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Internal Medicine Consultation Medical Transcription Sample Report / Example



REASON FOR CONSULTATION:  Lower abdominal pain.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female, who said that she was doing fine.  She started having abdominal pain located in the lower part of the abdomen; this started yesterday.  She had associated leg pain and shoulder pain.  The pain was predominantly in the left lower quadrant.  It was sore to touch.  Subsequently, she started having loose bowel movements.  She also complained of having chest pain and then nausea.  She did not throw up.  She denies dysphagia, odynophagia, rectal bleeding or melena.  She does have history of irritable bowel syndrome.  She does not have any known allergies. She had a colonoscopy done 4 years ago by Dr. Doe.  At that time, she had a gastroscopy done too.  These endoscopic examinations showed that she had internal hemorrhoids; otherwise, it was unremarkable.  Gastroscopy did not show any findings.  Eight years ago, she had an exercise Cardiolite study done and that was remarkable for mild chest pressure during the test.  Echocardiogram was done 8 years ago as well and that showed mild mitral regurgitation.  She had a cardiac catheterization done by Dr. John Doe.  It showed normal coronary arteries with exception of distal vessels being quite small.  Found to have elevated left ventricular end-diastolic pressure and normal left ventricular function.  Gastroscopy was done 8 years ago as well.  This was done by Dr. Jane Doe and it showed mild patchy hyperemia; otherwise, it was unremarkable.  Flexible sigmoidoscopy was done by Dr. Bradford Doe 8 years ago and that was also unremarkable.  A colonoscopy was done by Dr. Jeffrey Doe 8 years ago and it showed a small polyp.  She had a right palpable breast mass and excision was done by Dr. Ivan Doe 4 years ago. She had uterine fibroids and menorrhagia and she underwent laparoscopic-assisted vaginal hysterectomy by Dr. Christopher Doe.  This was done 6 years ago.

SOCIAL HISTORY:  The patient does not smoke and does not drink alcohol.  She does not use any recreational drugs.

FAMILY HISTORY:  Noncontributory.  Mother is alive and has diabetes.  Father is alive and has heart disease.

REVIEW OF SYSTEMS:  She does not have any neurological, pneumonia, cardiovascular or musculoskeletal symptoms at this time.

GENERAL:  The patient is alert and oriented to time, place and person.
HEENT:  Normal examination.  Pupils are responding.  Conjunctivae are pink.  Sclerae are anicteric.  Oral examination is unremarkable.
NECK:  Supple.  No cervical lymphadenopathy.  No thyromegaly.
CHEST:  Clear.  Normal vesicular breathing.  No rales.  No crepitation.  No pleural rub.
HEART:  S1 and S2 audible.  No S3.  No S4.  No murmur.
ABDOMEN:  Soft and nontender except in the left lower quadrant area.  There is guarding but there is no rigidity.  There is no shifting dullness.  Bowel sounds are audible.
EXTREMITIES:  Did not show any pedal edema.  Peripheral pulses are palpable.  No joint deformity.
NEUROLOGIC:  No focal or neurological deficit.

LABORATORY DATA:  WBC 8.2, hemoglobin 12.6, hematocrit 37.4, and platelet count 208,000.  Comprehensive metabolic panel is normal except glucose of 126, CK of 196.  Troponin and CK-MB normal.  Urine showed 3+ occult blood.

The patient had some laboratory workup done in the past.  Her ANA was negative.  Rheumatoid factor was negative.  Cholesterol was elevated at 208.  Protein C activity was normal.  Complement 3 level was normal.  Complement 4 level was normal.  Total complement level was normal.  RPR was nonreactive.  Rheumatoid factor was done again and that was normal.  B12 level was normal.  Folate level was normal.  Hepatitis panel for A, B and C was unremarkable.  Serum ferritin was normal.  Serum iron was normal.  Antiphospholipid antibody was negative.  DRVVT lupus anticoagulant was unremarkable.  Whole blood hemoglobin A1c was normal.  TSH was normal.  Free T4 was normal.  FSH was normal.  T3 was low and that was 70.  Thyroglobulin was 0.7.  Thyroid peroxidase antibody was negative.  Protein C activity was high 5 years ago at 142.  Protein S activity was high 5 years ago as well. Anti-DNA antibody was negative.  Kaolin clotting time was normal.  Lupus sensitive PTT was normal.  Estradiol level was normal.  RBC folate was normal.  Factor XIII assay was normal. Factor VIII assay was normal.  Thrombin time was normal.  Von Willebrand ristocetin cofactor was normal.  Old blood factor II gene mutation was negative.  No gene mutation was detected.  Hepatitis B surface antigen was negative.  Rubella IgG was positive.

The patient had an IVP done 10 years back and it showed minimal postvoid bladder residual.  Focal indentation of upper pole of the infundibulum of right kidney was reported.  CT scan of the brain was done 8 years ago and that was negative.  Upper GI series with air contrast was done 8 years ago and that was unremarkable.  Upper GI series was done 6 years ago and that was unremarkable.  Ultrasound of the gallbladder was done 5 years ago and that was normal.  MRI of the breast was done 4 years ago.  CT scan of brain was repeated 4 years ago and that was normal.  Gallbladder ejection fraction was done 4 years ago and that was unremarkable.  MRI of the lumbar spine was done and showed a mild facet arthropathy at L4 and L5.  At L5 and S1, dehydration, degenerative loss in disk height was reported.  Renal ultrasound was done 3 years ago and that was normal.  Thyroid ultrasound was done 3 years ago.  It showed a small hyperechoic nodule.  MR of the neck was unremarkable except for a 2.5 mm left lower pole nodule that was identified in the thyroid.  MR of the orbit and brain was normal.  MR of the hip was done and it showed greater trochanteric bursitis on the left side.  This was done 2 years ago.  MR of the lumbar spine was done 2 years ago and it showed disk degeneration, bulging and spur at L5-S1 with symmetrical foraminal stenosis and mild facet arthropathy at L4 and L5.  This was stable compared to previous examination.  A CT scan of the brain was done in April of this year and there was a small asymmetric vessel in the right parietal lobe, probably representing a small vascular malformation.  MR angiogram was done and that was unremarkable.  MRI of the brain was done and that was unremarkable.  CT scan of the brain was done in October of this year and that was unremarkable.

1.  Left lower quadrant pain.
2.  History of irritable bowel syndrome.

PLAN:  The patient presents with the above-mentioned problems.  Symptomatic treatment is being given with pain management.  IV fluids are being given.  CT scan of the abdomen and pelvis are pending.  After that, I will determine further management.  I will continue to follow her and I will assess the need of colonoscopy after the CT scan result.

Thank you for the opportunity to participate in this patient’s care.

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