Sample Transcription and Medical Terminology
Below are some samples of the dictation that you’ll be transcribing throughout our program. I’ve only included a cross-section of the specialties since the format for each specialty is very similar.
Notes for transcriptionist: Following are short notes to be typed one after another in a short paragraph format. Many physicians prefer this style of note. After being transcribed, it is usually clipped into the patient chart. Each short paragraph represents an individual chart note. Although the format provided here is not the standard type of format presented in the samples contained in the introduction, this is a variation of a typical progress note.
Letters are also included and can be transcribed using the standard format.
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At 40 weeks gestation, the patient went into spontaneous labor and on 01/15, had UVD over midline episiotomy of a healthy female with Apgars of 8/9 and weight of 8 lb 4 oz. Delivery and postpartum course were unremarkable.
At 40 weeks gestation, the patient underwent labor induction because of a ripped cervix and previous C-section. Following a relatively long labor, under epidural anesthesia, she had the vacuum extraction delivery over midline episiotomy on 12/15 of a healthy male with Apgars 8/10 and weight 8 lb 11 oz. Delivery was complicated by postpartum hemorrhage secondary to retained placenta, probably secondary to a partial placenta increta. Blood loss was estimated at 1500 cc and bleeding maintained by a D&C and manual removal. The postpartum hemoglobin was 8.7 and she otherwise had no postpartum complications.
Maria returns for follow-up. We discussed the potential complications involved. I explained to her and her husband the risks, and went over the usage of RhoGAM or Gamulin Rh. I addressed isoimmunization in Rh-negative women. They understand and will proceed as agreed.
I returned Jonna’s phone call this evening. I explained that MetroGel has the same efficacy as her current regimen. She is a nurse at the hospital, so I gave her some basic information, and that the cure rate is the same with q.hs and bid dosing. Vaginally applied metronidazole could be absorbed in sufficient amounts to produce systemic effects. She is aware of the need for caution with patients with CNS diseases; her family has a history of seizures and neuropathy. I wish to do some checking with Drs. Knoll and Petrusky before proceeding.
Katrina called. We discussed the use of danazol. I explained that we would begin with 400 mg. PO bid then titrate downward to a dose sufficient to maintain amenorrhea for three to six months, for up to nine months. I want to check her history first for fibrocystic breast disease. She is not a diabetic, so that is not a consideration at this time.
The patient is now two weeks status post diagnostic laparoscopy for hemorrhagic left ovarian cyst and possible endometriosis. The surgery is discussed in detail with the patient, especially concerning the possibility of endometriosis and recurrent disease. She had bleeding for approximately one week after surgery, which is now resolved. She has had a normal period with much less menstrual cramps. She also notes no leftsided pain.
Physical exam: The puncture wounds are intact and well-healed.
Impression: Normal two week postop check.
Plan: Return on a p.r.n. basis should symptoms again become noticeable.
The patient is a 49-year-old white married female, G4 P4 seen for annual care, pap smear and estrogen replacement. Her only gyn complaint currently is an approximately one week vaginal irritation, itching, burning around the opening of the vagina and perirectally. She had a TAH-BSO approximately six years ago secondary to abnormal bleeding and has been on intermittent estrogen replacement since that time, and off for the last several months. Her last exam and pap smear was over a year-and-a-half ago. She did have a mammogram approximately one year ago.
Upon physical exam, her abdomen reveals a healed appendectomy scar and healed Pfannenstiel. Breasts – Implants bilaterally with the left one being somewhat firm, but no masses palpable. Vaginal cuff is closed, cervix and uterus are absent as are the adnexa. Bimanual exam reveals no masses palpable.
Impression: Normal exam with yeast vaginitis.
1. Pap smear.
2. SBE encouraged. Mammo recommended in one year.
3. Premarin, 0.625 mg Mon – Fri.
4. Monistat vaginal cream.
Dr. Kline called this morning regarding Katie Helms. Katie is a former patient and she has moved to Albany. Dr. Kline and I have discussed Katie’s situation. He is recommending emergency contraception. I spoke with him about taking the first dose as soon as possible, then an identical dose 12h later. Each dose is either two pills of Ovral or Ogestrel. The same could
be used with 4 pills of Levlen or Levora. If vomiting occurs within one hour of taking either dose, consider whether or not to repeat that dose and give an antiemetic, 1h prior.
