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: Feet & Hand Cramping

Description: Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to "pop into place." He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.

He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.

He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.

He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.

PAST MEDICAL HISTORY: He has diabetes, but this is well controlled. He also has hepatitis C and HIV.

CURRENT MEDICATIONS: He takes insulin and Bactrim.

ALLERGIES: He has no known drug allergies.

SOCIAL HISTORY: He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.

FAMILY HISTORY: His father and mother had diabetes.

REVIEW OF SYSTEMS: A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.

PHYSICAL EXAMINATION:
Vital Signs: Blood pressure 130/70 HR 80 RR 18 Wt 153 pounds
General Appearance: Patient is well appearing, in no acute distress.
Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.
Chest: The lungs are clear to auscultation bilaterally.
Skin: There are no rashes or lesions.
Musculoskeletal: There are no joint deformities or scoliosis.

NEUROLOGICAL EXAMINATION:
Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact.

Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.

Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.

Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent.

Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.

Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk.

Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal.

LABORATORY DATA: August 06, 2008: Glucose 122. BUN 23. CR 1.16. Ca 7.8. K 4.6. Na 135. ALT 85. AST 192. HIV positive. Hemoglobin A1c 5.5. CD4 326. HPV positive. HCT 37.9. PLT 129. ESR 34.

ASSESSMENT: The patient is a 61-year-old gentleman with a longstanding history of HIV, who developed a recent history of nocturnal cramps in his feet and less frequent cramps in his hands. His neurological examination today is normal. I think it is possible that the cramps are related to the Bactrim. This is a very rare side effect, but it has been reported in the literature that patients can develop cramps due to this medication. He does not have any obvious metabolic abnormalities such as hypocalcemia, hypomagnesemia, or hypokalemia that can cause muscle cramps. He also does not have any evidence of an underlying neuromuscular disorder as I would expect him to have weakness or other abnormalities if this were the case. Certain metabolic myopathies can be associated with normal neurological examination and muscle cramps. This can be seen in the HIV patients who are taking antiretrovirals, but he has not been taking any of these medications for a long time.

RECOMMENDATIONS:
1. I think that he should try to stop taking the Bactrim and see if his symptoms improve. I told him that I would defer to his primary care physician for this option. Specifically, if there is another medication that he could take instead of Bactrim, this would be most desirable. He will discuss this with his primary care physician. If he cannot stop the medication, then I am not sure we would figure out if this is a true cause.
2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with the patient. I instructed him to slowly taper the dose over several days to 300 mg t.i.d. I am hopeful this will provide some symptomatic relief. If this does not, I would consider starting on baclofen.
3. If he stops taking the medication and his pain improves, then I would consider pulling back on the Neurontin and seeing if he is completely asymptomatic. However, if he continues to be symptomatic despite stopping Bactrim, then I would consider performing further diagnostic testing such as an EMG and nerve conduction studies and ordering additional serologic testing such as a CPK.

Keywords: consult - history and phy., cramps, muscle contractions, calf pain, muscle cramps, neurological examination, illness, toes, muscle, feet,
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