontender.
HEART: Regular rate and rhythm. No murmurs, heaves, gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft. Positive bowel sounds. Nontender. No organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema. No Homans or palpable cords.
SKIN: No rash.

DIAGNOSTIC STUDIES: A chest x-ray, 2-view, PA and lateral, interpreted by the radiologist and reviewed by us as normal.

ADDITIONAL DATA: None.

EMERGENCY DEPARTMENT COURSE: She remained stable here.

PROCEDURE: None.

CRITICAL CARE: None.

CONSULTATIONS: None.

MEDICAL DECISION MAKING: We do not feel we are dealing with entities that include but are not limited to an ACS, pericarditis, myocarditis, Boerhaave syndrome, Mallory-Weiss tear, esophageal obstruction, mass in the chest, pneumonia or pneumothorax either. We think this individual is probably dealing with a chest pain that is probably more related to reflux as she gets it with swallowing. She may have irritation in the distal esophagus. She admits to a foul taste in her mouth with awakening as well as a soreness of the throat. Perhaps, she is having reflux and the stomach acid is coming up into those parts of the nasopharyngeal region. Avoidance of caffeine, nicotine and alcohol is crucial. We have told her she should probably stay on the ibuprofen for the chronic back problems, and we will place her on an H2 blocker as cost is an issue.

IMPRESSION:
1. Atypical chest pain.
2. GERD.

PLAN:
1. Stop smoking, caffeine and alcohol.
2. Return if cannot swallow fluids, profuse vomiting, fever or worse in any way.
3. Follow up with Dr. John Doe in 2 days.
4. A prescription for Pepcid is given.

Chest pain ER Admission Medical Report Format #2

CHIEF COMPLAINT: Chest pain.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who reports chest pain, just left to his sternum, that has been there for a week now. He states it is sort of hurting quite a bit if he coughs or sneezes and somewhat when he moves around. He has had no fevers, chills or upper respiratory congestion. He has an occasional smoker’s cough but no productive cough. There is no nausea, no vomiting, no diarrhea, no dysuria, urgency or frequency.

PAST MEDICAL HISTORY: Otherwise unremarkable.

MEDICATIONS: None.

ALLERGIES: None.

SOCIAL HISTORY: He is a smoker.

REVIEW OF SYSTEMS: All other systems are reviewed and negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 132/82, temperature 98.2, pulse 92, respirations 16, and 99% on room air.
GENERAL: A (XX)-year-old, awake, alert, comfortable appearing, no acute distress.
HEENT: Head is normocephalic, atraumatic. Pupils are equal, round, reactive to light. Extraocular muscles are intact. No nasal discharge. No facial trauma. Intraoral exam shows moist mucous membranes with no tonsillar enlargement or exudate. Tympanic membranes are normal. The canals are clear.
NECK: Supple with no cervical lymphadenopathy No meningismus. No goiter.
CARDIOVASCULAR: Regular rate, without murmur, rub or gallop.
PULMONARY: Equal breath sounds bilaterally with no wheezing, rales or rhonchi. There is no chest wall tenderness or instability.
ABDOMEN: He does have reproducible tenderness to palpation just left of his sternum around the fourth intercostal space. There are no bruising, erythema or skin changes noted.
EXTREMITIES: Strong peripheral pulses. There is no clubbing, no cyanosis and no edema.
SKIN: No rash.

EMERGENCY DEPARTMENT COURSE: On his evaluation here in the emergency room, EKG sinus rhythm rate of 76, no ischemic changes. His chest x-ray shows normal cardiac silhouette, clear lung fields, no pneumothorax, no bony abnormalities. He was given IM Toradol.

DISPOSITION: Discharged home in good condition.

DIAGNOSIS: Chest wall pain, possibly some mild costochondritis.

PLAN:
1. He is prescribed Anaprox.
2. He is to rest.
3. Follow up with his primary care provider.
4. Return as needed.

Chest pain ER Admission Medical Report Format #3

CHIEF COMPLAINT: Chest pain.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a history of coronary artery disease, status post quadruple bypass and multiple MIs and stenting as recently as 1 week ago to the LAD, who comes to the emergency department saying he was watching TV at 12:45 a.m. when he had the abrupt onset of substernal chest pain with radiation to his jaw similar to his prior anginal equivalent. This was associated with nausea and diaphoresis, no vomiting. He immediately called the ambulance, and his wife gave him two sublingual nitroglycerins, which took his pain from an 8/10 down to approximately 6/10.

En route, he received 325 mg of aspirin as well as an additional nitro spray, which reduced his pain to a 4. He was brought to the emergency department still complaining of substernal pain. He states that he has had no other fevers, chills, nausea or vomiting. He has had no dyspnea on exertion or exertional pain and this pain has not happened since his last stent.

