Medical Transcription

NAME: Robert Smith
DOB: 08/14/1963
CHIEF COMPLAINT: The patient is here for a follow-up on his cholesterol.
SUBJECTIVE
HPI-ROS:
The patient is here for a follow-up on his cholesterol. He has been taking atorvastatin 10 mg a
day for the past year and has not had any side effects from the medication at all. He does feel that
he has changed his lifestyle and diet enough that he once tried coming off the medication.
REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in the nature of urine.
Musculoskeletal: Remarkable for occasional knee pain and slight elbow pain, denies any known
trauma.
Neurologic: No weakness, no tremors, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, and oriented.
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally.
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use
of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Extremities: Mild crepitus at the range of motions on right knee, left knee is normal; left elbow
shows pain to palpation and resistance at supination and pronation over the lateral epicondyle of
the left elbow, no obvious swelling was seen and there is no erythema.
ASSESSMENT
PLAN
1. He’s due for laboratory, again it has been 1 year. He says he has changed his lifestyle and
has lost some weight since last year. We are going to have to discontinue the atorvastatin
for right now and he could do a laboratory in 1 month consisting of a comprehensive
metabolic panel and fasting lipid panel. Calls 3 to 4 days afterward for results.
2. As to his right knee, he only has occasional pain and said it was not debilitating
whatsoever; whereas his left elbow does have some pain with gripping objects and
twisting fingers like screwdrivers etcetera, but he does not find it as serious enough to
cause him to stop his activities. Reassurance was given and told to avoid any twisting
motions and very repetitive gripping and pulling motions when it flares up he can
ensure(?) and put some ice on it and or use over-the-counter non-steroidal anti-
inflammatory such as ibuprofen or naproxen.
3. Hopefully, his laboratory come back with normal values and we could just continue the
atorvastatin at that time. Further recognized(?), there is a pending laboratory.

NAME: Stanley Hudson
DOB:
CHIEF COMPLAINT:
He is here for a followup on his diabetes.
SUBJECTIVE
HPI-ROS:
The patient is here for a followup on his diabetes. He has had a type 2 diabetes for the past 15
years or so. He is here for refill medications and needs to get lab work done. Last lab was done 6
months ago. He had an A1C of 6.8% and did have some slight proteinuria at that time as well.
Otherwise denies any neuropathy symptoms, denies chest pain, no shortness of breath. He does
check his glucose periodically at home and says his fasting glucose is running around 125 to 135
range, very rarely takes a postprandial glucose but says he is always below 200 when that
happens. He has been trying to lose weight but really has not lost any weight at all in the past 6
months.
REVIEW OF SYSTEMS:
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.

Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
PERSONAL, FAMILY & SOCIAL HISTORY are reviewed. MEDICATION is also reviewed.
OBJECTIVE
General: Awake, alert, and oriented in no acute distress.
Ears: External auditory canals are clear, TMs are clear.
Nose: Nares are clear.
Throat: Pink and moist.
Neck: Soft, supple. No JVD, no adenopathy. Trachea is midline.
Heart: Regular rhythm and rate. No S3, S4 murmurs or rubs.
Chest: Lungs clear to auscultation bilaterally, without rales, rhonchi, or wheezes.
Abdomen: Slightly overweight. Soft, nontender. Bowel sounds are normal x4 quadrants. No
organomegaly.
Extremities: No cyanosis, no clubbing, or edema. Foot exam reveals no perils of calluses. He
also has palpable pulses. The feet are warm. Toenails appear to be normal also without any
onychomycosis at all.
Neuro: He has normal sensation to vibratory sense as well as monofilament testing. Otherwise,
cranial nerves 2-12 are grossly intact. There are no gross sensory deficits.
ASSESSMENT
1. Type 2 diabetes without complications
2. Proteinuria
PLAN

1. We are going to do urine microalbumin, hemoglobin A1C, comprehensive metabolic
panel, lipid panel. He is also due for his PSA so we will order that and just be a total
PSA.
2. He is also going to be coming up due for a screening colonoscopy. Give him a referral to
Dr. Daly for that as well.
3. Refill his medications for the metformin 500 mg BID also his glipizide 5 mg BID and he
denies any symptoms of hypoglycemia at all.
4. He calls in 3 or 4 days for results and otherwise after he gets all results if all looks good
we will just see him every 6 months. Also reminded him that in 6 more months he will be
due for his diabetic eye exams. He says he will put it on his calendar and so he does
understand that as well.

NAME: Phyllis Vance
DOB:
CHIEF COMPLAINT:
Here for a general checkup.
SUBJECTIVE
HPI-ROS:
The patient is here for a general checkup. She really has no new complaints. She does her
gynecologist for annual pap smears and breast exams. There is a family history of diabetes and
she is overweight. She is concerned about diabetes. She has been monitoring her blood pressure
with a home blood pressure monitor and says that sometimes it is running above 140 for the
systolic and in a high 80s for the diastolic.
REVIEW OF SYSTEMS:
emesis, no melena.
or numbness.

