Other Medical Reports Samples (3)

Endovaginal Sonogram Report Sample #1

RE: Debra Jones
DATE: 12/01/10
MR: 240804
DOB: 12/01/65

 

PELVIC ENDOVAGINAL SONOGRAM:

The patient is a 35-year-old female who complains of a cough for one week. She reports a fever last Saturday that is now resolved. She has a slightly hoarse voice. She is a nonsmoker. She takes Prozac 20 mg daily for depression.

Neither ovary is definitively seen. No adnexal masses, cyst or fluid collections are identified however. The bladder appears normal.

IMPRESSION:

NONVISUALIZATION OF THE OVARIES. NO DEFINITE ADNEXAL MASSES OR CYST ARE SEEN HOWEVER.

NORMAL APPEARING UTERUS.




Stress Test Report Sample #2

EXAM: NUCLEAR STRESS TEST- DUAL ISOTOPE

METHOD: The patient was administered 3 mCi of Thallium 201 Chloride and a routine SPECT rest study was performed. The patient was subsequently exercised using the standard Bruce protocol until at least 85% of MPHR was achieved. The patient was then administered 30mCi of Tc99m Myoview at peak stress. Dynamic gated SPECT stress imaging was performed with computer-assisted quantitation of myocardial motion and thickening. Patient exercised for a total of 5 minutes and 30 seconds attaining maximum heart rate of 136 bpm, which represents 93% of the maximum predicted heart rate. Peak workload was 7.0 METS. Maximal blood pressure was 180/85.

FINDINGS: There is mild decreased perfusion identified at the anteroseptal wall at stress which demonstrates normal perfusion at rest. In addition, there is mild to moderate decreased perfusion along inferolateral wall at stress which demonstrates normal perfusion at rest. These findings are likely related to ischemia. Remainder of the myocardia is well perfused with no transient dilatation.

SPECT LVEF:Normal at 53%

IMPRESSION:Suggestive of mild anteroseptal and mild to moderate inferolateral wall ischemia.




Surgical Report Sample #3

RE: David Jones
DATE: 12/01/12
MR: 240804
DOB: 12/01/65

 

SURGICAL REPORT

PREOPERATIVE DIAGNOSIS: Left inguinal hernia.

POSTOPERATIVE DIAGNOSIS: Left indirect inguinal hernia.

PROCEDURE: Repair of left indirect inguinal hernia with extra large mesh plugs.

FINDINGS: The patient is a 52-year-old gentleman with multiple medical problems and a symptomatic left inguinal hernia. He was chronically constipated and this caused that hernia to pop out. He also had urinary frequency. In the operating room, he had a left indirect inguinal hernia sac, but also was catheterized before the surgery and 700 cc was removed.

PROCEDURE: After adequate general endotracheal anesthesia was introduced using a bronchoscopic incubation, a full catheter was placed and an impression device replaced on lower extremity. The patient was then prepped and draped in the usual sterile manner. I did a left parallel angle incision. The fascia was exposed leaving point coagulated a tie with 3-0 Vicryl. The fascia was lifted through external ring and the cord mobilized with a Penrose drain. The floor was completely intact and the creamasteric fibers and internal spermatic fascia opened. It was immediately evident there was indirect sac. This was dissected down to the internal ring. It was reduced and the hemostasis was excellent. The hernia was pushed back and an extra large plug with a central pedal removed was placed and secured with a 2-0 Prolene anteriorally and medially. The wound was irrigated with antibiotic suture and enclosed with 0 Vicryl on the external, 3-0 Vicryl, 4-0 subcuticular Vicryl, and Steri-Strips on the skin.

Estimated blood loss through the entire procedure was less than 10 cc and no drainage replaced. Specimen to pathology was none. The patient tolerated the procedure well and gauze dressing applied and was taken to recovery room. He was extubated in stable condition.

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