Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Atrial Fibrillation

Description: Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Atrial fibrillation.

HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke. She was found to have confusion while in her facility. She then came to the emergency room and found to have a right sided acute stroke. 12-lead EKG performed on August 10, 2009, found to have atrial fibrillation. Telemetry also revealed atrial fibrillation with rapid ventricular response. Currently, the telemetry is normal sinus rhythm. Because of the finding of atrial fibrillation, cardiology was consulted.

The patient is a poor historian. She did not recall why she is in the hospital, she said she had a stroke. She reported no chest discomfort, no shortness of breath, no palpitations.

The following information was obtained from the patient's chart:

PAST MEDICAL HISTORY:
1. Coronary artery disease status post bypass grafting surgery. Unable to obtain the place, location, anatomy, and the year it was performed.
2. Carotid artery stenosis status post right carotid artery stenting. Again, the time was unknown.
3. Diabetes.
4. Hypertension.
5. Hyperlipidemia.
6. History of stroke with left side hemiplegia.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient is a resident of Lake Harris Port Square. She has no history of alcohol use.

CURRENT MEDICATIONS: Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.

REVIEW OF SYSTEMS: Unable to obtain.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air. Temperature 99, respiratory rate 16.
GENERAL: The patient is sitting in the chair at bedside. Appears comfortable. Left facial droop. Left side hemiplegia.
HEAD AND NECK: No JVP seen. Right side carotid bruit heard.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: PMI not displaced, regular rhythm. Normal S1 and S2. Positive S4. There is a 2/6 systolic murmur best heard at the left lower sternal border.
ABDOMEN: Soft.
EXTREMITIES: Not edematous.

DATA: A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.

Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute. Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.

LABORATORY DATA: WBC 7.2, hemoglobin 11.7. The patient's hemoglobin was 8.2 a few days ago before blood transfusion. Chemistry-7 within normal limits. Lipid profile: Triglycerides 64, total cholesterol 106, HDL 26, LDL 17. Liver function tests are within normal limits. INR was 1.1.

A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%. Mild apical hypokinesis. Mild dilated left atrium. Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. No intracardiac masses or thrombus were noted. The aortic root was normal in size.

ASSESSMENT AND RECOMMENDATIONS:
1. Paroxysmal atrial fibrillation. It is unknown if this is a new onset versus a paroxysmal atrial fibrillation. Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated. However, given the patient's current neurologic status, the safety of falling is unclear. We need to further discuss with the patient's primary care physician, probably rehab physician. If the patient's risk of falling is low, then Coumadin is indicated. However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended. Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management. Therefore, I will not recommend transesophageal echocardiogram at this point. Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.
2. Carotid artery stenosis. The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery. It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting. If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency. However, given the patient's current acute stroke, revascularization is not indicated at this time.
3. Coronary artery disease. Clinically stable. No further test is indicated at this time.

Keywords: cardiovascular / pulmonary, grafting surgery, hemiplegia, status post bypass grafting, carotid artery stenosis, coronary artery disease, normal sinus rhythm, normal sinus, carotid artery, atrial fibrillation, atrial, coronary, rhythm, artery, carotid, fibrillation, stroke,
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