Transfer of Care Medical Transcription Sample Reports

Transfer of Care Medical Transcription Sample Report #1

TRANSFER DIAGNOSES:
1. Upper gastrointestinal bleeding secondary to duodenal ulcer in the setting of nonsteroidal anti-inflammatory drugs and steroid use, status post EGD.
2. Anemia, status post packed red blood cells transfusion.

SECONDARY DIAGNOSES:
1. Hypertension.
2. Hyperlipidemia.
3. Osteoarthritis, chronic back and hip pain.
4. History of renal calculi.
5. Dementia with baseline significant confusion.

PAST SURGICAL HISTORY: Appendectomy in the past.

PROCEDURES: Upper endoscopy revealing bleeding duodenal ulcer, treated with epinephrine injection and BICAP which achieved hemostasis.

REASON FOR ADMISSION: Dark tarry stools.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old woman who presented to the emergency room complaining of dark tarry stool. She recently, prior to admission, had been treated with steroids for sciatica and hip pain. Also has been taking NSAIDs for her osteoarthritis and the low back pain as well as baby aspirin for coronary artery disease prophylaxis.

The patient on admission to the emergency room was noted to have a hemoglobin of 11.7 and hematocrit of 34.2 with stable hemodynamics. Systolic blood pressure 153, diastolic 96. Rectal exam was performed in the emergency room revealing black stool, melena. The patient was taken to the procedure suite where she has undergone upper EGD, which revealed a bleeding duodenal ulcer, which was treated with epinephrine and BICAP. Hemostasis was achieved.

The patient was transferred to the intensive care unit for further observation given upper gastrointestinal bleeding.

PHYSICAL EXAMINATION: On admission to the intensive care unit, blood pressure 156/76, heart rate 74, oxygen saturation 100% on 2 liters, temperature 98.2, respiratory rate 18. General: A pleasant elderly-appearing female, alert and oriented only to self and place, not to time. Head and Neck: Unremarkable. Pupils equal, round and reactive to light and accommodation. Extraocular muscles intact. Oral mucosa moist. No oropharyngeal exudate. Chest: Clear to auscultation bilaterally with good respiratory excursion. Cardiovascular: Normal S1 and S2. No murmurs. Abdomen: Soft, nontender, nondistended with positive active bowel sounds. No guarding, no rebound tenderness. Extremities: Warm without clubbing, cyanosis or edema.

PAST MEDICAL HISTORY: As above.

HOME MEDICATIONS:
1. Metoprolol XL 100 mg orally daily.
2. Aspirin 81 mg orally daily.
3. Aricept 10 mg orally day.
4. Simvastatin 20 mg orally daily.
5. Tramadol 50 mg orally daily p.r.n. for pain.
6. Dyazide 50/25 mg orally daily.
7. Etodolac 400 mg p.o. t.i.d.

ALLERGIES: The patient reports allergies to vancomycin and atorvastatin.

SOCIAL HISTORY: The patient is a nonsmoker, nondrinker. She is married. All children are healthy. She lives with her husband who takes care of her. The patient is baseline demented.

HEALTH MAINTENANCE: Last colonoscopy in (XXXX).

FAMILY HISTORY: Positive for coronary artery disease in father. No history of cancers, including colon cancer or stomach cancer.

LABORATORY DATA: On discharge from the intensive care unit, white blood cell count 6.64, hemoglobin 11.4, hematocrit 33.2, platelet count 109,000, MCV 92. Sodium 144, potassium 3.5 (this was repleted), chloride 115, bicarbonate 25, BUN 12, creatinine 0.7, glucose 101, calcium 8, magnesium 2.2, phosphate 2.6. INR 1.1, PTT 25. Her MRSA screen and VRE screen obtained upon ICU admission were both negative.

