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: Nephrology Consultation - 1

Description: Nephrology Consultation - Patient with renal failure.
(Medical Transcription Sample Report)

REASON FOR CONSULTATION: Renal failure.

HISTORY OF PRESENT ILLNESS: Thank you for referring Ms. Abc to ABCD Nephrology. As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital. She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease. She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin. Her creatinine both at XYZ Hospital and University of A was elevated at 2.4. I do not have the results from the prior years. A repeat creatinine on 08/16/06 was 2.3. The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration. She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection. She had bladder studies a long time ago. She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria. She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones. She denies any nonsteroidal antiinflammatory drug use. She denies any other over-the-counter medication use. She has chronic hypokalemia and has been on potassium supplements recently. She is unsure of the dose.

PAST MEDICAL HISTORY:
1. Hypertension on and off for years. She states she has been treated intermittently but lately has again been off medications.
2. Gastroesophageal reflux disease.
3. Gastritis.
4. Hiatal hernia.
5. H. pylori infection x3 in the last six months treated.
6. Chronic hypokalemia secondary to chronic diarrhea.
7. Recurrent admissions with nausea, vomiting, and dehydration.
8. Renal cysts found on a CAT scan of the abdomen.
9. No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.
10. Stomach bypass surgery 1975 with chronic diarrhea.
11. History of UTI multiple times recently.
12. Questionable history of kidney stones.
13. History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.
14. Depression.
15. Diffuse degenerative disc disease of the spine.
16. Hypothyroidism.
17. History of iron deficiency anemia in the past.
18. Hyperuricemia.
19. History of small bowel resection with ulcerative fibroid.
20. Occult severe GI bleed in July 2001.

PAST SURGICAL HISTORY: The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.

CURRENT MEDICATIONS:
1. Nexium 40 mg q.d.
2. Synthroid 1 mg q.d.
3. Potassium one q.d., unsure about the dose.
4. No history of nonsteroidal drug use.

ALLERGIES: Sulfa causes hives.

TRANSFUSIONS: Transfusion in 1993.

FAMILY HISTORY: Mother is deceased at the age of 55 of breast cancer and also had type 2 diabetes. Father is deceased of known cause. Strong family history of diabetes in the mother, grandmother, sisters, maternal aunts, and uncles.

SOCIAL HISTORY: She works as a cook for a nursing home, is single and has one daughter. Never smoked. Denies any alcohol. Has not been sexually active in a long time.

REVIEW OF SYSTEMS: Positive for 5-6 pound weight loss in recent months. Poor appetite. She wears glasses. She complains of a funny sensation in the throat and clearing her throat all of the time. GI: She has recurrent nausea. Currently, has no active vomiting. Chronic diarrhea since the time of the bypass with eight watery stools per day. She has joint aches and has all of the time spasms in both legs. Has had cysts removed in both breasts and recent mammogram in March 2006 was normal. History of depression and high stress with multiple psychosomatic complaints in the past. She reports that her fingersticks were high in the hospital and subsequently were rechecked and were normal. History of iron deficiency anemia in the past. Allergies: Sulfa causes hives.

PHYSICAL EXAMINATION: An overweight cushingoid-looking lady in no acute distress. WEIGHT: 170 pounds. TEMPERATURE: 96.7. BLOOD PRESSURE: 130/84. RESPIRATIONS: 12. PULSE: 62. HEENT: Conjunctivae are anicteric. Lids have no ptosis. Pupils are equal, round, and reacting to light. Optic disks are flat. No hemorrhages. ENT: Appear normal. Mucosa is moist. NECK: Supple. No JVD. No thyromegaly. LUNGS: Clear to auscultation. CARDIOVASCULAR: Normal heart sounds and 1/6 ejection systolic murmur. PULSES: All peripheral pulses are present. EXTREMITIES: No peripheral edema. BREASTS: Inspection of the breasts is normal. ABDOMEN: Soft and nontender. Normal bowel sounds. Multiple surgical scars. Multiple striae. No bruit. No hepatosplenomegaly. LYMPHATIC: No neck, axillary, or groin lymphadenopathy. MUSCULOSKELETAL: Gait and station are normal. No clubbing or cyanosis. SKIN: No rashes. NEUROLOGICAL: Cranial nerves are intact. Deep tendon reflexes are 2+. Strength is 5/5. PSYCHIATRIC: Judgment and insight are good. Orientation to time, place, and person is normal.

LABORATORY DATA: Laboratory data on 08/16/06: BUN 15, creatinine 2.3, sodium 142, potassium 3.4, chloride 102, uric acid 9.2, and albumin 3.9.

In August 2006, BUN 25 and creatinine 2.4.

On August 11, 2006: Hematocrit 37.3, hemoglobin 12.5, platelets 96,000, and white count 7.6.

UA done today: Specific gravity 1.015, blood trace, pH 5.5, and leukocyte esterase moderate.

On microscopy: There were few RBCs, some crystals, and multiple WBCs.

A CT of the chest report brought by the patient from 03/07/06: Stable splenomegaly, no evidence of liver metastasis, nonspecific dilated small bowel loops with a questionable possible idiopathic changes, and tiny benign cysts in the posterior aspect of the right kidney. The left kidney demonstrated a 1-cm cyst in the posterior aspect of the left kidney.

A DEXA scan report from 05/04/01 was normal.

ASSESSMENT AND PLAN:
1. Renal. This patient has chronic kidney disease stage 4 with an estimated creatinine clearance of 23 mL/minute. I unsure whether this renal failure is recent or she has had slow progression of her renal failure. I would appreciate it if you could forward the results of any laboratory tests done in the last two to three years to determine her creatinine. I am unsure of the exact etiology of her renal failure. I ordered a renal ultrasound to evaluate the kidney size and also to evaluate if she has been emptying her bladder completely. The patient does report that she has dribbling of urine and some incontinence. Also, I ordered a comprehensive metabolic panel, CBC, intact PTH, hepatitis B and C panel, and a 24-hour urine for protein and creatinine clearance. The patient has had recurrent UTIs in the past and it is possible that she has had chronic pyelonephritis and scarring resulting in chronic renal failure. She has a urinary tract infection currently with multiple WBCs on the microscopy. I prescribed ciprofloxacin 250 mg q.d. for 10 days and we will send her urine out for cultures, and we adjust her antibiotics if her urine cultures shows resistant organisms. I explained to the patient that if her renal function continues to worsen we might need to discuss renal replacement therapy with regards to either transplantation or dialysis. We will address this issue after the results are available. I also ordered a postvoid residual to see if she is emptying her bladder completely. I have advised her not to use any nonsteroidal antiinflammatory drugs.
2. Hypertension. Blood pressure is controlled off medications. We will reevaluate the blood pressure
on the next visit.
3. Urinary tract infection. Prescribed Cipro 250 mg q.d. pending cultures.
4. Chronic diarrhea. The patient states she has tried multiple agents with no relief of the diarrhea.
5. Chronic hypokalemia. The patient has been advised to call in with the potassium dose.
6. Follow up in six weeks.

Keywords: consult - history and phy., nephrology, consultation, hiatal hernia, hyperuricemia, renal failure, transfusion, uti, bladder, creatinine, creatinine clearance, dribbling, dysuria, emptying, frequency, hematuria, hypokalemia, incontinence, kidney stones, urgency, urinary tract infection, coronary artery disease, nephrology consultation, chronic hypokalemia, urinary tract, chronic diarrhea, infection, cysts,
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