REVIEW OF SYSTEMS: As per HPI. All other systems are reviewed and are negative.

PAST MEDICAL HISTORY:
1.  History of stroke in the room.
2.  Past diabetes.
3.  Coronary artery disease, status post CABG and multiple MIs and status post PTCA as recently as MM/DD/YYYY.

MEDICATIONS: See nursing notes.

ALLERGIES: Penicillin.

SOCIAL HISTORY: Denies any tobacco use, alcohol consumption or IV or recreational drug use.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, pulse 100, blood pressure 118/68, respirations 18, oxygen saturation 99% on nonrebreather.
GENERAL: He is a well-appearing male in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Oropharynx is moist without erythema or exudate.
NECK: Supple without lymphadenopathy or thyromegaly.
LUNGS: Clear to auscultation bilaterally with good air movement.
CARDIOVASCULAR: Regular rate and rhythm with no audible murmurs, rubs or gallops. He had 2+ carotid, radial and dorsalis pedis pulses.
ABDOMEN: Soft, nontender, and nondistended without rebound or guarding.
EXTREMITIES: Warm without clubbing, cyanosis or edema.
SKIN: Warm without evidence of rash or petechia.
NEUROLOGIC: He is alert and oriented x3 with cranial nerves II-XII intact. No focal motor deficits.
PSYCHIATRIC: Mood and affect were appropriate to the examination.

EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. An EKG was immediately performed, which showed no change from prior. IV was placed. Labs were drawn. Chest x-ray was performed. The patient was given an inch of nitro paste and continued to have pain. Nitroglycerin drip was ordered, however, with 5 mg morphine. His pain was completely controlled, and, therefore, the nitrate was discontinued. It was never initiated. He was heparinized for ACS protocol and was discussed with the CCU team for admission.

LABORATORY DATA: Serum chemistries were within normal limits with a creatinine 1.2 and a mildly elevated glucose of 244. CBC was within normal limits with a mild left shift and his white count was 7.8. His CK-MB and troponin I was negative on the first set. BNP was normal at 63. Coagulation studies were within normal limits. Chest x-ray shows no acute cardiopulmonary pathology and EKG performed for indication of chest pain showed normal sinus rhythm at a rate of 74 beats per minute. He had Q waves in lead III, which are not new. He had no acute ST elevations or T-wave inversions. He had normal intervals with QTc 404 milliseconds in comparison to prior EKG dated MM/DD/YYYY. There was no significant change.

MEDICAL DECISION MAKING: See above. This patient presents approximately 1 week after catheterization to the LAD with abrupt onset of unstable angina similar to his prior anginal equivalent. He has no indication for urgent catheterization at this time as his EKG is unremarkable; however, given his history, we feel he is at extremely high risk of acute coronary syndrome versus unstable angina, and therefore, he will be heparinized and admitted to the CCU service.

IMPRESSION: Chest pain, rule out acute coronary syndrome.

DISPOSITION: The patient being admitted in stable condition.

PLAN: Further work and evaluation by the CCU team.

The post Chest pain ER Admission Medical Report Format appeared first on Medical Transcription Sample Reports.

CHIEF COMPLAINT: Abdominal pain.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who presents to the emergency room with abdominal pain. He states that he had hemorrhoid surgery done on Saturday and that he has not had a bowel movement since then.

He states that he has also had a difficult time passing his urine. He had passed some urine prior to the emergency room visit. He states that he has not passed enough normal. He did notice some blood and some clotted blood through the urethral meatus, and he continues to have abdominal pain and rectal pain.

PAST MEDICAL HISTORY: Hemorrhoidectomy in 2000 and 2006.

SOCIAL HISTORY: Denies alcohol, tobacco or illicit drug use.

FAMILY HISTORY: Noncontributory.

MEDICATIONS:
1. Oxycodone.
2. Colace.
3. Castor oil.

ALLERGIES: No known drug allergies.

REVIEW OF SYSTEMS: As mentioned, otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 94/58, pulse 84, respirations 16, temperature is 98.2, O2 sat 96% on room air.
GENERAL: He is awake, alert and oriented, in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy, no carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, somewhat tender to palpation in the suprapubic area.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal. Sensation is grossly intact.

EMERGENCY DEPARTMENT COURSE: The patient and was seen and evaluated for abdominal pain. It seems as though he is having painful urination, difficult time with urination, urinary retention, and constipation. We did place the Foley catheter that drained some urine, less than 200 mL was released from the bladder. He also states that he has been able to void on his own here in the emergency room. Urinalysis was done and was positive for protein, nitrites, leukocyte esterase, bacteria. He will therefore be treated with an antibiotic. He is concerned about his bowels. We will get him Colace and laxative to take at home. Otherwise, his emergency room course was uneventful. He was stable throughout the entire emergency room course and will be discharged home in stable condition.

