Letter Worktype Medical Transcription Sample Reports / Transcribed Examples


January (DD), (YYYY)



John Doe, MD
Address Line1
Address Line2
City, State  ZIP Code

RE:  PATIENT LAST NAME, Patient First Name
MRN#:  XXXXXX
DATE OF SERVICE:  MM/DD/YYYY
DATE OF BIRTH:  MM/DD/YYYY

Dear Dr. Doe:

Thank you for referring this patient for evaluation of syncope and ongoing cardiology care.

HISTORY OF PRESENT ILLNESS:
This (XX)-year-old Hispanic male has known coronary disease with previous stents and atrial fibrillation.  He also has had a problem with diffuse rash over the last several years for which he has seen an allergist.  He was in his usual state of good health yesterday, when he went through his usual exercise program on the treadmill.  He does a cycle where the treadmill speeds up and then later slows down and then repeats the cycle.  He goes for a total of 45 minutes for about 3.5 miles and he does this several days each week.  Yesterday, he was doing this at about 12 noon, and afterwards, he got hot and flushed.  He sat down.  His pulse was 88.  Then, he started to get his heat-induced rash.  He got in the shower to cool off and he stayed in the shower a long time.  While in the shower, he got lightheaded and dizzy.  He got out and was standing at the sink, when he failed to respond to his wife.  He started to slump and she caught him and eased him to the floor.  He became gray and ashen and remained unresponsive.  The paramedics were called, but within about 1 minute, he started to respond.  She put him in Trendelenburg position.  His blood pressure was 66/40, but he was able to sit up and was asymptomatic at that point.  He went to the ER and had a negative workup.  Further evaluation was requested.

PAST MEDICAL HISTORY:
1.  Atrial fibrillation.
2.  Coronary artery disease.
3.  History of hypertension.
4.  Some visual changes.

ALLERGIES:
NKDA.

MEDICATIONS:
1.  Amiodarone 200 mg daily.
2.  Altace 2.5 mg daily.
3.  Plavix 75 mg daily.
4.  Aspirin 81 mg daily.
5.  Vytorin 10/20 one daily.
6.  Nitrostat 0.4 mg p.r.n.
7.  Multivitamin daily.

FAMILY HISTORY:
Father died at the age of 77.  One brother with no heart problems.

SOCIAL HISTORY:
The patient is married.  He drinks 3 drinks a day, usually beer or wine.  He quit smoking 15 years ago.

REVIEW OF SYSTEMS:
Positive for headaches, dizziness, weak spells, passing out, and rash as above.  No other symptoms.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE:  A well-developed, well-nourished Hispanic male, in no acute distress.
VITAL SIGNS:  Weight 224 pounds.  Blood pressure 122/82, left arm; 118/78, right arm; pulse 66; respirations 16 and unlabored.
HEENT:  Normocephalic, atraumatic.  PERRL.  EOMI.  No lid lag, no exophthalmos, no xanthelasma, conjunctivae pink, no scleral icterus.  Ears and nose externally normal.  Pharynx normal.
NECK:  No JVD.  No carotid bruit, no thyromegaly, no adenopathy.
CHEST:  Lungs clear.  Breath sounds normal bilaterally.
HEART:  PMI in the 5th intercostal space, no lift or thrill.  S1 and S2 normal.  No gallop, murmur or rub.
ABDOMEN:  Obese.  Otherwise, flat, soft, nontender.  Normal bowel sounds.  No bruit.  No palpable aortic aneurysm, mass or organomegaly.
EXTREMITIES:  Full range of motion.  No cyanosis or clubbing.  Trace edema.
HEMATOLOGIC:  No history of anemia, easy bruising, bleeding or clotting disorders.
MUSCULOSKELETAL:  No myalgias, arthralgias, joint swelling.
NEUROLOGIC:  Alert and oriented x3.  Cranial nerves intact.
PSYCHIATRIC:  No noted disturbance in mood or cognitive function.
SKIN:  No significant skin lesions or rashes.

IMPRESSION:
1.  Syncopal episode yesterday after strenuous exertion, overheating, rash with probable associated vasodilatation and then prolonged standing in the shower.  I suspect he vasodilated and became hypotensive from that.  The immediate response to supine position would seem to confirm that as well.  There were no palpitations to suggest a recurrence of atrial fibrillation or any other arrhythmia at the time.  The episode was preceded by dizziness and lightheadedness, also suggesting a vasodilatory phenomenon.
2.  Coronary artery disease, stable.
3.  History of paroxysmal atrial fibrillation, on amiodarone, in sinus rhythm now.
4.  Questionable elevation of TSH level in the past.  No records available on that.

