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Medical Transcription History and Physical Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS:  The patient is an (XX)-year-old female with history of TIAs, hypertension, hyperlipidemia, IBS and hypothyroidism, who was admitted yesterday after syncopal episode at home. The patient reports sitting outside for a while and then when she got up to walk into the house, she felt faint, slightly lightheaded and, when she got to the door, apparently fainted but seemed to recover within a few minutes. Her niece was there and witnessed the episode. There was some very short-lived confusion after the patient recovered, but then she felt better right away. There was no seizure activity, incontinence or postictal state. The patient denied any chest pain or palpitations prior to the syncopal episode. She does report that it was similar to a syncopal episode after having a bowel movement several years ago. Of note, the patient was most recently admitted to the hospital about two weeks ago for left facial numbness and TIA, which she has had multiple times in the past. At that time, workup included a negative EEG, a normal 2-D echocardiogram, carotid MRAs and Doppler studies as well as a brain MRI, which did not reveal any acute bleeds or ischemia, but did demonstrate the patient's known AV malformation. The patient had been evaluated by the neurology service, and once her workup was completed, she was discharged home in stable condition. She was seen in the office last week and was doing quite well until this event yesterday. This morning, she is doing well. She looks fine. There are no other complaints. Of note, she does report having a negative stress test 4 years ago.

PAST MEDICAL HISTORY:  TIAs, hypertension, hyperlipidemia, hypothyroidism, history of AV malformation and IBS.

MEDICATIONS:  Aspirin 81 mg daily, levothyroxine 25 mcg daily, Zocor 10 mg daily and lisinopril 40 mg daily.

ALLERGIES:  SULFA.

SOCIAL HISTORY:  No smoking, alcohol or drug use.

FAMILY HISTORY:  Mother died of colon cancer. Father had heart disease.

PHYSICAL EXAMINATION:  
VITAL SIGNS:  Blood pressure 144/74, pulse 72, respirations 18.
GENERAL:  The patient is alert and oriented x3. No acute distress. Nontoxic appearing.
HEENT:  Negative.
NECK:  Supple. No lymphadenopathy.
LUNGS:  Clear.
HEART:  Regular rate and rhythm with a faint holosystolic murmur consistent with the patient's mild mitral valve insufficiency seen on recent echocardiogram.
ABDOMEN:  Soft, nontender and nondistended. No hepatosplenomegaly. No masses.
EXTREMITIES:  No edema.
NEUROLOGIC:  Nonfocal.
SKIN:  Warm and dry. No rashes.

LABORATORY DATA:  On admission, white blood cell count was 6.6, hemoglobin 14.4, hematocrit 41.6, platelets 169,000. Glucose 104, BUN 21, creatinine 0.9. Sodium 134, potassium 3.6, chloride 101, CO2 of 28. LFTs were normal. Troponin was less than 0.4. Calcium was 9.3. D-dimer was 774. BNP was 23.

CT scan of the chest in the emergency room was negative for PE.

ASSESSMENT:
1.  Syncope, likely due to orthostatic hypotension.
2.  Hypertension.
3.  History of transient ischemic attacks.
4.  Hyperlipidemia.
5.  Hypothyroidism.
6.  History of arteriovenous malformation.
7.  History of irritable bowel syndrome.

PLAN:  We will repeat troponin this morning and check orthostatic blood pressures. If troponin is negative, we will obtain an adenosine stress thallium and await further neurology input and reevaluation.