Hematology - Oncology Consult Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REQUESTING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Hematological clearance.

Thank you, Dr. Doe, for allowing us to participate in this patient's medical care.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old female who has a history of von Willebrand disorder, which has never been confirmed.  She has been seen by more than one hematologist and the laboratory studies have been repeated in the past.  The patient, however, has history of easy bruising, history of bleeding post laparoscopic procedure, and significant bleeding post arthroscopy.  The patient stated that her family members have been diagnosed of plasminogen activator inhibitor deficiency.  Therefore, she consulted with a hematologist who ordered a test to determine if indeed she could have this.  Indeed, the patient was diagnosed as having plasminogen activator inhibitor deficiency.  She was going to have a tympanoplasty sometime in the recent past, and she was prescribed Amicar prior to the procedure.  The procedure went off uneventfully without any bleeding activity during the procedure, although it was not a significantly invasive procedure.  On further questioning, she denies having any excessive menstrual bleeding.  Usually, her menstruations lasts for approximately 5 days and it comes every 3 weeks, but there were times in the past that she had some vaginal bleeding that lasted sometimes up to 4 months.  Currently, she does not take any aspirin or nonsteroidal anti-inflammatory agents.  The patient stated that 4 days ago, after she ate a ham sandwich, when she was already feeling unwell with abdominal discomfort, she had abdominal crampy pain.  The day that she decided to come to the emergency department, yesterday, the abdominal pain was significant and the patient decided to come to this hospital for evaluation and treatment.  Concomitantly, she developed diarrhea. At the time of my evaluation, the patient was ready to have her breakfast and was hungry and stated that the abdominal pain had significantly decreased and, on a scale of 1 to 10, was a 3.  She denied any chills, any fever, and denied any urinary symptoms.  The patient's menstrual period had started approximately 4 days ago.  She denied any rectal bleeding, but she has been diagnosed with hemorrhoids.

SOCIAL HISTORY:  The patient denies smoking cigarettes and drinks alcohol socially.

ALLERGIES:  SHE HAS NO KNOWN DRUG ALLERGIES.

MEDICATIONS:  She was not taking medications prior to admission.

PAST MEDICAL HISTORY:  Otherwise unremarkable, except for previous laparoscopic evaluation, previous arthroscopy and tympanoplasty.  Denied any hypertension, any heart condition, and denied any liver disease.

FAMILY HISTORY:  As above.  The patient's family members have been diagnosed with plasminogen activator inhibitor deficiency.

REVIEW OF SYSTEMS:  Unremarkable.  She has no history of anorexia, any weight loss, any chest pain, cough, chills or fevers.

PHYSICAL EXAMINATION:
GENERAL:  This is a normal-appearing female in no significant distress at the time of the evaluation.
SKIN:  Her skin color was normal.  She has no petechiae or ecchymoses.
LYMPH NODES:  She has no palpable neck supraclavicular, axillary, inguinal adenopathy.
HEENT:  Evaluation was normal.
LUNGS:  Clear to auscultation.
HEART:  Regular rate and rhythm with normal heart sounds.
ABDOMEN:  Soft and nontender with increased bowel sounds without hepatosplenomegaly and without ascites.
RECTAL:  Examination was deferred.

DIAGNOSTIC IMPRESSION:  Coagulopathy of unclear etiology, von Willebrand disease, which has never been confirmed, and plasminogen activator inhibitor deficiency as per the patient's information.  The patient clearly appears to have tendency of bleeding following procedures.

RECOMMENDATIONS:  In view of this, I have recommended withholding the colonoscopy procedure since the patient could be at risk, particularly if any biopsy is taken during the procedure.  I recommended instead a full diagnostic workup that can be done as an outpatient.  The patient's symptoms have improved significantly and her diarrhea has improved.  She has an appointment to see Dr. Doe as an outpatient in approximately 10 days.  I will attempt to contact you and discuss with you my recommendations.

Thank you for allowing me to see your patient.

Medical Transcription Word Help

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

ENT Consult Medical Transcription Transcribed Sample Report / Example

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

CONSULTANT:  Jane Doe, MD 

REASON FOR CONSULTATION:  Acute dizziness.

IMPRESSION:
1.  Acute exacerbation of chronic benign positional vertigo.
2.  Underlying complex medical history including acute exacerbation of chronic obstructive pulmonary disease, depression, diabetes, and hypertension.
3.  No evidence of external or middle ear disease.
4.  History of presbyacusis exacerbating above.

