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: Lightheaded & Dizziness

Description: Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Lightheaded, dizziness, and palpitation.

HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female who came to the Emergency Room. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia. The patient had some cardiac workup in the past, results are as mentioned below. Denies any specific chest pain. Activities fairly stable. She is actively employed. No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.

CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus. Nonsmoker. Cholesterol normal. No history of established coronary artery disease and family history noncontributory.

FAMILY HISTORY: Nonsignificant.

SURGICAL HISTORY: Tubal ligation.

MEDICATIONS: On pain medications, ibuprofen.

ALLERGIES: SULFA.

PERSONAL HISTORY: She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.

PAST MEDICAL HISTORY: History of chest pain in the past. Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal. Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal. An echocardiogram at that time was also normal. At this time, presentation with lightheaded, dizziness, and palpitation.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: No history of fever, rigors, or chills.
HEENT: No history of cataract, blurry vision, or glaucoma.
CARDIOVASCULAR: As above.
RESPIRATORY: Shortness of breath. No pneumonia or valley fever.
GASTROINTESTINAL: No epigastric discomfort, hematemesis or melena.
UROLOGICAL: No frequency or urgency.
MUSCULOSKELETAL: Nonsignificant.
NEUROLOGICAL: No TIA. No CVA. No seizure disorder.
ENDOCRINE/HEMATOLOGIC: Nonsignificant.

PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.
HEENT: Atraumatic and normocephalic.
NECK: Neck veins flat. No carotid bruits. No thyromegaly. No lympyhadenopathy.
LUNGS: Air entry bilaterally fair.
HEART: PMI normal. S1 and S2 regular.
ABDOMEN: Soft and nontender. Bowel sounds present.
EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.
CNS: Benign.
PSYCHOLOGICAL: Normal.
MUSCULOSKELETAL: Nonsignificant.

EKG: Normal sinus rhythm, incomplete right bundle-branch block.

LABORATORY DATA: H&H stable. BUN and creatinine within normal limits. Cardiac enzyme profile negative. Chest x-ray unremarkable.

IMPRESSION:
1. Lightheaded, dizziness in a 50-year-old female. No documented arrhythmia with the symptoms of palpitation.
2. Normal cardiac structure by echocardiogram a year and half ago.
3. Normal cardiac catheterization in 11/07.
4. Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile.

RECOMMENDATIONS:
1. From cardiac standpoint, observation, no other investigation at this juncture.
2. The patient was started on low dose of beta-blocker and see how she fares. Fortunately, no arrhythmia documented. If there is no documentation of arrhythmia, we will do observation. The patient was started empirically on beta-blocker and workup on outpatient basis explained to her. As mentioned above, she does not have any cardiac risk factors.

Keywords: consult - history and phy., passing out, echocardiogram, cardiac catheterizatio, normal sinus rhythm, cardiac enzyme, beta blocker, sinus rhythm, cardiac, heart, sinus, rhythm, ekg, chest, arrhythmia, palpitation, lightheaded, dizziness,
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