Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF CATHETERIZATION:  MM/DD/YYYYPROCEDURES PERFORMED:  Left heart catheterization, left ventriculography.REASON FOR PROCEDURE:  Unstable angina and abnormal stress test.FINDINGS:1.  The left main coronary artery was short and patent. 2.  The left anterior descending coronary artery had total occlusion in the proximal and mid portion. 3.  The circumflex coronary artery had 95% lesion in the proximal portion. 4.  The right coronary artery had 90% proximal and 100% total occlusion in the mid.GRAFTS:  The left internal mammary artery graft to the left anterior descending coronary artery was patent.  The saphenous vein graft to the diagonal vessel was also patent.  The saphenous vein graft to the obtuse marginal was not located and...

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Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF PROCEDURE:  MM/DD/YYYYPREPROCEDURE DIAGNOSES:1.  Nonsustained ventricular tachycardia. 2.  Normal left ventricular ejection fraction. 3.  History of coronary disease.  Status post coronary artery bypass graft with patent bypass grafts on cardia cath. PROCEDURE:  Electrophysiology study. DETAILS OF PROCEDURE:  The patient was brought to the electrophysiology lab where ECG and vital signs were continuously monitored.  The right groin was meticulously prepared with Betadine solution and was draped in the usual sterile fashion.  Lidocaine 1% was administered subcutaneously for local anesthetic.  Using modified Seldinger technique, two #6 French introducer sheaths were inserted into the right femoral vein.  Two quadripolar EP...

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History and Physical Sample Report (General)

HISTORY OF PRESENT ILLNESS:  This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills, and sweats.  He denies cough and diarrhea.  He has mild anorexia.  Past Medical History:  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994. MEDICATIONS:  Advil and Ibuprofen. ALLERGIES:  NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY:  He occasionally...

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Hematology Oncology History and Physical Medical Transcription Sample Reports

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman with diffuse large B-cell lymphoma, complicated by spinal cord compression, right lower lobe pulmonary embolism, and bilateral leg deep venous thromboses. She began the R-CHOP chemotherapy regimen on MM/DD/YYYY. Cycle 2 started on MM/DD/YYYY and cycle 3 started on MM/DD/YYYY. The patient presented to my office today for a Neupogen injection. Today is cycle 3, day 10. In my office, the patient had a temperature of 101.5 degrees, and she was found to be neutropenic with WBC 0.4. She was admitted for treatment of neutropenic fever. Symptomatically, the patient reports subjective fevers, although she has no localizing symptoms suggestive of infection. She has no other complaints today. Regarding the lymphoma, the...

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CONSULTATION (Pulmo case)

CONSULTATION This is a 32-year-old white male, lifelong nonsmoker, referred to me. He complains of a less than 2-weeks history of dry cough associated with dull substernal discomfort and dyspnea, particularly on exertion. Otherwise, he has been remarkably free of any other associated symptoms. In particular, he denies any preceding cold or flu or allergic exposure, and denies any associated fevers, chills, sweats, or weight loss. He does admit to having childhood asthma but felt he grew out this by the time he was a teenager. He was traveled extensively outside the U.S., including travel to the California deserts and Central Valley. He has not had pneumonia vaccine. He did have TB skin test 10 years ago and did have flue vaccine 3 years ago. PAST MEDICAL HISTORY: Past medical...

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EMERGENCY ROOM REPORT (Pulmonary case)

EMERGENCY ROOM REPORT HISTORY OF PRESENT ILLNESS: Patient is a one-year-old female that has been congested for several days. The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago. Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin, cough syrup, and Slo-bid 100 mg b.i.d. but is not improving. Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations. PHYSICAL EXAMINATION GENERAL: Physical exam in the ER showed an alert child in moderate respirator distress. VITAL SIGNS: Respiratory rate was 40, pulse 20, temperature 99.6. HEENT: Within normal limits. NECK: Positive for mild to moderate stridor. CHEST: Chest showed a diffuse inspirator and expiratory wheezing....

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History and Physical Sample Report (Optha case)

HISTORY AND PHYSICAL EXAMINATION PREOPERATIVE DIAGNOSIS: 1. Cataract of left eye. 2. Pseudophakia of the right eye. 3. Dermatomyositis. 4. Rheumatoid arthritis. HISTORY OF PRESENT ILLNESS: Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function. She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye. She has had dry eyes and uses artificial tears frequently. She had had ectropion repair of the right lower lid. She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this. She is presently taking Persantine twice daily and Inderal 40 mg twice daily. She is allergic to...

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