History and Physical Medical Transcription Sample Transcribed Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:  Not Dictated.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old white female who was in her usual state of health until yesterday morning when she began noticing shortness of breath with cough productive of clear phlegm and wheezing. She used her albuterol inhaler, but it did not improve. She had a neighbor bring her to the emergency room. She has been treated aggressively here in the emergency room and is feeling somewhat better. She reports no fever. No nasal congestion or sore throat. No nausea, vomiting or diarrhea. She does report some tightness at the base of the neck, which was unrelieved by nitroglycerin but was relieved by the respiratory treatments. The patient has a long-standing history of asthma. Usually uses Flovent and Serevent inhalers routinely, as well as Singulair.

PAST MEDICAL HISTORY:
1. Minimal atherosclerotic heart disease. She was admitted 8 years ago with an episode of atypical chest pain. Heart catheterization showed a 15-25% mid diffuse left anterior descending obstruction. The patient had a renal artery, on the left side, with greater than 90% stenosis. This was treated with angioplasty and stent by Dr. Doe that same month. He wanted to redo the stent indicating that there is probably some recurrent disease. She has not yet consented to this.
2. Dysrhythmia. Dr. Jane Doe, her prior cardiologist, had recommended pacemaker and AICD. I do not believe she ever had an electrophysiologic study. She has not been noted to have any arrhythmia problems in the last year or two.
3. Stroke with diplopia in the late 1980s. CT scan apparently showed an abnormality in the brain stem. She had a carotid Doppler done in September 1991, which did not show any significant stenoses.
4. Hypothyroidism. Followed by Dr. Jack Doe. She had Graves disease. Unsure how it was treated.
5. Recent episode of what sounds like vertigo. She did come to the emergency room about a week ago for this. She was treated in the emergency room, improved, went home, and has had no further problems.

PAST SURGICAL HISTORY:
1. Hysterectomy.
2. Left breast biopsy x3.

MEDICATIONS: Flovent 110 mcg 2 puffs b.i.d., Serevent 1 puff b.i.d., albuterol p.r.n., and Singulair 10 mg daily. She has used Rhinocort in the past. Levoxyl 137 mcg half tablet daily.

ALLERGIES: PENICILLIN CAUSED A RASH, CODEINE CAUSED CNS SYMPTOMS, NOVOCAIN AND XYLOCAINE ASSOCIATED WITH SYNCOPE, ACCUPRIL CAUSED A COUGH. SHE HAD A TAPE REACTION WITH CATHETERIZATION.

FAMILY HISTORY: Mother died in childbirth. Father died of heart disease. Sisters have breast cancer, diabetes, atrial fibrillation and hypertension. A brother had prostate cancer.

SOCIAL HISTORY: The patient is widowed. She has no family in town. She lives alone. She does not smoke or drink. She follows no special diet.

REVIEW OF SYSTEMS: The patient has some proptosis. An MRI scan showed this secondary to retroorbital fat. She has an ANA, which is slightly positive at 1:160 nucleolar with a sedimentation rate of only 16. No other rheumatologic symptoms. The patient did have hypertension secondary to her left renal stenosis. She is not on any medication at this time.

PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is currently afebrile with normal vital signs. Blood pressure was 135/78. O2 saturation is 97% on oxygen.
HEENT: ENT examination is unremarkable.
NECK: Supple without nodes or enlarged thyroid. Carotids are 2+ with a right carotid bruit.
LUNGS: Clear at this time with some slightly diminished breath sounds throughout.
HEART: Regular with a grade 1-2/6 systolic murmur at the right upper sternal border.
BREASTS: Without masses.
ABDOMEN: Soft and nontender. Bowel sounds are normal without organomegaly.
EXTREMITIES: Without edema. Pedal pulses are 2+.
NEUROLOGICAL: Nonfocal.
SKIN: Unremarkable.

LABORATORY DATA: Potassium 3.5, BUN 21, creatinine 1.2, and glucose 84. The rest of the profile, including liver enzymes, is normal. The CPK is 234 but the MB CPK is 3.5. Troponin is normal. EKG shows no significant ischemic changes. There is an inverted T wave in V3 and V4. INR is 0.92, PTT 28.6, hemoglobin 13.8, white blood cell count 3600, normal differential, and platelets are 155,000.