HOSPITAL COURSE BY ISSUE: This is a (XX)-year-old female who was admitted to the intensive care unit for further observation after undergoing EGD to achieve hemostasis for bleeding duodenal ulcer.
1. Gastrointestinal bleeding. The patient is status post EGD. Hematocrit was monitored initially every 8 hours, remained stable, ranges from 31 to 33 for the last 48 hours. The patient did not have any bloody or black stools any longer. She was initiated on Protonix drip after a bolus of Protonix was given. Upon transfer to the floor, the patient will be switched to IV Protonix 40 mg b.i.d. Hematocrit can be checked now twice a day. The patient was recommended to avoid NSAIDs and diet had been advanced to clear liquids as tolerated.
2. Anemia, requiring blood transfusion. The patient has been transfused 2 units, hematocrit monitored as above. The patient started on iron sulfate in the intensive care unit, 325, may continue on the floor for a week but not strongly indicated.
3. Baseline dementia. The patient was agitated on the first night of the admission to the intensive care unit and was confused, disoriented, pulling on lines, gowns and blankets. She was diagnosed with ICU delirium. She was taking her trazodone as at home for insomnia without effect. She was given Seroquel 25 mg for ICU delirium treatment. That did not prove to be effective for her. She required further administration of 1 mg IV Haldol with good effect. The patient slept overnight. She was continued on her home dose of Aricept, that should be continued on the floor. Haldol can be used in small doses p.r.n. since the patient is very sensitive. EKG can be checked to ensure no QT prolongation develops. Her last EKG showed QTc of 487 msec, which is slightly prolonged.
4. Hyperlipidemia. The patient was continued on simvastatin on her home dose regimen.
5. Hypertension. On the second day of admission to the intensive care unit, her blood pressure had persistently been elevated to over 130 to 140 systolic. Given that initially both antihypertensive medications have been held for possibility of hemodynamic instability secondary to gastrointestinal bleeding, we are restarting her metoprolol 25 mg orally twice a day. Smaller dose than patient takes at home to date. That dose might be increased. Also, the patient should be monitored for signs of GIB, although, her hematocrit remains stable. The patient could be restarted on her dose of Dyazide if no further hemodynamic issues arise tomorrow.
6. For DVT prophylaxis, the patient had Venodynes on while she was in the intensive care unit. She has been on Protonix drip, which has been switched to IV Protonix b.i.d. Fluids at this time remain saline locked. Electrolytes will be repleted as needed.
7. Nutrition: The patient should continue on clear liquid diet, which could be advanced slowly on the floor and further per GI recommendations.
8. Resuscitation: CODE STATUS is full.

Family has been updated by the ICU team. The patient’s husband is actively participating in her care.

Transfer of Care Medical Transcription Sample Report #2

REASON FOR ADMISSION: Upper gastrointestinal bleed.

DISCHARGE DIAGNOSIS: Upper gastrointestinal bleeding, status post EGD.

DISCHARGE MEDICATIONS:
1. Metoprolol 50 mg orally twice a day, hold for systolic blood pressure less than 100, heart rate less than 60.
2. Warfarin 2.5 mg p.o. daily.
3. Heparin drip at 18 units/kg per hour.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old woman with history of prosthetic aortic valve and mitral valve who is on Coumadin and Lovenox who has been admitted via the emergency room where she came in complaining of maroon-colored stools of 1 day’s duration. The patient did have EGD.

At that time, a 2 cm sessile polyp had been removed from the antral portion of her stomach. The patient was hemodynamically stable and was discharged to home. While she was observed in the emergency room, her hematocrit was 30.9 and she had been hemodynamically stable, also slightly tachycardic with a heart rate of 106.

She was admitted to the telemetry floor for further observation and monitoring of her gastrointestinal bleed. At 1:45 a.m., the patient went to the commode to have a bowel movement and had an unconscious episode. Code Blue was called to her room. The patient regained consciousness almost immediately. She was found to have vomited dark clots, and NG tube placed to suction produced copious amounts of dark clotted blood. The patient has been hemodynamically stable through the event and has been transferred to the intensive care unit for further observation.

PAST MEDICAL HISTORY:
1. Hyperlipidemia.
2. History of mitral valve replacement and aortic valve replacement.
3. History of paroxysmal atrial fibrillation.
4. History of hypertension.
5. History of ankle injury many years ago.
6. Osteoarthritis.
7. Hypothyroidism.
8. Osteoporosis.

ALLERGIES: No known drug allergies.

