PRACTICE/ SAMPLE FILES

These are the  transcribed sample files of Cardiology, Dermatology, Endocrionology, LOM,  ENT, Gastro, Hematology, Musculoskeletal, Neurology, OB GYN, Pharmacology, Pulmanology, Radiation and Oncology,etc.

Letter

March 12, 2010


Jack Thomas M.D.
#14, ST.Thomas Church Road,
Cochin, Kerala, India


RE: John Issac .
DOB: 11/08/1957


Dear Dr. Debobatra:

Mr.John Issac was admitted at 15:00 hours after having had an episode of weakness following a GI bleeding approximately three weeks earlier. He was seen by the ambulance people and was in a rapid heartbeat, the exact nature of which we do not know but at any rate, Xylocaine was started and by the time he reached the emergency room, his heart rate was between 75 and 80 with a sinus rhythm. He had excellent ST segments and upright T-waves.

When I saw him, his blood pressure was 166/88. His pulse was 75 with a regular sinus rhythm. He had a good carotid pulse bilaterally. His lungs were clear. The heart was not enlarged. There were no murmurs.

He was started on a cardiac monitor. A chemistry panel was drawn and the only abnormal finding was a BUN of 22.4.

He was observed closely for any ST or T-wave change and there was none. He had no episode of hypotension. There was no reason to do any cardiac enzyme studies. He did have a follow-up upper GI done because of his bleeding in late June and this was reported as negative.

There was no further pain. There was no further arrhythmia and at no time were there any ST or T-wave changes present. I had no reason to do cardiac enzymes, and when I found that his GI tract was stable, and that his upper GI did not reveal any new bleeding, and there was no drop in his hemogram, I discharged this patient to be followed by his regular physician.

I hope this information will be of help.


Sincerely,

Initial Office Evaluation

INITIAL OFFICE EVALUATION


CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: This elderly female was on Tonocard, Cardizem, Lasix, digoxin, Darvocet. She had no oxygen in the home and there was no one to oversee her medications. She did quite well on Thursday and Friday but yesterday, began getting more short of breath. Her legs were swollen last night. She was short of breath and had to sit up to breath last night.

PHYSICAL EXAMINATION: On physical examination, she says that she is quite comfortable at the present time. Her neck veins are slightly distended. Her carotids are easily felt. There is no bruit. Her lungs are clear to percussion and auscultation. The heart is enlarged to the left. There is an apical impulse that is heaving. There is a grade 4 systolic murmur at the apex. No diastolic component. The breasts are atrophic. No masses. The abdomen is soft. The liver is at the right costal margin. No other masses are felt. She has a good femoral pulse but I cannot feel the pulse in her feet. There is 2‑3+ pitting edema in both legs and a lot of superficial veins are present.

DIAGNOSIS: She is hypertensive cardiovascular disease with left ventricular hypertrophy, mitral insufficiency, and congestive heart failure. She also has arteriosclerosis obliterans of the lower extremities.

She will be admitted to the hospital, started on oxygen, given intravenous diuretics. We will try to get the edema out of her body and then she will either need to go to a nursing home or go home with oxygen in the house along with someone to care for her and make sure her meds are given regularly.

Cardio - Chart Note

CHART NOTE


A hypertensive male with a pacemaker placed, who is complaining tonight of a period of blackout that occurred approximately a half hour before arrival here, and unheralded by any prior symptoms. He did not have chest pain, shortness of breath or cough prior to his syncope. This happened once before and resulted in the placement of a cardiac pacemaker. He has, in the past two weeks, experienced several episodes of mild lightheadedness for which he has been treated with Antivert 25 mg t.i.d. He takes a blood pressure medicine that he cannot name. His pacemaker was checked for function this week and found to be functioning satisfactorily.

PHYSICAL EXAMINATION: A well-developed, well-nourished male in no apparent distress. His blood pressure is 120/84, pulse 88, respiratory rate 20, and temperature 99.6. He is alert and well oriented and has normal pupils. There is no ataxia. The neck is nontender. The lungs are clear and the heart has a regular sinus rhythm without murmurs. The pacemaker is palpable in the left pectoral region. The abdomen is nontender, soft and has normal bowel sounds. There is no pretibial edema.

LABORATORY FINDINGS: The patient's EKG was normal. The BUN was 18 and the CPK 67, the glucose was 156. His potassium was 5.0 and sodium 136; chloride was 102 and total CO2 27. The white count was 10,500 with 3% bands and 76% segs. The hematocrit was 50.

It was elected to admit the patient to the CCU for observation and for reevaluation of his pacemaker.

DIAGNOSES:
1. Arterial hypertension.
2. Probable pacemaker malfunction.

Sample Report: SOAP NOTE

Patient name:
Account number:
Provider number:
Chart number:

DOB:

S- This is a case of a 100-year-old female who presented at the office today complaining of depression for the last 6-8 weeks. The patient denied suicidal ideation. The patient delivered her baby 2 weeks ago. The patient complaining of depressed mood and decreased energy for the last 6-8 weeks. The patient has no other subjective complaints.

O- On examination, blood pressure 120/60, pulse of 72, respiratory rate of 18. General assessment: The patient is comfortable, not in acute distress, appropriate mood, appropriate act affect. Chest and lungs: Clear to auscultation. Heart: Regular rate and rhythm.

A/P- For her possible post-partum depression, the patient's past medical history is unremarkable and patient's family history is unremarkable. The case was discussed with the patient. The patient was advised lifestyle and diet modification. The patient was advised that I will refer her Behavioral Health specialist for further evaluation and management. The patient was advised to follow up with me in 1-2 weeks for re-evaluation.



PC/MT
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