DISCHARGE DIAGNOSES:
1. Urinary retention.
2. Constipation.
3. Abdominal pain.

PLAN:
1. Cipro 250 twice daily for 5 days for UTI.
2. Colace twice daily and a magnesium citrate half bottle in the a.m. Repeat and use the other half if necessary.
3. Return to emergency room, any worsening of symptoms.
4. We advised him to contact his physician tomorrow for followup plans.

DISPOSITION: He was discharged home in stable condition.

Abdominal Pain ER Template Format #2

CHIEF COMPLAINT: Abdominal pain.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman seen for evaluation of abdominal pain. He has a complicated medical history. He had gastric bypass surgery done 3 years ago without complication. He has had numerous umbilical hernia repairs. He does not give exact history; it sounds like he may have had an incarcerated hernia and repair by his description.

At this time, he has abdominal pain with no accompanying symptoms. He denies nausea, vomiting, diarrhea, constipation, hematuria or rectal bleeding. He has just abdominal pain that he states is in the middle of his abdomen. It does not seem to radiate to his back. It does not seem to radiate to other quadrants. This has been persistent at this time for about 4 days, but it seems that it is an ongoing issue.

He tells me that he has been to the emergency room 4 to 5 times for similar complaints and his testing thus far is negative.

PAST MEDICAL HISTORY: As mentioned in HPI and is also significant for Parkinson’s disease.

SOCIAL HISTORY: He denies alcohol, tobacco or illicit drug use.

FAMILY HISTORY: Noncontributory.

MEDICATIONS: Include Requip, Sinemet and Celexa.

ALLERGIES: No known drug allergies.

REVIEW OF SYSTEMS: Positive for abdominal pain, otherwise is negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 122/78, pulse 58, respirations 20, temperature 97.7, pulse ox 98% on room air.
GENERAL: He is awake, alert and oriented, and in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy and no carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Minimal tenderness to palpation in the epigastric area with some radiation into the umbilicus. There is no tenderness in either lower quadrants, some discomfort to palpation in the right upper quadrant. There is no rebound or guarding. There is no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal.

EMERGENCY DEPARTMENT COURSE: The patient was seen for evaluation of abdominal pain. He does have a complicated medical history, especially as related to abdominal pain with multiple surgeries in the past. We did do some blood work. He had an electrolyte panel done that was basically normal. Sodium and potassium were normal. BUN of 15 and creatinine of 1. He had a urinalysis done that showed trace blood; otherwise, he had no evidence of any infectious process going on. CBC demonstrated white count of 4.6, H&H of 11.3 and 34.3, and platelet count was 224,000. Blood sugar was 150. Amylase and lipase were normal at 63 and 36. His liver enzymes were normal. His AST was 15, ALT was 3, bilirubin was normal. His testing was normal.

He did have some improvement in the emergency room itself without having any medications. He is concerned that he may have a muscle strain. He does see his primary care physician rather regularly. We advised him to discuss this further with his primary care physician. At this time, there is no evidence of any emergent condition, and he is stable to be discharged home.

DIAGNOSIS: Abdominal pain.

PLAN: He should followup with his primary care physician. He, in fact, has an appointment already. He is advised to keep this. He can take over-the-counter Tylenol as needed for mild abdominal discomfort. He should return to the emergency room if pain worsens or if he has any worsening or if he has symptoms otherwise related to abdominal pain.

DISPOSITION: He was discharged home in stable condition.

Abdominal Pain ER Template Format #3

CHIEF COMPLAINT: Abdominal pain.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with long history of pain problems, which included a kidney abscess. Most recently, she was diagnosed with osteomyelitis of her pubic symphysis and has been placed on ampicillin IV therapy, which she has been compliant with. She has a PICC line and she is here for abdominal pain.

She has been seen in the ED in the last couple of days for the same thing; it is a chronic suprapubic pain. She reports she had a washout about 2 weeks ago. She has no vomiting or diarrhea. No fevers. The pain is constant, nothing seems to make it worse. It is better with morphine. It does not radiate. It is not associated with dysuria and bleeding or discharge. Furthermore, the patient reports she has no other problems at this time.

PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Chronic osteo.

ALLERGIES: See nurse’s notes.

MEDICATIONS: See nurse’s notes.

SOCIAL HISTORY: No alcohol, drugs, smoking reported to me.

