Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Syncope Consultation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Syncope.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old female with a history of hypoglycemia who had a syncopal episode earlier today and is brought in to seek further medical attention. The patient states that she was in her usual state of health up until yesterday, when she had some trouble sleeping. She had some diminished appetite and did not eat dinner. She did not sleep well during the night and skipped breakfast this morning as well. She was brought to work by her daughter due to her fatigue and weakness. Shortly after arriving at work, the patient had a true syncopal episode. The patient does not recollect how long she was down for. No bladder or bowel incontinence or tongue biting was noted.

The patient denies any prodrome, shakiness, as she has had in previous syncopal episodes with the last one occurring approximately 4 years ago. The patient does have a history of hypoglycemia and reportedly had a blood sugar of 58 at the time of the syncopal episode today. The patient was given some glucose and had significant improvement in her symptoms. The patient denied any chest pain or shortness of breath. She denied any palpitations during this episode. She denied any fevers, chills, nausea, vomiting or diarrhea. The patient denied any bright red blood per rectum or melena or hematemesis.

PAST MEDICAL HISTORY:  The patient has a history of hypoglycemia previously treated medically and was instructed to eat frequent meals, history of previous syncope with the last episode approximately 4 years ago, related to hypoglycemia, per her description, and 2 prior pregnancies with no complications.

ALLERGIES:  None.

MEDICATIONS:  Ambien as needed.

SOCIAL HISTORY:  The patient is a nonsmoker. She denies any heavy alcohol use. She has 2 children.

FAMILY HISTORY:  Positive for history of hypertension and diabetes. No early family history of coronary artery disease.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  No fevers, night sweats or weight loss.
HEAD AND NECK:  No blurred vision or tinnitus.
PULMONARY:  No productive cough, shortness of breath or chest pain.
CARDIOVASCULAR:  See HPI.
GASTROINTESTINAL:  No melena or bright red blood per rectum or abdominal pain.
GENITOURINARY:  History of 2 previous pregnancies, currently on estrogen patch for birth control.
ENDOCRINE:  No history of diabetes or thyroid disease.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Initial blood pressure was 114/76, pulse 68, weight 182 pounds, temperature 98.6.
GENERAL:  The patient is an alert and pleasant female, in no acute distress.
HEENT:  Normocephalic and atraumatic. Oropharynx is moist. No thrush.
NECK:  Supple. No adenopathy JVD.
LUNGS:  Clear to auscultation bilaterally.
CARDIOVASCULAR:  Shows normal S1 and S2. There was a soft 2/6 systolic murmur with splitting of the second heart sound noted. No gallops or rubs.
ABDOMEN:  Soft and nontender. No hepatosplenomegaly.
EXTREMITIES:  Warm. No cyanosis, clubbing or edema.
NEUROLOGIC:  The patient is alert and oriented x3. Cranial nerves II through XII intact, 5/5 upper and lower extremity strength, 2+ deep tendon reflexes bilaterally.
DIAGNOSTIC DATA:  EKG shows sinus rhythm. There is incomplete right bundle-branch block. Nonspecific ST changes are noted.

LABORATORY DATA:  White blood cell count 7.6, hemoglobin 12.6, hematocrit 39.2, and platelets 266,000. Glucose is elevated at 136, BUN of 9, creatinine of 0.9. Initial CK-MB is less than 0.7.

IMPRESSION:  Syncope, vasovagal versus related to hypoglycemia.

PLAN:  Agree with telemetry monitoring overnight. The patient is now not orthostatic and feels much better after glucose administration. This likely implicates hypoglycemia as being the culprit for her syncope. Agree with 2D echo to better rule out valvular heart disease as a culprit for syncope. The patient did not have any chest pain or exertional shortness of breath, and there was no further need for an ischemia evaluation at this time; although, one may reconsider in the future on an outpatient basis. I agree with gentle hydration. Consideration for outpatient tilt table testing if there is recurrence of syncope. Suggest further workup of etiology of hypoglycemia.