DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Syncope.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old female with a history of hypoglycemia who had a syncopal episode earlier today and is brought in to seek further medical attention. The patient states that she was in her usual state of health up until yesterday, when she had some trouble sleeping.

She had some diminished appetite and did not eat dinner. She did not sleep well during the night and skipped breakfast this morning as well. She was brought to work by her daughter due to her fatigue and weakness. Shortly after arriving at work, the patient had a true syncopal episode.

The patient does not recollect how long she was down for. No bladder or bowel incontinence or tongue biting was noted.

The patient denies any prodrome, shakiness, as she has had in previous syncopal episodes with the last one occurring approximately 4 years ago. The patient does have a history of hypoglycemia and reportedly had a blood sugar of 58 at the time of the syncopal episode today.

The patient was given some glucose and had significant improvement in her symptoms. The patient denied any chest pain or shortness of breath. She denied any palpitations during this episode. She denied any fevers, chills, nausea, vomiting or diarrhea. The patient denied any bright red blood per rectum or melena or hematemesis.

PAST MEDICAL HISTORY:  The patient has a history of hypoglycemia previously treated medically and was instructed to eat frequent meals, history of previous syncope with the last episode approximately 4 years ago, related to hypoglycemia, per her description, and 2 prior pregnancies with no complications.

ALLERGIES:  None.

MEDICATIONS:  Ambien as needed.

SOCIAL HISTORY:  The patient is a nonsmoker. She denies any heavy alcohol use. She has 2 children.

FAMILY HISTORY:  Positive for history of hypertension and diabetes. No early family history of coronary artery disease.

REVIEW OF SYSTEMS:

CONSTITUTIONAL:  No fevers, night sweats or weight loss.

HEAD AND NECK:  No blurred vision or tinnitus.

PULMONARY:  No productive cough, shortness of breath or chest pain.

CARDIOVASCULAR:  See HPI.

GASTROINTESTINAL:  No melena or bright red blood per rectum or abdominal pain.

GENITOURINARY:  History of 2 previous pregnancies, currently on estrogen patch for birth control.

ENDOCRINE:  No history of diabetes or thyroid disease.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Initial blood pressure was 114/76, pulse 68, weight 182 pounds, temperature 98.6.

GENERAL:  The patient is an alert and pleasant female, in no acute distress.

HEENT:  Normocephalic and atraumatic. Oropharynx is moist. No thrush.

NECK:  Supple. No adenopathy JVD.

LUNGS:  Clear to auscultation bilaterally.

CARDIOVASCULAR:  Shows normal S1 and S2. There was a soft 2/6 systolic murmur with splitting of the second heart sound noted. No gallops or rubs.

ABDOMEN:  Soft and nontender. No hepatosplenomegaly.

EXTREMITIES:  Warm. No cyanosis, clubbing or edema.

NEUROLOGIC:  The patient is alert and oriented x3. Cranial nerves II through XII intact, 5/5 upper and lower extremity strength, 2+ deep tendon reflexes bilaterally.

DIAGNOSTIC DATA:  EKG shows sinus rhythm. There is incomplete right bundle-branch block. Nonspecific ST changes are noted.

LABORATORY DATA:  White blood cell count 7.6, hemoglobin 12.6, hematocrit 39.2, and platelets 266,000. Glucose is elevated at 136, BUN of 9, creatinine of 0.9. Initial CK-MB is less than 0.7.

IMPRESSION:  Syncope, vasovagal versus related to hypoglycemia.

PLAN:  Agree with telemetry monitoring overnight. The patient is now not orthostatic and feels much better after glucose administration. This likely implicates hypoglycemia as being the culprit for her syncope. Agree with 2D echo to better rule out valvular heart disease as a culprit for syncope. The patient did not have any chest pain or exertional shortness of breath, and there was no further need for an ischemia evaluation at this time; although, one may reconsider in the future on an outpatient basis. I agree with gentle hydration. Consideration for outpatient tilt table testing if there is recurrence of syncope. Suggest further workup of etiology of hypoglycemia.

The post Syncope Consult Medical Transcription Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

DATE OF CONSULTATION:  MM/DD/YYYY

REASON FOR CONSULTATION:  Atrial fibrillation.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with no known history of organic heart disease, who was found to be in atrial fibrillation on a routine examination.  The patient denies any history of tachypalpitations.  She denies any recent history of increased fatigue or shortness of breath.  The patient denies PND, orthopnea, pedal edema or exertional chest discomfort.

