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: Chest Wall Lump - Consult

Description: Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor.
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Lump in the chest wall.

HISTORY OF PRESENT ILLNESS: This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. It is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.

CHRONIC/INACTIVE CONDITIONS
1. Hypertension.
2. Hyperlipidemia.
3. Glucose intolerance.
4. Chronic obstructive pulmonary disease?
5. Tobacco abuse.
6. History of anal fistula.

ILLNESSES: See above.

PREVIOUS OPERATIONS: Anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery.

PREVIOUS INJURIES: He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. He told me that he hit a moose once, but he does not remember hitting his chest.

ALLERGIES: TO BACTRIM, SIMVASTATIN, AND CIPRO.

CURRENT MEDICATIONS
1. Lisinopril.
2. Metoprolol.
3. Vitamin B12.
4. Baby aspirin.
5. Gemfibrozil.
6. Felodipine.
7. Levitra.
8. Pravastatin.

FAMILY HISTORY: Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke.

SOCIAL HISTORY: The patient is married. He works as a truck driver and he drives in town. He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.

REVIEW OF SYSTEMS
CONSTITUTIONAL: Denies weight loss/gain, fever or chills.
ENMT: Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision.
CV: See history of present illness. Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains.
RESPIRATORY: He has a chronic cough. Denies shortness of breath, wheezing, sputum production or bloody sputum.
GI: Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation.
GU: Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain.
MS: Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness.
NEURO: Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis.
PSYCH: Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts.
INTEGUMENTARY: Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration.

PHYSICAL EXAMINATION
CONSTITUTIONAL: Blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds. The patient is well developed, well nourished, and with fair attention to grooming. The patient is moderately overweight.
NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.
RESPIRATION: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs. There is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum.
CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click, or rub. Carotid pulses 2+ without bruits. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 2+ bilaterally, without audible bruits. Extremities show no edema or varicosities.
BREASTS: Breasts are symmetric, without skin retraction or nipple discharge. No masses or tenderness in either breasts or axillae.
GASTROINTESTINAL: No palpable tenderness or masses. Liver and spleen are percussed but not palpable under the costal margins. No evidence for umbilical or groin herniae.
LYMPHATIC: No nodes over 3 mm in the neck, axillae or groins.
MUSCULOSKELETAL: Normal gait and station. There is an old traumatic amputation of his right fifth digit. Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.
SKIN: There are no rashes, lesions, or ulcers. No induration or subcutaneous nodules to palpation.
PSYCHIATRIC: Oriented to time, place and person. Appropriate mood and affect.

LABS: The only significant finding in the ultrasound of the area is that it shows this to be related to bone.

DIAGNOSES
1. Chest wall mass.
2. Hypertension.
3. Hyperlipidemia.
4. Glucose intolerance.
5. Chronic obstructive pulmonary disease?
6. Tobacco abuse.

PLANS/RECOMMENDATIONS: The most likely explanation on this lump is that this is probably an old fracture of the area with callus formation. We need to rule out the possibility of a tumor. Therefore, I have ordered the patient to have a CT of the chest. He will come back to the office next time after this is done.

Keywords: consult - history and phy., ct of the chest, chest wall, chest, tenderness, axillae, hypertension, respiratory, abdominal, bruits, lump, masses,
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