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: Cardiac Consultation - 7

Description: The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old African-American male previously well known to me. He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation. There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission. He has a previous history of transient ischemic attack with no residual neurologic deficits.

The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation. The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.

PAST MEDICAL AND SURGICAL HISTORY:
1. Type I diabetes mellitus.
2. Hyperlipidemia.
3. Hypertension.
4. Morbid obesity.
5. Sleep apnea syndrome.
6. Status post thyroidectomy for thyroid carcinoma.

REVIEW OF SYSTEMS:
General: Unremarkable.
Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.
Gastrointestinal: Unremarkable.
Genitourinary: See above.
Musculoskeletal: Unremarkable.
Neurologic: Unremarkable.

FAMILY HISTORY: There are no family members with coronary artery disease. His mother has congestive heart failure.

SOCIAL HISTORY: The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs.

MEDICATIONS PRIOR TO ADMISSION:
1. Clonidine 0.3 mg b.i.d.
2. Atenolol 50 mg daily.
3. Simvastatin 80 mg daily.
4. Furosemide 40 mg daily.
5. Metformin 1000 mg b.i.d.
6. Hydralazine 25 mg t.i.d.
7. Diovan 320 mg daily.
8. Lisinopril 40 mg daily.
9. Amlodipine 10 mg daily.
10. Lantus insulin 50 units q.p.m.
11. KCl 20 mEq daily.
12. NovoLog sliding scale insulin coverage.
13. Warfarin 7.5 mg daily.
14. Levothyroxine 0.2 mg daily.
15. Folic acid 1 mg daily.

ALLERGIES: None.

PHYSICAL EXAMINATION:
General: A well-appearing, obese black male.
Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.
HEENT: Grossly normal.
Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.
Chest: Midline sternotomy scar.
Lungs: Clear.
Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.
Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.
Extremities: Normal. No edema. Pulses bilaterally intact, carotid, radial, femoral, and dorsalis pedis.
Neurologic: Mental status, no gross cranial nerve, motor, or sensory deficits.

ELECTROCARDIOGRAM: Normal sinus rhythm. Right bundle-branch block. Findings compatible with old anteroseptal and lateral wall myocardial infarction.
_______ nonspecific ST-T abnormality.

IMPRESSION:
1. Status post nephrolithotomy with postoperative hematuria.
2. Aortic valve disease, status post aortic valve replacement on 10/15/2007.
3. Congestive heart failure, diastolic, chronic, stable, NYSHA class I to II.
4. Paroxysmal atrial fibrillation.
5. Status post remote transient ischemic attack with no residual neurologic deficits.
6. Type I diabetes mellitus.
7. Hyperlipidemia.
8. Hypertension.
9. Morbid obesity.
10. Sleep apnea syndrome.
11. Chronic therapeutic anticoagulation.

RECOMMENDATIONS: Until resolution of the hematuria, I agree with the necessity of discontinuation of all anticoagulation. There is obvious risk both due to prosthetic aortic valve and paroxysmal atrial fibrillation with continuation of anticoagulation; however, the risk of uncontrolled bleeding is essentially worse.
Continue other medications.

Keywords: consult - history and phy., aortic valve disease, aortic valve replacement, anticoagulation, paroxysmal atrial fibrillation, congestive heart failure, neurologic deficits, atrial fibrillation, aortic valve, heart, ischemic, atrial, neurologic, aortic, valve, disease,
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