Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF CATHETERIZATION:  MM/DD/YYYY

PROCEDURES 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 was not selectively engaged.

COLLATERALS:  There were collaterals noted from the left anterior descending, septal and obtuse marginal to the right side.

Left ventriculography revealed an overall ejection fraction of around 40% with inferobasal akinesis and mid anterior and septal hypokinesis.  End-diastolic pressure was normal at 13 mmHg.  There was no gradient across aortic valve on pullback.

At the end of the procedure, the decision to proceed with angioplasty and stent placement of the critical circumflex lesion was made.

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Cardiac Catheterization (Electrophysiology Study) Medical Transcription Sample Reports

DATE OF PROCEDURE:  MM/DD/YYYY

PREPROCEDURE 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 catheters were inserted into the sheaths and advanced under fluoroscopic guidance.  One was positioned in the area of the high right atrium and one in the area of the His bundle.  The high right atrial catheter was later moved to the RV apex for ventricular stimulation.  Endocardial potentials were recorded and baseline measurements were performed.  The sinus cycle length was 1195 milliseconds.  The AH interval was 115 milliseconds.  The HV interval was 45 milliseconds with a pacing cycle length of 800 milliseconds.  The sinus node recovery time was 1430 milliseconds with the pacing cycle length of 700 milliseconds.  The sinus node recovery time was 1465 milliseconds with a pacing cycle length of 600 milliseconds.  The sinus node recovery time was 1570 milliseconds.  AV Wenckebach recorded an atrial pacing cycle length of 450 milliseconds.  The AV node effective refractory period was 320 milliseconds with the pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 600 milliseconds.  The pacing threshold from the right ventricular apex was 0.5 milliamps, 1:1 VA conduction was present at a ventricular pacing cycle length of 600 milliseconds.  The ventricular effective refractory period was 240 milliseconds with a pacing cycle length of 600 milliseconds and 240 milliseconds with a pacing cycle length of 400 milliseconds.  After single, double and triple extrastimuli were performed at two pacing cycle lengths from the RV apex, Isuprel was started at 2 mcg per minute.  This was gradually increased to 4 mcg per minute in order to achieve a good heart rate response.  The ventricular effective refractory period was 220 milliseconds with the pacing cycle length of 400 milliseconds.  All ventricular pacing was performed from the RV apex.  After completion of programmed electrical stimulation, catheters were removed.  Good hemostasis was achieved using manual compression.  The patient was then transferred to the recovery room in good condition.
IMPRESSION:
1.  Mildly abnormal sinus node function.
2.  Normal atrioventricular node function without evidence of dual atrioventricular node physiology.
3.  Normal His-Purkinje function without evidence of infra-His block.
4.  Frequent nonsustained ventricular tachycardia with single, double and triple ventricular extrastimuli from the right ventricular apex.  The morphology of the nonsustained ventricular tachycardia varied between left bundle, left axis and left bundle right axis morphology.  Nonsustained ventricular tachycardia or prolonged nonsustained ventricular tachycardia was induced.

RECOMMENDATIONS:  The patient will be continued on beta blocker, which should be increased as tolerated.  If the patient has recurrent symptoms, despite medications, an ablation procedure may be considered.  However, given the differing morphologies of the nonsustained VT, this may make ablation difficult.

 

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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 drinks.  He is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982, which he described as "very active." He denies intravenous drug use.  The patient is currently employed.

FAMILY HISTORY:  Unremarkable.

PHYSICAL EXAMINATION:
General:  This is a thin, black cachectic man speaking in full sentences with oxygen.
Vital Signs:  Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.
HEENT:  Funduscopic examination normal. He has oral thrush.
Lymph:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.
Neck:  No goiter, no jugular venous distention.
Chest:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.
Heart:  Regular rate and rhythm, no murmur, rub or gallop.
Abdomen:  Soft and nontender.
Genitourinary:  Normal.
Rectal:  Unremarkable.
Skin:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms.

LABORATORY:  Sodium 133, potassium 5.3, BUN 29, creatinine 1.8, hemoglobin 14, white count 7100, platelet count 515, total protein 10, albumin 3.1, AST 131, ALT 31, urinalysis shows 1+ protein, trace blood, total bilirubin 2.4, and direct bilirubin 0.1.

X-RAYS:  Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.

IMPRESSION:
1.   Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.
2.   Thrush.
3.   Elevated unconjugated bilirubin.
4.   Hepatitis.
5.   Elevated globulin fraction.
6.   Renal insufficiency.
7.   Subcutaneous nodules.
8.   Risky sexual behavior in 1982 in Haiti.
PLAN:
1.   Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.
2.   Begin intravenous Bactrim and erythromycin.
3.   Begin prednisone.
4.   Oxygen.
5.   Nystatin swish and swallow.
6.   Dermatologic biopsy of lesions.
7.   Check HIV and RPR.
8.   Administer Pneumovax, tetanus shot, and Heptavax if indicated.

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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 patient presented on MM/DD/YYYY with spinal cord compression. CT-guided needle biopsy of a lumbar mass on MM/DD/YYYY showed lymphocytes, which were positive for CD19, CD20, CD22, and lambda light chain, and negative for CD10. Cytology was consistent with large cell lymphoma. Bone marrow biopsy was negative. CT scans of the chest, abdomen, and pelvis showed lymphadenopathy in the left lower neck, supraclavicular areas, retroperitoneum, bilateral psoas muscles, and L1 vertebral body. LDH was mildly elevated at 276, and the patient did not have any significant symptoms. In summary, the patient has stage IV diffuse large B-cell lymphoma, based on extranodal involvement of the L1 vertebral body. On MM/DD/YYYY, the patient was admitted to the hospital with sinus tachycardia. Workup revealed pulmonary embolism and bilateral leg deep venous thromboses. The patient has been on anticoagulation. She should be taking Coumadin 2.5 mg alternating with 5 mg per day, although her compliance with this regimen has been questionable. Recently, she was found to be supratherapeutic with INR greater than 7. I instructed her to withhold Coumadin for two days, then resume at the prescribed dose. She did not have any significant hemorrhagic complications. 

