Physical Exam Medical Transcription Dictation Examples

PHYSICAL EXAMINATION:  The patient is a very pleasant young girl. Height is 61.6 inches, 21st percentile. Weight is 117 pounds, 66th percentile. Body mass index is 21.7, 70th percentile. Blood pressure is 104/64. HEENT:  Both tympanic membranes are clear. Both conjunctivae are clear. Nose is clear. Mouth is clear. There is no neck mass. Lungs:  Good air entry and clear breath sounds. Heart:  Normal first and second heart sounds. Regular rhythm. No murmurs. Abdomen:  Flat, soft, no mass, no tenderness. Breasts:  Tanner IV. Female Genitalia: Tanner IV. Skin: Clear. Neurologic examination is normal. Extremities: Femoral pulses are equally palpable. No deformity noted. Full range of motion of all four extremities.

PHYSICAL EXAMINATION:  Blood pressure was 122/72, pulse 84, and respiratory rate was 20. The patient seemed somewhat depressed but in no acute distress. Neck was supple, no bruits. Heart had regular rhythm. Extremities had no edema noted. On neurologic examination, the patient was alert and oriented x3. Normal attention and language. No neglect or apraxia was noted. Cranial nerve examination:  Pupils were equal and reactive to light. Full visual fields to confrontation. No visual extinction to double simultaneous stimulation was noted. Disks were sharp bilaterally. Extraocular movements were intact with no nystagmus. The patient's strength was normal. Normal hearing bilaterally. Palate elevated well and symmetrically. Normal shoulder shrugs. Tongue was midline. Motor strength was 5/5 throughout without any pronator drift. Normal muscle tone. No abnormal movements were noted. Intact pinprick throughout. No sensory extinction to double simultaneous stimulation was noted. No significant finger-to-nose or heel-to-shin test. Gait was normal based with intact tandem gait.

PHYSICAL EXAMINATION:  Height 5 feet 7 inches, weighs 164 pounds. Healthy-appearing male, in no acute distress. He is walking with a slight antalgic gait. He has significant pain while walking on his toes. He can walk on his heels. He can walk on the outer border of his foot. Good sagittal motion, good hindfoot motion, 5/5 strength in dorsiflexion, plantarflexion, inversion, eversion. Ankle and hindfoot are stable to stress examination. Sensation is intact in all four dermatomes. Palpable pulse on the dorsum of his foot. Skin is supple. No abnormal callus formation. Tender to palpation throughout his midfoot, but essentially at the second and third metatarsals. He is also having significant pain at his fourth proximal metatarsal shaft. He has significant hallux valgus with a widened intermetatarsal angle hypermobility. No tenderness at his first MTP joint. No hammering of toes.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure is 152/78 with a heart rate of 82. Weight is 204 pounds. Respirations are 12. Temperature is 98.4. Pain score is 10.
GENERAL:  The patient is alert and oriented x3. Appears to be in some distress while climbing up to the examination table.
HEENT:  Pupils are equal and reactive to light bilaterally. Extraocular muscles are intact. The oropharynx is within normal limits. Nasal turbinates are also within normal limits. Uvula is midline. There is no JVD noted. Trachea is midline.
LUNGS:  Clear to auscultation bilaterally.
HEART:  S1, S2, regular rate and rhythm. No murmurs, no rubs or gallops.
ABDOMEN:  Bowel sounds are positive in all 4 quadrants.
SKIN:  Intact. No rashes. No erythema. Multiple seborrheic keratoses were noted.
EXTREMITIES:  The patient has 5/5 strength in all extremities. The patient complains of pain to palpation in the glenohumeral joint on the left. No pain on the right. The patient also complains of joint pain over the medial aspect of the elbow. The patient has full range of motion of all 4 extremities. Sensation is intact in all 4 extremities. Reflexes are +2, biceps, triceps, patellar.

PHYSICAL EXAMINATION:  Blood pressure 124/84, heart rate 58, weight 220 pounds, temperature 97.4, oxygen saturation 98% on room air. Has 7/10 pain all over, particularly at the knees, back, and left foot. He has no synovitis in the wrists, PIPs or MCPs. He has some Heberden's and Bouchard's nodes. Knees are cool without effusions. He has crepitus. No clubbing, cyanosis, or edema. Do not detect any dactylitis or synovitis in the feet. Lungs are clear. Heart has regular rate and rhythm, S1, S2. Negative straight leg. Toes are downgoing.

