Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic
Sample Name: FCR tendinitis

Description: Consultation for FCR tendinitis
(Medical Transcription Sample Report)

HISTORY OF PRESENT PROBLEM: XYZ was seen by Dr. ABC for an FCR tendinitis. We do not have his reports, but by history she has had two cortisone shots. She plays musical instruments, and it does bother her from time to time. She was considering surgery, but she takes ibuprofen and it seems to be well-controlled. She is here now for consultation.

CLINICAL/PHYSICAL EXAMINATION:
General: The patient is alert and oriented times three in no acute distress.
Skin: No skin breakdown or hyperhidrosis.
Vascular: 2+ radial and ulnar artery pulses.
Musculoskeletal: Wrist, elbow, shoulder and neck exams reveal no focal findings except for some tenderness to palpation over the FCR tendon on the scaphoid tubercle, but there is no SL instability and no signs of lunotriquetral instability or midcarpal instability. The DRUJ is stable. Flexion/extension of the fingers is all intact. Forearm, elbow and shoulder exams reveal no other focal tenderness to palpation.
Neurologic: Negative Tinel's, Phalen's and compression median nerve test. APB, EPL and first dorsal interosseous have 5/5 strength. Forearm, elbow and shoulder exams reveal no neurologic compromise.
Gait: Normal.
Neck: Negative Spurling sign. Negative signs of thoracic outlet.
HEENT: Pupils equal and reactive with no asymmetry.

CLINICAL IMPRESSION: By history, possible FCR tendinitis.

EVALUATION/TREATMENT PLAN: At this point, we have asked her some questions again. She is not that sore at this point, and she has had a couple of cortisone shots. Without being the initial treating physician, she has FCR tendinitis that fails to respond to cortisone shots. She is a candidate for an FCR tunnel release. It has been described and is effective for those patients with that problem. My only consideration would be, if the patient should choose, to get an MRI when she is symptomatic to confirm the FCR tendinitis. She will followup with Dr. ABC as needed or come back to us when she is thinking more along the lines of surgery.

Keywords: orthopedic, fcr tendinitis, fcr tunnel release, cortisone shot, tendinitis, tunnel release, signs, oriented, shoulder, fcr,
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