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: Foreign Body - Fingernail

Description: Foreign body of the left fifth fingernail (wooden splinter). He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.

The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with "horse serum." Consequently, he has declined to update his tetanus immunization.

MEDICATIONS: He is currently on several medications, a list of which is attached to the chart, and was reviewed. He is not on any blood thinners.

ALLERGIES: HE IS ALLERGIC ONLY TO TETANUS SERUM.

SOCIAL HISTORY: Patient is married and is a nonsmoker and lives with his wife.

Nursing notes were reviewed with which I agree.

PHYSICAL EXAMINATION
VITAL SIGNS: Temp and vital signs are all within normal limits.
GENERAL: The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.
EXTREMITIES: Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate. It does not protrude beyond the end of the nail plate. There is no active bleeding. There is no edema or erythema of the digit tip. Flexion and extension of the DIP joint is intact. The remainder of the hand is unremarkable.

TREATMENT: I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off. In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain. Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip. I was able to grasp the splinter and remove this. No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.

ASSESSMENT: Foreign body of the left fifth fingernail (wooden splinter).

PLAN: Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid. If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.

Keywords: consult - history and phy., horse serum, wooden splinter, foreign body, nail plate, grasp, fingernail, splinter,
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