IMPRESSION:
1. Exacerbation of underlying asthma.
2. Minimal atherosclerotic heart disease.
3. Renovascular hypertension.
a. Status post left renal artery angioplasty and stent.
b. Normotensive post procedure.
4. History of dysrhythmia.
5. Stroke, late 1980s, with resolution.
6. Hypothyroidism.
7. Right carotid bruit.

PLAN: The patient is admitted to the hospital to continue pulmonary toilet with intravenous steroids. Singulair will be continued, as will her Flovent and Serevent. Carotid sonogram will be done.


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Selective Coronary Cineangiography and PCI Transcribed Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURES PERFORMED:
1.  Diagnostic selective coronary cineangiography.
2.  Percutaneous coronary intervention of an occluded right coronary artery.
3.  Intracoronary nitroglycerin and Integrilin injection.

OPERATOR:  John Doe, MD

DESCRIPTION OF PROCEDURE:  The patient was transferred from an outside hospital after a diagnostic catheterization. The patient was brought to the catheterization lab in the usual fasting state. Informed consent was obtained and the patient was prepared and draped in the usual fashion. Following this, we obtained access to the left groin and a 6 French sheath was placed. We did not obtain access to the right groin as an Angio-Seal device was placed recently. Following this, we proceeded to advance a 5 French JR4 catheter and obtained multiple images of this vessel. Following this, we advanced a 5 French JL4 catheter to the ostium of the left main coronary artery and obtained multiple images of the left system.

Subsequently, these catheters were removed and the images were reviewed and decision was made to proceed with PCI of the occluded right coronary artery. Heparin, 5000 units, was administered. Following this, we advanced a 6 French JR4 guide catheter up to the ostium of the right coronary artery. We used an Asahi 0.014 Prowater wire to cross this lesion. After the lesion was crossed, we advanced a 2.5 x 15 mm Voyager balloon and multiple inflations were performed in the mid and proximal portions. Following this, angiography revealed flow down the vessel. There was significant thrombus in this vessel, especially in the proximal region, which was suggestive of probably an acute occlusion in this area. Subsequently, the patient received intracoronary nitroglycerin and repeat angiographic images after that showed some resolution of the thrombus.

Following this, we proceeded to advance a 3 x 33 mm Cypher drug-eluting stent into the mid and distal portion of this vessel and this was deployed at about 16 atmospheres for 30 seconds. Subsequently, we advanced a 3.5 x 28 mm Cypher drug-eluting stent into the proximal portion and this was deployed at 16 atmospheres for 30 seconds. Subsequently, angiographic images were obtained in multiple views and we determined that there was slight haziness proximal to the stent deployment; this was not thought to be due to a thrombus or dissection. Good distal flow was noted and excellent stent deployment was also noted. The patient was stable during the procedure and had no complaints. After confirming that we were in the true lumen in the distal portion of this vessel, the patient was given Integrilin infusion per protocol for platelet inhibition. Sheath was sewn in place and the patient was subsequently transferred to the CVR for sheath removal and will be admitted for further management.

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Lab and Diagnostic Medical Transcription Words - Transcribed Examples

LABORATORY DATA:  On admission, the patient's CBC showed normal white count, low H and H with MCV of 101, and platelet count was normal indicating macrocytic anemia. By discharge, the patient's white count was 8.9, hemoglobin was 8.8, hematocrit 26.7, and platelet count was 230,000. PT/INR and PTT were normal. Chemistry profile showed, on admission, an elevated sodium at 146, uncontrolled blood sugar at 392, BUN 99, and creatinine of 3.2. AST, ALT, and alkaline phosphatase levels were all normal. By discharge, the patient's chemistry profile showed a sodium of 136, BUN is down to 51 with a creatinine of 1.3. AST, ALT, and alkaline phosphatase levels were normal. The patient's magnesium levels were normal. The patient did have a few episodes of hyperglycemia during her hospital course, probably secondary to IV and p.o. steroids. The patient's cardiac enzymes were normal. She had a BNP on admission that was 186, repeated a few days later and it was 372. The patient also had a urinalysis, as stated earlier, that was abnormal, Candida albicans. The patient's blood cultures showed no growth. The patient had no other diagnostic or invasive interventions during this hospital course.

