Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Cardioversion

Description: Cardioversion. An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation
(Medical Transcription Sample Report)

HISTORY: The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress. Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation. I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure. After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday. The patient declined. I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.

PROCEDURE NOTE: The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff. The patient participated actively in this. She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect. She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm. This was confirmed on 12 lead EKG.

IMPRESSION/PLAN: Successful resumption of normal sinus rhythm from recurrent atrial fibrillation. The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress. She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted. She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.

This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.

Keywords: surgery, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial,
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