PHYSICAL EXAMINATION: The patient is 5 feet 7 inches tall. He weighs 170 pounds. He is pleasant, cooperative, and in no acute distress. No pain to palpation in his left shoulder. He has full range of motion with pain at the end ranges. Positive Hawkins maneuver, mild tenderness with cross-body adduction testing. He has weakness with external rotation and mild weakness with supraspinatus testing. Neurovascularly intact distally.

PHYSICAL EXAMINATION:
VITAL SIGNS:  The patient is afebrile with a pulse of 84, blood pressure 158/88, respiratory rate of 22, and O2 saturation of 92%.
GENERAL:  This is a well-developed, well-nourished woman who is in no apparent distress. She is mildly tachypneic but is able to speak full sentences without difficulty.
HEENT:  Anicteric sclerae. There is no sinus tenderness. Does have dentures. There is no oral thrush.
NECK:  No lymphadenopathy or JVD.
LUNGS:  There is no stridor.  Lung exam is remarkable for intermittent inspiratory squeak over the left upper lobe anteriorly. There is also soft end expiratory wheeze over the right upper lobe posteriorly. There is no accessory muscle use.
HEART:  Regular rate and rhythm without any murmurs, gallops, or rubs.
ABDOMEN:  No distention. There is normal bowel sounds. Abdomen is soft and nontender.
EXTREMITIES:  No cyanosis, clubbing, or edema.
NEUROLOGICAL:  Grossly nonfocal on strength testing. However, this was limited because of her overall condition.

PHYSICAL EXAMINATION:  Height is 5 feet 4 inches. Weight is 124 pounds. The patient presents in no acute distress but is notably uncomfortable in the right shoulder. Examination of the right shoulder revealed forward flexion, forward extension 175; external rotation 60 degrees, internal rotation to T5. The patient had 5/5 strength. She was neurovascularly intact during gross exam. Positive O’Brien test. Positive dynamic labral shear. Negative apprehension test, negative Jobe relocation test, negative load and shift, negative lift-off, positive Neer test, positive cross-body adduction but pain was not isolated at the AC joint, positive Speeds test, no AC joint tenderness, positive biceps tenderness proximally. The patient had no obvious deformities, ecchymosis, or erythema. Skin was intact.

PHYSICAL EXAMINATION:  The patient is a somewhat anxious (XX)-year-old male in no acute distress. He is oriented x3 and cooperative. Blood pressure is 144/90. Heart rate is 94 with occasional extrasystoles. Oxygen saturation is 99%. Eyes show round, reactive pupils. Sclerae are anicteric. Chest was clear to auscultation bilaterally. Heart is in regular rhythm with a grade 3/6 crescendo-decrescendo systolic ejection murmur over the sternal border and a grade 2/6 holosystolic murmur of mitral regurgitation heard at the apex and radiating out toward the axilla. There is also a diastolic murmur, grade 2/6, heard over the precordium and out to the left ventricular apex. The abdomen is soft without organomegaly or masses. Bowel sounds are normal. The pulses show symmetric radial and brachial pulses without a water hammer quality. Pedal pulses are 3/4 bilaterally. There is no ankle edema.

PHYSICAL EXAMINATION:  On exam, the patient is not in acute distress. She has Heberden's and Bouchard's nodes and squaring at the base of her thumb bilaterally without any significant synovitis. She has a positive Finkelstein sign on the right hand consistent with de Quervain's tenosynovitis and is very tender at the abductor tendons along the thumb. Knees are cool without effusions. She is tender at the right pes anserine bursa on palpation. She is tender at the bilateral greater trochanters on palpation. She has a little bit of swelling at the lateral malleolus and right ankle, nontender over any of the MTP heads, and no swelling or acute podagra. Moist mucous membranes. No overt alopecia. Lungs were clear. Abdomen is soft and nontender. Regular rate and rhythm, 2/6 systolic ejection murmur at the left upper sternal border. No clubbing, cyanosis, or edema. Alert and oriented x3.

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Gastrectomy Medical Transcription Dictation Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Gastric cancer.

POSTOPERATIVE DIAGNOSIS:  Gastric cancer.

OPERATIONS PERFORMED:  Gastrectomy with extended lymphadenectomy, including en bloc distal pancreatectomy, splenectomy, cholecystectomy, and placement of anti-adhesion barrier.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

INDICATIONS:  Gastric cancer.

OPERATIVE FINDINGS:  The stomach appeared leathery throughout the body.  The wall was thickened.  No overt penetration of tumor.  No overt involvement of adjacent organs.  Lymph nodes in region of left gastric artery appeared suspicious clinically.