PAST MEDICAL AND SURGICAL HISTORY:

1.  Ectopic pregnancy.

2.  Ventral hernia.

CORONARY DISEASE RISK FACTORS:

1.  Cigarettes are positive.  The patient smokes about a pack a week, but at her peak was smoking three packs a day.

2.  Diabetes is negative.

3.  Hypertension is negative.

4.  Cholesterol was 155, HDL 30, LDL 108, and triglycerides are 78.

SOCIAL HISTORY:  The patient is not a drinker.  The patient does not get much exercise.

FAMILY HISTORY:  Negative for premature coronary disease.

ALLERGIES:  No known allergies.

MEDICATIONS:

1.  Metoprolol 50 mg daily.

2.  Aspirin 5 grains daily.

3.  Citracal 250 mg daily.

4.  Multivitamin daily.

5.  Actonel 35 mg once a week.

REVIEW OF SYSTEMS:

GENERAL:  Weight is down 5 to 10 pounds.  She denies any fever or chills.

CARDIORESPIRATORY:  As in the present illness.

NEUROLOGIC:  She denies any symptoms compatible with TIAs.

MUSCULOSKELETAL:  There are no symptoms of intermittent claudication.

GENITOURINARY:  There is no hematuria or dysuria.

GASTROINTESTINAL:  There is no hematochezia or melena.

SKIN:  There are no new rashes.

HEMATOLOGIC:  She does not bruise easily.

The rest of review of systems is negative.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 124/64, heart rate of 114 and irregularly irregular.

GENERAL:  The patient is a well-developed and well-nourished female, in no acute distress.  She is alert, oriented, and cooperative with normal affect.

HEENT:  Head is negative.  Eyes:  EOMs are intact.  Sclerae white.  Conjunctivae are pink.  The mouth is without lesions.  The tongue protrudes in the midline.

NECK:  Without JVD.  Carotid pulses are 2+ and equal.  There are no bruits.

LUNGS:  Clear except for bilateral scattered rhonchi.

HEART:  Irregularly irregular rhythm.  There is a soft 2/6 apical systolic murmur.  There is no S3.  There is no diastolic murmur appreciated.

ABDOMEN:  Soft and nontender.  No palpable masses or organomegaly.  The abdominal aorta was not palpable.  Bowel sounds were active.  There was no abdominal bruit appreciated.

EXTREMITIES:  Without edema bilaterally.  Femoral pulses are 2+ and equal without bruits.  Dorsalis pedis pulses 2+ on the left, not palpable on the right.  Posterior tibial was not palpable on the right and 1+ on the left.

NEUROLOGIC:  Grossly intact.

LABORATORY DATA:  CBC showed hemoglobin, hematocrit, white count, and platelet counts to be normal.  Free T4 is 1.4, which is within normal limits.  Electrolytes: BUN and creatinine are normal.

IMPRESSION:

1.  Atrial fibrillation of undetermined age.  The patient is basically asymptomatic with this.  Rates, however, are somewhat fast.

2.  The patient may have peripheral vascular disease, but it is asymptomatic.

RECOMMENDATIONS:

1.  We are going to go ahead and increase the metoprolol to 75 mg b.i.d.

2.  We will anticoagulate her with Lovenox and Coumadin.

3.  We will set her up for an adenosine Cardiolite stress test.

4.  We spoke about the importance of her stopping her cigarettes completely.

Thank you, Dr. John Doe, for asking us to see the patient.

The post Atrial Fibrillation Consult Medical Transcription Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR HOSPITALIZATION:  Worsening dyspnea.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old African-American female with no prior pulmonary history, who was admitted with a one-week history of increasing breathlessness and a significant increase in these symptoms over the past one to two days.  The patient notes dyspnea with exertion, minimal activity, worsening significantly over the past several days.  This is not associated with cough, upper respiratory tract infectious symptoms, purulence, chest pain, fever, or wheeze.

PAST MEDICAL HISTORY:

1.  Hypertension.

2.  Rheumatoid arthritis.

3.  Spinal stenosis.

MEDICATIONS:

1.  Inderal.

2.  Prednisone 5 mg daily.

3.  Vasotec.

4.  KCl.

5.  Motrin.

6.  Arava.

7.  Cardizem.

No oxygen or inhalers are used at home.

