Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Holter Monitor Report Transcription Sample / Example

DATE OF HOLTER:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

HOLTER FINDINGS:  The base rhythm was normal sinus with episodic sinus bradycardia and sinus tachycardia with rates ranging between 55 and 130 beats per minute with an average rate of 80 beats per minute.  No heart block was observed.  No ventricular ectopy was seen.  Rare PACs were detected with a total Holter count of 6.  No major ST or T wave changes from baseline were observed during monitoring.  No symptom diary was returned by the patient for symptom correlation.

CONCLUSIONS:
1.  Normal sinus rhythm with sinus arrhythmia and episodic sinus bradycardia and sinus tachycardia.
2.  Rare PACs.
3.  No symptom diary was returned for symptom correlation.

*********************************************************************************
24-HOUR HOLTER MONITOR REPORT

DATE OF HOLTER:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

HOLTER FINDINGS:  The base rhythm was sinus tachycardia with episodic sinus rhythm with rates ranging between 80 and 150 beats per minute with an average rate of 100 beats per minute.  Persistent conduction block of the right bundle type was noted throughout the recording session.   No high-grade AV block was seen.  There were frequent PVCs detected.   There were no runs of ventricular tachycardia observed, but there were runs of ventricular bigeminy noted.  No major ST or T wave changes from baseline were seen.  No symptom diary was returned by the patient for symptom correlation.

CONCLUSIONS:
1.  Sinus tachycardia with sinus rhythm.
2.  Right bundle branch block.
3.  Frequent PVCs.
4.  Frequent PACs.
5.  No symptom diary was returned for symptom correlation.

*********************************************************************************
M-MODE, 2-D AND DOPPLER INTERROGATION

DATE OF STUDY:  MM/DD/YYYY

PROCEDURE PERFORMED:  M-mode, 2-dimensional and Doppler echocardiographic study.

REFERRING PHYSICIAN:  John Doe, MD

INDICATIONS:  The patient is a (XX)-year-old gentleman with history of dementia and CVA.

FINDINGS:
1.  This is a technically limited study; however, there is evidence of left ventricular hypertrophy, and based on limited views, he appears to have preserved systolic function without any obvious regional wall motion abnormalities. However, not all walls are seen clearly. The estimated left ventricular ejection fraction is approximately 55% based on limited views.
2.  Normal right ventricular size and preserved function.
3.  Right atrial size is within normal limits and there is left atrial enlargement.
4.  Aortic root was measured to be of normal caliber.
5.  Aortic valve appears to be calcified but mobile. There is no clear evidence of regurgitation and no stenosis across the aortic valve by 2-D and Doppler interrogation. There is trace regurgitation and no stenosis across the mitral valve on 2-D and Doppler interrogation. There is moderate tricuspid regurgitation as well as moderate pulmonic regurgitation.
6.  There is evidence of severely elevated pulmonary hypertension. Estimated RV systolic pressure approximately 82 mmHg.
7.  No obvious evidence of intracardiac thrombi, vegetation or mass.
8.  No evidence of pericardial effusion.

CONCLUSIONS: 
1.  Technically limited study. 
2.  Left ventricular hypertrophy with preserved systolic function in limited views without obvious regional wall motion abnormalities; however, not all walls were seen clearly.
3.  Based on limited images, it appears that the patient's systolic function appears to be within normal limits. Ejection fraction visually estimated at approximately 55%.
4.  Left atrial enlargement.
5.  Moderate tricuspid and pulmonic regurgitation.
6.  Severe pulmonary hypertension.
7.  There was no evidence of pericardial effusion.