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: Diplopia

Description: He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.

For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.

There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.

At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.

PAST MEDICAL HISTORY: The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.

MEDICATIONS: He does not take any medications.

ALLERGIES: He has no known drug allergies.

SOCIAL HISTORY: The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.

FAMILY HISTORY: His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.

REVIEW OF SYSTEMS: A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.

PHYSICAL EXAMINATION:
Vital Signs: BP 124/76 HR 101 RR 20 Wt 226 pounds Temp 97.4
General Appearance: He is well appearing, in no distress.
Cardiovascular: He has a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.
Chest: His lungs are clear to auscultation bilaterally.

NEUROLOGICAL EXAMINATION:
Cranial Nerves: The pupils are slightly asymmetric with the right pupil measuring about 4 mm and the left 3 mm. This is probably physiologic. They are round and reactive to light and accommodation in the light and dark. Visual fields are full. Optic discs are normal. Extraocular movements are intact without nystagmus. He does report horizontal diplopia in both directions. There is no vertical diplopia. I do not appreciate any frank ptosis. He may have mild proptosis of the right eye, but this is the subtle at best. Facial sensation is normal. Hearing is grossly normal. Shoulder shrug is full. There is no facial, jaw, palate, or tongue weakness.

The rest of the neurologic examination was not completed as the patient did not wish to continue with testing. He has a friend who is a physician, who informed him that the shorter the amount of time he spend in the office, the less the visit will cost him. I did explain to the patient that I would like to conduct a complete neurological examination in order to complete my assessment, but the patient deferred this.

IMPRESSION: The patient is a 53-year-old gentleman who developed acute onset of diplopia that has since improved. At one point in time, he was documented to have ptosis and extraocular movement abnormalities. There is also question of pupillary abnormalities. My examination today is actually fairly benign. It is possible that he had a small midbrain infarct causing a third nerve or other palsy, although often these lesions are pupil sparing. Myasthenia would also be something to consider, although this also does not affect the pupil. It is reassuring that he had normal neuro imaging.

RECOMMENDATIONS:
1. I do think that the patient should follow up with an ophthalmologist and he will call today to make an appointment.
2. I do not have any other further recommendations at this time. I will be interested in hearing what the ophthalmologist has to say. I do not schedule any followup, but the patient can call me back if he needs to be seen in the future.

Keywords: consult - history and phy., double vision, ophthalmologic, extraocular movements, neurological examination, myasthenia, ptosis, pupils, diplopia, neurological,
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