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: Organic Brain Syndrome

Description: Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.
(Medical Transcription Sample Report)

REASON FOR CONSULT: Organic brain syndrome in the setting of multiple myeloma.

SOURCE OF HISTORY: The patient himself is not able to give a good history. History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.

HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words. Not a very clear history at this time and the patient himself is not able to give any history despite no family member was present in the room. Neurology consult was called to evaluate any organic brain syndrome in the setting of multiple myeloma. The patient since the morning has improved, but still not completely back to the baseline. Even I evaluated the patient previously, hence not very sure about his baseline.

PAST MEDICAL HISTORY: History of IgG subtype multiple myeloma.

SURGICAL HISTORY: Nothing significant.

PSYCHIATRIC HISTORY: Nothing significant.

SOCIAL HISTORY: No history of any smoking, alcohol or drug abuse.

ALLERGIES: CODEINE AND FLAGYL.

IMMUNIZATION HISTORY: Nothing significant.

FAMILY HISTORY: Unobtainable.

REVIEW OF SYSTEMS: The patient was considered to ask question for systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy/immunology, endocrinology, toxicology, oncology, and found to be positive for the symptoms mentioned in the history of the presenting illness. The patient himself is not able to give any history only source is the chart. For details, please review the chart.

PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure of 97/54, heart rate of 97, respiratory rate of 19, and temperature 98.5. The patient on supplemental oxygen was FiO2 on 2 L 96%. Limited physical examination.
HEENT: Head, normocephalic and atraumatic. Throat clear. No discharge from the ear and the nose. No discoloration of conjunctivae and the sclerae.
NECK: Supple. No signs of any meningismus. Though a limited examination, the patient does appear to have arthritic changes, questioning contracture deformities, as not able to follow the commands to show full range of motion. No bruit auscultated over the neck and the orbits.
LUNGS: Clear to auscultation.
HEART: Normal heart sounds.
ABDOMEN: Benign.
EXTREMITIES: No edema, clubbing or cyanosis. No rash. No leptomeningeal or neurocutaneous disorder.
NEUROLOGIC: Examination is limited. Mental state examination, the patient is awake, alert, and oriented to himself, not able follow commands, and give a proper history, and still appeared to be confuse and disoriented. Cranial nerve examination limited, but apparently nonfocal. Motor examination is very limited except for the grips, which were strong enough. I was not able to obtain much. Deep tendon reflexes were not reliable. Toes equivocal and downgoing. Sensory examination is not reliable, though intact for painful stimuli with limited examination. Coordination could not be tested. Gait could not be tested.

IMPRESSION: History of multiple myeloma and altered mental status in multiple myeloma setting. Rule out brain metastasis including lepto-meningismus, possible transient ischemic attack related to hyperviscosity syndrome or provoked seizure related to ischemia, and delirium related to any electrolyte imbalance or underlying infarction.

PLAN AND RECOMMENDATIONS: The patient is to continue with current level of management. I will review the chart before ordering any further testing that may include a CT scan of the brain, if has not been ordered, EEG, urine test, and the latest CBC with diff. to rule out any urinary tract infection or indication of any other seen of infection. No other intervention at this time. The patient may be started on aspirin, if it is okay with Dr. X.

Keywords: consult - history and phy., altered mental status, brain metastasis, lepto-meningismus, transient ischemic attack, hyperviscosity syndrome, provoked seizure, ischemia, delirium, organic brain syndrome, multiple myeloma, brain, myeloma,
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