Consultation Medical Transcription Transcribed Sample Reports

Consultation Transcribed Medical Transcription Example Reports for Reference

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HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who has a history of kidney stones.  He presented with a 5-day history of severe left flank and groin pain.  It is associated with severe nausea and vomiting.  Basically, the patient has not been able to keep anything down.  He denies any fever.  He had significant urgency and frequency at the time.  He also had noticed some slowing and hesitancy in his urinary stream.

PAST MEDICAL HISTORY:  Positive for hypertension, high cholesterol, history of kidney stones and back problems.

PAST SURGICAL HISTORY:  Back surgery x2.

MEDICATIONS ON ADMISSION:  Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin.


SOCIAL HISTORY:  The patient denies tobacco, alcohol or illegal substance abuse.

REVIEW OF SYSTEMS:  No fever or chills.  No headaches or seizure disorders.  No shortness of breath or wheezing.  No chest pains or palpitations.  No heart problems.  Positive for hypertension and high cholesterol.  Severe nausea and vomiting with renal colic, otherwise none.  GU, see above.  The patient has a history of back problems.  No arthralgia.

PHYSICAL EXAMINATION:  Vital Signs:  Review of the vital signs show that his temperature is 98.6 degrees, pulse is 94 per minute, respirations are 20 per minute and blood pressure is 164/101.  General:  The patient currently is in no apparent distress.  He is alert and oriented x3.  He is well nourished, well developed, cooperative, not anxious or agitated.  He states that he got one injection of pain medication, and since that time, he has been completely pain-free and feels much better.  Head and Neck:  Head is normocephalic and atraumatic.  Neck is supple.  Trachea is midline.  No JVD noted.  Lungs:  Respirations are unlabored.  No audible wheezing or rhonchi.  Abdomen:  Soft, nondistended and nontender.  No abnormal masses.  No CVA tenderness on either side.  Extremities:  Full range of motion x4.  No obvious focal neurological deficits noted.

LABORATORY DATA:  The laboratory results are reviewed.  Urinalysis shows specific gravity of 1.024, pH of 5.1, trace albumin and 2+ blood.  Microscopic shows 0-3 rbc's, 0-4 wbc's and 1+ bacteria.  CBC shows WBC of 28,700, hemoglobin of 17.5, hematocrit of 50.7 and platelet count of 232,000.  Differential shows 77% neutrophils.  Comprehensive metabolic panel shows essentially normal electrolytes, BUN 38 and creatinine 2.5.  Liver functions normal.  CT scan shows a 2-3 mm calculus at the left ureterovesical junction causing minimal hydronephrosis and hydroureter.

IMPRESSION AND RECOMMENDATIONS:  Left renal colic due to a passable stone.  The patient has now acutely become pain-free suggestive of possible stone passage.  The patient has a creatinine of 2.8, very likely due to dehydration because the patient has had severe nausea and vomiting over the last 5 days.  The patient has severely elevated white blood cell count, but he states that he has been on steroids fairly recently.  His baseline white blood cell count 2 months ago was 9000.  His baseline creatinine was 1.3.  Recommendation at this time is to continue monitoring the patient.  It appears that he may have passed the stone.  Rehydrate the patient.  I will continue to closely monitor the patient with you.

Thank you for this consultation.  If there are any questions, please do not hesitate to contact me.




HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old female with known multiple myeloma, who has chronic and intractable lumbar and thoracic back pain secondary to compression fractures and osteoporosis with or without possible multiple myeloma involvement. On outpatient basis, she has been on chronic dexamethasone therapy for her multiple myeloma. This is probably the contributing factor for her osteoporosis. She had a recent lengthy hospital stay because of the back pain. She was noted to have intermittent fevers during that hospital stay. She was mostly observed for a lengthy period of time off antibiotics and eventually had a tagged white cell scan, which demonstrated uptake in both lower lobes. At that point, we elected to treat her as if she had a hospital-acquired pneumonia. She was given cefepime and vancomycin for approximately eight days. She defervesced very rapidly after the initiation of antimicrobial therapy. After the antibiotics were stopped, she remained afebrile. She was eventually discharged to a skilled nursing facility. The skilled nursing facility noted that she was having some low-grade temperatures. She had blood drawn demonstrating a white count of 14,000. Hemoglobin of 6.2 was also noted. So, she was sent to the hospital for further management and evaluation. Since being admitted to the hospital, she has been placed on ciprofloxacin and cefepime. Urinalysis has not demonstrated any pyuria. Chest x-ray done in a PA and lateral format has not demonstrated any evidence of pneumonia. She has not complained of cough or shortness of breath. Blood cultures were obtained and, so far, have no growth to date, nearly 48 hours of growth. A bone marrow biopsy has been performed. CBC shows white count of approximately 12,000 with no bandemia. She remains on ciprofloxacin and cefepime. She had spikes of some temperature since she has been here. She reached a temperature of 39.2 as a T-max yesterday. The patient herself has not noticed that she has had these temperatures. Infectious Disease is now consulted for further diagnostic and management options in regard to her fever. 

PAST MEDICAL HISTORY:  Multiple myeloma with ongoing chemotherapy, chronic lower back pain secondary to osteoporosis and compression fractures, osteoporosis, bilateral cataracts, history of recent nosocomial pneumonia, possible coag-negative Staph bacteremia, anemia and thrombocytopenia, hyperlipidemia, hypokalemia.


SOCIAL HISTORY:  She does not smoke or drink. She is married. She normally does have full activities of daily living with a walker; although, she had to have some assistance recently. When she was in the hospital recently, she was able to ambulate to and from the bathroom on her own. 

