MEDICAL TRANSCRIPTION SAMPLE REPORT HISTORY AND PHYSICAL EXAMINATION

DATE OF ADMISSION:

ADMITTING PHYSICIAN:  

CHIEF COMPLAINT:  "I passed out."

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant 51-year-old white male, who apparently passed out when he was grocery store.  When he woke up, he was brought to the hospital.  He stated that he had a sore head, but otherwise, he said he felt fine.  He has had a very high D-dimer with a negative CTA of the chest and negative CAT of the brain.  He states that he has no real medical problems other than some underlying lung disease.  He uses Primatene inhaler.  He states that he had no aura, although this was happening to him he did not lose continence.  He said that he felt okay and afterwards he felt a little confused, but he said they went away within a minute or so.

PAST MEDICAL HISTORY:  He denies any medical history other than a chronic cough.

PAST SURGICAL HISTORY:  He denies any surgical history.

MEDICATIONS:  He uses Primatene inhaler OTC.

SOCIAL HISTORY:  He smokes one pack per day.  He says that he does not drink alcohol.  He says he works, he cuts lawns, etc., and works harder than he probably should be.

FAMILY HISTORY:  His mother died of advanced age of unknown cause.  Father was killed in World War II.

REVIEW OF SYSTEMS:  HEENT:  Negative.  Pulmonary:  He has a chronic cough.  Cardiac:  He denies any chest pain or palpitations.  Abdomen:  He denies any abdominal pain.  He has positive bowel movements.  No rectal bleeding.  Neurological:  The patient said that he had syncopal event.  Although, he does not know, how that happened, he recalls nothing prior to it.  Rest of complete review was negative.

PHYSICAL EXAMINATION:

GENERAL:                            An elderly male lying in the cot.  He is alert and oriented.  He answers questions without difficulty.  He knows that he is in the hospital and knows that it is 2005.

HEAD AND NECK:             Normocephalic and atraumatic.  External examination of the ears reveals no bleeding.  The oropharynx is clear.  Extraocular movements are intact.  Thyroid examination is unremarkable.  Carotids:  Right sound is diminished as compared to the left, but no distinct bruit can be heard.

LUNGS:                                 Diminished breath sounds bilaterally.  No rhonchi, rales or wheezing.

HEART:                                 Tachycardia, regular at approximately 104.  No S3.

ABDOMEN:                          Soft.  Positive bowel sounds.  No pain, no masses, and no bruits.

PERIPHERAL:                      No edema.

NEUROLOGIC:                    Cranial nerves II through XII are grossly intact.  No focal deficit noted.  Romberg testing is negative.  He has 5/5 grips bilaterally and 5/5 motor in the lower extremities.

IMPRESSION AND PLAN:

1.  Syncopal events etiology uncertain, maybe multifactorial.  His CT of the chest is negative for PE, although his D-dimer is very high.  At this point, he is stable neurologically and hemodynamically.  His hemoglobin is 14, I am going to start him on Lovenox, subcutaneously in case of myocardial infarction, which is at risk, as well as possible deep venous thrombosis or still could have a small pulmonary embolism.  We will have pulmonary see him as he is hypoxemic and has an abnormal chest x-ray as well.

2.  Thrombocytopenia/leukocytosis etiology uncertain, he does not appear to have an infectious process.  He denies alcohol use.  Further work up will be dictated on repeat lab testing.

3.  Chronic obstructive pulmonary disease. Discontinue the Primatene, can induce arrhythmias.  Start albuterol and Atrovent as needed. Counseled on nicotine abuse.

4.  Check lipid profile.

5.  Syncopal event, carotid Dopplers, echocardiogram, and CPKs.  EKG is abnormal.