RECOMMENDATIONS:
1.  Physical therapy evaluation for vestibular evaluation and possible rehabilitation.
2.  Vestibular testing can be performed, but it is generally performed in the office as an outpatient.  We recommend that the patient be followed up once she is discharged and sent back to her extended care facility. 

CHIEF COMPLAINT AND HISTORY:  This is an (XX)-year-old female seen in consultation, who presents with history of increasing shortness of breath.  She has a history of chronic respiratory failure, pulmonary fibrosis, and COPD.  Also, of note, over the last several days, she has had intermittent episodes of acute spinning-type vertigo.  She notes this is typically 2-3 o'clock in the morning when in bed.  She denies any daytime dizziness and notes that she is fairly stable otherwise.  She denies any change in her hearing; although, she has a history of hearing loss.  She denies any tinnitus.  There has been no otalgia and no drainage posteriorly and no drainage in the ears.

PAST MEDICAL HISTORY:  As noted.

PAST SURGICAL HISTORY:  Reviewed at length in the chart. 

LABORATORY DATA:   The data is reviewed and this is relatively normal, except for elevated glucose.

PHYSICAL EXAMINATION:
GENERAL:  On examination today, she is sleeping quietly but is easily awakened.
VITAL SIGNS:  Pulse 86, blood pressure 134/74, and respirations 22.
HEENT:  The head is normocephalic.  Trachea is in the midline.  Both ears, including auricles, external auditory canal and tympanic membranes are all intact.  The middle ear shows no effusion or retraction.  Nose externally is in the midline and internally shows mild septal deviation.  Oropharynx shows upper and lower plates.  She has had a tonsillectomy.  She has an intact gag reflex.  Tongue protrudes in the midline.  There are no ulcerations or lesions present.
NECK:  No lymphadenopathy.
HEART:  Regular rate and rhythm.
LUNGS:  Lung sounds are distant and shallow.

At this point, the patient appears to have had an acute exacerbation of her chronic benign positional vertigo.  She does not appear to have had any distinct treatment for this.  As such, physical therapy including Cawthorne and Brandt-Daroff exercises can generally clear this for the most part.  We recommend physical therapy evaluate them for this.  If she has continued disequilibrium, then certainly vestibular testing should be performed and this could be done in my office.

Thank you for the opportunity to participate in the care of your patient.

Nephrology Consult Medical Transcription Transcribed Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Acute rhabdomyolysis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who unfortunately has residual organic brain syndrome.  The patient was brought in to the emergency department because of new onset of right-sided weakness and inability to talk, which has significantly improved.  The patient is being treated for acute CVA.  It was noted that the patient had a CPK level around 2100 on admission; it has further increased to 19,500.  The patient had been taking Vytorin as an outpatient, and currently, in the hospital, he is on Zetia and Pravachol.  The patient does not have any recent history of falls, trauma, and does not have any history of renal disease, hypertension and diabetes mellitus.

PAST MEDICAL HISTORY:  As stated in history of present illness, also left eye blindness.

OUTPATIENT MEDICATIONS:  Effexor, aspirin, Risperdal, Remeron, and has been recently started on Vytorin.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  He lives in assisted living facility.  No tobacco or alcohol use.

REVIEW OF SYSTEMS:
NEUROLOGIC:  No prior history of stroke or epilepsy.  He did have organic brain syndrome as previously described.
PULMONARY:  No productive cough.
CARDIOVASCULAR:  No chest pain.
GASTROINTESTINAL:  No nausea or vomiting.
GENITOURINARY:  No pain on urination.
MUSCULOSKELETAL:  Denies any joint tenderness or muscle aches, or tenderness to touch.
PSYCHIATRIC:  He has had history of depression.
HEMATOLOGIC:  No overt bleeding complications.
DERMATOLOGIC:  No skin cancer.
ENDOCRINE:  No history of diabetes or thyroid disease.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 118/74, heart rate 64 per minute, respirations 22 per minute.
GENERAL:  The patient is a thin male.  He is comfortable and oriented x3.
HEENT:  Normocephalic.  Right pupil reactive to light and accommodation.  Extraocular movements are grossly intact, relatively pink conjunctiva, anicteric.  Oral cavity shows no obvious lesions of the soft or hard palate.
NECK:  Supple with full range of motion.  No JVD.  Trachea is midline.
LUNGS:  Grossly clear to auscultation and percussion.  No intercostal retractions.
HEART:  Regular in rate and rhythm.  S1 and S2.  No obvious rub or gallop.  There is a soft 1/6 systolic ejection murmur at the left sternal border.
ABDOMEN:  PMI is at the midclavicular line.  Bowel sounds are present.  Soft, depressible, and nontender.  No sign of any palpable masses.  No evidence of hepatosplenomegaly.
EXTREMITIES:  No clubbing, cyanosis or edema.
NEUROLOGIC:  He has still some weakness on the right side.  He is able to talk at this time.  Upon presentation, he did not have any ability to talk.
SKIN:  No active lesions or rash.

LABORATORY DATA:  BUN 18, creatinine 0.3. On admission, CPK was around 2100.  Subsequently, it has increased to 19,500.

IMPRESSION:
1.  Acute rhabdomyolysis.
2.  Acute cerebrovascular accident.
3.  Hyperlipidemia.
4.  Organic brain syndrome.

The patient is a (XX)-year-old male with no prior history of renal disease, who now is developing acute rhabdomyolysis in the absence of any overt trauma.  At this point in time, it is seriously considered that the onset of the rhabdomyolysis may be associated to the therapy currently being used for treatment of his underlying dyslipidemia.  The patient at this point in time will need discontinuation of the cholesterol-lowering agents and also will need to continue hydration to maintain adequate urinary flow to prevent any precipitation of myoglobin in the renal tubules, which can then result in acute renal failure.  We will also obtain records from the PCP to see what the patient's baseline liver function tests were, they are mildly elevated, and whether any CPKs were done, and to obtain the exact date of initiation of therapy with the cholesterol-lowering agents.

DIAGNOSTIC DATA:  Upon presentation, his EKG showed normal sinus rhythm and he also had an echocardiogram, which showed mild mitral regurgitation and tricuspid regurgitation.  CT of the brain showed no acute pathology.

PLAN:  Further recommendations for the management of this patient will depend on the patient's clinical course and the results of whether the patient has further progressive increase in CPKs.  At this point in time, we would refrain from obtaining special serologic tests to assess for intrinsic muscle disease.

Thank you very much for allowing me to participate in the management of this patient.

Medical Transcription Word Help

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Rheumatology Consult Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Evaluation of inflammatory polyarthritis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who was admitted to the hospital with complaints of low back pain that she states has been going on for the past 2 years.  She denies any history of trauma or injury.  She states that she has been hurting in the back for the past 2 years, and lately, the pain has been getting worse.  She denies any prolonged morning stiffness.  She does not complain of any fever or any chills.  There is no prior history of any connective tissue disease or rheumatic disorder.

PAST MEDICAL HISTORY:  Thyroidectomy.

FAMILY HISTORY:  No history of any connective tissue disease like lupus erythematosus.

SOCIAL HISTORY:  Does not smoke and does not drink.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

CURRENT MEDICATIONS:  Aspirin, cyclobenzaprine, tramadol, Novolin, enalapril, amlodipine, metoprolol, bumetanide, Novolin R, and cefazolin IV.

REVIEW OF SYSTEMS:  The patient has been gaining weight over the last several years.  Denies any recent increase in weight or loss of weight.  Does complain of generalized fatigue and weakness.  Denied any fever or any chills.  She has history of coronary artery disease.  Denying any chest pain or shortness of breath at this time.  Denies any abdominal bloating.  Denies any history of skin rashes.  No history of any prior blood clots or deep venous thrombosis.  Musculoskeletal wise, the patient has been experiencing low back pain for the past 2 years.  Denies any joint pain or joint swelling in her hands, wrists or feet.  She has been having difficulty moving her right shoulder joint.  There is no history of any trauma.  Denies any Raynaud's.  No mouth or nasal ulcers.  Denies any hair loss.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 132/62, pulse 86, respiratory rate 20, temperature 98.6, and T-max was 100.4.
GENERAL APPEARANCE:  The patient is a (XX)-year-old obese female lying in bed, basically being fed with the help of the nurse.
HEENT:  Pupils equal, round, reactive to light and accommodation.  Extraocular movements intact.  No tenderness on palpation over the temporal arteries bilaterally.
CHEST:  Clear, has bilateral breath sounds.
HEART:  S1 and S2.
ABDOMEN:  Soft, obese, and nontender.
EXTREMITIES:  No pedal edema.  Musculoskeletal examination: Limited range of motion of the right shoulder joint, and left shoulder joint seems to move fine.  She is tender on palpation, likely over the anterior and lateral aspect of the right shoulder joint.  Elbow joints appeared to be fine.  Limited range of motion of the hip joints.  She has crepitus in her knee joints, and on examination of her hands, wrists, and feet, there is some puffiness in her right hand, but there was no tenderness on palpation over the PIP, DIP, and the MCP joints.  Her motor power appears to be decreased in the right upper extremity.  She was unable to move the shoulder joint.  It could be because of pain in the shoulder that she is not able to move the right arm.  No obvious muscular wasting observed.
NEUROLOGIC:  She is alert and oriented.

LABORATORY DATA:  CBC shows white cell count of 14.2, H and H of 9.4 and 29.6, and platelet count 229,000.  Chemistries:  Her BUN is elevated at 54, creatinine 2.6, calcium 9.4.  C-reactive protein is elevated at 13.8.  Sedimentation rate was 94.

DIAGNOSTIC STUDIES:  Chest x-ray shows cardiomegaly without acute infiltrate and thoracic spondylosis.  MRI of the lumbar spine shows presence of significant lumbar stenosis at L4-5 due to degenerative grade 1 spondylolisthesis and severe facet arthropathy with synovitis and enhancement involving the facet joints.  Imaging characteristics are suggestive of a possible osteomyelitis.  Technetium bone scan shows increased activity in the region of posterior superior iliac in the sacral ala bilaterally, of uncertain significance, could represent inflammation.

ASSESSMENT AND PLAN:  The patient is a (XX)-year-old female who is admitted with complaints of low back pain with a history of arthritis in her back for the past 2 years.  Her MRI and bone scan does point towards some inflammatory process going on.  The patient is currently on antibiotics for possible infection.  From the rheumatic aspect, I will be getting some baseline labs on her to rule out any underlying autoimmune or rheumatic disorder.  With a high sedimentation rate, limited range of motion of the right shoulder joint, and the amount of discomfort she has in her back, the possibility of inflammatory arthritis is very high.  At this point, I will be getting an MRI of the right shoulder joint because of decreased mobility.  We will hold off empirical treatment with steroid at least until the initial workup is completed in view of high suspicion of infection.  She does not give typical features of polymyalgia rheumatica.  The patient is also being worked up to rule out any underlying malignancy.  Her blood cultures have been negative so far, not showing any growth after one day.

I will be following the patient with you.  Thank you for the consult.

MT Word Help

Medical Transcription Samples

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Infectious Disease Consultation Medical Transcription Sample Report

Neurology Consult Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  TIA versus stroke.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with a history of hypertension and atrial fibrillation with permanent pacemaker, who presented to the ER complaining of acute left-sided weakness and numbness 1 day prior to admission.  The patient reports that she woke up on Tuesday morning with left-sided weakness and numbness.  She presented to the ER about 24 hours later for evaluation.  The patient reported at that time that her left side was weak.  She also had some slurred speech.  Admission note from the ER stated that the patient said that her symptoms have resolved, but upon interview, at this time, she states that the symptoms actually have not completely resolved.  The patient has a history of chronic atrial fibrillation and is on Coumadin, and her INR on presentation was therapeutic at 2.6.

PAST MEDICAL HISTORY:  Hypertension, atrial fibrillation, status post permanent pacemaker placement, history of gastrointestinal polyps, and history of Helicobacter pylori infection.

PAST SURGICAL HISTORY:  Cholecystectomy; hysterectomy; right breast tumor removal, which was benign, and pacemaker placement in the past.

MEDICATIONS:  As an outpatient, Coumadin, Cozaar, digoxin, and atenolol.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient denies any drugs, alcohol or tobacco.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Stable.
HEART:  S1 and S2, paced.
NECK:  No bruits.
NEUROLOGIC:  Mental status:  The patient is awake, alert, and oriented x3.  Speech is fluent.  Good comprehension.  Cranial Nerves:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Face is symmetric.  Tongue is midline.  Palate is symmetric.  Motor:  5/5 in the right and 4+/5 in the left with some apparent give-way weakness.  Of note, there is no pronator drift present in the upper extremity.  Good tone.  No tremors noted.  Reflexes are 1+ in right upper extremity, 2+ in left upper extremity, 1+ at the knees bilaterally, and 1+ at the ankles bilaterally.  Plantars are downgoing bilaterally.  Sensory:  Decreased pinprick in the left face, arm, and leg.  Decreased vibration on the left.  Coordination is intact, finger-to-nose, with a mild intention tremor, but no ataxia.

LABORATORY AND DIAGNOSTIC DATA: CT of the brain done was negative for acute event.  Repeat CT of the brain done 24 hours later was also negative.  INR was 2.69 on admission.  Chest x-ray was negative.

