Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Initial Office Visit / Chart Note Medical Transcription Transcribed Sample Report

SUBJECTIVE:  This is a (XX)-year-old male with multiple past medical history including arrhythmia, which most likely is paroxysmal atrial fibrillation, currently in sinus rhythm with PVCs, status post pacemaker placement and ICD; this was subsequently revised.  History of CAD, status post CABG with two-vessel disease; status post MI x1; hypertension; hyperlipidemia; hypothyroidism; status post CVA with initial residual deficit in the right eye which has resolved; BPH; B12 deficiency; status post surgery for peptic ulcer disease, most likely with perforation; status post spinal surgery x2; status post TURP for BPH.  The patient came for initial visit complaining of vertigo/generalized dizziness for the last two weeks.  This usually is precipitated during change in position from supine to upright but without any preceding or accompanying signs or symptoms like headache or amaurosis fugax.  No presyncope or syncopal episode.  No focal deficit.  The patient denied any tinnitus, although with some aural fullness or decreased aural acuity.  The patient has seen his former PCP and was given meclizine, which relieved the symptoms, but then it caused the patient to be more lethargic and the patient decided to stop the medication.  Currently, the patient's vertigo or dizziness has markedly improved.

PAST MEDICAL/SURGICAL HISTORY:  As mentioned above.

FAMILY HISTORY:  Significant for cancer.  No other heredofamilial diseases noted.

SOCIAL HISTORY:  The patient denied recreational drugs.  He used to smoke, but quit many years ago.  Denied any heavy alcohol use.

MEDICATIONS AT HOME:  Warfarin 5 mg one-half tablet on Monday, Wednesday, Friday, and one tablet on Tuesday, Thursday, Saturday, Sunday; potassium 10 mEq two tablets once a day; lisinopril 20 mg daily; simvastatin 40 mg at bedtime; levothyroxine 0.05 mg daily; meclizine 25 mg b.i.d. p.r.n.; promethazine 25 mg one-half tablet to one tablet q.6h. p.r.n.; clindamycin as SBE prophylaxis for any procedures, especially dental procedures; Betapace 80 mg b.i.d.; betamethasone lotion 0.1% b.i.d. p.r.n.; magnesium; and zinc.

ALLERGIES:  THE PATIENT IS ALLERGIC TO PENICILLIN.

REVIEW OF SYSTEMS:  HEENT:  Unremarkable.  CENTRAL NERVOUS SYSTEM:  As mentioned, vertigo.  This was followed by generalized dizziness.  CARDIOVASCULAR:  Unremarkable.  PULMONARY:  Unremarkable.  GASTROINTESTINAL:  Nausea, but this was associated with the vertigo.  No abdominal pain.  Occasional episodes of vomiting with the nausea.  No change in bowel habits.  No melena.  No hematochezia.  No hematemesis.  Mild anorexia, but no weight change.  GENITOURINARY:  Unremarkable.  MUSCULOSKELETAL:  Unremarkable.  INTEGUMENTARY:  Unremarkable.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a well-nourished, well-developed male.  Alert and oriented x3, not in acute distress, ambulatory.
VITAL SIGNS:  Temperature 98.4, blood pressure 138/92, pulse 66, respirations 22, and weight 180 pounds.  Height 5 feet 4 inches.
HEENT:  Normocephalic.  Pupils equally reactive to light and accommodation.  Anicteric.  Pink conjunctivae.  No nasal or pharyngeal congestions.  No oral lesions.  Otoscopy:  There is a mild effusion behind the right tympanic membrane, but no erythema and no discharge.
NECK:  Supple.  There is no mass.  No palpable cervical lymph nodes.  No carotid bruit.  No evidence of jugular venous distention.
LUNGS:  Clear to auscultation.
HEART:  Normal rate.  Regular rhythm.  There is no gallop.  There are premature beats intermittently.
ABDOMEN:  Soft and flabby.  Presence of bowel sounds.  Presence of abdominal scar.  There is no bruit.  No hepatojugular reflux.  Nontender.
EXTREMITIES:  Equal radial and pedal pulses.  There is about +1 pitting leg edema.  There is no cyanosis, no petechiae, no hematoma.
NEUROLOGIC:  There is no focal deficit.

ASSESSMENT AND PLAN:
1.  Vertigo/generalized dizziness, most likely this is secondary to orthostatic hypotension by history, although have to rule out any other cause, especially vertebrobasilar insufficiency.  The patient does have very high risk for arteriosclerosis.  Unlikely benign positional vertigo.  Can be secondary to labyrinthitis.  Plan is to continue with the same medication.  We will get a carotid ultrasound.  We will refer the patient to Neurology for further evaluation and management.
2.  History of pacemaker placement as well as AICD.  Continue observation.  The patient needs to be referred back to Cardiology for a pacemaker as well as defibrillator check.
3.  History of CAD, status post CABG with two-vessel disease and status post MI x1.  Continue with the same management and risk modification factors.
4.  History of arrhythmias, most likely secondary to paroxysmal atrial fibrillation, currently in sinus rhythm.  Continue with the same medications, especially with Betapace.  The patient will need cardiology followup as well.
5.  History of hyperlipidemia.  Continue with the same treatment and diet.  Need to recheck the lipid profile and LFTs.
6.  Hypertension, currently fairly controlled.  Continue with the same treatment and diet.  Recheck the blood pressure on the next followup.
7.  Hypothyroidism.  Continue with the same treatment.  Need to recheck the TSH level.
8.  History of CVA with no residual deficit.  Continue with the same management and risk modification factors.
9.  History of B12 deficiency.  Need to check B12 level and folic acid level.  We will continue with the B12 shot monthly.
10.  History of BPH, status post TURP.
11.  History of peptic ulcer disease, status post surgery, currently resolved.  We will just observe.
12.  Health maintenance screening, which would include a PSA level.  We will get the result of both the upper endoscopy and the colonoscopy per GI, which was done not too long ago.  The patient will also be advised about pneumonia vaccine at the next followup.