Review Sample Radiology Report
Radiology Report
Patient Name: Marietta Mosley
Hospital No.: 11446
X-ray No.: 98-2801
Admitting Physician: John Youngblood, M.D.
Procedure: Left hip x-ray.
Date: 08/05/20XX
PRIMARY DIAGNOSIS: a partial femur (thigh bone) fracture where the femur joins the pelvic bone
CLINICAL INFORMATION: patient presented with left hip pain, no history of previous food or drug allergies.
A Dynamic Hip Screw or Sliding Hip Screw (an orthopedic device developed for the repair of specific forms of hip fractures that permits coordinated dynamic movement of the femoral head portion along the construct) is pictured transfixing the left femur neck (Oberg & Villemaire, 2018).
The fracture is noted outside of the hip capsule, i.e., extracapsular, and is a stable intertrochanteric fracture, according to Hinkle and Cheever (2018), fractures of the proximal femur at the level of the greater and lesser trochanter. A trochanter is a femoral prominence at the hip bone’s joint.
Trochanters are essential to muscle anchoring sites in humans. There is a radiolucent band (partially permeable X-ray) consistent with an unspecified date fracture that exhibits likely nonunion at the position of the orthopedic screw in the left portion of the femoral neck, at the position of the lesser trochanter.
Previous infection with limited blood flow to the injury site that did not heal after a prolonged period of time is also noted. Under the cartilage in the hip joint, there is both lateral thickening of the bone, as well as moderate offset and displacement fracture in which the endpoints of the femur pieces are at opposite angles (Oberg & Villemaire, 2018). Modest repair of an unstable fracture is observed along the femoral shaft, which is a long and extended section of the long bone.
IMPRESSION:1. There was no indication of considerable femoral neck dislocation.
- Non-healing of a fracture running crosswise along the shaft of the femur at the lesser trochanter.
Neil Nofsinger, M.D.NN: xx
D:08/05/20XX
T:08/05/20XX
Review Sample Pathology Report
Pathology Report
Patient Name: Sumio Yukimura
Hospital No.: 11449
Pathology Report No.: 98-S-942
Admitting Physician: Donna Yates, M.D.
Preoperative Diagnosis: Cholelithiasis. Cholelithiasis is the development of gallstones, which is a calcified deposits in the fluid of the gallbladder, a tiny organ located under the liver.
Postoperative Diagnosis: Cholelithiasis. Cholelithiasis is the development of gallstones, which is a calcified deposits in the fluid of the gallbladder, a tiny organ located under the liver.
Specimen Submitted: Gallbladder and stone.
Date Received: 06/05/20XX
Date Reported: 06/06/20XX
Gross description: Specimen ( material collected as representative for investigation or study )received in one container labeled “gallbladder.” The gallbladder specimen showed a tiny, pear-shaped organ. The specimen consists of a 9-cm gallbladder measuring 2 cm in average diameter (Oberg & Villemaire, 2018). The surface of the serosa is light brown and gleaming.
The area opposite the liver is tanned, increased in size 4 fold, and roughened. There are no obvious abnormalities on the outside. When the specimen is opened, it displays dark green viscous bile. The mucosa covering is greenish and velvety, with several adhering soft yellow polypoid stone that resists rubbing and does appear to impede the gallbladder’s neck. The epithelial surface appears to be normal. Representative sections are submitted in one cassette.
Gross diagnosis: Gallstone.
KM:xx
D:06/05/20XX
T:06/05/20XX
Microscopic diagnosis: A microscopic inspection reveals many polypoid outgrowths (A noncancerous growth that protrudes from the mucosal covering and can occasionally cause blockage(Honan, 2018)) originating from the mucosal surface, which are made up of lipid (cholesterol) rich, foamy macrophages within the lamina propria. Bleeding severe cholecystitis associated with cholelithiasis of the gallbladder.
Robert Thompson, M.D.
RT:xx
D:06/06/20XX
T:06/06/20XX
Discharge Summary
Patient Name: Joyce Mabry
Hospital No.: 11709Admitted: 02/18/20XX
Discharged: 02/24/20XX
Consultations: Tom Moore, M.D.,
HematologyProcedures: Splenectomy.
Complications: None
.Admitting Diagnosis: Elective splenectomy for idiopathic thrombocytopenic purpura and systemic lupus erythematosus.
History :
The client is a 21-year-old white lady who has been experiencing significant bruises and bleeding since June. Her condition was identified as thrombocytopenic purpura, which is a disorder in which the body’s immune response destroys platelets (blood cells that allow blood clotting factors to form) (Oberg & Villemaire, 2018). A low platelet count leads to easy injuries and hemorrhage, which can manifest as purple spots on the skin.
Concurrently, a prognosis of systemic lupus erythematosus (An autoimmune illness that occurs when the body’s defense system attacks the body’s own organs (Hinkle & Cheever, 2018)) was made. The bruising persisted in the patient. The patient was treated on steroids and prednisone 20 mg, but her platelet count stayed low, below 20,000.