REVIEW OF SYSTEMS: CARDIOVASCULAR: No chest pain. PULMONARY: No shortness of breath. GI: Positive for abdominal pain. All other systems reviewed and otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: See nurse’s note.
GENERAL: The patient appeared well.
HEENT: TMs are clear. Oropharynx is clear.
NECK: Nontender to palpation.
PULMONARY: Lungs are clear to auscultation bilaterally.
CARDIOVASCULAR: S1, S2. Regular rate and rhythm.
ABDOMEN: Soft, nontender. No rebound or guarding.
SKIN: The patient had an incision in her suprapubic region. It was clean, dry and intact.
EXTREMITIES: Nontender.

EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated, treated with morphine and Phenergan with relief of symptoms. Laboratory significant for a renal panel with bicarbonate of 25.

MEDICAL DECISION MAKING: This is a female with a history of abdominal pain. It seems to be chronic. She is to get antibiotics to treat. The patient at this time is stable to be discharged to home.

CLINICAL IMPRESSION: Abdominal pain.

Abdominal Pain ER Template Format #4

CHIEF COMPLAINT: Abdominal pain.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old, typically healthy young lady, who states that over the last 2 days she has had dysuria, urinary frequency and hesitancy. She denies fevers or chills, nausea or vomiting, any abdominal pain. She just has a burning sensation when she urinates. No unusual vaginal bleeding or discharge. Her last menstrual period was 2 weeks ago and was normal for her. She denies pregnancy at this time. She denies any back pain.

REVIEW OF SYSTEMS: As above or is otherwise negative.

PAST MEDICAL HISTORY:
1. Asthma.
2. Sleep apnea.

MEDICATIONS: Albuterol.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Noncontributory.

PHYSICAL EXAMINATION:
VITAL SIGNS: On admission to the ER today, temperature is 98.4, blood pressure 124/86, pulse 98, respiratory rate 16, O2 saturations 99% on room air.
GENERAL: This is a (XX)-year-old well-developed, well-nourished black female in no acute distress. She is awake, alert, and oriented x3. She is pleasant and cooperative with exam. She is well appearing.
HEENT: Head is normocephalic, atraumatic.
NECK: Supple, nontender, without lymphadenopathy.
HEART: Regular rate and rhythm.
EXTREMITIES: Pulses are symmetric and intact.
LUNGS: Clear. She is breathing easily.
ABDOMEN: Soft, nondistended, minimally tender to palpation to the suprapubic region without guarding, rebound or peritoneal signs. Good bowel sounds throughout. No CVA tenderness bilaterally.
SKIN: Intact without rash or petechia.
NEUROLOGIC: She has no focal neurologic deficits.

EMERGENCY DEPARTMENT COURSE: Here in the emergency department, her nursing notes are reviewed. Urinalysis is positive for nitrites, positive for blood, positive for leukocyte esterase. Urine hCG is negative for pregnancy. She was given her first dose of Cipro here.

ASSESSMENT: Urinary tract infection.

PLAN:
1. The patient will be discharged home.
2. She is started on Cipro and Pyridium. She is warned against wearing contacts while on Pyridium and that it will turn her pee and tears orange.
3. She is to push clear fluids and cranberry juice.
4. She is to return for worsening or persistent symptoms.
5. Follow up with her doctor.

She understands and agrees with the plan.

DISPOSITION: Home in stable condition.

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CHIEF COMPLAINT: Kidney stone.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who was seen last night in the emergency department with a kidney stone. He has a 2 mm stone at the right UPJ, with moderate hydronephrosis. He saw Urology today. He states that he was changed from Lortab to Percocet. He states that he has had increased pain in the right side of his abdomen. It is intermittent and sharp, currently 8/10 in intensity. He did take Percocet several hours ago without improvement in his symptoms. No nausea, vomiting or diarrhea.

PAST MEDICAL HISTORY:
1. Significant for gout.
2. Kidney stones.

SOCIAL HISTORY: Unremarkable.

ALLERGIES: None.

PHYSICAL EXAMINATION:
VITAL SIGNS: BP 110/66, temperature 97.8, pulse 70, respirations 18.
GENERAL: A well-developed (XX)-year-old. Appears a little uncomfortable, otherwise in no distress.
HEENT: Moist mucous membranes.
CARDIOVASCULAR: Regular rate and rhythm, S1, S2.
RESPIRATORY: Lungs clear to auscultation bilaterally.
GASTROINTESTINAL: The patient’s abdomen is soft. Positive bowel sounds. Slight tenderness in the right lower quadrant.
MUSCULOSKELETAL: Slight tenderness, right CVA region.

ANCILLARY SERVICES: KUB of the abdomen shows no evidence of renal calculi.

EMERGENCY DEPARTMENT COURSE: He was seen and examined. He was given IV fluids as well as Dilaudid, Toradol, and Phenergan. His old charts were reviewed. He did have a CT with a 2 mm stone at the right UPJ last night. There is a normal appendix seen. The patient was re-examined. He was pain-free, and he was discharged in good condition.