At 40 weeks gestation on 07/17, the patient had the SVD of midline episiotomy of a healthy male with Apgars 7/9, a cord pH of 7.192 and a weight of 8 lb, 7 oz. Delivery was complicated by terminal bradycardia, but otherwise the postpartum course was unremarkable.
The patient is seen today for possible vaginitis. She notes a complete course of antibiotics one to two weeks ago and since that time, has had itching, burning, foul-smelling discharge. She tried a course of Monistat III with partial relief, but again notes the return of symptoms.
Ext. genitalia – Slightly erythematous.
Vagina – Rugae with whitish discharge, which on wet mount reveals yeast.
S: Peter has been feeling more dyspneic with exertion lately. He tires easily. Medications
include Covera-HS 240mg/day; Lanoxin, 0.125 q.d.; Cardizem t.i.d. and aspirin.
O: Pulse is 60 and regular. Blood pressure 68/88. Lungs are clear. Heart unchanged with
mild AS and moderate AI. There is perhaps trivial distal edema noted.
A: 1) Suspect recent diminution of exercise tolerance is the effects of glucose tolerance and
2) Status post permanent pacemaker implantation. 3) Mild chronic renal failure.
P: 1) Increase his Cardizem back to 60 p.o. t.i.d., as the increase has not obviously helped him. 2) Hydralazine, 25 mg p.o. t.i.d. 3) Will consider switching to Lasix with his next visit. 4) Will be due for a follow-up Doppler echo sometime after the first of the year. 5) We will see him for follow up in two weeks.
Thomas Patterson, D.O. Circle One Branson, MO
RE: Harriet Davis
Dear Dr. Patterson:
I saw Harriet in the office today after her recent coronary angiogram at Mercy Care Center last week.
She has fairly well-preserved left ventricular function, except for a small infra-apical area of hypokinesis, compatible with previous infarction in that region. She has total occlusion of the native LAD, as well as occlusion of the first obtuse marginal branch of the circumflex. Her right coronary artery is a small, diffusely diseased vessel with a subtotal rib stenosis distal to the RCA graft anastomosis. The obtuse marginal graft is occluded. The LAD graft is widely patent with a few distal rub-offs. Correlation may be experiencing intermittent ischemic symptoms on the basis of her coronary disease. The vessel is, however, so small that I do not believe that it poses either a major threat of major infarction or that medically there is anything we can do about that very small vessel. I would neither rebypass that nor attempt to angioplasty it. The left ventricular function is overall well-maintained and her major graft is patent.
We have opted for a continued course of medical therapy, noninclusive of sustained release Verapamil, 240 mg p.o. q.d. and a single aspirin per day. She did have intermittent right upper chest atypical, more musculoskeletal sounding, discomfort last weekend, but she is moving and doing more activity than would likely be advisable. In addition to that, she has been under a fair amount of stress. I doubt that her chest discomfort is on the basis of myocardial ischemia at this time.
A 12-lead EKG performed in the office today was unremarkable.
Overall, I think that Harriet is doing quite well and again do not believe that her recurrent chest discomfort is on the basis of myocardial ischemia, but cannot exclude this completely. The possibility exists of ischemic induced arrhythmias. I feel it is appropriate to continue her on her medical therapy as noted above.
She has also mentioned that her serum cholesterol has been significantly elevated in the past and I believe this should be repeated after a good attempt at weight loss and dietary restrictions. Should her serum cholesterol remain above 230, then I would strongly consider initiation of
I am also recommending treadmill stress testing at least on an annual basis.
Dr. Patterson, thanks again for allowing me to participate in the care of this pleasant, challenging lady with you. If I can be of any further assistance, please don't hesitate to contact me.
Perry DeWitt, M.D.
13657 W. McDowell Rd., Su 118
Goodyear, AZ 85338
RE: Jennifer Landry
Dear Dr. DeWitt:
Your patient, Jennifer Landry, returned to my office for re-evaluation of MS.
