Sample Name: Pressure decubitus
Description: Pressure decubitus, right hip
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Pressure decubitus, right hip.
HISTORY OF PRESENT ILLNESS: This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a wheelchair. She relates recently she has been spending up to 16 hours a day in a wheelchair. She has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. She is now presenting for evaluation and management of same. Denies any chills or fever, any other symptoms.
PAST MEDICAL HISTORY: Back closure for spina bifida, hysterectomy, breast reduction, and a shunt.
SOCIAL HISTORY: She denies the use of alcohol, illicits, or tobacco.
MEDICATIONS: Pravachol, Dilantin, Toprol, and Macrobid.
REVIEW OF SYSTEMS: Other than the above aforementioned, the remaining ROS is unremarkable.
GENERAL: A pleasant female with deformity of back.
HEENT: Head is normocephalic. Oral mucosa and dentition appear to be normal.
CHEST: Breath sounds equal and present bilateral.
GI: Obese, nontender, no hepatosplenomegaly.
SKIN: She has a full-thickness pressure decubitus involving the right hip which is 2 x 6.4 x 0.3, moderate amount of serous material, appears to have good granulation tissue.
PLAN: Daily applications of Acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week.
DIAGNOSIS: Sequelae of spina bifida; pressure decubitus of right hip area.
Keywords: general medicine, pressure decubitus, acticoat, sequelae, breast reduction, decubitus, hysterectomy, ischial area, pressure, spina bifida, trochanter, wheelchair, bifida,