MEDICAL DECISION MAKING: A (XX)-year-old male with renal calculi. We will discharge him to home. He is to push clear liquids. Strain urine. Dilaudid 2 mg, #15. Toradol 10 mg, #12. Follow up with Urology. Return if worsened symptoms.

DISPOSITION: Home.

DIAGNOSIS: Acute right renal calculi.

Kidney Stone ER Sample Report #2

CHIEF COMPLAINT: Kidney stone.

HISTORY OF PRESENT ILLNESS: This (XX)-year-old female states that for the last 2 to 3 days she has had a history of left flank pain. She states at 3 a.m. yesterday morning it became worse. It is present in her left flank and is nonradiating. She has had stents in both ureters. She states that her urine has been dark. Her pain has been constant, sharp, 9/10 in intensity, nonradiating. She has taken Percocet without any improvement. She is now out of it.

PAST MEDICAL HISTORY:
1. Renal calculi.
2. Tubal ligation with reversal.
3. Nephrostomy tube.

SOCIAL HISTORY: Unremarkable.

ALLERGIES: Vicodin.

PHYSICAL EXAMINATION:
VITAL SIGNS: BP 150/106, temperature 98.4, pulse 108, respirations 16.
GENERAL: A well-developed (XX)-year-old in no distress, appears uncomfortable.
HEENT: Moist mucous membranes.
NECK: Supple.
CARDIOVASCULAR: Regular rate and rhythm, S1, S2.
RESPIRATORY: Lungs clear to auscultation bilaterally.
GASTROINTESTINAL: The patient’s abdomen is soft. Positive bowel sounds. Slight tenderness in the left lower quadrant.
MUSCULOSKELETAL: She is tender with percussion in the left CVA region.

ANCILLARY SERVICES: CT abdomen, stone protocol, shows bilateral stents. There is hydronephrosis. It is essentially unchanged from March according to the radiologist. Pregnancy test negative. Urinalysis shows 50-100 wbc’s, positive nitrite, many bacteria. CBC is normal.

EMERGENCY DEPARTMENT COURSE: She was seen and examined. She underwent workup. She was given IV fluids as well as Dilaudid, Phenergan and Toradol. Upon re-examination, she was feeling better, but her pain was still 4/10 in intensity. She was given another dose of Dilaudid and she was given a dose of p.o. Cipro. She was discharged in good condition.

MEDICAL DECISION MAKING: A (XX)-year-old female with renal colic and UTI. We will discharge her to home. Cipro 500 mg, #10, Percocet 7.5 mg, #12. She is to push clear liquids. Follow up with Urology tomorrow and return if worsened symptoms.

DISPOSITION: Home.

DIAGNOSES:
1. Acute urinary tract infection.
2. Acute renal colic.

Kidney Stone ER Sample Report #3

CHIEF COMPLAINT: Kidney stone.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Caucasian male with a history of kidney stones who presents to the emergency department complaining of left lower quadrant pain, left flank pain, that radiates to left lower quadrant since last night. The patient states he thinks it may be kidney stones. He has had kidney stones in the past, approximately 5 years ago, and does feel somewhat similar. He has had nausea but denies any vomiting or diarrhea. Denies any dizziness, lightheadedness, headache, blurred vision, neck pain or stiffness, fever or chills, shortness of breath, chest pain, palpitations or cough. Denies any dysuria, hematuria, frequency, urgency, bowel or bladder incontinence. Denies any back pain or paresthesias, melena or dark tarry stools.

PAST MEDICAL HISTORY:
1. Knee surgery.
2. Back surgery.
3. Asthma.
4. Kidney stones.

CURRENT MEDICATIONS: Proventil.

ALLERGIES: CODEINE.

SOCIAL HISTORY: Occasional alcohol use. Denies any tobacco or illicit drug use.

FAMILY HISTORY: Unremarkable.

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

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/86, pulse 86, respirations 20, temperature 98.8, and O2 saturation on room air is 98%.
GENERAL: The patient is alert and oriented x3, no acute distress, nontoxic in appearance, is ambulatory in the emergency department.
SKIN: Warm and dry to touch.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Positive bowel sounds, all 4 quadrants. The patient does have left lower quadrant tenderness but no rebound, no guarding. No organomegaly or masses noted.
BACK: Negative CVA tenderness.
EXTREMITIES: The patient has 2+ pulses in all extremities. No ecchymosis, edema, erythema or deformity noted.

EMERGENCY DEPARTMENT COURSE: CBC, renal, urinalysis, CT scan of the abdomen and pelvis without contrast were all ordered. The patient did receive a liter of normal saline, wide open, Toradol 30 mg IV for pain. He did not want anything for nausea.

