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Consultation Medical Transcription Sample Report

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Abdominal pain and abnormal ultrasound.

HISTORY OF PRESENT ILLNESS: The patient is a delightful (XX)-year-old white female who was admitted to the hospital after experiencing syncopal symptoms. She was admitted on to a telemetry floor and has ongoing cardiology consultation and followup. She was noted to have complaints of abdominal pain, of midepigastric and substernal location. She states that she has onset of these symptoms approximately weekly, and due to concern of her cardiac ischemia with a history of coronary artery disease, cardiac consultation was requested. She currently describes no symptoms of abdominal or chest pain. She states that she was having significant postprandial reflux complaints, and she manages with p.r.n. Nexium therapy. She states that food occasionally will feel stuck in her lower chest area, approximately once or twice a week, and she states that this happens on an intermittent basis and is not associated with any typical food intake such as dry breads or meat products. She states that sometimes she merely gets a sensation of tightness in her lower chest and a fullness sensation. This is consistent with a globus sensation of the esophagus.

She has a significant past GI history, of approximately 4 years, having evaluation by my partner, Dr. John Doe, for reflux and esophageal spasm. She had an EGD and an empiric dilation of lower esophagus performed with short-term relief of symptoms. Subsequently, she has been noted, on this hospitalization, to have right-sided abdominal pain. She describes the pain as subacute in nature, not of recent onset, and involving the right lower quadrant and at previous surgical site. She states that her bowels are generally hard and require stool softeners regularly. She states that she will often get the sensation of fullness or pain about the right lower quadrant that she relates to a hernia that she localizes to that area. She has several surgical scars and states that in the past she has been told she has postsurgical adhesions, which affect her bowel regularity. She has not had a colonoscopy in the last 5 years. She has not had an EGD in the last 3 years.

PAST MEDICAL HISTORY: She has no diabetes. She has positive coronary artery disease. She has positive hypercholesterolemia, and she has current evaluation for symptomatic bradycardia.

PAST SURGICAL HISTORY: She had a hysterectomy, she had an appendectomy, and she had an exploratory laparotomy performed in the distant past.

ALLERGIES: SHE HAS DRUG ALLERGIES TO PENICILLIN AND QUESTIONABLE IODINE SENSITIVITY WITH RADIOPHARMACEUTICAL DYE.

MEDICATIONS: As an outpatient, Nexium taken on a p.r.n. basis. She takes also Dyazide, Xanax half a tablet a day, baby aspirin a day, and Atacand daily.

FAMILY HISTORY: Negative for colon cancer, negative for gastric cancer, positive for a female family member with pancreatic disease of unclear etiology. She has 2 female family members who are status post cholecystectomy for symptomatic gallstones. She herself has not had prior hospitalization for cholelithiasis or cholecystitis.

REVIEW OF SYSTEMS: On comprehensive review of systems, she has positive cardiac complaints, positive pulmonary complaints, positive GI complaints, positive constitutional complaints, negative endocrine, negative skin, negative neurologic, and negative GYN or urologic complaints.

PHYSICAL EXAMINATION: Vital Signs: Temperature is 97.2 degrees, heart rate is 52, she has a respiratory rate of 16, and blood pressure of 139/51. She is saturating 98% on room air at this time. General: She is taking her afternoon meal with no abdominal complaints, and she has been eating a general diet for the last 24-48 hours. HEENT: On examination, she has anicteric sclerae. She has a normocephalic and atraumatic head examination. Oropharyngeal examination is intact. Mucous membranes are moist. Neck: Supple. No lymphadenopathy. No goiter. No thyromegaly. Cardiac: Bradycardia. Normal S1 and S2. No murmur. Chest: Clear to auscultation bilaterally. Abdomen: She has 3 healed surgical incisions. She has positive bowel sounds. She has a soft and nontender abdomen. She is tender to manipulation of the right lower quadrant in the region of the appendectomy. She has an incisional hernia present. She has an apparent incisional hernia along the midline, and she has no right upper quadrant tenderness. No Murphy sign. No rebound. No guarding. The remainder of the abdomen is soft and benign. She has a nonincarcerated hernia of the right lower quadrant. Extremities: She has no edema, no skin and joint finding. Neurologic: Examination is intact.

LABORATORY STUDIES: She has a WBC count of 3200, hemoglobin 10.3, and platelet count 214,000. She has sodium of 140, creatinine 0.6, and magnesium 2.3. She has a normal GGT. She has a normal AST and normal ALT. She has a normal total bilirubin. Her alkaline phosphatase is elevated at 190. The remainder of her serum chemistries are normal.

RADIOLOGY IMAGING: Right upper quadrant ultrasound reveals no intrahepatic ductal dilatation, reveals a small single 2 mm stone within the gallbladder, reveals a normal-appearing gallbladder wall, no wall thickening, no edema, no pericholecystic fluid. Her common bile duct is diffusely at the upper limit of normal at 8-9 mm. There is some dilation to approximately 9 mm at the most proximal extent near the common hepatic duct. There are no other abnormalities noted on ultrasound.

IMPRESSION: The patient is a pleasant (XX)-year-old white female who was admitted to the hospital with syncopal symptoms and has symptomatic bradycardia. She is experiencing some midepigastric and mid chest discomfort, and these symptoms could be consistent with esophageal spasm or stricture as her past gastrointestinal history would suggest. She is status post esophageal dilation with some relief of her symptoms. These are consistent with noncardiac chest pain-type symptoms. Additionally, she has some right lower quadrant tenderness at the site of a postsurgical site incisional hernia. She has a benign right upper quadrant. She additionally has symptoms and history of gastroesophageal reflux disease and constipation.

The patient is feeling well, as she has no right upper quadrant symptoms, as she has a normal GGT and liver function tests, which all correlate with an essentially normal right upper quadrant ultrasound with the exception of a small stone present in the gallbladder. The diameter of her common bile duct is not alone impressive with lack of AST/ALT elevation and right upper quadrant symptoms. I have personally reviewed the ultrasound findings with the radiologist.

SUGGESTIONS: My suggestions at this time include: 
1. Twice daily Nexium therapy to be taken before meals, directed at control of her GERD symptoms, which have been more significant recently. 
2. Continued pacemaker evaluation, which should be useful provided her symptomatic bradycardia. 
3. It is important that she follows up with me in the office in 1-2 weeks, for most likely she will need an EGD with esophageal dilation and I will at that time complete repeat liver function testing and examination of the right upper quadrant to verify my impression as above.

I have suggested noninvasive MRI of the biliary tree; however, she attempted to have an MRI during this admission and she experienced significant anxiety related to potential claustrophobia. Should she be able to complete the study, this would be useful for definite evaluation of the anatomy of her biliary tree; however, in the setting of tolerance of her diet and no right upper quadrant symptoms with normal liver function tests, which do not suggest gallstone in the common bile duct, I feel that it would be reasonable for her to have close outpatient followup with me. I have explained to her that should right upper quadrant symptoms recur, should temperature elevate or should she experience nausea or any change in symptoms, she needs to tell her primary physician or call my office for further management.

Thank you for allowing me to participate in this patient's care. If you have any further questions or concerns, please do not hesitate to contact me.

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