She says that she is having increasing difficulties with lower extremity strains and constantly with her gait. She does have some discomfort, particularly at night, in her lower extremities. She says that her hand coordination and therefore, her ability to write, also has diminished. She has seen Dr. Delia Cranston, in Tucson, for psychiatric evaluation and Dr. Cranston has suggested an occupational therapy evaluation. She says that her mood is relatively stable, although she says that her physical problems are depressing, at times.
On examination, she’s walking stably, with a walker, but lower extremity strains remain 4-/5 bilaterally (and probably slightly weaker than in April, though the number is the same). There’s a very mild dysmetria in finger-to-nose testing. Eye movements remain full and smooth. Cognitive functioning is superficially intact.
MS, secondarily progressive.
1. Continue Prozac 40 mg daily.
2. Continue Ditropan.
3. Continue Neurontin 300 mg TID.
4. Continue baclofen, but change dosing to 10 mg at breakfast and lunch or 20 mg at dinner and 30 mg at bedtime (I have attempted to reduce daytime dosing to improve strength and increase the evening dosage to improve comfort; she will try this only for a period of a week and if it’s not beneficial, she will revert to her old dosage of 20 mg QID).
5. Provigil 100 mg every morning.
6. Valium 5 mg PRN at bedtime.
7. Continue Betaseron.
8. Continue to follow up with Dr. Cranston. Dr. Cranston can provide her with a name of an appropriate occupational therapist.
9. Consider the possibility of using some atypical medications, such as 4-aminopyridine (for example, an initial dosage of 5 mg BID). This is not a recognized medication in MS. It has been used, favorably, in many settings, including University of Texas Southwestern, with symptomatic improvement in patients. Ms. Landry will consider this possibility. I would be happy to write for it to be compounded, if she is interested.
I will see her again in January or if she calls sooner, if there are problems in the interim.
Kenneth Fishman, M.D.
2520 Coldwell Place
RE: Benton Grovers
Your patient, Benton Grovers, returned to my office for re-evaluation of headaches.
In the interim since his last visit, he has discontinued Thera-Gesic and Naprosyn and tizanidine and has limited his intake of triptans (Axert or Frova) to about once a week. He is no longer taking Duragesic. He says that he is feeling much greater clarity intellectually, but he says that headaches and neck aches persist, at about the level that they were a month ago. He says that D.H.E. 45 (I gave him a sample) appears to work better than a triptan.
I am pleased that Mr. Grovers has been able to get off his symptomatic medications. At the present, he has been taking Lexapro 40 mg daily, Gabitril 4 mg daily, once weekly triptan, melatonin and bedtime Klonopin. I suggested that he discontinue Gabitril, since it doesn’t appear to be beneficial. I suggested that rather than Frova or Axert, he had D.H.E. 45 nasal spray, limited intake to one or two doses per week maximally. He will continue on Lexapro, melatonin and Klonopin and return to see me in six to eight weeks.
RE: Rhonda Avery
Your patient, Rhonda Avery, returned to my office.
She says that she’s been doing well, in general. She says that her energy is generally good and that she’s generally happy. She says that she’s not troubled by her headache frequency, because she gets prompt relief with Imitrex, even the tablet form, or the injector form. Her headache frequency is varied between five and 12 times per month. I prescribed Topamax and afterward, she had a marked reduction in headache frequency, but it produced unacceptable side effects and she is not interested in trying other prophylaxis at this time. She would, in fact, like to taper off Neurontin (which I told her is acceptable).
Screening assessment is normal.
1. Continue amitriptyline 100 mg nightly.
2. Taper Neurontin over the next week.
3. Continue Imitrex per injection at the onset of headache.
4. Return visit in January.
REPORT OF CONSULTATION
Ms. Burns is a 31-year-old female who was doing relatively well until she went into labor. Apparently, the patient developed active labor earlier this morning. She suddenly became hypotensive. Her obstetrician, gynecologist, Dr. Myers, was called over. However, she was found to be hypotensive and taken for C-section. Preliminary diagnosis at that time was possibly a uterine rupture and abruptio placenta. The patient was stablized in surgery. Blood pressure became stable and she had a C-section.
Following C-section, she once again became quite hypotensive and was transferred to the intensive care unit, intubated and on a ventilator. I was called to see her by Dr. Myers and by Dr. Nichols.
