Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

History and Physical (H&P) Medical Transcription Sample Report


DATE OF ADMISSION:  XX/XX/XXXX


CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old white female who was in her usual state of health until yesterday morning when she began noticing shortness of breath with cough productive of clear phlegm and wheezing. She used her albuterol inhaler, but it did not improve. She had a neighbor bring her to the emergency room. She has been treated aggressively here in the emergency room and is feeling somewhat better. She reports no fever. No nasal congestion or sore throat. No nausea, vomiting or diarrhea. She does report some tightness at the base of the neck, which was unrelieved by nitroglycerin but was relieved by the respiratory treatments. The patient has a long-standing history of asthma. Usually uses Flovent and Serevent inhalers routinely, as well as Singulair.


PAST MEDICAL HISTORY:
1. Minimal atherosclerotic heart disease. She was admitted 8 years ago with an episode of atypical chest pain. Heart catheterization showed a 15-25% mid diffuse left anterior descending obstruction. The patient had a renal artery, on the left side, with greater than 90% stenosis. This was treated with angioplasty and stent by Dr. Doe that same month. He wanted to redo the stent indicating that there is probably some recurrent disease. She has not yet consented to this.
2. Dysrhythmia. Dr. Jane Doe, her prior cardiologist, had recommended pacemaker and AICD. I do not believe she ever had an electrophysiologic study. She has not been noted to have any arrhythmia problems in the last year or two.
3. Stroke with diplopia in the late 1980s. CT scan apparently showed an abnormality in the brain stem. She had a carotid Doppler done in September 1991, which did not show any significant stenoses.
4. Hypothyroidism. Followed by Dr. Jack Doe. She had Graves disease. Unsure how it was treated.
5. Recent episode of what sounds like vertigo. She did come to the emergency room about a week ago for this. She was treated in the emergency room, improved, went home, and has had no further problems.


PAST SURGICAL HISTORY:
1. Hysterectomy.
2. Left breast biopsy x3.


MEDICATIONS: Flovent 110 mcg 2 puffs b.i.d., Serevent 1 puff b.i.d., albuterol p.r.n., and Singulair 10 mg daily. She has used Rhinocort in the past. Levoxyl 137 mcg half tablet daily.


ALLERGIES: PENICILLIN CAUSED A RASH, CODEINE CAUSED CNS SYMPTOMS, NOVOCAIN AND XYLOCAINE ASSOCIATED WITH SYNCOPE, ACCUPRIL CAUSED A COUGH. SHE HAD A TAPE REACTION WITH CATHETERIZATION.


FAMILY HISTORY: Mother died in childbirth. Father died of heart disease. Sisters have breast cancer, diabetes, atrial fibrillation and hypertension. A brother had prostate cancer.


SOCIAL HISTORY: The patient is widowed. She has no family in town. She lives alone. She does not smoke or drink. She follows no special diet.


REVIEW OF SYSTEMS: The patient has some proptosis. An MRI scan showed this secondary to retroorbital fat. She has an ANA, which is slightly positive at 1:160 nucleolar with a sedimentation rate of only 16. No other rheumatologic symptoms. The patient did have hypertension secondary to her left renal stenosis. She is not on any medication at this time.


PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is currently afebrile with normal vital signs. Blood pressure was 135/78. O2 saturation is 97% on oxygen.
HEENT: ENT examination is unremarkable.
NECK: Supple without nodes or enlarged thyroid. Carotids are 2+ with a right carotid bruit.
LUNGS: Clear at this time with some slightly diminished breath sounds throughout.
HEART: Regular with a grade 1-2/6 systolic murmur at the right upper sternal border.
BREASTS: Without masses.
ABDOMEN: Soft and nontender. Bowel sounds are normal without organomegaly.
EXTREMITIES: Without edema. Pedal pulses are 2+.
NEUROLOGICAL: Nonfocal.
SKIN: Unremarkable.


LABORATORY DATA: Potassium 3.5, BUN 21, creatinine 1.2, and glucose 84. The rest of the profile, including liver enzymes, is normal. The CPK is 234 but the MB CPK is 3.5. Troponin is normal. EKG shows no significant ischemic changes. There is an inverted T wave in V3 and V4. INR is 0.92, PTT 28.6, hemoglobin 13.8, white blood cell count 3600, normal differential, and platelets are 155,000.


IMPRESSION:
1.  Exacerbation of underlying asthma.
2.  Minimal atherosclerotic heart disease.
3.  Renovascular hypertension.
a.  Status post left renal artery angioplasty and stent.
b.  Normotensive post procedure.
4.  History of dysrhythmia.
5.  Stroke, late 1980s, with resolution.
6.  Hypothyroidism.
7.  Right carotid bruit.


PLAN: The patient is admitted to the hospital to continue pulmonary toilet with intravenous steroids. Singulair will be continued, as will her Flovent and Serevent. Carotid sonogram will be done.

MT Word Help

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites