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Cardiovascular Consultation Medical Transcription Sample Report / Example



REASON FOR CONSULTATION:  Questionable syncope and atrial fibrillation with rapid ventricular response.

HISTORY OF PRESENT ILLNESS:  The patient is an (XX)-year-old female with a history of coronary artery disease with non-Q-wave myocardial infarction, angioplasty, stent delivery to the LAD and reduced ejection fraction of 40%, recently been evaluated at 60% with Coreg therapy.  She is in a rehabilitation center after a hospitalization in July, when she was found down on the floor by nursing staff.  When I interviewed the patient, she has some mild confusion; however, she does adamantly state that she did not pass out.  She denies any dizziness, palpitations, chest pain or shortness of breath prior to this falling episode.  She states that she was attempting to get out of bed to use the rest room when she fell down.  She was found by the nursing staff immediately and they called EMS for transportation to an outside hospital for further evaluation and treatment.

PAST MEDICAL HISTORY:  Coronary artery disease status post non-Q-wave myocardial infarction, angioplasty and stent delivery to the mid LAD.  Cardiac catheterization in July revealed a patent stent and nonobstructive epicardial coronary artery disease, otherwise.  Mild ventricular systolic dysfunction was noted with an EF of 40%.  Mildly elevated right-sided pressures with moderate to severe pulmonary hypertension.  Echocardiogram in July revealed an ejection fraction of 60% with mild concentric left ventricular hypertrophy and moderate pulmonary hypertension.  Past medical history is also significant for pneumonia, methicillin-resistant Staphylococcus aureus, urinary tract infection, severe COPD which is end stage, pulmonary fibrosis, congestive heart failure in the past, diabetes mellitus, atrial fibrillation, dysphagia, hypertension, hypothyroidism, hyperlipidemia and osteoporosis with status post vertebroplasty.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient denies tobacco, alcohol or illicit drug use.


MEDICATIONS:  MAR reveals aspirin 81 mg p.o. daily, Combivent MDI inhaler 2 puffs every 6 hours, Cozaar 25 mg p.o. daily, Prozac 20 mg p.o. daily, Lasix 80 mg p.o. daily, Lipitor 10 mg p.o. at bedtime, magnesium oxide 400 mg p.o. daily, Nitro-Dur patch 0.3 mg per hour, Os-Cal 500 plus D daily; Pacerone 200 mg p.o. daily, Plavix 75 mg p.o. daily, potassium chloride supplementation at 10 mEq 4 tablets p.o. 3 times a day, prednisone 10 mg p.o. daily, protein powder with meals twice a day, Protonix 40 mg p.o. daily, Synthroid 137 mcg p.o. daily, Tiazac ER 120 mg p.o. at bedtime and 300 mg p.o. every morning, Xopenex nebulizer every 12 hours, and Novolin insulin per sliding scale coverage.

REVIEW OF SYSTEMS:  See HPI for details.

GENERAL:  This is an (XX)-year-old female lying supine with the head of bed up to 30 degrees, in very minimal respiratory distress.  The patient states that this breathing pattern is normal for her, and from what I can recall from a previous hospitalization, she is right.
VITAL SIGNS:  Blood pressure in the emergency department 114/74, heart rate 116, respirations 22 and temperature 97.6.
HEENT:  Normocephalic and atraumatic.  Pupils equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae anicteric.
NECK:  Reveals a midline trachea.  No JVD or bruit.
LUNGS:  Reveal inspiratory crackles only.  No expiratory crackles in the upper fields and significantly diminished in the left lower lobe.  Very minimal scattered rhonchi in the right lower lobe.
HEART:  S1, S2, irregularly irregular rhythm.  No S3, S4, click, murmurs or rubs appreciated.
ABDOMEN:  Flat, soft, nontender, and nondistended.  Bowel sounds are active x4.
EXTREMITIES:  No clubbing or cyanosis.  Trace 1+ pitting pedal edema is noted.
NEUROLOGIC:  The patient is alert and oriented x3; however, mildly confused.  Feels that she fell 3 days ago, when actually she fell this morning at approximately 3 a.m.  Husband is at the bedside, who states that she has been somewhat confused over the previous week or so.

DIAGNOSTIC DATA:  EKG done in October reveals a supraventricular tachycardia with an irregular narrow complex, ventricular response, could be atrial fibrillation versus multifocal atrial tachycardia due to 3 P waves being present and differing in morphology.  No significant ST or T-wave changes.  Followup EKG in November revealed once again a supraventricular tachycardia with poor R-wave progression.  Once again, poor R-wave progression is noted in the anteroseptal leads; however, this could be lung disease pattern.  Once again, nonspecific ST and T-wave changes.

1.  Status post mechanical fall with subsequent left humerus fracture, left humeral neck fracture and left facial ecchymosis.
2.  Atrial fibrillation with rapid ventricular response.
3.  Coronary artery disease status post non-Q-wave myocardial infarction.
4.  Angioplasty with stent delivery with catheterization in July revealing a patent stent and mild nonobstructive coronary artery disease, otherwise.
5.  Probable pneumonia.
6.  Methicillin-resistant Staphylococcus aureus urinary tract infection.
7.  Pulmonary fibrosis.
8.  End-stage chronic obstructive pulmonary disease.
9.  Diabetes mellitus.
10.  Hypertension.
11.  Hyperlipidemia.

1.  Admit the patient to PCU and place on telemetry due to acute arrhythmia.
2.  Rule out myocardial infarction with serial EKGs and serial enzymes.
3.  Workup for heart rate response, would like to start Cardizem drip at 5 mg/hour and continue the patient's p.o. Cardizem.  Also, I would like to check a BNP level.
4.  Due to severe pulmonary fibrosis and potential worsening of dyspnea symptomatology, we would like to discontinue the patient's amiodarone.
5.  Further plans and recommendations are according to the clinical course of this patient.

Thank you, Dr. Doe, for including me in the care of your patient.  We will follow closely along with you.

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