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: Atrial Fibrillation Management

Description: The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Atrial fibrillation management.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation. The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam. EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation. The patient states that for the last 3 years, she has had episodes of her heart racing. It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake. Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain. They subsequently resolve on their own and do not limit her in anyway. However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe. She said she can walk no more than 25 feet without becoming tired. She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint. Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills. She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.

PAST MEDICAL HISTORY:
1. Hypertension.
2. Myocardial infarction in 2003.
3. Left heart catheterization at University Hospital.
4. Hypercholesterolemia.
5. Arthritis.
6. CVA in 2002 and in 2003 with right eye blindness.

PAST SURGICAL HISTORY:
1. Left total knee replacement in 2002.
2. Left lower quadrant abscess drainage in 12/07

FAMILY MEDICAL HISTORY: Significant for lung and brain cancer. There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.

SOCIAL HISTORY: She is retired as a cook in a school cafeteria, where she worked for 34 years. She retired 7 years ago because of low back pain. She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995. Denies alcohol, and denies IV or illicit drug use.

ALLERGIES: No known drug allergies.

MEDICATIONS:
1. Coumadin 5 mg a day.
2. Toprol-XL 50 mg a day.
3. Aspirin 81 mg a day.
4. Hydrochlorothiazide 25 mg a day.
5. Plendil 10 mg daily.
6. Lipitor 40 mg daily.

REVIEW OF SYSTEMS: As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg. GENERAL: A well-developed, well-nourished, middle-aged African American female in no acute distress. NECK: Supple. No JVD. No carotid bruits. CARDIOVASCULAR: Irregularly irregular rate and rhythm. Normal S1 and S2. No murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive, soft, nontender, and nondistended. No masses. EXTREMITIES: No clubbing, cyanosis or edema. Pulses 2+ bilaterally.

LABORATORY DATA: EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.

IMPRESSION: The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.

RECOMMENDATIONS:
1. Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.
2. We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.
3. We will check a thyroid function panel.
4. We will continue Coumadin as directed and to follow up with Dr. X for INR management.
5. Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.
6. Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization. We will await results of transthoracic echocardiogram.
7. We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period. She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.

The patient was seen, discussed, and examined with Dr. Y in electrophysiology.

Keywords: consult - history and phy., hypertension, hypercholesterolemia, heart catheterization, transthoracic echocardiogram, atrial fibrillation, toprol, electrophysiology, atrial, transthoracic, echocardiogram, coumadin,
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