Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Hematology - Oncology Consult Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Hematological clearance.

Thank you, Dr. Doe, for allowing us to participate in this patient's medical care.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old female who has a history of von Willebrand disorder, which has never been confirmed.  She has been seen by more than one hematologist and the laboratory studies have been repeated in the past.  The patient, however, has history of easy bruising, history of bleeding post laparoscopic procedure, and significant bleeding post arthroscopy.  The patient stated that her family members have been diagnosed of plasminogen activator inhibitor deficiency.  Therefore, she consulted with a hematologist who ordered a test to determine if indeed she could have this.  Indeed, the patient was diagnosed as having plasminogen activator inhibitor deficiency.  She was going to have a tympanoplasty sometime in the recent past, and she was prescribed Amicar prior to the procedure.  The procedure went off uneventfully without any bleeding activity during the procedure, although it was not a significantly invasive procedure.  On further questioning, she denies having any excessive menstrual bleeding.  Usually, her menstruations lasts for approximately 5 days and it comes every 3 weeks, but there were times in the past that she had some vaginal bleeding that lasted sometimes up to 4 months.  Currently, she does not take any aspirin or nonsteroidal anti-inflammatory agents.  The patient stated that 4 days ago, after she ate a ham sandwich, when she was already feeling unwell with abdominal discomfort, she had abdominal crampy pain.  The day that she decided to come to the emergency department, yesterday, the abdominal pain was significant and the patient decided to come to this hospital for evaluation and treatment.  Concomitantly, she developed diarrhea. At the time of my evaluation, the patient was ready to have her breakfast and was hungry and stated that the abdominal pain had significantly decreased and, on a scale of 1 to 10, was a 3.  She denied any chills, any fever, and denied any urinary symptoms.  The patient's menstrual period had started approximately 4 days ago.  She denied any rectal bleeding, but she has been diagnosed with hemorrhoids.

SOCIAL HISTORY:  The patient denies smoking cigarettes and drinks alcohol socially.

ALLERGIES:  SHE HAS NO KNOWN DRUG ALLERGIES.

MEDICATIONS:  She was not taking medications prior to admission.

PAST MEDICAL HISTORY:  Otherwise unremarkable, except for previous laparoscopic evaluation, previous arthroscopy and tympanoplasty.  Denied any hypertension, any heart condition, and denied any liver disease.

FAMILY HISTORY:  As above.  The patient's family members have been diagnosed with plasminogen activator inhibitor deficiency.

REVIEW OF SYSTEMS:  Unremarkable.  She has no history of anorexia, any weight loss, any chest pain, cough, chills or fevers.

PHYSICAL EXAMINATION:
GENERAL:  This is a normal-appearing female in no significant distress at the time of the evaluation.
SKIN:  Her skin color was normal.  She has no petechiae or ecchymoses.
LYMPH NODES:  She has no palpable neck supraclavicular, axillary, inguinal adenopathy.
HEENT:  Evaluation was normal.
LUNGS:  Clear to auscultation.
HEART:  Regular rate and rhythm with normal heart sounds.
ABDOMEN:  Soft and nontender with increased bowel sounds without hepatosplenomegaly and without ascites.
RECTAL:  Examination was deferred.

DIAGNOSTIC IMPRESSION:  Coagulopathy of unclear etiology, von Willebrand disease, which has never been confirmed, and plasminogen activator inhibitor deficiency as per the patient's information.  The patient clearly appears to have tendency of bleeding following procedures.

RECOMMENDATIONS:  In view of this, I have recommended withholding the colonoscopy procedure since the patient could be at risk, particularly if any biopsy is taken during the procedure.  I recommended instead a full diagnostic workup that can be done as an outpatient.  The patient's symptoms have improved significantly and her diarrhea has improved.  She has an appointment to see Dr. Doe as an outpatient in approximately 10 days.  I will attempt to contact you and discuss with you my recommendations.

Thank you for allowing me to see your patient.

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