Upon arrival in the intensive care unit, the patient was tachycardiac at about 176. Blood pressure was 30 to 40 systolic, but the patient was awake and urine output was markedly diminished. Over the next hour, the patient was given fresh frozen plasma, packed cells, intravenous fluid, Dopamine as well as Pitocin for bleeding status post C-section.
Swan-Ganz catheter was passed by myself and with this, we found the pulmonary artery pressure to be 34/10 with a wedge of 67 and a cardiac index of 3.8.
Significant laboratory work other than the above revealed leukocytosis with a mild left shift. No toxic granules or bodies. Hemoglobin and hematocrit 14 and 39. PT mildly elevated at 14.4. PTT normal at 34. Platelet count 300,000. Fibrinogen was 365 mg percent. Arterial blood gases revealed a pO2 on 100% of 538 with a CO2 of 28 and a pH 7.26. On the ventilator her pO2 was 260, CO2 26, pH 7.46.
Chest x-ray was reviewed and radiograph revealed no cardiomegaly, no infiltrates. EKG revealed low voltage throughout, but no signs of acute injury or other abnormalities. Electrolytes were normal, except for potassium which was 5.4.
On physical examination, the patient was intubated, followed with feeble pulses. Her blood pressure at the time seen was 70/40, pulse rate was 140. The head and neck exam, the funduscopic was benign. There was some ecchymosis noted. The trachea was normal. There was no palpable adenopathy. The chest was symmetrical. Breath sounds revealed expiratory rhonchi bilateraly and coarse inspiratory rales. The heart, apical rate was equal to 140 with a I/VI apical systolic murmur, but no gallops or heaves or thrills. The abdomen was tender and post C-section distended. The extremities revealed no clubbing, edema or cyanosis.
1. Acute hypotensive episode with the current status post surgery, etiology unclear at this
time. Possibility would include pulmonary embolus although present arterial blood gas findings and pulmonary capillary wedge pressure, diastolic gradients speak against this.
2. Rule out amniotic fluid embolus. 3. Rule out anaphylaxis, etiology cause unknown, other than Demerol, which the patient
received preoperatively. 4. Rule out an occult bleed. 5. Rule DIC.
1. Try to wean her ventilator. 2. Continue intravenous fluids, monitor wedge. 3. Blood cultures. 4. Continue Cefoxitin. 5. Hematology consultation. 6. Cardiac enzymes. 7. Monitor urine for both quantity and check BUN and creatinine.
Further recommendations pending the above.
REPORT OF CONSULTATION
REASON FOR CONSULTATION: Post partum bleed.
HISTORY: The patient is a 31-year-old Caucasian female whom I was asked to see in emergency consultation due to a post partum hemorrhage. The patient was in labor for the birth of her first child when after a contraction, she apparently became hypotensive and was coded by the anesthesiologist. Following successful coding procedure, her child was delivered by cesarean section and she was transported up to the Intensive Care Unit. She became hypotensive again and was coded for a second time. Following this, she was found to have excessive vaginal bleeding without the formation of clots and I was asked to see her in consultation.
I initially met her when I was asked to evaluate her for von Willebrand's disease. At that time, I found her Factor VIII activity to be normal, but she had a low normal Factor VIII antigen. In addition, her von Willebrand factor was slightly depressed. However, her ristocetin platelet aggregation was normal as was her bleeding time. At that time, I could not confirm a diagnosis of von Willebrand's disease and felt that if she had any type, she had a very mild variant and it would not cause her any form of bleeding dyscrasia in that her bleeding time was 3. I feel the same at this point in time.
When I was asked to see her postoperatively, her start bleeding time was 3 minutes, which is well within the normal range. In fact, it is low normal. However, some of her coagulation parameters were somewhat perplexing. Her PT was elevated at 14.5 with a PTT elevated at 37.0.
Her fibrinogen was 378. Her fibrinogenous products were greater than 40. She was transfused with cryoprecipitate, plasma and blood products. When I did see her, she was intubated, but she was alert and responsive.
PAST MEDICAL HISTORY: Is positive for endometriosis, as well as gastritis. She has never had any type of anaphylactic reaction.
PAST SURGICAL HISTORY: Is positive for laparoscopy, perforated appendix, abdominal abscess x 2. In addition, she has had D&Cs.