ALLERGIES:  NKDA.

SOCIAL HISTORY:  The patient lives with her husband and appears to have supportive children in the area.  The patient is a nonsmoker.  The patient relates description of significant home stress in being the full-time caregiver for her husband.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 100/48 mmHg, pulse 62 beats per minute and regular, respirations 18 breaths per minute and nonlabored, and temperature 97.6 degrees.

GENERAL:  This is a well-developed, talkative African-American female, in no acute distress.  She has no shortness of breath noted.

HEENT:  There is no thrush appreciated.  Sclerae anicteric.

NECK:  Supple.  No nodes are found.

HEART:  Heart tones S1 and S2, RRR.  There is a small murmur heard at the sternal border.

CHEST:  Excursion is even, regular, and nonlabored.  There is no accessory muscle use.  Respirations are symmetrical.

LUNGS:  Clear breath sounds to auscultation.  There is no egophony noted.  No wheeze.  ABDOMEN:  Soft and nontender.  No hepatosplenomegaly noted.

EXTREMITIES:  Warm.  No edema.  Pulses are equal bilaterally.

LABORATORY DATA:  Oxygen saturation currently 96% on 2 liters nasal canula O2.  Chest CT, a low probability for pulmonary embolus, although tiny pericardial effusion is found.  The patient also has a 5 mm superior segment right lower lobe mass, which may be granulomatous.  D-dimer is 992, BNP 102, PT 10.6, with INR 1.0.  WBC is 8.8 with hemoglobin 12.2, hematocrit 36.8, and platelets 262,000.  Potassium 3.9, BUN 28, creatinine 1.0, and glucose 108.

IMPRESSION AND PLAN:

1.  Dyspnea.  This patient notes progressive dyspnea with activity, which has worsened over the last several days prior to admission.  Workup shows negative pulmonary origin for this dyspnea at this point; however, she will be followed closely.  Oxygen saturations with activity on room air will be assessed.  If need be, the patient may benefit from outpatient pulmonary stress testing evaluating airflow and oxygenation with simple treadmill stress.  In addition, outpatient pulmonary function testing may be considered.  Nebulized bronchodilators will be continued at this point.

2.  Hypoxemia.  Oxygen will be weaned and oxygen saturations will be assessed.  Arterial blood gas will be drawn if there are any hypoxemic events.

3.  Anxiety.  As noted in her initial history, the patient personally stated that she is under increasing familial stress and wonders if this could be related.  Social service consult will be obtained for further evaluation.

4.  Hypertension.  Blood pressure is now stable.  Stress test results from the hospital would be forwarded.

Thank you, Dr. John Doe, for the opportunity to care for your patient.

The post Dyspnea Consultation Work Type Medical Transcription Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

ENT Consult Medical Transcription Sample Report

DATE OF ENT CONSULTATION:  MM/DD/YYYY

REASON FOR ENT CONSULTATION:  Right ear pain.

REFERRING PHYSICIAN:  John Doe, MD

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who has been complaining of right ear pain. The patient relates that she had a similar episode approximately 4 weeks ago and saw a nurse practitioner, who diagnosed the patient with acute otitis media and treated her with antibiotics. The patient completed the course and had some improvement after 3-4 days.

The patient denies any hearing loss, any problems with upper respiratory infection prior to the onset of the ear pain, and significantly, she does have allergy problems which have been exacerbated in the fall season. She has been taking Zyrtec prior to admission. She relates that she continues with nasal congestion and drippiness from her nose with associated postnasal drip, despite the fact that she is in the hospital currently. She has had difficulty with sinusitis. Importantly, she has also had problems with infected teeth and had root canals. However, denies any current or recent dental problems. She has had history of TMJ syndrome in the past. She relates that the pain is somewhat similar to this.

The patient relates that she has had difficulty with cervical myalgia in the past as well as migraine headaches. She has undergone chiropractic treatment for her migraine headaches with improvement in her headache symptoms. Significantly, she has been involved in multiple accidents sustaining whiplash injuries on 4 separate occasions, according to the patient.

She recently notes that she was given a diagnosis of a nasal septal deviation as well. She denies any throat pain. She has had tonsillectomy performed in the past. She describes the pain as throbbing, achy pain. She denies any hearing loss, vertigo or otorrhea. She relates that she has had longstanding tinnitus, which she describes as a high-pitched ringing sound, worse on the right than the left, and not associated with fullness of the ear or any facial weakness.