The patient had a venous Doppler of bilateral lower extremities secondary to severe edema, showed no deep vein thrombosis. The patient also had a chest x-ray on admission that showed right central line placement, slight infiltrate within the left lung base, as well as cardiomegaly with tortuous and ectatic thoracic aorta. The patient had a repeat chest x-ray a few days prior to discharge that showed cardiomegaly. No interval change, no left effusion or left lower infiltrate.

LABORATORY DATA:  On admission showed a CBC that was within normal limits. His white count was normal at 8.5. By discharge, his white count was 6.5, his hemoglobin 11.8, his hematocrit was 32.8, his platelet count was 527. PT/INR at the time of discharge was 22.4, his INR was 1.95. His chemistry profile on admission showed some slight abnormalities, as CO2 was 20. His BUN was 44. His creatinine was 1.3. TSH was normal. On discharge, his chemistry profile was unremarkable except for a slightly elevated glucose of 129. The patient is diabetic. The patient also had some cardiac enzymes on admission that were negative. He had a BNP that was 209. Urinalysis was negative. He had occult blood stools that were negative x2 and he had a urine culture that showed no growth. His blood cultures also showed no growth.

The patient also had an ultrasound of his kidneys during the stay that showed a single right kidney, identified without hydronephrosis. At the time, the patient had complaints of some dysuria as well as some retention. The patient also had a chest x-ray that showed bilateral pleural effusion, bibasilar opacities suggestive of atelectasis or infiltrates.

LABORATORY DATA:  Serology studies showed on admission that the patient's CBC was slightly abnormal. His white count was elevated at 13.3 and H and H and platelet count were normal. By discharge, the patient's white count was 9.3, his hemoglobin was 11.9, his hematocrit was 35.5, platelet count was 243,000, and MCV was 89.6. He does have anemia of chronic disease and was on Aranesp during his hospital stay. PT, PTT, and INR normal. Chemistry profile on admission was also abnormal indicating mild hyperkalemia as well as mild hyponatremia. By discharge, the patient's chemistry profile was within normal limits except for elevated BUN of 38 with a creatinine of 1.7 secondary to his chronic renal failure. The rest of his chemistry profile was within normal limits. Magnesium levels were normal. His CK enzymes and troponins were, I believe, normal. His CK-MB actually was elevated, but he had normal troponins. BNP was 103 on admission, repeat was 65. TIBC 358 with a ferritin level of 265. Urinalysis on admission was negative for any bacteria or pyuria. MRSA screens were negative even though the patient had a history of MRSA and no other studies were performed.

Nuclear medicine renal scan showed split renal function, 45 left and 55 right. Otherwise, fairly symmetrically diminished perfusion consistent with renal disease. No evidence of obstructive uropathy. The patient had a chest x-ray on admission that showed slightly improved CHF and no active pulmonary disease. 

LABORATORY DATA:  White count 12.9, hemoglobin 11.2, hematocrit 34.8, platelets 365, 53% segs, 13 bands, 11 lymphs, 22% monos. Absolute monocyte count was elevated at 2.8. White count was as high as 23.9 previously. PT/INR and PTT essentially unremarkable. Alkaline phosphatase was 258, slightly elevated. Sodium 144, potassium 3.6, chloride 108, CO2 of 26, BUN 22, creatinine was down to 1.7. LFTs were normal. Serial blood sugars were obtained during the hospital stay. Lipase elevated at 274 and 241. This was as high as 290 and 236 previously. Total iron binding capacity 245, unconjugated iron binding capacity 218. Iron level 24. B12 of 280, folate 11.8, and haptoglobin 376. B-type natriuretic peptide was 426. CK-MB and troponins were negative. Urine; trace albumin, trace leukocyte esterase. Stool for occult blood was negative. Cultures on the chart negative.

Venous Doppler of the lower extremities revealed no evidence of DVT. Echocardiogram:  Mild to moderate concentric left ventricular hypertrophy with normal leaflet size and function with normal systolic function, left ventricular diastolic dysfunction, however, and trace mitral regurgitation. EKG:  Sinus rhythm, low voltage. The patient underwent fine needle aspiration with guidance with successful ultrasound-guided drainage, loculated small pocket of fluid adjacent to the anterior abdominal wall, represented purulent material. Ultrasound of the gallbladder:  Pancreas is not enlarged. It has heterogeneous echotexture, nonspecific. Exophytic cyst along the right lobe of the liver was seen on prior CT. No evidence of gallstone or definite right renal stone. Minimal right perirenal fluid and a small fluid collection in the right mid abdomen measuring 4.4 x 4.6 x 1.4. CT of the abdomen limited with small fluid accumulation in the right mid abdomen measuring 1.4 x 2.6, probable liver cyst. Also, possible partial small bowel obstruction, distal ileum, and there is some fecal material in the colon. CT pelvis:  Low-grade partial small bowel obstruction.

