Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Occupational Medicine Consult - 3

Description: Occupational medicine consult with questions-answers and records review.
(Medical Transcription Sample Report)

ALLOWED CONDITIONS: Sprain of left knee and leg.
CONTESTED CONDITION: Left knee tear medial meniscus, left knee ACL tear.
EMPLOYER: YYYY
REQUESTING PARTY: XXXX

Mr. XXXXXX is a xx-year-old male who was evaluated for an independent medical examination on September 20, 2007, because of an injury sustained to the left leg. The injured worker does state that he was working as a processor for the ABCD Company on July 18, 2007, when he injured his left knee. He does state he was working in a catwalk when he stepped up. He noticed his sight glass was not open on the tank. He then stepped straight down and his knee went sideways. His knee popped and he sat down secondary to discomfort. At that time he could not do any type of activity secondary to the pain. The nurse called the ambulance subsequent to this injury and he was taken to Bethesda North. X-rays were obtained which demonstrated no evidence of fracture. Thereafter, he was referred to X who he saw on July 19, 2007. It was felt that a MRI scan about the knee needed to be obtained and it was obtained on July 24. It was noted that there was evidence of an anterior cruciate ligament tear and a slight medial meniscal tear. On his second visit, it was felt that arthroscopic surgery intervention was indicated as related to the left knee.

On September 7, 2007, he underwent surgical intervention at ABC for the anterior cruciate reconstruction as well as the partial medial meniscectomy.

At the present time, he is progressing along with physical therapy. He is utilizing one crutch.

He does admit to significant bruising and swelling about the left lower extremity. If he does indeed move too fast, the discomfort is increased. His pain about the left knee is approximately 6 to 7 on a scale of 1 to 10.

He has had injuries to the right knee in which he wrecked his bicycle and did have some type of fracture bone spur when he was 13 years of age.

He underwent arthroscopic surgery as related to the right knee at that time and really did quite well.

His next appointment with Dr. X is on October 4, 2007.

The injured worker denies any previous history of similar problems as related to the left knee.

MEDICATIONS: Glucophage, Lipitor, Actos, Benicar, glimepiride, and Januvia.

SURGICAL HISTORY: Arthroscopic surgery of the left knee and arthroscopic surgery of the right knee.

SOCIAL HISTORY: The patient denies alcohol consumption. He does smoke approximately one and a half packs of cigarettes per day. His education is that of 12th grade.

PHYSICAL EXAMINATION: This is a healthy appearing 34-year-old male who is 5 feet 9 inches and weighs 285 pounds. He does not appear to be in distress at this time. Examination is limited to the left knee. One could appreciate a healed scar as related to the inferior pole inferior to the patella. There are healed arthroscopic scars as well. The range of motion of left knee reveals 50 to 70 degrees of flexion. There is evidence of medial and lateral joint line discomfort. Anterior Lachman's test was negative. No evidence of atrophy is noted. There is weakness with aggressive function about the quadriceps and hamstring musculature.

The patient is ambulating with one crutch at this time.

There is mild degree of swelling as related to the left knee. Deep tendon reflexes are +2/+2 bilaterally symmetrical. Sensory examination was normal as related to the foot, but abnormal as related to the left knee.

I did review pictures that were taken at the time of the surgery, which demonstrates the meniscectomy and the anterior cruciate ligament reconstruction.

MEDICAL RECORDS REVIEW:
1. July 18, 2007, x-rays of the left knee demonstrated evidence of a small suprapatellar joint effusion. It should be noted that the exam demonstrated evidence of medial and lateral joint line discomfort. There was specific mention of intraarticular effusion.
2. On July 27, 2007, MRI scan of the left knee was obtained, which demonstrated evidence of the complete tear of the mid to distal ACL. Findings suggestive of a chronic injury. Grade I sprain of the MCL was noted. Contusion __________ plateau medial femoral condyle and lateral femoral condyle was noted. There was evidence of a small peripheral longitudinal tear of the posterior horn of medial meniscus. Chondromalacia of the lateral femoral condyle and patella was noted. It should be noted that the changes of degeneration of the cartilages of the injured worker's knee and the chronic anterior cruciate ligament changes were noted related to the July 18, 2007, injury.
3. July 18, 2007, first report of injury, occupational disease, and/or death.
4. Evaluations of ABCD Hospital. It should be noted that the mechanism of injury was such that he was walking down the stairs when his left knee locked up.
5. July 18, 2007, x-rays of the left knee were obtained, which demonstrated the evidence of no acute fracture or significant osteoarthritis. There is evidence there maybe a small suprapatellar joint effusion.
6. Notes from the office of Dr. X. It should be noted on physical examination his range of motion is 8 to 20 degrees.
7. Physical therapy prescription for __________ Orthopedics and Sports Medicine Corporation.
8. August 10, 2007, requests for arthroscopic anterior cruciate ligament reconstruction with patellar tendon.
9. Physician narrative of August 24, 2007. It is noted that the injured worker did indeed have evidence of hypertension, hyperlipidemia, and diabetes. His BMI was 42. This was felt __________ pre-injury MRI scan.

Following your review of the medical information and your physical examination, please answer the following questions as these pertain to the allowed conditions. Please express your opinion based upon a reasonable degree of medical probability.

QUESTION: Mr. XXXXXX has filed an application for the additional allowance of left knee tear of the medial meniscus and left knee ACL tear.

Based on the current objective findings, mechanism of injury, or and medical records or diagnosis studies, does the medical evidence support the existence of any of the requested conditions.

ANSWER: The MRI sustains and verifies that these conditions do indeed exist subsequent to the injury of July 18, 2007.

QUESTION: If you find any of these conditions exist, are they a direct and proximate result of the July 18, 2007, injury.

ANSWER: There is mention of degeneration as related to the knee prior to this episode. This is not surprising considering the individual's weight. There is no question degeneration as related to anterior cruciate ligament and the meniscus has been occurring for a lengthy period of time. There has been an aggravation of this condition. Without having a MRI to review prior to this injury, I believe, it would be safe to assume that there has been aggravation of a pre-existing condition as related to the left knee and __________ meniscal and anterior cruciate ligament pathology. Thus there is definitely evidence of an aggravation of a pre-existing condition but not necessarily a direct and proximate result of the July 18, 2007, injury.

QUESTION: Do you find Mr. XXXXXX's injury or disability was caused by natural deterioration of tissue, an organ or part of the body?

ANSWER: There is no question that there is a contribution of the natural deterioration of the anterior cruciate ligament as well as the medial meniscus based up on the morbid obesity that was indeed present. Not everyone who is morbidly obese __________ any type of physical activity is more likely to have a natural deterioration of the meniscus and ligament.

QUESTION: In addition, if you find that any of the requested conditions exist, are there non-occupational activities or intervening injuries that have contributed to Mr. XXXXXX's condition?

ANSWER: There is no question that the requested conditions do indeed exit. Activities of daily living can very much be the culprit with regards to the cause of the difficulty that is indeed present. It does not seem that there was a very high velocity injury that is going to cause a combination of meniscal and anterior cruciate ligament tear.

This information is based upon review of the medical records and independent medical examination performed. If you have any further questions as related to this evaluation, please feel free to contact my office.

Keywords: consult - history and phy., records review, anterior cruciate ligament, occupational medicine, arthroscopic surgery, anterior, injury, knee, occupational, meniscus, independent, arthroscopic, cruciate, ligament,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples