Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Gastroenterology
Sample Name: Clostridium Difficile Colitis Followup

Description: Still having diarrhea, decreased appetite.
(Medical Transcription Sample Report)

SUBJECTIVE: The patient seen and examined feels better today. Still having diarrhea, decreased appetite. Good urine output 600 mL since 7 o'clock in the morning. Afebrile.

PHYSICAL EXAMINATION
GENERAL: Nonacute distress, awake, alert, and oriented x3.
VITAL SIGNS: Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.
HEENT: PERRLA, EOMI.
NECK: Supple.
CARDIOVASCULAR: Regular rate and rhythm.
RESPIRATORY: Clear to auscultation bilaterally.
ABDOMEN: Bowel sounds are positive, soft, and nontender. EXTREMITIES: No edema. Pulses present bilaterally.

LABORATORY DATA: CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000. BMP, BUN of 28.3 from 32.2, creatinine 1.8 from 1.89 from 2.7. Calcium of 8.2. Sodium 139, potassium 3.9, chloride 108, and CO2 of 22. Liver function test is unremarkable.

Stool positive for Clostridium difficile. Blood culture was 131. O2 saturation result is pending.

ASSESSMENT AND PLAN:
1. Most likely secondary to Clostridium difficile colitis and urinary tract infection improving. The patient hemodynamically stable, leukocytosis improved and today he is afebrile.
2. Acute renal failure secondary to dehydration, BUN and creatinine improving.
3. Clostridium difficile colitis, Continue Flagyl, evaluation Dr. X in a.m.
4. Urinary tract infection, continue Levaquin for last during culture.
5. Leucocytosis, improving.
6. Minimal elevated cardiac enzyme on admission. Followup with Cardiology recommendations.
7. Possible pneumonia, continue vancomycin and Levaquin.
8. The patient may be transferred to telemetry.

Keywords: gastroenterology, decreased appetite, acute renal failure, urinary tract infection, leucocytosis, clostridium difficile colitis,
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