Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Elevated BNP - Consult

Description: Elevated BNP. Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.
(Medical Transcription Sample Report)

REASON FOR REFERRAL: Elevated BNP.

HISTORY OF PRESENT ILLNESS: The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested. The patient denies any chest pain or shortness of breath. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.

ALLERGIES: No known drug allergies.

MEDICATIONS: At this time, he is on:
1. Atrovent and albuterol nebulizers.
2. Azithromycin.
3. Potassium chloride 10 mEq p.o. daily.
4. Furosemide 20 mg IV daily.
5. Enoxaparin 40 mg daily.
6. Lisinopril 10 mg p.o. daily.
7. Ceftriaxone.

PAST MEDICAL HISTORY: History of hypertension.

PAST SURGICAL HISTORY: History of abdominal surgery.

SOCIAL HISTORY: He does not smoke. Drinks occasionally.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: Denies chest pain, PND, or orthopnea. He has cough. No fever. No abdominal pain. No syncope, near-syncope, or palpitation. All other systems were reviewed.

PHYSICAL EXAMINATION:
GENERAL: The patient is comfortable, not in distress.
VITAL SIGNS: His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.
HEENT: Atraumatic, normocephalic. Eyes PERRLA.
NECK: Supple. No JVD. No carotid bruit.
CHEST: Clear.
HEART: S1 and S2, regular. No S3. No S4. No murmur.
ABDOMEN: Soft, nontender. Positive bowel sounds.
EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.
CNS: Alert, awake, and oriented x3.

DIAGNOSTIC DATA: EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay. CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe. Loculated pleural effusion in the left upper lobe. No PE. Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.

LABORATORY DATA: Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05. White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.

ASSESSMENT:
1. Pneumonia.
2. Diastolic heart failure, not contributing to his present problem.
3. Hypertension, controlled.
4. History of falls.

PLAN: We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics. No further cardiac workup at this time.

Keywords: cardiovascular / pulmonary, bnp, pneumonia, coronary artery disease, pleural effusion, elevated bnp, hypertension, heart,
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