Sample Name: Gen Med Consult - 43
Description: A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.
(Medical Transcription Sample Report)
HISTORY: A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital. The patient subsequently developed CVA. She also developed thrombosis of the right arm, which ultimately required right hand amputation. She was stabilized and eventually transferred to HealthSouth for further management.
Vital Signs: Pulse of 90 and blood pressure 150/70.
Heart: Sounds were heard, grade 2/6 systolic murmur at the precordium.
Chest: Clinically clear.
Abdomen: Some suprapubic tenderness. Evidence of right lower arm amputation.
The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted. She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage. Wound care to the right heel was supervised by Dr. X. The patient initially was fed through NG tube, which was eventually discontinued. Physical therapy was ordered. The patient continued to do well. She was progressively ambulated. Her meds were continuously adjusted. The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day. Dr. Y also followed the patient closely for left heel ulcer.
1. Atherosclerotic heart disease, status post coronary artery bypass graft.
2. Valvular heart disease, status post aortic valve replacement.
3. Right arm arterial thrombosis, status post amputation right lower arm.
5. Uncontrolled diabetes mellitus, type 2.
6. Urinary tract infection.
9. Peripheral vascular occlusive disease.
10. Paroxysmal atrial fibrillation.
13. Carotid stenosis.
Keywords: general medicine, arterial thrombosis, valvular heart disease, atherosclerotic heart disease, type ii diabetes, hypertension, carotid stenosis, heart disease, diabetes, carotid, stenosis, bypass, amputation, heart, atherosclerotic,