DESCRIPTION OF OPERATION:  The patient was prepped and draped in the standard fashion.  An upper midline laparotomy incision was made.  The peritoneal cavity was entered and no carcinomatosis was encountered.  The liver appeared clear.  The abdomen was explored.  It was notable for a fairly thick-walled stomach, particularly in the area of the body.  There was no overt extension of the tumor anteriorly as I could visualize.  The gallbladder appeared pale and shriveled.  This was consistent with chronic cholecystitis.  We elevated the omentum off of the colon and then entered the lesser sac.  The adventitial tissue connecting the stomach to the pancreas was taken down using electrocautery.  Again, there was no overt extension here.  There were, however, palpable lymph nodes, small in size, but hard and irregular and more noticeable than other lymph node basins in the distribution of the left gastric artery and splenic artery region, in the distribution of the left gastric vein and splenic vein region.  Because of this, we felt the patient should undergo an extended lymphadenectomy.  Because of the diffuse nature of the tumor with leathery stomach, we felt that the patient should undergo a total gastrectomy.

The omentum was completely mobilized and left tethered to the stomach.  The spleen was then elevated along with the pancreas and separated from surrounding structures.  A Bookwalter retractor was used to facilitate exposure.  The greater curvature attachments were taken down off of the stomach.  Well beyond the pylorus, the duodenum was divided using the endovascular GIA.  Lesser curvature was then taken using the LigaSure device as close to the liver as possible.  No clinically palpable nodes were appreciated here.  The tail of the pancreas was then divided.  The spleen was elevated up, remained connected to the stomach with the short gastrics, and was separated from its posterior and other attachments.  The cardia was then dissected out and the gastroesophageal junction was identified.  Two 3-0 PDS sutures were placed on either side of the esophagus and the gastroesophageal junction was divided using electrocautery.  Grossly, this margin as well as the duodenal margin appeared clear.  Posteriorly, the remaining attachments including the neurovascular bundle of the left gastrics were divided, taking great care to identify the hepatic and splenic vessels.  We took the gastric artery right at its base, incorporating all of the lymph nodes.  Splenic artery lymph node, splenic hilum lymph node, peripancreatic lymph nodes, as well as hepatic artery lymph nodes were included in the specimen, not to mention all the perigastric lymph nodes.  The specimen was handed off the field and confirmed that distal and proximal margins were negative.  We next began the reconstruction.

First, retrograde cholecystectomy was performed, keeping a critical view of safety in mind, including both the cystic artery and cystic duct.  Hemostasis was assured with electrocautery and Surgicel.  The ligament of Treitz was identified, and approximately 40 cm distal to this, the bowel was divided.  The mesentery was divided using the LigaSure.  The distal bowel was brought up antecolic and an end-to-side esophagojejunostomy was performed using interrupted 3-0 PDS.  The jejunum was secured to the paraesophageal region using 2-0 silk sutures.  The NG tube was threaded through down into the proximal jejunum.  Distally, a side-to-side functional, end-to-end anastomosis was performed, bringing the small bowel together.  This was approximately at 40 cm from the esophagojejunostomy.  This was done using the GIA and TA-60.  The TA-60 actually appeared to narrow the Roux limb slightly, and for that reason, an even more proximal enteroenterostomy performed in the same fashion was made to prevent obstruction.  All staple lines were oversewn.  They appeared viable.  A redundant portion of the duodenal end of the small bowel was resected as it looked slightly dusky.  Again, by the end of the case, the patient was hemostatic, her bowel appeared viable, all potential areas of internal herniation had been closed using 2-0 suture, and all suture lines were oversewn using silk suture.

A Witzel feeding jejunostomy was placed in the duodenal limb near the ligament of Treitz.  A 2-0 silk was used also outside of the Witzel technique to pexy this to the posterior abdominal wall.  The tube was flushed and there was evidence of leakage.  Its distal limb was threaded into the proximal enteroenterostomy.  We then oversewed the duodenal stump using interrupting Vicryl 2-0 as well as the pancreatic margin.  Two large Blake drains were placed from the right side near the anastomosis, duodenal stump and pancreatic staple line.  All drains and feeding tubes were secured with multiple 2-0 silk suture.  The viscera were then oriented and reinspected, and we irrigated with significant amounts of fluid and all effluent was removed.  The patient was hemostatic.  Lap, needle, and instrument counts were deemed correct x2 and then furthermore at the end of the case.  Seprafilm was placed atop the viscera as it was oriented properly.  The fascia was then closed using heavy PDS suture.  The skin was stapled after irrigating subcutaneous tissues.  Betadine ointment was placed to all drain sites and staples along with dry dressings.  The patient appeared to tolerate the procedure.  We explained all the aforementioned, including the extent of the surgery and the reason an extended lymphadenectomy had been performed.