FAMILY HISTORY: There is no problem with bleeding in either parent, but an aunt and cousins have several bleeding problems. Her father has coronary artery disease. Her brother has no medical problems. One sister has cystic breast disease.
SOCIAL HISTORY: She does not drink nor does she use cigarettes. She admits to bruising very easily. She has had frequent nose bleeds as a child, but has never required any hospitalization for the same. She admits to minimal exertional dyspnea.
PHYSICAL EXAMINATION: Finds her to be alert and oriented on the ventilator. Her vital signs are presently stable, except for tachycardia. Pupils are equal. She has no scleral icterus. Neck is supple. There is no supraclavicular or cervical adenopathy. Breasts are cystic and consistent with pregnancy state. Lungs revealed decreased breath sounds in all fields. Abdomen has a new incision on it and I was not able to adequately evaluate her abdomen. She has no peripheral edema. She has no pathologic neurologic reflexes. IMPRESSION: 1. The etiology of her hypotension x 2 is unknown and it appears to have resolved. 2. Post partum coagulopathy. Rule out secondary to hypotensive episodes. 3. Low fibrinogen for a pregnant state with a normal PT and PTT. Rule out primary
RECOMMENDATIONS: Appropriate tests have been ordered.
SURGEON: R. Myers, M.D.
ANESTHESIOLOGIST: T. White, M.D.
PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy at term, severe bradycardiac, post maternal hypertensive episode. Rule out uterine rupture. Rule out ruptured placenta.
POSTOPERATIVE DIAGNOSIS: No uterine rupture nor ruptured placenta found. The same as above.
PROCEDURE: Emergency primary cesarean section. Radical skin incision, low flap transverse. After successful induction of the general anesthesia, the patient was prepped very quickly for an abdominal procedure. A fast vertical radial skin incision was performed and carried down to the fascia which was incised upwards and downwards. Then the rectus muscle was split in the midline. The peritoneum was identified, grasped with two hemostats and incised upwards and downwards. Then the lower end of the bowels were retracted and placed behind the symphysis pubis and the peritoneum covering the lower uterine segment was incised in a smiling fashion.
The uterine segment was also incised in a smiling fashion and a viable baby boy, Apgar 4/7 was delivered. Normal placenta grossly inspected with no suggestion of a ruptured placenta. Inspection was done obviously after the manual delivery of the placenta. The baby was handed out to the pediatricians, Drs. Smith and Haverhill, who were present in the operating room. The baby was resuscitated quite fast. Then the uterus was inspected. Both tubes and ovaries were found to be normal. The uterus was found to be within normal limits. No free blood in the abdominal cavity noted other than the blood generated by the cesarean section itself. The endometrial cavity was irrigated with antibiotics and the uterine cavity was reapproximated in three imbricated layers. The bladder flap was also reapproximated. By the way, a Foley catheter was inserted prior to the surgery and the urine output was within normal limits all throughout the procedure. The patient was stable through the procedure. After the correct counts of instru-ments, the abdominal wall was closed in layers. Estimated blood loss 300-400 cc. The patient was transferred to the intensive care unit for further care. Her urine output at the end of the procedure was about 450 cc.
SURGEON: C. Donaldson, D.O.
PREOPERATIVE DIAGNOSIS: Prolonged hypotension and shock.
POSTOPERATIVE DIAGNOSIS: Prolonged hypotension and shock.
OPERATION: Swan-Ganz insertion.
PROCEDURE: With the patient in a supine position, intubated in the Intensive Care Unit, an area over the left internal jugular was cleansed with Betadine and draped in sterile manner. Following this, a Cordis was introduced into the left internal jugular under sterile technique without complication. The Swan-Ganz was then passed via the Cordis. Initial pulmonary artery pressures were 34/10 with a pulmonary capillary wedge pressure of 5 to 6. The procedure was well-tolerated. There were no complications.