She had been previously evaluated by an otorhinolaryngologist, who performed an audiometric evaluation and found her hearing to be fine. The patient denies any significant noise exposure history. The patient denies eustachian tube dysfunction symptoms including pressure, pain, throbbing or popping sensation of the ears. She denies any acute dental problems. She denies frank symptoms of prodromal aura or migraine headaches. She denies any type of temple headache to suggest temporal arteritis. She has not had any recent trauma to the ear area.

The patient denies upper respiratory infection symptoms or symptoms related to sore throat. She has no numbness or tingling sensation of the face or the head. She has discomfort related to her abdominal procedure. The patient was referred for an ENT consultation.

CURRENT MEDICATIONS:  Pepcid, Ancef, Lidoderm patch as well as a PCA, Lovenox.

PAST MEDICAL HISTORY:  Morbid obesity, GERD, hypercholesterolemia, environmental allergies, peripheral edema, insomnia, chronic arthritis with associated chronic pain, history of hepatitis and TMJ syndrome. Suspect a recent history of acute otitis media.

PAST SURGICAL HISTORY:  Significant for tonsillectomy, ocular procedures, appendectomy, cholecystectomy, gastric banding, bilateral podiatric procedures, tubal ligation, carpal tunnel, rotator cuff surgeries and left total knee arthroplasty.

FAMILY HISTORY:  Significant for diabetes, hypertension, and coronary artery disease.

SOCIAL HISTORY:  Nonsmoker. She uses alcohol on a social basis.

REVIEW OF SYSTEMS:  As noted in HPI.

PHYSICAL EXAMINATION:

The post ENT Consultation Medical Transcription Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

Neurology Consultation Transcription Sample #1

DATE OF CONSULTATION: MM/DD/YYYY

REQUESTING PHYSICIAN:

Jane Doe, MD

CONSULTING PHYSICIAN:

John Doe, MD

HISTORY OF PRESENT ILLNESS:

I am asked to see this patient with an unknown left temporal lobe lesion, readmitted from hospice. He was originally admitted to this facility for what was presumed to be a CVA. He made slow progress and was transferred to hospice. He developed worsening mental status and was returned to an outside hospital where neurology was re-consulted. Increased mass effect was noted on the CT at that time, and it was therefore thought that this was a hopeless situation, and he was transferred to hospice. His original MRI was done MM/DD/YYYY and suggested tumor. Stereotactic brain biopsy done MM/DD/YYYY showed only ischemic changes. He did have his course complicated by DVT in August and then he was brought here after that.

He was discharged from the outside hospital in July on Tegretol and steroids, and he had a six-week increasing history of fatigue, aphagia and intermittent visual change. He was seen by Dr. Doe on MM/DD/YYYY, and a repeat head CT, as above, showed increased mass effect. The head CT report is available for review and shows decreased attenuation on MM/DD/YYYY in the left posterior parieto-occipital region, mild mass effect in the left lateral ventricle and effacement of the sulci over the left frontal and parietal convexities. There was a pore in cephalic region that was likely an old insult, and there was another area of decreased attenuation in the medial temporal lobe on the left suggestive of infarct of indeterminate age. During his stay in the hospice, his mental status improved and he was brought back here, as above, for further treatment.

On MM/DD/YYYY, MRI of the brain at the outside hospital showed diffuse white matter edema in the left temporal lobe extending into the left posteroparietal region. There was focal cystic structure, which they mentioned in the CT report and called infarct. Here, they were not specific as to its etiology. There was ischemic change in the right cerebral hemisphere, and after contrast, there was abnormal enhancement in the left cerebral white matter in the temporoparietal regions. This extended superiorly and was felt to cross the corpus callosum onto the left side. There was enhancement of the cystic lesion in the medial left temporal lobe. It was felt that this corpus callosum involvement would represent malignancy such as glioblastoma, and lymphoma was another consideration.

The note from hospice is not helpful and only states that biopsy was negative, as we know, and then he was sent to hospice on MM/DD/YYYY. On admission, he opened his eyes there but did not have any other verbal responses. Over the last several weeks, he has improved markedly with speech and movement and is able to feed himself, awake, but slow to respond. He was brought here after that.

MEDICATIONS ON ADMISSION:

1. Glucophage.

2. Lanoxin.

3. Azmacort.

4. Senokot.

5. Morphine.

ALLERGIES:

DILANTIN AND CEFAZOLIN.

