Family Practice Medical Transcription Transcribed Sample Report / Example



ADMITTING DIAGNOSIS:  Late effect, L1 incomplete paraplegia, American Spinal Injury Association category B, secondary to epidural abscess.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with a long history of insulin dependent diabetes, type 2; coronary artery disease; chronic renal insufficiency; peripheral vascular disease, also secondary to diabetes; who was originally admitted to an outside hospital for what appeared to be acute paraplegia, lower extremities.  Evidently, MRI indicated a large epidural abscess around T5-8.  The patient was transferred to another hospital and underwent laminectomy, T5-8, and drainage of abscess.  He was positive for MRSA and was placed on vancomycin and completed complete course.  The patient’s hospital course was complicated with acute renal failure on chronic as well as lower extremity paraplegia and completed a course of antibiotics.  The patient was transferred to this facility for PT/OT rehabilitation as well as continued medical management of epidural abscess and complete paraplegia, as well as coronary artery disease, diabetes, and peripheral vascular disease.  His course here was relatively uneventful with the exception that he was seen and evaluated by a psychiatrist and placed on Wellbutrin for depression, as well as the patient did have numerous episodes of constipation, believed to be secondary to medication, as well as neurogenic bowel.  He did receive a course of Bactrim for 14 days for UTI.  Evidently, at some point in time, the patient was noted to develop a pressure-type wound on the sole of his left foot and left great toe.  He was also noted to have a large sacral wound; this is in a similar location with his previous laminectomy, and this continues to receive daily care.  The patient was transferred secondary to inability to participate in full physical and occupational therapy and continue medical management of his diabetes, the sacral decubitus, left foot pressure wound, and associated complications of diabetes.

PAST MEDICAL HISTORY:  L1 incomplete paraplegia secondary to epidural abscess; epidural abscess, T5-8, status post laminectomy and I and D; history of coronary artery disease, status post one vessel stent; history of hypertension, type unknown, possibly secondary to renal insufficiency; history of hypothyroidism; depression; neurogenic bladder secondary to L1 incomplete paraplegia secondary to epidural abscess; neurogenic bowel secondary to L1 incomplete paraplegia secondary to epidural abscess; history of acute-on-chronic renal insufficiency; stage II gluteal and sacral decubitus pressure wound, left foot, mid soleus as well as 3 small areas in the left great toe; history of right BKA secondary to peripheral vascular disease; history of polyneuropathy secondary to diabetes; history urinary tract infection; history of neuropathic pain, chronic; and history of MRSA sepsis.

MEDICATIONS:  Fragmin 5000 units subcutaneously daily, Xenaderm to wounds topically b.i.d., Lantus 40 units subcutaneously at bedtime, OxyContin 30 mg p.o. q.12 h., folic acid 1 mg daily, levothyroxine 0.1 mg p.o. daily, Prevacid 30 mg daily, Avandia 4 mg daily, Norvasc 10 mg daily, Lexapro 20 mg daily, aspirin 81 mg daily, Senna 2 tablets p.o. q.a.m., Neurontin 400 mg p.o. t.i.d., Percocet 5/325 mg 2 tablets q.4 h. p.r.n., magnesium citrate 1 bottle p.o. p.r.n., sliding scale coverage insulin, Wellbutrin 100 mg p.o. daily, and Bactrim DS b.i.d.


SOCIAL HISTORY:  The patient lives by himself.  He lives in an apartment on the first floor, wheelchair accessible.

FAMILY HISTORY:  Positive for diabetes and coronary artery disease in his mother as well as one brother.

REVIEW OF SYSTEMS:  The patient states having undergone right BKA for peripheral vascular disease complications approximately 5 to 8 months ago; otherwise, no acute weight changes, no skin changes, heat or cold intolerance.  He denies any chest pain or shortness of breath, bladder or bowel changes with the exception as noted above.  Since mid October, respiratory complaints.  He denies any new heat or cold intolerance, some palpitations.  He denies any new symptoms of numbness or tingling.  He still has severe deficiencies in sensorium in lower extremities as well as upper extremities but it is equal and symmetrical.  He denies any slurred speech or dysphasia.