PLAN:
1.  Schedule for CBC, BMP and thyroid profile with TSH.
2.  Schedule for echocardiogram and Cardiolite stress test for followup of his atrial fibrillation and CAD.
3.  Return visit in 2 weeks to review results.
4.  We will need to keep close followup of him in the future.
5.  He will need cholesterol followup also and he requests referral for primary care.

Sincerely,




John Doe, MD



-----------------------------------


January (DD), (YYYY)



John Doe, MD
Address Line1
Address Line2
City, State  ZIP Code

RE:  PATIENT LAST NAME, Patient First Name
MRN#:  XXXXXX
DATE OF SERVICE:  MM/DD/YYYY
DATE OF BIRTH:  MM/DD/YYYY

Dear Dr. Doe:

I was able to see your patient in my urologic practice. As you may recall, he is a (XX)-year-old gentleman with a known bulbar stricture. I was able to consult with him several weeks ago but brought him back today to perform imaging studies.

AUA symptom score 4. Bother score 3. Erectile function score, he reports priorly that was 14.

PROCEDURE:
The patient was prepped and draped in a normal sterile fashion. Ten mL of Renografin was injected into the urethra. This revealed a dense stricture in the distal bulbar area; it appears to be quite short. There were no other strictures identified in the anterior urethra. Cannulated this with an 8-French and passively filled his bladder with 300 mL of Cystografin. Three views of the bladder were obtained. He did not leak urine on straining. On his voiding cystogram, you could see dilation clear through his post urethra into the bladder. This indicates high degree of obstruction.

IMPRESSION:  Dense anterior urethral stricture in the distal bulbar urethra.

ASSESSMENT AND RECOMMENDATION:
I spent well over 45 minutes discussing the results with the patient. He would like to schedule surgery. I will perform either an anastomotic urethroplasty or a ventral buccal urethroplasty. I explained the risks in detail to him. All of his questions were answered to his satisfaction. He does wish to proceed.

It was a pleasure being involved in his care. If you should have any further questions, please do not hesitate to contact me.

Sincerely,




John Doe, MD



-----------------------------------


January (DD), (YYYY)



John Doe, MD
Address Line1
Address Line2
City, State  ZIP Code

RE:  PATIENT LAST NAME, Patient First Name
MRN#:  XXXXXX
DATE OF SERVICE:  MM/DD/YYYY
DATE OF BIRTH:  MM/DD/YYYY

Dear Dr. Doe:

I saw this patient regarding consideration for bariatric surgery. She certainly meets the criteria for surgery and she would like to plan for this later in the year. Her insurance requirements require a period of supervised weight loss by her primary care physician and she may contact you regarding this.

I have attached a copy of my consultation note. If I could be of any further assistance, please let me know.

Sincerely,




John Doe, MD



-----------------------------------


January (DD), (YYYY)



John Doe, MD
Address Line1
Address Line2
City, State  ZIP Code

RE:  PATIENT LAST NAME, Patient First Name
MRN#:  XXXXXX
DATE OF SERVICE:  MM/DD/YYYY
DATE OF BIRTH:  MM/DD/YYYY

Dear Dr. Doe:

I have evaluated the patient again for his complaints and symptoms. His evaluation included another MRI of the brain for his facial numbness and sensation with and without contrast along with complete metabolic profile, liver function, lipids, urinalysis and chest x-ray. These were all done as he had some coughs and pains in his chest and he was having some flank pain. In addition, the patient tells me that he may have sleep apnea symptoms. In this regard, I have booked him a sleep study for which he will return and fortunately the MRI is normal. Urinalysis is normal. Liver function is normal. His lipid profile, however, is mildly abnormal with cholesterol of 218 and an LDL of 154.

I am not sure of what is actually causing the patient's symptoms of numbness. He does have some anxiety and at least may be using benzodiazepine somewhat regularly, but I am not certain of this. In this regard, to see if we can afford some empiric relief of these symptoms, I will start him on Neurontin 300 mg at bedtime and he will be in touch with me as to how he is doing with this. He is also going to be seeing an ophthalmologist as he had some minor visual symptoms. I suspect he has presbyopia only.

Again, thank you for sending the patient to me for evaluation. If there are any questions please do not hesitate to contact my office. I will be mailing the patient his lab results directly.

Sincerely,




John Doe, MD




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