LABORATORY RESULTS: CBC: White count 19.3, hemoglobin 16.4, hematocrit 47.8, platelets are 282. Renal: Sodium 138, potassium 4.8, chloride 103, bicarbonate 24, BUN is 11, creatinine is 1.0, glucose is 113, anion gap is 11, calcium is 10.1. Urinalysis showed 15 ketones but otherwise negative.

CT SCAN: CT scan of the abdomen and pelvis did show positive lower descending diverticulitis, no abscess, no hydronephrosis or stone. Positive cholelithiasis.

IMPRESSION: This is a (XX)-year-old male with left lower quadrant pain with white count of 19,000 with diverticulitis on CT scan. He was started on Cipro 400 mg IV and Flagyl 500 mg IV here in the emergency department. At this point, we spoke to Dr. John Doe. The patient is adamant about going home. He does not want to be admitted to the hospital. Dr. John Doe is okay with the patient being discharged home with close followup with Dr. John Doe next week.

DIAGNOSIS: Diverticulitis.

PLAN:

1. The patient was given Vicodin 1, four to six hours p.r.n. pain, #20.
2. Cipro 500 b.i.d. x7 days and Flagyl 500 t.i.d. x 7 days.
3. He is to follow up with Dr. John Doe on Monday at 10:30. He is to call for an appointment.
4. Decrease greasy foods.
5. Liquid diet x2 days, then as tolerated. No greasy fatty foods.
6. If fevers, vomiting, increased pain or worse, the patient can return to the emergency department.

DISPOSITION: The patient was discharged in stable condition.

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PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

PROCEDURE PERFORMED: Lumbar epidural steroid injection.

COMPLICATIONS: Nil.

SPECIMENS REMOVED: Nil.

DETAILS OF PROCEDURE: The patient was evaluated in the preoperative holding area. The history and physical were reviewed again. The consent was checked. Details of the procedure, risks, benefits, and complications were discussed with the patient. The patient agreed for the procedure and was taken to the procedure room and laid prone on the procedure table.

The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-5 interlaminar space was identified using fluoroscopy. The skin was anesthetized with 1% lidocaine and 17 gauge 3.5 inch Tuohy needle was gently introduced into interlaminar space using intermittent fluoroscopy and loss of resistance technique.

After identification of the epidural space, the confirmation was obtained by using 1.5 to 2 mL of Isovue dye. After confirmation of the correct placement of the needle in the epidural space, an 8 mL solution containing 0.25% Marcaine and 120 mg Depo-Medrol was slowly injected into the epidural space.

The patient tolerated the procedure well. There were no immediate complications and was taken to the postop area and was monitored as per protocol. The patient was discharged home on the same day with advice to attend the Pain Clinic as arranged earlier.

Lumbar Epidural Steroid Injection Procedure Description Sample #2

PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

PROCEDURE PERFORMED: Lumbar epidural steroid injection.

DETAILS OF PROCEDURE: The patient was evaluated in the preoperative area. The history and physical details of the procedure including risks, benefits and complications were discussed with the patient. The patient agreed for the procedure.

He was taken to the procedure room. The patient was laid prone on the procedure table, and his skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 space was identified using the fluoroscopic guidance. The skin was anesthetized with 1% lidocaine including the subcutaneous tissue.

The L4-L5 space was identified using the intermittent fluoroscopic and loss of resistance technique. After identification of the L4-L5 epidural space, which was confirmed by using 1.5% Isovue, an 8 mL solution containing 0.125% lidocaine and 120 mg of Depo-Medrol was gently introduced into the epidural space.

The patient tolerated the procedure well. There were no immediate complications. The patient was taken to the postoperative area and was monitored as per the protocol. The patient was discharged home on the same day with advice to attend the pain clinic as arranged earlier.

Lumbar Epidural Steroid Injection Procedure Description Sample #3

PROCEDURES PERFORMED: Lumbar epidural steroid injection, fluoroscopy, epidurography and IV sedation.

DETAILS OF PROCEDURE: A solution of Ringer’s lactate was commenced in the patient’s right hand. She was given a total of 4 mg of Versed intravenously and monitored with blood pressure and pulse oximetry.

The patient was placed prone on the x-ray table with pillows under her pelvis. Her lumbar area was painted with alcohol and Betadine. Sterile drape was applied to her lumbar area. Fluoroscopy was used to identify the L5-S1 disk space.

Then, 1.5% lidocaine with epinephrine was used to anesthetize the skin and visualized the L5-S1 interspace. Under fluoroscopic guidance, a 17 gauge Tuohy needle was advanced into the epidural space to the left of the midline. The epidural space was encountered using loss of resistance technique. This was achieved without any problems, complications or CSF drainage. Two milliliters of Isovue 300 was injected through the needle. This revealed flow of contrast in the epidural space to the left of the midline. This was confirmed under lateral fluoroscopy.