PAST MEDICAL HISTORY:  Peptic ulcer disease and osteoporosis. 

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Coumadin 2.5 mg alternating with 5 mg per day and Protonix 40 mg per day. 

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient denies alcohol and tobacco use.

FAMILY HISTORY:  There is no known history of inherited hematologic or oncologic disorders. 

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  The patient reports subjective fevers x1 day. Otherwise, she denies night sweats, weight loss, fatigue or bleeding. GASTROINTESTINAL:  The patient has chronic dyspepsia, which is temporarily relieved with Mylanta or Maalox. All other systems in a 10-point review of systems were reviewed and were negative.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 110/56, heart rate 112, respiratory rate 22, and temperature 102.5.

GENERAL APPEARANCE:  The patient is alert and oriented, in no acute distress, ambulating slowly without assistance.

HEENT:  PERRL. EOMI. Sclerae anicteric. Oral mucosa clear.

PULMONARY:  Clear to auscultation bilaterally.

HEART:  Regular rate and rhythm. No murmurs.

ABDOMEN:  Soft, nontender, and nondistended. No palpable organomegaly.

EXTREMITIES:  No edema.

LYMPH NODES:  No palpable lymphadenopathy.

SKIN:  No rashes, petechiae or ecchymoses.

NEUROLOGIC:  No focal neurologic deficits, although, the patient ambulates slowly because of low back pain, which has been present since her initial presentation for spinal cord compression.

LABORATORY DATA:  WBC 0.4, hemoglobin 9.8, hematocrit 29.6, and platelets 172,000.

ASSESSMENT AND PLAN:  This is a (XX)-year-old woman with diffuse large B-cell lymphoma, pulmonary embolism, and bilateral leg deep venous thromboses, now on R-cyclophosphamide, hydroxydaunorubicin, Oncovin, prednisone cycle 3, day #10. She is now admitted with neutropenic fever without localizing signs or symptoms suggestive of infection. The patient will start empiric cefepime, and blood and urine cultures will be drawn. Neupogen 300 mcg per day will be continued. Antibiotic coverage will be adjusted based on culture findings and clinical examination. Regarding the anticoagulation for pulmonary embolism and deep venous thromboses, the patient will start Coumadin 2.5 mg per day tomorrow. Currently, she is likely to be supratherapeutic. For peptic ulcer disease, the patient will continue Protonix with the addition of p.r.n. Mylanta or Maalox.

 

 

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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 history is remarkably negative.

PHYSICAL EXAMINATION: Blood pressure 140/80, pulse 85, respiratory rate 22, temperature 99.3.Chest exam is complete normal. There are no rales, wheezes, rhonchi, rubs. Even on forced exhalation, there was no cough or prolongation. Cardiac exam showed a regular rate and rhythm with no murmur or gallop.

LABORATORY DATA: PA chest x-ray is striking for a new interstitial infiltrate seen on both midlung zones with some shagging of the cardiac borders, indicating involvement of the lingual and right middle lobe. Surprisingly, the lowest part of the lung fields and the apices appear to be spared. Spirometry before and after bronchodilator performed in my office show a vital capacity of 3.79 or 69% after an 11% improvement with bronchodilator. FEV-1 achieves 3.24 L or 72% of predicted after 12% improvement wih bronchodilator. FEV-1/FVC ratio was mildly increased at 85 instead of predicted 82.

ASSESSMENT AND PLAN: Differential diagnosis includes the following:
1. Hypersensitivity pneumonitis.
2. Mycoplasma pneumonia.
3. Less likely candidates appear to be Wegener’s granulomatosis, Goodpasture’s syndrome, sarcoidosis, alveolar proteinosis, and allergic bronchopulmonary aspergillosis.

RECOMMENDATIONS:
1. CBC, differential, chemistry-20, Wintrobe sed rate, angiotensin converting enzyme, urinalysis, and Mycoplasma titers.
2. Full pulmonary function test within 2 weeks
3. Vibramycin 100 mg q. day for 14 days. If he still has significant symptoms and restriction on PFTs within 2 weeks, he will have to be evaluated for one of the more chronic diagnoses, which may ultimately require open lung biopsy. Otherwise we should hope that within 2 weeks the patient will be improved and his x-ray will have cleared.

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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. No rales were noted. Viewing the chest wall, patient had subcostal-intercostal retractions.
HEART: Regular rhythm without murmur, gallop, or rub.
ABDOMEN: Soft, nontender, bowel sounds normal.
EXTREMITIES: Within normal limits.

The child was sent for a PA and lateral chest x-rays to rule out pneumonia. No pneumonia was seen on the films.
It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3 h. The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.

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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 penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.

PHYSICAL FINDINGS:
VITAL SIGNS: Blood pressure 110/80, pulse 76 and regular.
HEENT: Eyes; Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left. Pupils and extraocular motility were normal. Intraocular pressures where 18. Slit-lamp exam showed the eyelids in good position with weakness of the orbicularis and facial muscles. There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left. Fundus examination in each eye was normal.
EARS, NOSE, AND THROAT: Tympanic membranes are normal. The oral cavity showed dentures in place, and the pharynx had no lesions.
NECK: The neck showed a slight right carotid bruit, and the left was normal.
CHEST: The chest was clear to auscultation.
HEART: Heart had a regular sinus rhythm without murmur.
EXTREMITIES: Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.

PLAN: Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient. The risks of the procedure, including possible loss of the eye, were discussed.

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