Pneumonia Consult Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Pneumonia.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with history of HIV.  The patient stated approximately three days ago, he started having chills and severe cold associated with fever.  The patient also noticed some dry cough and worsening of chronic shortness of breath.  Because of persistence of his symptoms, the patient decided to come to the emergency department.  The patient denies any sore throat, nasal congestion, nausea, vomiting, diarrhea, abdominal pain, significant weight loss, anorexia, presyncope, loss of consciousness, seizure, motor or sensory deficits, vision abnormalities, speech problems, dysphagia, heartburn, reflux or aspiration.  He denies any pleuritic chest pain, retrosternal discomfort, orthopnea, PND or edema of lower extremities.  He denies any polydipsia, polyuria or polyphagia.  He denies any flank pain or urinary symptoms.  He denies any heat or cold intolerance.  Admits to diffuse musculoskeletal pain.

PAST MEDICAL HISTORY:  HIV positive for several years, status post pneumonia x2.  A year back, the patient was admitted to the hospital and was diagnosed with PCP.  There appeared to be a lot of emphysematous and cystic lesions in the lungs at that time.  The patient since then has been using oxygen on and off at home.  He does feel short of breath on exertion normally.  He does not appear to have progressed in the past year.  Also, he has some mild cough.  Approximately a month ago, the patient was seen because of pneumonia and p.o. antibiotics were given.  The patient was also admitted to hospital about four months ago, and he remained there for about one week for pneumonia.

SOCIAL HISTORY:  Denies any alcohol or smoking.

ALLERGIES:  Not known.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 114/58, heart rate 106 per minute, respiratory rate 22 per minute, oxygen saturation is 96% and T max was 101.4.
GENERAL:  The patient appears as an ill male, medium built, in no acute distress.  He is alert and oriented.
HEENT:  Pupils are equal and reactive.  Nasal passages are patent.  Oropharynx appears noncongested.
NECK:  Supple.  No carotid bruits, thyromegaly, stridor or tracheal deviation.
LUNGS:  Symmetric chest excursion.  Breath sounds are bilaterally diminished.  No crackles or wheezes are heard.
HEART:  Normal.  Regular S1 and S2.  No S4 noted.
ABDOMEN:  Soft, nontender, no organomegaly.
EXTREMITIES:  No tenderness, clubbing, cyanosis or edema.

DIAGNOSTIC DATA:  Chest x-ray shows a bilateral bullous disease in both lung fields and hyperinflation.  There appears to be cavitary lesion in the right upper lobe.  CT scan of the chest showed multiple cystic lesion/bullous emphysema in both lung fields, presented diffusely with mostly peripheral distribution.  One lesion in the right upper lobe appears with significantly thick walls, suggesting the possibility of a cavity.  Within this lesion, there is an eccentric mass based in the periphery of the lesion, solid, suggesting the possibility of a fungal ball.

LABORATORY TESTS:  WBC count 4400, hemoglobin 10.6, hematocrit 32, and platelet count 132,000, segmented 78%, bands 3%, and lymphocytes 11%, PTT of 44, PT of 13.2.  Sodium 133, potassium 3.9, chloride 100, CO2 of 21, glucose 88, BUN 8.2, creatinine 0.8, calcium 9, albumin 3.0.  Total bilirubin 1.9, alkaline phosphatase 196, SGPT 29, and SGOT 72.

IMPRESSION:
1.  Right upper lobe cavitary lesion, thick wall, with eccentric peripheral solid nodule consistent with fungal ball.  Cannot exclude malignancy or tuberculosis.
2.  Bilateral bullous disease, likely sequela of previous Pneumocystis carinii pneumonia.
3.  Left lower lobe interstitial infiltrate with some linear component, some nodular component as well. Cannot exclude active versus sequela of previous infection.
4.  Human immunodeficiency virus, no current retroviral therapy.
5.  Abnormal liver function test.

RECOMMENDATION:  Sputum AFB and bronchoscopy.

Thank you very much for the opportunity to take care of this patient.

Pulmonary Consult Sample #1     Pulmonary Consult Sample #2     Consult Sample Reports

Intracranial Hemorrhage Medical Transcription Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Intracranial hemorrhage.

