Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: General Medicine
Sample Name: Recurrent Abscesses - Consult

Description: Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.

HISTORY OF PRESENT ILLNESS: A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas. She would usually have pustular type of lesion that would eventually break and would be quite painful. The drainage would be malodorous. It would initially not be infected as far as she knows, but then could eventually become infected. She stated that this first started after she had her first born about 2 years ago. She had recurrences of these abscesses and had pain, actually hospitalized at Hospital approximately a year and a half ago for about 1-1/2 months. She was treated with multiple courses of antibiotics. She had biopsies done. She was seen by Dr. X. Reportedly, she had a HIV test done that was negative. She had been seen by a dermatologist who said that she had a problem with her sweat glands. She has been on multiple courses of antibiotics. She never had any fevers. She has pain, drainage, and reportedly there was some bleeding in the area of the perineum/vaginal area.

PAST MEDICAL HISTORY:
1. History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years. Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa. Probably, she has had Staphylococcus infection associated with it as well.
2. Reported history of asthma.

GYNECOLOGIC HISTORY: G3, P1. She is currently 5 months' pregnant.

ALLERGIES: None.

MEDICATIONS: Her medication had been Augmentin.

SOCIAL HISTORY: She is followed by a gynecologist in Bartow. She is not an alcohol or tobacco user. She is not married. She has a 2-year-old child.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: The patient has been complaining of diarrhea about 5 or 6 times a day for several weeks now.

PHYSICAL EXAMINATION
GENERAL: The patient is a pleasant female lying in bed in no acute distress.
VITAL SIGNS: Temperature 97.4, pulse 78, respirations 18, and blood pressure 81/49.
LUNGS: Clear to auscultation.
HEART: Regular rhythm.
ABDOMEN: Soft.
GENITAL AREA: There are some multiple scars and some tender indurated areas in her pubic area. There appears to be a tender area in the right inguinal/perineal area that is draining clear fluid. I do not see any obvious blood. There are multiple scars in the inguinal fold area as well as the upper medial thigh. I do not see any obvious active fluctuant lesion.

LABORATORY DATA: WBC count is 13.9, hemoglobin 11.1, and platelets 291,000. BUN 7, creatinine 0.7, and glucose 80.

IMPRESSION:
1. Recurrent hidradenitis suppurativa, which sometimes may become superinfected with skin organisms when it ruptures and drains. It is essentially overactive sebaceous glands that become abscess. In the past, Accutane has been used. Obviously, she cannot get this. I do not know what new treatments are available by dermatologist. I usually refer these patients to dermatologist. I do not think she has an obvious current abscessed lesion, although there is some drainage. She has been on Augmentin for 1 month.
2. Diarrhea in a patient who had been on Augmentin for 1 month. Need to rule out Clostridium difficile colitis.
3. Mild leukocytosis.
4. Intrauterine pregnancy, 5 months' pregnant.

PLAN: Would not continue antibiotics when the patient is discharged since the patient would be at increased risk for developing resistant organisms as well as developing side effects such as Clostridium difficile colitis. Check Clostridium difficile toxin. I agree about trying to arrange for whirlpool therapy as an outpatient since plain sitz bath is not working currently. Refer to dermatologist as an outpatient.

Keywords: general medicine, accutane, abscesses, hidradenitis, hidradenitis suppurativa, leukocytosis, intrauterine pregnancy, clostridium difficile colitis, clostridium difficile, recurrent abscesses, augmentin, dermatologist, told,
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