Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Consultation Transcribed Medical Transcription Sample Report / Example




REASON FOR CONSULTATION:  Left foot ischemia.

HISTORY OF PRESENT ILLNESS:  The patient is a very pleasant (XX)-year-old female presenting to the emergency room from her primary care physician's office with complaints of left foot pain and discoloration.  The patient indicates progressive bluish discoloration involving the lateral aspect of the left foot, ultimately involving the toes and the plantar aspect of the forefoot.  This was associated initially with pruritus with subsequent paresthesias, ultimately resulting in significant pain.  Symptoms are worse in the dependent position.  The patient has had no similar symptomatology in the past.  The patient indicates no history of known deep venous thrombosis, no arterial thrombosis in the past.  No history of cardiac dysrhythmia.  No reported history of malignancy other than skin cancers, nonmelanoma.  Additional studies today did include a coagulation profile, which was normal, CBC revealing normal parameters, and comprehensive panel revealing no significant abnormality.  The patient indicates a strong family history of atherosclerotic cardiovascular disease, particularly myocardial infarction in several relatives.  The patient has no known history of rheumatologic disease.  Plain film evaluation of the left foot was entirely unremarkable.

PAST MEDICAL HISTORY:  Includes sigmoid diverticulosis without diverticulitis, atherosclerotic cardiovascular disease, mainly with peripheral arterial calcification, history of severe motor vehicle accident resulting in substantial right foot, pelvic, and facial trauma requiring reconstruction in the remote past, hypothyroidism, questionable history of superficial thrombophlebitis involving the right foot several years ago, requiring no anticoagulation.  History of hypercholesterolemia.  History of gastritis.  The patient denies known history of rheumatic or scarlet fever.  No history of liver disease or hepatitis, gallbladder, heart, lung or kidney disease.

MEDICATIONS:  Include Sinequan 25 mg daily, Synthroid 88 mcg daily, Darvocet-N 100 one to two p.o. q.6 h. p.r.n. pain, and Prempro 0.45 mg p.o. daily.


SOCIAL HISTORY:  The patient admits to smoking a pack of cigarettes daily for over 30 years.  She indicates no significant history of alcohol use.

FAMILY HISTORY:  Significant for heart disease and stroke.

REVIEW OF SYSTEMS:  The patient indicates no headache, no reported lightheadedness, no visual change, no sore throat or difficulty swallowing, no chronic sinusitis or congestion.  She denies difficulty swallowing.  She has had no chest pain.  No reported palpitations.  She denies change in breathing.  She did have a mild episode of bronchitis and did receive an over-the-counter sinus medicine.  She has had no apparent nausea or vomiting.  No reported abdominal or pelvic pain.  No diarrhea, constipation, bright red blood per rectum or melena.  No pedal edema.  She does have chronic pain involving the right ankle since her previous motor vehicle accident.

VITAL SIGNS:  Include a blood pressure of 114/52, respirations 21, pulse 66, and T-max 98.8.
SKIN:  Skin evaluation with attention to the left foot indicates a bluish discoloration involving the ball of her foot as well as all five toes.  There is additional ischemia in the arch as well as the lateral aspect of the left foot.  No additional skin changes.  No evidence of livedo reticularis identified at this time.
HEENT:  Pupils are equal and reactive to light.  Extraocular muscles are intact.  The sclerae are anicteric and noninjected.  The oropharynx is clear with no oral mucosal abnormality.
NECK:  Palpation of the neck demonstrates no cervical or supraclavicular lymph nodes.  No apparent thyroid enlargement or nodularity is evident.
LUNGS:  Clear to auscultation with good breath sounds.
HEART:  Regular rate and rhythm with no murmur, no ectopy or S3.
ABDOMEN:  Soft with no palpable hepatic or splenic enlargement.  No apparent abdominal mass or tenderness is evident.  No suprapubic mass or tenderness.  No inguinal adenopathy.
EXTREMITIES:  Demonstrate surgical change involving the right ankle.  Arterial supply appears unremarkable.  There is a palpable pedal pulse on the left as well as in the femoral region.  Posterior tibial pulse is difficult to determine.
NEUROLOGIC:  No current neurologic change is evident.

LABORATORY AND DIAGNOSTIC DATA:  Include a PT of 12.2 and PTT of 30.4.  CBC demonstrates a white count of 6900, hemoglobin 14.6, and platelet count 179,000.  Sedimentation rate is normal at 8.

An EKG demonstrates normal sinus rhythm with occasional premature atrial contractions.  Radiographic studies of the left foot are entirely unremarkable.

IMPRESSION:  Arterial insufficiency involving the left foot, of unclear origin.  Rule out thrombotic versus embolic phenomena.  Rule out hypercoagulable state.  Rule out occult malignancy.

RECOMMENDATIONS:  I agree with heparinization.  I agree with vascular surgery evaluation.  Undoubtedly, the patient will require angiogram.  Would keep on telemetry.  We will obtain an echocardiogram.  We will perform hypercoagulable workup including anticardiolipin panel, lupus anticoagulant, protein C and S, antithrombin III level, factor VIII level, homocysteine level, factor V Leiden, activated protein C resistance, and prothrombin gene mutation evaluation.  Further recommendations pending the above review.

Thank you very much for allowing me to participate in this very pleasant patient's case.