Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Pulmonary Embolism

Description: Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Pulmonary embolism.

HISTORY: The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life. The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. At that time, her daughter was with her. No tonic-clonic movements. No cyanosis. The patient woke up on her own. The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years. She cannot get up one flight of stairs, but feels short of breath. She gets exerted and thinks to take a shower. She does not have any chest pain, no fever or syncopal episodes.

PAST MEDICAL HISTORY
1. Pulmonary embolism diagnosed one year ago. At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers. Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.
2. Coronary artery disease status post CABG at that time. She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.
3. Mitral regurgitation.
4. Gastroesophageal reflux disease.
5. Hypertension.
6. Hyperlipidemia.
7. History of aortic aneurysm.
8. History of renal artery stenosis.
9. Peripheral vascular disease.
10. Hypothyroidism.

PAST SURGICAL HISTORY
1. CABG.
2. Hysterectomy.
3. IVC filter.
4. Tonsillectomy.
5. Adenoidectomy.
6. Cosmetic surgery.
7. Renal stent.
8. Right femoral stent.

HOME MEDICATIONS
1. Aspirin.
2. Potassium.
3. Lasix.
4. Levothyroxine.
5. Lisinopril.
6. Pacerone.
7. Protonix.
8. Toprol.
9. Vitamin B.
10. Zetia.
11. Zyrtec.

ALLERGIES: SULFA

SOCIAL HISTORY: She used to be a smoker, not anymore. She drinks 2 to 3 glasses of wine per week. She is retired.

REVIEW OF SYSTEMS: She has a history of snoring, choking for breath at night, and dry mouth in the morning.

PHYSICAL EXAMINATION
GENERAL APPEARANCE: In no acute distress.
VITAL SIGNS: Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.
HEENT: No lymph nodes or masses.
NECK: No jugular venous distension.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender.
EXTREMITIES: No lower extremity edema. No redness or hotness.
NEUROLOGIC: The patient is alert and oriented x3.

LABORATORY: Labs showed creatinine 2.1 and hemoglobin 9.6. Chest x-ray was clear. V/Q scan was normal.

ASSESSMENT AND PLAN
1. Pulmonary embolism with contraindication to anticoagulation due to recurrent gastrointestinal bleed, status post IVC filter. No evidence of chronic thromboembolic disease per V/Q scan. We cannot rule out pulmonary hypertension.
2. Shortness of breath upon exertion. The patient will need a PFT as an outpatient. Chest x-ray is clear. We will do oxygen saturation with ambulation to rule out that as a source of loss of consciousness.
3. Mitral valve disease, coronary artery disease, and peripheral vascular disease per Cardiology.
4. Probable sleep apnea; will need a sleep study as an outpatient.

Keywords: consult - history and phy., cold sweats, anticoagulation, embolism, mild shortness of breath, coronary artery disease, peripheral vascular disease, chest x ray, shortness of breath, ivc filter, gi bleed, pulmonary embolism, ivc, pulmonary, peripheral, breath,
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