DIAGNOSTIC DATA:  CT of pelvis was performed revealing status post prostatectomy, diffuse metastatic disease to bone, large amount of fecal material in the rectosigmoid, and nodular contour to the posterior wall of the bladder, not significantly changed from prior.  Postsurgical CT abdomen revealed approximately a 2.3 cm soft tissue mass just posterior to the left common iliac vein suspicious for metastatic lesion, low attenuation lesion measuring 1.4 cm of parapelvic region of left kidney, most likely representing cyst, atrophy of the right kidney, diffuse metastatic disease to bone and CT appearance of an acute pathologic fracture involving L1 vertebral body.  CT of brain was negative for acute hemorrhage or mass effects and small vessel ischemic changes as well as lacunar infarct, right basal ganglia and internal capsule.  Negative for acute hemorrhage or mass effect.  CT of chest revealed enlarged lymph nodes within the mediastinum with the take-off of the left subclavian artery measuring up to 2.5 cm in size suspicious for metastatic disease.  Incidentally noted but not mentioned in the findings of the report.  There was 1.7 cm soft tissue lesion within the left subclavicular fossa, multiple nodular infiltrates throughout the right upper lobe and superior segment of the right lower lobe.  Differential diagnosis would include infectious etiology versus diffuse osseous metastatic disease.  CT of chest was performed to rule out pulmonary embolus as the patient had atypical chest pain during the course of hospitalization.  There was no PE or multiple osseous lesions.  Stable mediastinal adenopathy and nodular infiltrates persist within the right upper and lower lobes.  X-ray of spine revealed diffuse bony sclerotic metastasis, wedge compression deformity of L1, L3-L4, and L4-L5 degenerative disk disease, also facet degenerative disease on the left at L3 to S1.  

LABORATORY DATA:  CBC day prior to discharge; WBC 5.7, hemoglobin 11.4, hematocrit 35.4, platelets 296, neutrophils 47, bands 12, lymphocytes 35, monocytes 2, eos 4. Sedimentation rate initially was 93, decreased to 37 and increased finally to 60. CRP initially was 8.8, then 5.8, and finally 3.1. Glycosylated hemoglobin was 6.4. Chemistry on the day prior to discharge; sodium 141, potassium 3.9, chloride 102, CO2 of 28, glucose 116, creatinine 0.7, calcium 9.1, total protein 6.4, albumin 2.7, globulin 3.7, alkaline phosphatase 90, ALT slightly elevated at 77 and AST 32. Creatine kinase 16, which is low. Fasting lipids were as follows; cholesterol 103, triglycerides 116, HDL low at 18, LDL 62, VLDL is 23, fasting glucose was 100. Repeat Monospot test was negative. EBV IgG is positive, IgM is negative. Lyme and mycoplasma titers are still pending and EBV titers still pending. Amylase is also slightly elevated at 10.

LABORATORY DATA:  Hemoglobin 18, hematocrit 53.4, platelets 78, and white blood cell count 15.2 initially. Repeat hemoglobin was 15.6, hematocrit 47.2, platelets 63, white blood cell count 10.2. PTT was 31.8, PT was 22.1, and INR was 1.92 and elevated. Sodium was 138, potassium 4.2, chloride 104, CO2 of 24, BUN 18, creatinine 1.1, glucose 122, and calcium 8.8. Repeat sodium 132, potassium 2.8, chloride 103, CO2 of 22, BUN 9, creatinine 1.1, glucose 155, calcium 7.8.

EKG showed sinus arrhythmia at 96 to 142 with left axis deviation. Abdominal x-ray showed diffuse bowel gas pattern. Chest x-ray showed some perihilar questionable congestion. He had a CAT scan of the abdomen and pelvis. The CAT scan was consistent with diverticulitis involving the distal descending colon with localized perforation and extraluminal air adjacent to part of the colon consistent with localized perforation of the descending colon. No evidence of intra-abdominal abscess or free fluid. Mild splenomegaly.

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