Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Office Notes
Sample Name: Telemetry Monitoring

Description: The patient was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.
(Medical Transcription Sample Report)

DIAGNOSES PROBLEMS:
1. Orthostatic hypotension.
2. Bradycardia.
3. Diabetes.
4. Status post renal transplant secondary polycystic kidney disease in 1995.
5. Hypertension.
6. History of basal cell ganglia cerebrovascular event in 2004 with left residual.
7. History of renal osteodystrophy.
8. Iron deficiency anemia.
9. Cataract status post cataract surgery.
10. Chronic left lower extremity pain.
11. Hyperlipidemia.
12. Status post hysterectomy secondary to uterine fibroids.

PROCEDURES: Telemetry monitoring.

HISTORY FINDINGS HOSPITAL COURSE: The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine. She briefly was on Cymbalta; however, this was discontinued when she was transferred back. She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued. She was able to maintain her pressures then was able to ambulate without difficulty. We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.

DISCHARGE MEDICATIONS:
1. CellCept - 500 mg twice a daily.
2. Cyclosporine - 25 mg in the morning and 15 mg in the evening.
3. Prednisone - 5 mg once daily.
4. Hydralazine - 10 mg four times a day.
5. Pantoprazole - 40 mg once daily.
6. Glipizide - 5 mg every morning.
7. Aspirin - 81 mg once daily.

FOLLOWUP CARE: The patient is to follow up with Dr. X in about 1 week's time.

Keywords: office notes, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring,
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