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:  GENERAL:  The patient states that her appetite remains poor. She denies any nausea. HEENT:  She does report occasional headaches. These do not temporally correlate with the times that she has told she has fevers. She denies any difficulty swallowing or choking on food. RESPIRATORY:  She denies cough. She denies shortness of breath. There is no chest discomfort. GASTROINTESTINAL:  She has had no nausea or vomiting. There has been no diarrhea. She denies any abdominal pain, although states at times her abdomen gets quite distended and bloated. It is important to note that she did have an ileus and was essentially obstipated during her recent hospital stay. GENITOURINARY:  She has a catheter in place now but states that she did not have one during her recent stay in a skilled nursing facility. SKIN:  The patient denies any rash. As was seen on physical exam, she does have a very large right upper extremity hematoma and a nodule under her skin of the forearm at the left upper extremity, which she states have been present since she left the hospital recently and perhaps has become worse. LYMPHATICS:  She denies any swollen lymph nodes. NEUROLOGIC:  She denies any focal neurologic findings.  MUSCULOSKELETAL:  She continues to be diffusely weak, although is apparently able to ambulate about to perform all her full activities of daily living. 

VITAL SIGNS:  Blood pressure is 144/72, pulse is 82, respiratory rate is 22, she is 97% saturated on room air, temperature is 37.6 but she has had a T-max of 39.2. Her lowest blood pressure was 102/54 in the emergency department. 
GENERAL:  She is awake and alert. She is oriented. She can actually remember who I am.
HEENT:  Oropharynx is clear. There is no thrush.
NECK:  Supple. Has full range of motion. There is no cervical, clavicular, or axillary adenopathy.
LUNGS:  Auscultation is completely clear. There is good air flow.
CARDIAC:  Regular rhythm. There is no murmur. There is no S3. There is no S4.
ABDOMEN:  Soft. Bowel sounds are diminished but are present. It is diffusely and mildly tender to palpation. There is no splenomegaly or hepatomegaly. There is no costovertebral angle tenderness.
BACK:  Examination of her back reveals that she has two or three erythematous blotches. They are almost urticarial in nature. These do not itch and are not tender. I examined her spine briefly and there is minimal tenderness over her thoracic and lumbar spine; it is present however. Examination of her right upper extremity reveals that the inside of the arm between her elbow and her shoulder has a very large ecchymotic area that is moderately tender to palpation. On her left forearm, just distal to her olecranon fossa, there is a 3 x 3 cm nodular area, which is also mildly tender to palpation. There is no ecchymosis seen at this location. She has good radial pulses bilaterally. She has no decubitus ulcer. 
RECTAL/GU:  Perirectal exam is within normal limits. Perineal exam reveals that she has a Foley catheter in place. There is no obvious erythema or ulceration around her external genitalia.
EXTREMITIES:  Examination of her lower extremities is unremarkable. She has good reflexes at the patellar and Achilles location. There are no suspicious rashes on her lower extremities and she has good dorsal pedis pulses. 
NEUROLOGIC:  Nonfocal. Cranial nerves II through XII are grossly symmetric.

LABORATORY DATA:  CBC shows a white count of 12.4, hemoglobin is 10.8, hematocrit is 39.6, platelet count is 26,000. Chem-7 shows sodium of 136, potassium 3.7, chloride 107, CO2 of 24, BUN is 17, creatinine is 0.8, and glucose is 98. Urinalysis shows no pyuria. Microbiology reveals that two blood cultures obtained have no growth. The only positive culture during her last hospital stay was a coagulase-negative Staphylococcus species drawn in a single set. X-ray, PA and lateral, was reviewed by myself. This is a good quality film and there is no evidence of any infiltrate at this time. Bone marrow biopsy was performed by Hematology-Oncology today, results are pending. 

IMPRESSION:  This is a (XX)-year-old female with known multiple myeloma who is asked to come in from a nursing home because of the finding of fever and pancytopenia with the exception of leukocytosis rather than leukopenia. There is no obvious source of infection at this point. Blood cultures have returned negative. Urine is not consistent with urinary tract infection. Chest x-ray and symptoms do not support the diagnosis of pneumonia. Only symptomatic areas are her abdomen, which demonstrates mild abdominal tenderness, not inconsistent with what I have observed in her before. Her back which has known compression fractures plus or minus metastatic malignant melanoma. Both of her upper extremities have abnormalities. There is a very large ecchymosis on her right upper extremity and a nodule of unknown significance in her left upper extremity, both of which could represent clot or hematoma and could be the source of her fever. 

PLAN:  At this point, I have no reason to continue broad-spectrum antimicrobial therapy. It is probably wisest at this point to stop her antimicrobial therapy and observe her. We can watch her white count if it begins to climb. At least we might be more convinced that we have an infectious disease process. On the other hand, if her fever pattern remains unchanged, it may be more likely that her fevers have to do with the hematoma or a deep venous thrombosis or tumor fever. One could get upper extremity ultrasound of her right and left upper extremity to see if there is any evidence of deep venous thrombosis. I am not sure this would change management, as I am not sure that she is a Coumadin candidate or even a low-molecular weight candidate, but it would help us understand the nature of her fevers. Bone marrow biopsy has already been performed and will demonstrate whether lymphoma is active. One could consider further imaging of her back to see whether she has an infectious disease cause of her fever.

Thank you for this consultation.  If there are any questions, please do not hesitate to contact me.