We then proceeded to inject a 4 mL solution containing 80 mg of Depo-Medrol and 1 mL of Isovue 300. The needle was cleared and removed. Permanent films were taken. The patient was returned to the recovery room where she was observed and monitored for approximately 1 hour before being discharged.

X-RAY REPORT: On the lateral view of the lumbar spine, contrast can be seen extending from L3 as far as the sacrum. On PA view, contrast can be seen extending from the L3 as far as the sacrum with bilateral infiltration of contrast slightly moved to the left than the right.

Lumbar Epidural Steroid Injection Procedure Description Sample #4

PROCEDURES PERFORMED: Lumbar epidural steroid injection, fluoroscopy, epidurography.

DETAILS OF PROCEDURE: The patient was placed prone on the x-ray table with pillows under her pelvis. The lumbar area was cleansed with alcohol and Betadine. Sterile drape was applied to his lumbar area. Fluoroscopy was used to identify the L5-S1 interspace. Lidocaine 1% with epinephrine was used to anesthetize the skin and attention was taken at the L5-S1 interspace.

Under fluoroscopic guidance, a 17 gauge Tuohy needle was advanced into her epidural space to the right of the midline. The epidural space was encountered using loss of resistance technique. This was achieved without any problems, complications or CSF drainage.

About 2 mL of Isovue M 300 was injected through the needle. This revealed good flow of contrast in the epidural space to the right of the midline. This was confirmed with lateral fluoroscopy. We then proceeded to inject a 4 mL solution containing 80 mg of Depo-Medrol and 1 mL of Isovue 300. The needle was cleared and removed. Permanent films were taken.

The patient was returned to the recovery room and she was observed and monitored for approximately 30 minutes before being discharged.

X-RAY REPORT: On the lateral view of the lumbar spine, contrast can be seen extending from L3-4 disk space as far as the sacrum. On PA view, it was somewhat difficult to make out the contrast, but we could see bilateral distribution of contrast extending from proximity of L4-5 as far as the sacrum.

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PREOPERATIVE DIAGNOSIS: Complex regional pain syndrome, left upper extremity.

POSTOPERATIVE DIAGNOSIS: Complex regional pain syndrome, left upper extremity.

PROCEDURE PERFORMED: Left stellate ganglion block.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

COMPLICATIONS: Nil.

DETAILS OF PROCEDURE: The patient was reevaluated at (XX). Details of the procedure including risks, benefits, and complications were discussed with the patient. The patient agreed to the procedure, was taken to the procedure room, and laid supine on the table. The transverse process of C6 was identified using palpation. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After identification of the transverse border of C6 vertebra, the confirmation was obtained by x-ray. A 25-gauge needle was gently introduced and touched to the bone. Intermittent aspiration to avoid other blood barrier coming into the needle. Then a 30 mL solution containing Marcaine 0.5% and Depo-Medrol 40 mg was gently injected while maintaining the needle in position and with intermittent aspiration. The patient tolerated the procedure well, and there were no complications. The patient was monitored in the postoperative area as per protocol and was discharged home the same day with advice to attend the clinic as scheduled earlier.

Pain Medicine Procedure Sample Report #2

PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

PROCEDURE PERFORMED: Lumbar epidural steroid injection.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

DETAILS OF PROCEDURE: The patient was evaluated in the preoperative area. The history and physical details of the procedure, including risks, benefits and complications were discussed with the patient. The patient agreed for the procedure. He was taken to the procedure room. The patient was laid prone on the procedure table and his skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 space was identified using the fluoroscopic guidance. The skin was anesthetized with 1% lidocaine, including the subcutaneous tissue.

The L4-L5 space was identified using intermittent fluoroscopic and loss-of-resistance technique after identification of the L4-L5 epidural space, which was confirmed by using 1.5% Isovue. After confirmation of this epidural space, an 8 mL solution containing 0.125% lidocaine and 120 mg of Depo-Medrol was gently introduced into the epidural space. The patient tolerated the procedure well. There were no immediate complications. The patient was taken to the postoperative area and was monitored as per the protocol. The patient was discharged home on the same day with advice to attend the pain clinic as arranged earlier.

Pain Medicine Procedure Sample Report #3

PREOPERATIVE DIAGNOSIS: Facet arthropathy.

POSTOPERATIVE DIAGNOSIS: Facet arthropathy.

PROCEDURE PERFORMED: Right L3, L4, L5, and S1 medial branch block.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

DETAILS OF PROCEDURE: The patient was evaluated again in the preop area. History and physical, details of the procedure including risks, benefits, and complications were discussed with the patient again. The patient agreed, was taken to the procedure room and was laid prone on the procedure table. The right L3-4, L4-5, L5-S1 and L2-L3 facet joints were identified. The skin was prepped with ChloraPrep x2 and draped in a sterile fashion.