SOCIAL HISTORY:

He is a widower with a son with mental retardation. He has a history of COPD with no cigarettes for eight years.

FAMILY MEDICAL HISTORY:

Contributory for cancer of unknown type in his mother and diabetes in his father.

REVIEW OF SYSTEMS:

He had pain in the coccyx on review of systems, that information was from the family. From the patient, there is no information available.

The patient was started on Prozac recently for presumed depression.

PHYSICAL EXAMINATION:

Temperature 97.1 degrees, pulse 99, respiratory rate 16 and blood pressure 104/67.

The patient is seen at 5 o’clock at night. He is aphonic and nonverbal, hypomimic. He occasionally attempts words, but they are unintelligible. He could not repeat. He follows simple commands and does best in contacts, also does best in procedural-type of command or commands involving the appendicular muscles. He cannot follow two-step commands. Totally apraxic; however, this is difficult to interpret in the face of poor sustained attention, extreme latencies of response and very slow cognitive processing. He does appear to understand at least simple commands. Reading was not tested.

Cranial nerve examination shows fundi unremarkable. Pupils equal and reactive, widening in the right palpebral fissure with slight flattening of the right face. The patient was apraxic for mouth opening but could mimic a demonstrated command and had no asymmetry of the palate. Tongue was midline. Neck was supple. Carotids were unremarkable. The rest of his cranial nerves are grossly intact including his fundi.

His motor examination shows equal strength with proximal weakness. It is more pronounced in the legs than the arms.

He has trace reflexes in the ankles, 1 in the knees and 1 in the arms. Toes are down or equivocal. He has a positive grasp/release bilaterally, negative glabellar, mildly positive palmomental and increased jaw jerks bilaterally.

Rapid alternating movements are equal. He had no gross limited ataxia in reaching but was uncooperative or unable to cooperate with finger-to-nose, heel-to-shin. Gait was not tested.

LABORATORY AND DIAGNOSTIC DATA:

Recent laboratories were unrevealing, except a low sodium of 129, which may be related to his use of Tegretol in the past, which he no longer is on.

An EEG report from MM/DD/YYYY, while the patient was on Tegretol, reportedly showed further frontal intermittent rhythmic delta activity, nonspecific and not localizing.

IMPRESSION:

A patient with multiple lesions in the brain, most prominent sounds like the left temporal lobe and left posteroparietal region with gross enhancement of the white matter in those areas, extending superiorly and crossing over the midline to the corpus callosum onto the right side. There is extension downward into the left basal ganglia as well. There is small vessel disease in addition and the etiology of this enhancement is unclear.

PLAN:
1. Obtain more information: We will get his MRIs from his previous hospital to review.
2. We will consider a followup MRI in this patient given his last one was on MM/DD/YYYY. It may be reasonable to repeat another one just to look for change in the next two weeks or so. We will decide this after we see the films from his previous hospital.
3. Give him a trial of Sinemet 25/250 and see if this arouses him and makes him more alert given the left basal ganglia injury.
4. I would leave him off the Tegretol at this time and not repeat any more EEGs unless the patient clearly had a clinical seizure.

We will continue to follow him.

I appreciate being able to share in his care. More testing may be suggested after we see the brain MRI

Neurology Consultation Transcription Sample #2

DATE OF CONSULTATION: MM/DD/YYYY

REQUESTING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Syncope.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a history of chronic low back pain status post surgery, hypothyroidism, depression, hepatitis C, who presented to the ED complaining of severe low back pain. According to the patient, she has had severe back pain for quite some time now and she had a history of a fractured vertebra. The patient reports that she lost her Medicaid and that she has been unable to follow up with her primary care physician; therefore, she has not had any prescriptions for pain medications. The patient reports that her pain is becoming very intense in her low back and that is why she came in for evaluation. The patient also complained of episodes of loss of consciousness. She reported that she has been having episodes where she passes out with complete loss of consciousness for about 3 minutes. She denies any diplopia, dysarthria, vertigo, weakness or numbness associated with these episodes. The patient denies taking any medical help during or after these episodes. The patient denies any seizure-like activity with these passing out events. She denies any tonic-clonic activity. She denies any incontinence, any postictal state.

PAST MEDICAL HISTORY: As above.

ALLERGIES: IVP DYE.