HOME MEDICATIONS:
1. Metoprolol 100 mg p.o. b.i.d.
2. Hydrochlorothiazide 25 mg p.o. daily.
3. Coumadin 2.5 mg daily.
4. Lovenox 150 mg daily.
5. Lipitor 20 mg daily.
6. Levothyroxine 25 mcg p.o. daily.
7. Vitamin D 1000 units daily.
8. Calcium 1 tablet daily.
9. Travatan eye drops once a day.

SOCIAL HISTORY: The patient lives with her husband. She is independent in activities of daily living. She does not smoke tobacco and has no reported alcohol or drug use.

PHYSICAL EXAMINATION: On discharge, the patient is alert and oriented to person, place and time. A pleasant elderly female who is lying in bed. NG tube discontinued today. Head and neck exam normal. Pupils equal, round, reactive to light and accommodation. Extraocular muscles intact. Cranial nerves II through XII intact. Cardiovascular exam reveals normal S1 and S2. There is murmur consistent with prior valves replacement. Lungs: Clear to auscultation bilaterally. Abdomen: Obese, soft, nontender, nondistended with very active positive bowel sounds. Extremities: Warm. No edema. Pedal pulses 2/4 bilaterally in all 4 extremities. Skin is intact. The patient is on 2 liters of nasal cannula oxygenation.

Vital signs at discharge; temperature 98.6, blood pressure 133 to 144 systolic, 44 to 70 diastolic. Heart rate 85 to 95, respiratory rate 16, oxygen saturation 98 to 100% on 2 liters. Urine output 50 to 75 mL an hour. The patient’s cumulative balance is positive, about 2300 mL since last 24 hours.

LABORATORY DATA: On discharge, white blood cell count 11.2, hemoglobin 9.2, hematocrit 26.8. Last hematocrit was 30, platelet count 193,000. MCV 88, sodium 140, potassium 3.1, which was repleted. Sodium 109, bicarbonate 28, BUN 21, creatinine 0.8, glucose 107, calcium 7.5, magnesium 1.5, that was repleted, phosphate 2.7. INR 2.1, PTT 155. Blood glucose was varying, 111 to 112 in the last 24 hours.

ASSESSMENT: This is a (XX)-year-old woman with upper gastrointestinal bleed, on anticoagulation, status post removal of 2 cm sessile polyp from her stomach, status post EGD showing clean base gastric ulcer with no bleeding.
1. Upper gastrointestinal bleed. The patient had an EGD, which showed clean ulcer without any evidence of bleeding. The patient was given erythromycin to empty the stomach, IV. The patient was transfused a total of 3 units of packed red blood cells since admission. Last transfusion was overnight. Last hematocrit value was 30. The patient should be transfused to goal hematocrit of over 30. She completed PPI, Protonix drip and now switched today to Protonix 40 mg IV b.i.d.
2. History of MVR and AVR. The patient needs anticoagulation. She has been seen by Cardiology in consult yesterday. Recommended to keep on heparin drip until INR is therapeutic. Coumadin was restarted today at 2.5, which is her home dose. The patient should be monitored for signs of GI bleeding, and heparin drip should be stopped immediately if any signs of GI bleeding occurred again.
3. Hypertension. The patient will continue her home dose medication. Blood pressure is well controlled. Heart rate is well controlled again, given the patient’s beta blockers recently for other signs of GI bleeding.
4. Hyperlipidemia. The patient will continue on Lipitor.
5. Paroxysmal atrial fibrillation. The patient has been in normal sinus rhythm since admission to intensive care unit. Did not require any antiarrhythmic administration.
6. Hyperglycemia. The patient has borderline hyperglycemia. We initially placed on NovoLog insulin sliding scale, but it was discontinued since blood glucose over the last 24 to 48 hours has never been over 120. Should be monitored daily if needed.
7. Question of sleep apnea. The patient is snoring all night and has occasional episodes of desaturation to lower 90s. Maybe needs a sleep study to be evaluated for sleep apnea.
8. Nutrition. The patient remains n.p.o. This was discussed with GI doctor. Diet could be advanced to clear liquids again. Please notify GI once advancement of diet.
9. For DVT prophylaxis, the patient is currently on heparin drip. For PPIs, she is on Protonix IV b.i.d. Fluids at this time remain at KVO. Electrolytes should be repleted on as-needed basis.
10. Resuscitation. CODE STATUS is full. The patient’s next of kin is her husband.