HISTORY OF PRESENT ILLNESS:  The history was obtained from the patient's wife at length. No old records were available, including records of recent hospitalization. The patient is apparently a poor historian because of dementia. This is a (XX)-year-old right-handed gentleman who five days ago was admitted initially to an outside hospital and then transferred to another hospital after a car accident. His brain imaging studies revealed left parietal hemorrhage. According to his wife, the patient had an MRI scan of the brain, which revealed evidence of cerebral amyloid angiopathy. The patient has hypertension and stayed in the ICU for several days to control the blood pressure. On their request, the patient was transferred two days ago here. The patient was sent to have vascular studies of the lower extremity for DVT, which was negative, but on his way back, he struck his head to the window of the ambulance. The patient underwent CT scan of the brain, which again revealed parietal parenchymal hemorrhage, but no evidence of any acute bleed on the left side where he was struck. For several months, the patient's cognitive functions have been declining slowly. He has been noticed to have been confused and at times wandering. His blood pressure also has been fluctuating. His blood pressure medicines were being adjusted recently.

PAST MEDICAL HISTORY:  As above. History of hypertension, history of recently progressive cognitive deficit and he was started on Aricept for that reason. The patient has no history of head trauma. He has no history of seizures.

CURRENT MEDICATIONS:  Include lisinopril, Zestril, Aricept, and Proscar.

FAMILY HISTORY:  The patient's mother died of brain hemorrhage. His father died of heart disease. He has one older sister, who has Parkinson's disease.

SOCIAL HISTORY:  The patient smokes two to six cigarettes a day. He occasionally drinks alcohol. There is no history of illicit drug use.

REVIEW OF SYSTEMS:  As per the history of present illness. No additional pertinent information was obtained.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a well-developed and well-nourished man, who is not in any apparent distress.
VITAL SIGNS:  Blood pressure is 150/90, pulse is 74, respiratory rate is 18, and temperature 98.4.
NECK:  Supple. There are no carotid bruits.
HEART:  Rate and rhythm are regular.
HEENT:  Head is atraumatic and normocephalic.
CHEST:  Clear.
ABDOMEN:  Soft. There is no peripheral edema.
NEUROLOGIC:  The patient is awake and alert. He is oriented to person and time, although he did not know the date. He is oriented to place, but he could not tell me the room number or floor. Short-term memory is 1/3 at 5 minutes. Attention and concentration are mildly impaired. Speech is fluent. Cranial Nerves:  Pupils are equal and reactive. Visual fields on examination revealed left-sided visual field defect and visual extension on the left side. There is very mildly decreased left facial nasolabial fold. Tongue is midline.  Motor:  There is no drift. Strength seems to be 5/5 in all four extremities. Sensations are intact to pinprick, but the patient has sensory neglect on the left side. Gait is unsteady. Attention and coordination are normal.

DIAGNOSTIC STUDIES:  Reviewed the CT scan of the brain done two days ago and the findings are as described before. There is mild mass effect also.

IMPRESSION:
1.  Subacute left parietal parenchymal hemorrhage. The location of the hemorrhage is not typical of hypertensive, but hypertension probably has contributed to the hemorrhage. Underlying etiology likely is cerebral amyloid angiopathy.
2.  Cerebral amyloid angiopathy.
3.  Mild to moderate dementia, also probably related to cerebral amyloid angiopathy.
4.  Uncontrolled hypertension.

RECOMMENDATIONS:  At this time, blood pressure control is of prime importance. We will review old records from outside hospital, which have been requested and are awaited. We will observe fall precautions and use restraints if needed. Continue physical and occupational therapy as well as gait training. We will continue the patient on Aricept and increase the dose in three to four weeks to 10 mg daily.

Thank you, Dr. John Doe, for letting me participate in the care of the patient.


Subdural Hematoma Consult Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Right-sided subdural hematoma.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old right-handed male with a history of a right-sided stroke and left-sided weakness.  He presented with a complaint of headache and dizziness after a fall yesterday.  CT scan of the head was performed that showed evidence of a right-sided acute subdural hematoma for which we were called for neurosurgical evaluation.  The patient denied any new weakness or any numbness.  The patient, of note, did present to the hospital one week prior with a complaint of vertigo and CT at that time apparently was unremarkable for hemorrhage.

PAST MEDICAL HISTORY:  Significant for dyslipidemia, hypertension, hypothyroidism, and stroke.