GENERAL:  The patient is a well-nourished, well-developed, obese male, awake, alert, and oriented x4, in no apparent distress.
VITAL SIGNS:  Blood pressure 132/84, pulse 72 and regular, respiratory rate 16 and unlabored.
SKIN:  Dry.  The patient has numerous superficial wounds; in particular, left foot has an area approximately 3.5 x 4.5 cm, mid soleus, blackened skin area.  There is no fluctuance.  It is nontender to touch.  It is not warm.  There is no localized erythema or red streaks.  He has 4 to 5 approximately 3 to 4 mm in diameter round areas on the lateral aspect of his left great toe, but his leg has no localized erythema.  He has 2 to 3+ edema.  Distal pulses were absent.  Feet were not warm however.  Capillary refill was 2 seconds.  He has well-healed BKA on the right side.  Tissue appears somewhat hyperemic, but it is not cool to touch, nontender.  There is no discharge or drainage, otherwise unremarkable on exam.
HEENT:  Grossly normocephalic, atraumatic.  He is edentulous for upper and lower.  PERRLA.  EOMI.  No APD.  Sclerae anicteric.
NECK:  Supple and had good range of motion.  No anterior and posterior cervical adenopathy.  Thyroid appeared grossly normal.
HEART:  Regular rate and rhythm without murmurs, rubs or gallops.
CHEST:  Clear with slightly diminished breath sounds bilaterally at the bases without rhonchi, rales or wheezes.
ABDOMEN:  Obese, soft, nontender, and nondistended.  Bowel sounds were active in all quadrants.  There was no rebound or guarding.  No CVA or suprapubic tenderness or lymphadenopathy appreciated.
BACK:  Back and spine and paraspine unremarkable.  He does have rather large area stage II decubitus ulcer in the area of laminectomy.  There is no foul odor or gross discharges, hyperemic tissue peripherally.  There is pink granulation tissue at the edges and in the base.  It is nontender on exam.  However, this should be guarded since the patient does have a history of neuropathy.
EXTREMITIES:  See skin above.  Otherwise, upper extremities, radial and ulnar pulses, reflexes are equal and symmetrical, 2/3.  Proprioception is preserved.  There is some mild motor muscular atrophy.  Upper extremities, bilaterally, are symmetrical.  Lower extremity shows right BKA, marked sensorial deficits, including proprioception on the left side.  Digits were pale but not cool to touch.  Dorsalis pedis, posterior tibial pulses were diminished.  Reflexes, however, were intact.
NEUROLOGICAL:  See above and skin for neurologic or neuropathic changes; otherwise, grossly symmetrical without any gross deficit or obvious cognitive deficit.

1.  Paraplegia, incomplete, L1, secondary to epidural abscess.  PT and OT to evaluate and initiate treatment as necessary.  We will continue to follow.
2.  Epidural abscess with secondary wound infection.  We will continue with dressing changes b.i.d. as above and make changes as necessary.  I will review old records, however, for any definitive organism.  The patient was methicillin-resistant Staphylococcus aureus positive in the past, and I am not sure if this has been treated or cultured, and he will be treated differently.
3.  Foot pressure ulcer.  Recommend routine wound care, as well as elevation, pressure release.  We can follow.
4.  Diabetes.  Above noted medications with sliding scale coverage.  Fingerstick blood sugar at least q.a.c. and h.s. initially.  Hopefully, we will decrease it to twice a day as necessary.
5.  Coronary artery disease.  The patient is on aspirin as well as a number of cardiac medications.  He has no present complaints at this time.
6.  Peripheral vascular disease, status post right below-knee amputation.  Continue to follow.  His capillary refill is extremely sluggish at best in the upper extremities as well as left lower extremity, maybe a candidate for Plavix in the future.
7.  Depression.  The patient was seen by psychiatry and placed on Wellbutrin.  It is only about 100 mg daily at this time.  We would increase dosage and continue to follow and reevaluate with psychiatry as necessary.
8.  As for code status, discussed with patient, including CPR, medications, cardioversion, and intubation.  At this point in time, the patient has indicated he would prefer a full code status, including all of the above.