In an oblique view, the skin was anesthetized with 1% lidocaine at each levels and a 22-gauge spinal needle, 3.5 inches long, was gently introduced towards the junction of the transverse process in the facet joint. After confirmation of this needle placement with fluoroscopic guidance, the same procedure was repeated at next 3 medial branches and a solution containing 30 mg of Depo-Medrol and about 1 mL of 0.25% bupivacaine was injected at each level.

After that, needle was withdrawn and flushed with 0.25% bupivacaine, Band-Aid was applied. The patient was taken to the postoperative area and was monitored as per the protocol. There were no immediate complications, and the patient was discharged home on the same day with the advice to attend the clinic in due course of time as arranged earlier.

Pain Medicine Procedure Sample Report #4

PREOPERATIVE DIAGNOSIS: Bilateral sacroiliac pain.

POSTOPERATIVE DIAGNOSIS: Bilateral sacroiliac pain.

PROCEDURE PERFORMED: Bilateral SI joint injection.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

DETAILS OF PROCEDURE: The patient was reevaluated. The risks, benefits, and details of the procedure including complications were discussed with the patient. The patient agreed to the procedure and was taken to the procedure room and laid prone on the procedure table. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After identification of the SI joint, a 22-gauge needle was gently introduced into the right SI joint followed by left SI joint after anesthetizing the skin and the subcutaneous tissue. After confirmation of the needle in the SI joint with fluoroscopic guidance, a 3 mL solution containing 120 mg of Depo-Medrol and 0.25% of bupivacaine was equally divided and slowly injected into the SI joint.

The patient tolerated the procedure well. The needles were then withdrawn and flushed with 0.25% Marcaine and a Band-Aid was applied.

The patient tolerated the procedure well and was taken to the postoperative area and was monitored as per protocol. There were no immediate complications, and the patient was discharged home after being monitored with the advice to attend the clinic in due course of time as arranged earlier.

Pain Medicine Procedure Sample Report #5

PREOPERATIVE DIAGNOSIS: Bilateral sacroiliac joint pain.

POSTOPERATIVE DIAGNOSIS: Bilateral sacroiliac joint pain.

PROCEDURE PERFORMED: Bilateral sacroiliac joint injections.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

COMPLICATIONS: Nil.

SPECIMENS REMOVED: Nil.

DETAILS OF PROCEDURE: The patient was reevaluated. Details of the procedure including risks, benefits, and possible complications were discussed with the patient. The patient agreed for the procedure and was taken to the procedure room. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After prepping the SI joint, right SI joint was identified using the fluoroscopic guidance and a 22-gauge 5-inch needle was gently introduced into the lower portion of the right SI joint. After confirmation of the needle placement in the right SI joint, the same procedure was repeated on the left side.

After confirmation of both needle placement, a 3 mL solution containing 120 mL of Depo-Medrol and 0.25% bupivacaine was equally divided and injected slowly on each side. The needle was then flushed with 0.25% bupivacaine and a Band-Aid was applied after removing the spinal needles.

The patient tolerated the procedure well. There were no immediate complications, and the patient was monitored as per the protocol in the postoperative area and discharged home with stable condition on the same day with advice to attend the clinic as arranged earlier.

Pain Medicine Procedure Sample Report #6

PREOPERATIVE DIAGNOSIS: Low back pain and lumbar degenerative disk disease.

POSTOPERATIVE DIAGNOSIS: Low back pain and lumbar degenerative disk disease.

PROCEDURE PERFORMED: LESI.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

DETAILS OF PROCEDURE: The patient was evaluated in the preop area. She is a referral from the Orthopedic Clinic. The H&P and consent was obtained and the medications were reviewed. The risks, benefits, and details of the procedure including possible complications were discussed with the patient. The patient understood and agreed to the procedure.

The patient was taken to the procedure room and put prone on the procedure table. The skin was prepped with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 interlaminar space was identified using the fluoroscope, and the skin and the deeper tissues were anesthetized using 1% lidocaine. A 17-gauge 3.5-inch Tuohy needle was gently introduced into the interlaminar space using loss of resistance technique and intermittent fluoroscopy.

After identifying the epidural space, the confirmation was obtained by using 2 mL of Isovue dye. After confirmation of the correct placement of the Tuohy needle, an 8 mL solution containing 0.125% bupivacaine and 120 mg of Depo-Medrol was slowly injected into the epidural space.

The patient tolerated the procedure well. There were no immediate complications, and the patient was taken to the postoperative area and was monitored as per protocol. The patient was discharged home on the same day with advice to follow up in the orthopedic clinic and to call the pain clinic as per schedule for next LESI in 4 to 6 weeks.

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