PAST SURGICAL HISTORY:  Significant for inguinal hernia repair, cholecystectomy, and knee surgery.

HOME MEDICATIONS:  Include Lasix, potassium chloride, Lexapro, Lipitor, Synthroid, allopurinol, aspirin, Proscar, Antivert, and Flomax.

ALLERGIES:  NKDA.

SOCIAL HISTORY:  The patient denies tobacco or alcohol use.  He lives with his wife.

FAMILY HISTORY:  Unremarkable for history of intracranial pathology.

REVIEW OF SYSTEMS:  All 14-point review of systems was discussed with the patient, significant for those things mentioned above and recent dizziness over the past couple of weeks.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.4 degrees Fahrenheit, pulse 74, respirations 18, blood pressure 136/78, and O2 saturation on room air 98%.
GENERAL:  The patient is a pleasant male.  He is sitting on bed.  He does not appear to be in any acute distress.
HEENT:  The patient's head is normocephalic.  He has a small laceration over the vertex of his scalp with minimal underlying hematoma.  There is no palpable deformity underneath it.  Sclerae are noninjected and nonicteric.  His oropharynx is clear.  He has good speech.  He has normal dentition.
NECK:  The patient's neck is supple with good range of motion.  There is no Lhermitte or Spurling sign.  There is no thyromegaly.  No JVD.  He has normal carotid pulsations.
HEART:  Auscultation of the patient's heart does reveal evidence of perhaps a grade 3 systolic ejection murmur.  There are no gallops or rubs.  He has normal S1 and S2 sounds.
LUNGS:  Clear to auscultation bilaterally.  There is no rhonchi, wheeze, or rale.
ABDOMEN:  The patient's abdomen is soft, nontender, and nondistended.  He has normal bowel sounds.
EXTREMITIES:  There is no clubbing, cyanosis, or edema.  He has good pulses throughout.
NEUROLOGIC: The patient is awake, alert, and oriented x3.  He has clear speech.  He has normal mentation.  His pupils are 3 mm, trace reactive bilaterally.  Funduscopic exam reveals no evidence of papilledema.  Extraocular movements are intact.  His visual fields appear full.  He does have a trace amount of nasolabial flattening on the left.  His facial movement otherwise is symmetric.  He has slightly decreased hearing, but this is symmetric bilaterally.  His palate is upgoing.  His tongue protrudes in the midline.  He has normal shoulder shrug.  His strength reveals a trace amount of left upper extremity drift and perhaps a minimal amount of weakness diffusely in the left upper extremity.  His left lower extremity strength is 4+ to 5-/5; this is all old according to the patient.  He has normal sensation, light touch, and pinprick throughout.  He has 5/5 strength on the right.  His reflexes are 2/2 at the biceps, triceps, and patellae bilaterally.   His toes are downgoing on the right and they are equivocal on the left.  There is no Hoffmann sign.

LABORATORY DATA:  Sodium 137, potassium 4.3, BUN 46, creatinine 1.6, white count 4500, hematocrit 35.4, and platelets 136,000.  PT 14.6, PTT 33.8, and INR 1.17.

DIAGNOSTIC DATA:  We reviewed the patient's CT scan of head, which showed evidence of a 1 cm thick right acute frontal, temporal, parietal subdural hematoma, and 3 mm of right to left shift.  He has open cisterns.  His ventricles are open.  There is no evidence of herniation.  No intraparenchymal lesions are seen.

IMPRESSION AND PLAN:  The patient is a (XX)-year-old male with a history of a previous stroke and left-sided weakness.  He now has a right-sided subdural after a fall.  His exam appears stable.  We had a discussion with his wife, who told us that the patient does indeed have a history of left-sided weakness.  We suspect this is his baseline, however, we did explain to her our concerns stating that a subdural hematoma on the right side would cause similar symptoms, which she understands at this time.  Both she and her husband are in agreement that we will continue to monitor this very closely.  If he shows any evidence of worsening left-sided weakness or if his subdural hematoma increases in size with repeat imaging, we will recommend a right-sided craniotomy to evacuate the hematoma.  If, however, his symptoms remain stable and the hemorrhage does not increase in size, we will continue to manage him medically.  He should be admitted to the neurologic intensive care unit.  He should undergo repeat head CT in the morning and his aspirin should be held.  He should be started on Dilantin for seizure prophylaxis. We should be called if his neurologic exam worsens.  His blood pressures should be kept at 160.

Thank you, Dr. John Doe, for allowing me to participate in his care.


