Sample Name: Hypergranulation - Consult
Description: Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Non-healing surgical wound to the left posterior thigh.
HISTORY OF PRESENT ILLNESS: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control.
PAST MEDICAL HISTORY: Essentially negative other than he has had C. difficile in the recent past.
MEDICATIONS: Include Cipro and Flagyl.
FAMILY HISTORY: His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father.
SOCIAL HISTORY: He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney.
REVIEW OF SYSTEMS:
CARDIAC: He denies any chest pain or shortness of breath.
GI: As noted above.
GU: As noted above.
GENERAL: He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.
NECK: Supple. There is no mass, adenopathy, or bruit.
CHEST: Normal excursion.
LUNGS: Clear to auscultation and percussion.
COR: Regular. There is no S3, S4, or gallop. There is no murmur.
ABDOMEN: Soft. It is nontender. There is no mass or organomegaly.
EXTREMITIES: His right lower extremity is unremarkable. Peripheral pulse is good. His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. There is one small area right essentially within the graft site, and there is one small area down lower on the calf area. The patient has an external fixation on that comes out laterally on his left thigh. Those pin sites look clean.
NEUROLOGIC: Without focal deficits. The patient is alert and oriented.
IMPRESSION: Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.
PLAN: Plan would be for chemical cauterization of these areas. Series of treatment with chemical cauterization till these are closed.
Keywords: general medicine, surgical wound, traumatic injury, hypergranulation, chemical cauterization,