ASSESSMENT:
1.  Left-sided numbness and weakness.  The patient's main complaint consists of left-sided numbness of the face, arm, and leg.  This could possibly be consistent with a thalamic lacunar stroke.  Her weakness appears to be secondary to give-way rather than actual weakness.  I did not recommend repeating CT of the brain any further as the second CT was done 72 hours after the event, which should show an acute lesion.  I recommend checking a lipid profile.  I agree with baby aspirin.
2.  Peripheral neuropathy.  Not mentioned above. The patient complains of burning and tingling of her feet, started about 2 months ago.  Will send workup for neuropathy.

PLAN:
1.  Physical therapy/occupational therapy evaluation.
2.  Agree with aspirin therapy.
3.  Will send neuropathy workup.
4.  Will start gabapentin 200 mg p.o. q.h.s. for neuropathic symptoms.
5.  EMG/nerve conduction studies as an outpatient.

Thank you, Dr. Doe, for this consult.  We will follow along with you.


Oncology MT Sample Report                                              ENT Consult MT Sample Report 

Renal Consult MT Sample Report                                      Cardiovascular Consultation MT Sample Report


Cardiology Consult Medical Transcription Transcribed Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Not dictated.  

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who presented to the emergency department with abdominal pain and peritonitis.  The patient has been treated for that, but she does also have a history of peripheral vascular disease and is scheduled to undergo surgery within the next 3 weeks.  The patient requires cardiac clearance and had been scheduled for outpatient stress test this week, which she was unable to make due to her hospitalization.  At this time, the patient denies any anginal symptoms.  Prior to her MI, she had complaints of left arm pain but no chest pain.

PAST MEDICAL HISTORY:  Significant for peripheral vascular disease, history of coronary disease with previous myocardial infarction and angioplasty.  She has a history of diabetes; hypertension; dyslipidemia; COPD; and end-stage renal disease, on peritoneal dialysis.

HOME MEDICATIONS:  The patient is on Hectorol 2.5 mcg daily; Altace 2.5 mg daily; Plavix 75 mg daily; Renagel daily; Amaryl 2 mg daily; aspirin 1 daily; Toprol-XL 100 mg daily; Norvasc 10 mg daily; Catapres patch weekly; iron supplement; Lipitor 20 mg daily; potassium supplement 10 mEq daily; and Fosrenol 500 mg 3 times a day.

ALLERGIES:  SULFA.

SOCIAL HISTORY:  The patient does have a history of tobacco use.  She does not use alcohol or illicit drugs.

REVIEW OF SYSTEMS:
GENERAL:  No complaint of fever, chills or weight loss.
CARDIOVASCULAR:  Denies any chest pain or anginal equivalent.  No complaint of palpitations.
RESPIRATORY:  Positive for shortness of breath secondary to COPD with no acute change in her status.
GASTROINTESTINAL:  Positive for abdominal pain and peritonitis.  No blood in bowel movements or dark tarry stools.
GENITOURINARY:  End-stage renal disease, on dialysis.
NEUROLOGICAL:  No TIA or CVA symptoms.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a (XX)-year-old female in no acute distress.
VITAL SIGNS:  Stable.  The patient is afebrile.
HEENT:  Negative.
NECK:  No jugular venous distention or carotid bruits.
HEART:  Regular rate and rhythm.  No murmurs are heard.
LUNGS:  Clear bilaterally.
ABDOMEN:  Moderately tender throughout due to peritonitis, was not deeply palpated.  Bowel sounds present.
EXTREMITIES:  No edema or cyanosis.  She has faint peripheral pulses on the left; pulses on the right were nonpalpable.
NEUROLOGICAL:  No focal deficits.

DIAGNOSTIC DATA:  EKG is not done at this time.

LABORATORY STUDIES:  CBC:  WBC is 13.2, hemoglobin 10.4, hematocrit 31.6, and platelet count 184.  Metabolic panel:  Potassium is 4.8, BUN 49, creatinine 8.6, and TSH is within normal limits.

IMPRESSION:
1.  Coronary disease with history of myocardial infarction, status post percutaneous transluminal coronary angioplasty and stent.
2.  Peripheral vascular disease.
3.  End-stage renal disease, on peritoneal dialysis.
4.  Peritonitis, stable.
5.  Chronic obstructive pulmonary disease with history of tobacco use.
6.  Diabetes mellitus.
7.  Hypertension.
8.  Dyslipidemia.

RECOMMENDATIONS:  The patient is scheduled for peripheral vascular surgery.  We will proceed with a dual isotope stress test and 2D echocardiogram for clearance and obtain a 12-lead EKG for baseline.

Thank you for allowing us to participate in the patient's care.

Subscribe to: Posts (Atom)