Reason for admittance:
The client was hospitalized for an elective splenectomy. A splenectomy is a surgical operation that removes the spleen wholly or partly; and because of its propensity to efficiently eliminate encapsulated microorganisms, the spleen is a key organ in immunological function (Cooper & Gosnell, 2022).
Laboratory data on admission:
Chest x-ray showed no abnormalities in the chest. Electrocardiogram recorded the heart’s electrical activity, and the heart waves were normal. Sodium 138, potassium 5.2, chloride 104, CO2 25, glucose 111. Urinalysis; urine analysis using chemical and microscopical methods did not detect abnormalities in the urine. Hemoglobin (red blood cells level) 14.8, hematocrit (the proportion of red blood cell volume to total blood volume) 43.5, white blood cell count 15,000, platelet count 17,000, PT 11.5, PTT 27 (Oberg & Villemaire, 2018).
Hospital course:
The patient was taken to the operating room on February 19, where a splenectomy was performed. The patient’s postoperative course was uncomplicated, with the wound healing well. The platelet count was stable for the first 3 postoperative days.
The patient was transfused during surgery with 10 units of platelets and postoperatively with 10 additional units of platelets. However, on the fourth after surgery, the platelet count had risen to 77,000, which was a significant increase (Oberg & Villemaire, 2018). The patient was discharged for a follow-up in my office. She will also be seen by Dr. Moore, who will follow her SLE and ITP.
Discharge diagnosis:
Idiopathic thrombocytopenic purpura is a disorder in which the body’s immune response destroys platelets and systemic lupus erythematosus (An autoimmune illness that occurs when the body’s defense system attacks the body’s organs)
Discharge medications:
- Prednisone 20 milligrams once a day
- Percocet 1 to 2 per-oral 4 hourly when needed.
- Multivitamins, 1 in the morning; once a day
Carmen Garcia, M.D.
CG:xx
D:02/25/20XX
T:02/26/20XX
Operative Report
Patient Name: Kathy Sullivan
Hospital No.: 11525
Date of Surgery: 06/25/20XX
Admitting Physician: Taylor Withers, M.D.
Surgeons: Sang Lee, M.D., Taylor Withers, M.D.
Preoperative Diagnosis: Urinary incontinence secondary to cystourethrocele (protrusion of the female bladder’s apex and concomitant to urethra into the vaginal cavity)
Postoperative Diagnosis: Urinary incontinence secondary to cystourethrocele(protrusion of the female bladder’s apex and concomitant to urethra into the vaginal cavity)
Operative Procedure: Total abdominal hysterectomy (a medical operation that removes the uterine cavity through a lower belly incision) with Marshall-Marchetti correction (for the treatment of urethral hypermobility in females suffering from stress urinary incontinence)
Anesthesia: General endotracheal; a technique in which anesthetic delivery is expedited and the client benefits from an artificial expansion of the tracheobronchial tree via a tube via which the patient’s ventilation occurs
Description: After the medical operation that removes the uterine cavity through a lower belly incision had been performed by Dr. Withers, the serous layer that lines and protects the abdominal cavity and organs were closed by him, and the procedure was turned over to me. At this time, the supravesical space (The supravesical fossa is a triangle region that is bordered lateral and above by the umbilical ligament, which surrounds the umbilical artery remains (Cooper & Gosnell, 2022)) was entered.
The anterior portions of the bladder and urethra were cut free by blunt and sharp cuts. Arteries that were actively bleeding were clamped, and the heat was used to control bleeding as they were encountered. A wedge of the overlying sheath that surrounds the bones and provides blood, nerves, and cells were taken and roughened with a bone rasp (Oberg & Villemaire, 2018).
The urethra was then attached to the overlying symphysis (a point where one bone (physis) joins the body of the other) by placing two No. 1 absorbable sutures on each side of the urethra and one in the bladder neck. The urethra and bladder neck pulled up to the overlying symphysis bone very easily with no tension on the sutures.
Bleeding was controlled by pulling the bladder neck up to the bone. Penrose drains, according to Honan (2018), is a soft, malleable rubber pipes used as an operative drain to avoid fluid accumulation at the operative site) were placed on each side of the vesical gutter. Blood loss was minimal. The procedure was then turned back over to Dr. Withers, who proceeded with closure.
Sang Lee, M.D.
SL:xx
D:06/25/20XX
T:06/26/20XX
References
Cooper, K., & Gosnell, K. (2022). Adult health nursing – E-book (9th ed.). Elsevier.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner and suddarth’s textbook of medical-Surgical Nursing. Wolters Kluwer.
Honan, L. (2018). Focus on Adult Health: Medical-surgical nursing. Lippincott Williams & Wilkins.
Oberg, D., & Villemaire, L. (2018). Grammar and writing skills for the health professional. Cengage Learning.