Renal Failure Consultation Medical Transcription Sample

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Renal failure.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with multiple problems.  He has history of longstanding diabetes with complications, history of coronary artery disease, status post CABG and severe cardiomyopathy with poor EF around 20-25%, history of hypertension, history of hyperlipidemia, history of peripheral vascular disease with necrosis of both heels, history of obesity, history of anemia, history of prostate CA, history of chronic renal failure with acute worsening, needing hemodialysis temporarily on last admission.  He has been off of dialysis and his creatinine has been stable in the range of mid 2s.

The patient is now admitted to the hospital because of GI bleed.  The patient was found to have coagulopathy secondary to Coumadin toxicity.  GI has been consulted.  The patient is scheduled for endoscopy.  Also, ID has been seeing him for possible osteomyelitis.  His labs, which have been showing elevated BUN and creatinine, prompted the renal consultation.  His hospitalization course was reviewed.  He had a CT of the chest done without contrast, which showed small bilateral pleural effusion, left greater than right, with some associated atelectasis.  No adenopathy or pulmonary nodule seen.  His labs showed his creatinine has remained stable with slight elevation; today it is 60 and 2.4.  The patient has been started on IV fluids, since he has been n.p.o. for GI procedure.  His echocardiogram, which has been done on this admission, shows EF of around 20%.

PAST MEDICAL HISTORY:  As above.  History of multiple problems with multiple complications.  He has history of chronic renal failure with acute worsening on past admission needing temporary hemodialysis.  He has been off dialysis with stable chronic kidney disease with creatinine in range of mid 2s.  History of coronary artery disease and cardiomyopathy, EF around 20%.  History of CABG in the past, history of longstanding diabetes, history of hypertension, history of peripheral vascular disease, history of obesity, history of tobacco use, history of prostate CA, and history of anemia.

ALLERGIES:  No known allergies.

MEDICATIONS:  Lasix 40 mg daily; insulin, according to sliding scale coverage; Rocephin 1 g; Coreg 25 mg b.i.d.; Protonix 40 mg q. 24 h.; Zithromax 500 mg q. 24 h;, Lipitor 40 mg at bedtime; Zetia 10 mg at bedtime; and enalapril 10 mg b.i.d.; and he has received vitamin K.

SOCIAL HISTORY:  History of smoking in the past.  Denies any alcohol or IV drug use.

FAMILY HISTORY:  Significant for diabetes and heart problems.

PHYSICAL EXAMINATION:
GENERAL:  On exam, this is elderly male who is chronically ill, alert and awake.
VITAL SIGNS:  Blood pressure 124/58, heart rate 66, and temperature 98.6.
HEENT:  Normocephalic and atraumatic.  Pupils are equal and reactive.  Positive pallor, negative icterus.
NECK:  Supple.  No JVD.  No bruit.
LUNGS:  Have bilateral air entry anteriorly with diminished breath sound at the bases.
HEART:  S1 and S2 regular, distant.
ABDOMEN:  Obese, soft, and nontender, and difficult to evaluate organomegaly.
EXTREMITIES:  Shows no edema with gangrenous changes of both heels.
NEUROLOGIC:  Limited exam at this time.

LABORATORY AND DIAGNOSTIC DATA:  His white count is 10.4, hemoglobin 8.6, hematocrit 27.6, and platelets 124,000.  Sodium 141, potassium 3.8, chloride 111, CO2 is 22, BUN is 60, and creatinine 2.4.  His x-rays noted.  Echocardiogram noted above.

IMPRESSION:
1.  The patient was admitted with gastrointestinal bleed with coagulopathy and Coumadin toxicity.  Gastrointestinal workup is in progress.  The patient is scheduled for endoscopy.
2.  Renal failure, which is chronic, chronic kidney disease.  He had acute worsening in the past needing temporary hemodialysis.  Currently, he is off dialysis.
3.  Coronary artery disease and cardiomyopathy.
4.  Hypertension.
5.  Diabetes.
6.  Peripheral vascular disease.
7.  Obesity.
8.  Prostate carcinoma.

RECOMMENDATIONS:  At this time, I agree with current plans.  We will check his iron studies and start him on erythropoietin shot and replace iron as needed.  His creatinine seems stable.  We will check his 24-hour urine for creatinine clearance.  We will also check his phosphorus level and PTH level.  Further recommendation as we go along.

Thank you, Dr. Doe, for allowing me to participate in the care of the patient.

