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: End Stage Renal Disease - Consult

Description: Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.

HISTORY OF PRESENT ILLNESS: This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. He took some nitroglycerin tablets at home with no relief. He came to the ER. He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock. This is a late entry dictation. Presently lying in bed, but he feels fine. Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. Denies hematuria, dysuria, or bright red blood per rectum.

PAST MEDICAL HISTORY:
1. Coronary artery disease, status post stent placement two years ago.
2. Diabetes mellitus for the last 12 years.
3. Hypertension.
4. End-stage renal disease.
5. History of TIA in the past.

PAST SURGICAL HISTORY:
1. As mentioned above.
2. Cholecystectomy.
3. Appendectomy.
4. Right IJ PermaCath placement.
5. AV fistula graft in the right wrist.

PERSONAL AND SOCIAL HISTORY: He smoked 2 to 3 packets per day for at least last 10 years. He quit smoking roughly about 20 years ago. Occasional alcohol use.

FAMILY HISTORY: Noncontributory.

ALLERGIES: No known drug allergies.

MEDICATIONS AT HOME: Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.

PHYSICAL EXAMINATION
GENERAL: He is alert, seems to be in no apparent distress.
VITAL SIGNS: Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.
HEENT: Atraumatic and normocephalic.
NECK: No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.
LUNGS: Clear to auscultation. Air entry bilateral equal.
HEART: S1 and S2. No pericardial rub.
ABDOMEN: Soft and nontender. Normal bowel sounds.
EXTREMITIES: No edema.
NEUROLOGIC: The patient is alert without focal deficit.

LABORATORY DATA: Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.

IMPRESSION:
1. End-stage renal disease, plan for dialysis today.
2. Diabetes mellitus.
3. Chest pain for coronary angiogram today.
4. Hypertension, blood pressure stable.

PLAN: Currently follow the patient. Dr. Z is going to assume the care.

Keywords: consult - history and phy., end-stage renal disease, esrd, hemodialysis, dialysis, angiogram, chronic hemodialysis, stent placement, coronary angiogram, diabetes mellitus, renal disease,
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