OUTPATIENT MEDICATIONS: Acetaminophen.

PAST SURGICAL HISTORY: Cholecystectomy and hysterectomy.

SOCIAL HISTORY: The patient denies any regular use of drugs. The patient reports that she was on disability but that she lost it and is trying to obtain it again.

PHYSICAL EXAMINATION: Vital signs are stable. The patient is awake, alert and oriented x3. Speech is fluent. Good comprehension. Affect is flat. Pupils equally round and reactive to light. Extraocular movements intact. Visual fields are full. Face is symmetric. Tongue is midline. Palate is symmetric. Motor: Upper extremities, 5/5; left lower extremity, 5/5; right lower extremity, 3+/5. The patient complains of severe pain upon elevating her right leg. She states that this pain is in her back. Reflexes are 2+ throughout. Plantars are downgoing. Sensory: Decreased pinprick in the right lower extremity. Gait: Deferred.

DIAGNOSTIC DATA: CT scan of the brain not available.

ASSESSMENT:

1. Chronic back pain. The patient with history of vertebral fractures and previous surgery, which is causing her a lot of pain. Recommend treating her pain and referring to pain clinic upon discharge.

2. Syncope. The patient with history of syncope, which does not have any oral or postictal state associated with it. The patient’s syncopal events do not sound neurologic and are very possibly functional but need to rule out cardiac causes.

PLAN:

1. Referral to pain management.

2. Rule out cardiac causes of syncope.

3. MRI of the brain.

Neuro Consult Sample Report

Neurology Consultation Transcription Sample #3

DATE OF CONSULTATION:

MM/DD/YYYY

REFERRING PHYSICIAN:

John Doe, MD

REASON FOR CONSULTATION:

Stroke.

HISTORY OF PRESENT ILLNESS:

The patient is a (XX)-year-old female with a history of deafness, diabetes, hypertension, coronary artery disease, peripheral vascular disease and status post right toe amputation who presented to the ED status post a fall. Apparently, the patient’s family members found her lying down on the floor after a fall. The family noticed that the left side of her body appeared to be weak. The patient was brought into the ED for evaluation. According to the patient’s family, at her baseline, the patient uses both sides of her body equally and states that she has never had a stroke in the past. It is very difficult to get any history or physical, as she is completely deaf and her family members have to interpret via sign language. The patient’s family state that the patient does not want to be here and that she is asking to go home.

PAST MEDICAL HISTORY:

As above.

OUTPATIENT MEDICATIONS:

1. Celebrex.

2. Clonidine.

3. Glucophage.

4. Oxycodone.

5. Enalapril.

ALLERGIES:

No known drug allergies.

PAST SURGICAL HISTORY:

Fem-pop bypass and right toe amputation.

FAMILY HISTORY:

Noncontributory.

SOCIAL HISTORY:

The patient lives with family. Denies any drugs, tobacco or alcohol.

PHYSICAL EXAMINATION:

VITAL SIGNS: Stable. Blood pressure 180/106.

NEUROLOGIC: Mental Status: The patient is lethargic, but easily arousable. The patient appears to follow simple commands. Unable to assess speech. Cranial Nerves: Pupils are equal, round and reactive to light. Extraocular movements appeared to be intact. There is left nasolabial fold flattening. Tongue is midline. Palate is symmetric. Motor: Unable to test due to translation issues, but the patient has obvious left upper extremity drift and she is unable to clear the left leg from the bed as opposed to the right. Coordination: Unable to test. Sensory: Unable to test.

LABORATORY DATA:

CT of the brain shows encephalomalacia in the left cerebral hemisphere. No evidence of bleed. Glucose is 290.

ASSESSMENT:

Stroke. The patient presents status post fall, now has left-sided hemiparesis. Was unable to get a complete neurologic exam due to language difficulties. We would like a MRI and MRA of the brain for further evaluation. Will also like to check the results of carotid duplex and 2D echocardiogram. Agree with antiplatelet therapy. The patient is in need of physical therapy and occupational therapy evaluation.

PLAN:

1. Check carotid and echocardiogram results.

2. MRI and MRA of the brain.

3. Agree with antiplatelet therapy.

4. Physical therapy.

5. Check LDL and start statin if LDL is greater than 80. We will follow with you.

The post Neurology Consultation Transcription Sample For Medical Transcriptionists appeared first on Medical Transcription Phrases, Words, And Helpful Hints.