Epigastric and Chest Pain Consultation MT Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Epigastric and chest pain with vomiting and hematemesis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old African-American woman who has a history of peptic ulcer disease and gastroesophageal reflux disease.  The patient was admitted for epigastric and chest pain of 4 days' duration.  Per the patient, she has been experiencing aching pain in the epigastrium and in the retrosternal area, which is fairly constant, grade 8/10 in severity, pain associated with nausea and vomiting.  The pain was getting worse when eating food and better after vomiting.  She was vomiting all the food she was eating and had one episode of small amount of bright red blood hematemesis.  She also has on and off melena at home.  She has been taking Naprosyn 500 mg p.o. b.i.d. for the last 10 months because of chronic neck pain because of a motor vehicle accident.  She also was found to have peptic ulcer disease.  She has been taking Prevacid at home along with Flexeril and Naprosyn.  The pain got worse before she was admitted to the hospital because of which she was admitted for further evaluation.  She is status post cholecystectomy for gallstone disease.  There is no history of recent weight loss.  No history of fever.  On admission, the patient was found to have a white cell count of 15.5, which reduced to 8 today.  The hemoglobin was 9.8, which increased to 12 without any packed RBC transfusion.  Her electrolyte panel is otherwise unremarkable.

PAST MEDICAL HISTORY:  Significant for chronic neck pain because of a motor vehicle accident, peptic ulcer disease, gastroesophageal reflux disease, and ovarian cyst.

PAST SURGICAL HISTORY:  Cholecystectomy, appendectomy, and hysterectomy.

MEDICATIONS:  At home, the patient takes Naprosyn, Tylenol, Flexeril, and Prevacid.  In hospital, she is on Protonix and IV fluids.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  The patient's mother had coronary artery disease and died of an ovarian cancer.  She has one brother and one sister.  She is divorced, and she has one child.

SOCIAL HISTORY:  The patient does not smoke, does not drink alcohol, does not do any injection drugs.

REVIEW OF SYSTEMS:  As above.  Otherwise, negative for other systems.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a (XX)-year-old woman, who is alert and oriented x3, comfortable at rest.
VITAL SIGNS:  Temperature 98.6, heart rate 74, blood pressure 98/66, respirations 18.
HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, reacting to light and accommodation.  Extraocular muscles are intact.  ENT examination is normal.
NECK:  There is no JVD.  There is no lymphadenopathy.  There is no thyromegaly.  Neck is supple.
HEART:  First and second heart sounds normally heard.  No third sound.  No fourth sound.  No murmurs.
LUNGS:  Auscultation of the lungs showed bilateral vesicular breath sounds.
ABDOMEN:  Examination of the abdomen shows soft and scaphoid abdomen.  There is a surgical scar in the epigastrium.  There is a deep tenderness in the epigastrium in the right upper quadrant of the abdomen.  No hepatosplenomegaly.  No ascites.  Normal peristaltic sounds are heard.
EXTREMITIES:  Extremity examination shows no edema, no rash.
NEUROLOGIC:  No focal neurological deficits.

LABORATORY DATA:  The patient's labs shows a white cell count of 8, hemoglobin 12, platelet count 244,000 with an MCV of 88.  Electrolytes panel shows sodium 140, potassium 3.7, bicarbonate 24, chloride 109, BUN 12, creatinine 0.9, glucose of 84.  No LFTs have been done yet.

DIAGNOSTIC STUDIES:  Ultrasound of the abdomen shows the patient is status post cholecystectomy.  There is no biliary dilation.

ASSESSMENT AND PLAN:
1.  Epigastric pain with vomiting and one episode of small amount of hematemesis with a history of nonsteroidal anti-inflammatory drug use.  Rule out peptic ulcer disease, gastritis, esophagitis, and hepatitis.  The patient at this time needs to have an EGD to rule out acid peptic disease.  The procedure of EGD, including the risks of perforation, bleeding, infection, allergy, and hypotension secondary to sedation were explained to her in detail, and she was willing to have the procedure.  The patient will be kept n.p.o. now, and we will have the EGD today.  She is going to be started on oral feeding after the EGD is done on her.  Continue Protonix at this time.  Also, check the liver function tests.  Discontinue nonsteroidal anti-inflammatory drugs.  Further recommendations after EGD.
2.  History of black stools at home.  The patient's stools have been sent for guaiac.  In case there is no pathology seen in the upper GI tract and stools are positive for guaiac, she will require a colonoscopy as well.

Thank you, Dr. Doe, for the opportunity to participate in this patient's care.


Renal Consult MT Sample Report                                      Cardiovascular Consultation MT Sample Report
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