GROSS: The specimen is labeled "placenta". It consists of a mature placenta with attached umbilical cord stump. The placenta measures 19.0 x 17.0 cm in diameter and 2.5 cm in average thickness. The maternal surface appears to be complete. The membranes on the fetal surface of the placenta are smooth and shiny. A few slightly depressed yellowish-white to brown areas, measuring less than 3.0 cm in maximum dimensions are present in the placenta, beneath the fetal surface. The vascular pattern on the fetal surface is unremarkable. The umbilical cord stump is attached in an eccentric location. It measures 36.5 cm in length and 1.5 cm in average diameter. On cut sections, it is seen to have the usua three vessels. There is considerable meconium staining of the fetal membranes. The specimen container also includes a few blood clots. Sections of placenta and umbilical cord are in two cassettes.
MICROSCOPIC: The slides carry sections of placenta and umbilical cord. The placenta sections present the pattern of a mature term placenta. The chorionic villi are covered by a single layer of trophoblast and show a well-developed vascular pattern. The trophoblastic buds are small and cytologically uniform. There is no evidence of inflammation, vasculitis or viral inclusions. Occasional scattered foci of hyalinization and calcification are present in the placenta, primarily just beneath the fetal membranes. The fetal membranes are unremarkable, with no evidence of
inflammation. The umbilical cord section presents the usual pattern of two arteries and one vein set in a loose myxomatous fibrous connective tissue stroma which shows no evidence of in-flammation. There is no evidence of malignancy.
DIAGNOSIS: "Placenta". Term placenta with meconium staining of fetal membranes
S: Conrad Davies is seen today on a semi-urgent basis. Over the past five days, he has noted increased pain and swelling of the right knee. He has had no trauma or infectious symptoms. He has recently been restarted on antihypertensive medication Afeditab
O: Limited examination shows 1-2+ swelling of the right knee with palpable effusion. There is tenderness with forced flexion.
1. Rheumatoid arthritis.
2. Right knee effusion
P: Arthrocentesis of the left knee followed by intra-articular corticosteroid injection. The obtained synovial fluid will be sent for studies.
S: Andrew Mathias is seen today. He has a longstanding history of rheumatoid arthritis and this has been followed previously by Dr. Carolyn Meyer in Cincinnati. He has been on trials of different disease-modifying agents, including injectable gold, which was not beneficial. Enbrel and Remicade were initially helpful, although not after a period of time. He was on Remicade at a dosage of up to 10 mg per kg every four weeks and did not find it to be helpful at that dosage eventually. He has been maintained on maximal dosage of methotrexate at 25 mg oral weekly and chronic narcotic analgesic agent with OxyContin at 10 mg b.i.d. and Percocet up to 2 tablets daily. Unfortunately, he has an insurance plan that will not cover any disease-modifying agents or OxyContin. He has morning stiffness for up to 1-2 hours. He apparently also has a history of osteopenia and did have a recent bone mineral density test six to seven months ago. He does continue on Fosamax 70 mg weekly and feels that he cannot afford the medication.
Past Medical History: Pertinent for hypertension and diabetes mellitus. He was previously on corticosteroids, although not currently.
O: Weight: 238 pounds. He is afebrile. Vital signs: BP 114/76. Joint examination shows synovitis involving the proximal interphalangeal, metacarpophalangeal and wrist joints and limitation with wrist flexion. No subcutaneous nodules. Active shoulder and hip range of motion was intact. There was mild swelling of the right knee, although without significant effusion. There was swelling of the ankles and decreased inversion, eversion and subtalar motion. There was swelling of the foot metatarsophalangeal joints.
A: 1. Rheumatoid arthritis with active synovitis.
2. Chronic disease modifying therapy as discussed above.
3. Chronic opioid therapy as discussed above.
4. Osteopenic bone disease.
P: Because of his poor insurance coverage, we will change the long-acting narcotic analgesic to MS Contin 30 mg. b.i.d. and limit the use of Percocet for breakthrough pain only. He may be a candidate for one of the new research protocols coming up. We will
plan a follow-up within the next six to eight weeks. Recent hand x-rays are requested and we will check with the primary care physician’s office regarding the most recent laboratory studies.
Addendum: I have reviewed previous records from Dr. Meyer. In addition to what I have mentioned in my history, Mr. Mathias has also been on a previous treatment for rheumatoid arthritis with Imuran and Minocycline. Apparently, he did develop proteinuria with injectable gold. He had nerve conduction studies done in four years ago, which did document carpal tunnel syndrome. He had previous evaluation for what was apparently felt to be severe rheumatoid arthritis involving the shoulders.