OBJECTIVE
General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.
Eyes: Sclera is non-icteric.
Ears: TMs are clear, external auditory canals are clear.
Nose: Nares are clear.
Throat: Pink and moist.
Neck: Without any adenopathy. Trachea is in midline. There is no thyromegaly.
Heart: Regular rhythm and rate. No S3, S4. There is a 1/6 systolic murmur at the mitral valve
listening post.
Chest: Lungs clear to auscultation bilaterally without rales, rhonchi, or wheezes.
Abdomen: Obese. Soft, nontender. Bowel sounds are normal x4 quadrants. There is no palpable
masses, no organomegaly.
Extremities: No cyanosis, no clubbing, or edema. Full range of motion.
Neuro: Gait, ambulation all normal. Cranial nerves 2-12 grossly intact. There is no gross sensory
or motor deficits noted.
PLAN
1. We counsel her regarding her weight, her BMI right now is at 32 and recommended that
she look into her Atkins diet or maybe South Beach diet.
2. She may also want to do something such as Nutrisystem or weight watchers.
3. She has tried before a crashed dieting and that she is always rigging the weight. So I think
a more structured program might be better for her. She agrees to that as well.
4. In light of her mildly elevated blood pressure history, today her blood pressure is running
141/89. Recommend that she continue monitor but continue with lifestyle changes for
losing weight and some exercise.

5. Also decrease some sodium in her diet it will also be good. I think that will happen
anyway because she does eat a lot of potato chips she says and pretzels and not certainly
helping her to lose weight either.
6. In light of that, we are going to want to recheck her probably in a month and recheck her
BP at that time otherwise we are just going to have to get for some labs Sonora Quest
labs comprehensive metabolic panel, lipid panel, CBC, we are going to do complete
urinalysis with the reflex culture sensitivity, as well as a TSH free T3 and free T4 also I
wanna give her a referral for a dietician consultation as well and then we help to answer
some of her questions and again recommended a more structured diet program such as
listed above. Otherwise followup PRN in 1 month time sooner if any problems or any
questions arise.

NAME: Kelly Kapoor
DOB:
CHIEF COMPLAINT:
She presents today for an evaluation of some depression symptoms.
SUBJECTIVE
HPI-ROS:
The patient is here for evaluation of some depression symptoms. She says that she has been
feeling quite down and depressed after breaking up with her boyfriend Ryan about a month ago.
She says that she feels they are going to break up anyway but he is the one who actually broke up
with her so that bothers her more than if she had broken up with him she says. Anyway, she has
been having difficulty sleeping. She said she cannot stop thinking about him and feels like she
should have broken up with him first. It seems that really bother her that he did not rather her
reasons and she felt like she was going to break up with him anyway.
REVIEW OF SYSTEMS:
emesis, no melena.

or numbness.
OBJECTIVE
General: Awake, alert, and oriented in no acute distress. Conversant and friendly affect.
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs.
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops.
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use
of accessory muscles of respiration.
Back: Normal curvature, no tenderness.
Extremities: No deformities, no edema, no erythema. Range of motion WNL, pulses intact.
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.
ASSESSMENT
PLAN
1.
2.
3.

NAME: Dwight Schrute
DOB:
CHIEF COMPLAINT:
Presents today for pain in his right ankle.
SUBJECTIVE
HPI-ROS:
The patient is here for pain in his right ankle. He was walking through his farm when he tripped
over a clump of mud that have dried. He was getting ready to plant beets for this year’s season.
He was walking through his property he tripped and stumbled twisting his right ankle. He denies
any previous injuries. He does report that he put ice on it and has been elevating it since
yesterday when it happened but is very painful and unable to place any weight on it.
REVIEW OF SYSTEMS:
emesis, no melena.
or numbness.

OBJECTIVE
General: He is coming in with crutches. He is not in any acute distress.
Extremities: He is wrapped up in an ACE bandage. I took off the wrapping and found there is an
ecchymotic area to the lateral malleolus of the right ankle with obvious soft tissue swelling.
Pulses are intact distally. Capillary refills within 2 seconds. The foot and ankle are warm. There
is no sign of secondary infection at all. He does have some bruising which extends down
laterally on the foot under the base in the 5th metatarsal. He is tender to palpation on the lateral
malleolus to both palpation and palpation of the base of the 5th metatarsal as well makes me
suspicious for a possible Jones fracture. He obviously has pain with weight bearing and the range
of motion too of the foot and ankle.
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.
ASSESSMENT
ANKLE SPRAIN
PLAN
1. We will do a STAT foot and the ankle X-ray non-weight bearing.
2. In the meantime, we will recommend to continue with the ACE bandage and the
elevation.
3. And possible he will probably get the X-ray with them this afternoon.
4. He can call us tomorrow morning for results otherwise I advised him to also take
ibuprofen two 200 mg tablets 4 times a day. I saw him tonight with elevation and
continue wrapping with the ACE bandage. Recommend that he stay on his crutches non-
weight bearing for at least 3 or 4 days. If there is no fracture found I will just subject in a
prior auth given a week or so of using the crutches. If there is a fracture, we will send him
to a podiatrist.

NAME: SpongeBob SquarePants
DOB: 07/01/1946
CHIEF COMPLAINT: The patient is here for the management of blood pressure.
SUBJECTIVE
HPI-ROS:
The patient is here for a follow-up on his blood pressure management. He has been taking his
medications but has found that his blood pressure is still elevated many times when he takes
them. He uses a wrist monitor at home. He has not had any headaches, dizziness, chest pains, or
shortness of breath. Past medical history is remarkable for (?) hypertension, hyperlipidemia, and
diabetes.
REVIEW OF SYSTEMS:
emesis, no melena.
or numbness.

OBJECTIVE
General: The patient is awake, alert, oriented, very friendly, and has no acute distress
whatsoever.
Heart: Regular rhythm and rate; no S3, S4 murmurs or rubs.
Chest: Lungs cleared auscultation bilaterally; no rales, rhonchi, or wheezes.
Extremities: No cyanosis, no clubbing, no edema, full range of motion; he does have some mild
crepitus to flexion and extension of both knees.
ASSESSMENT
PLAN
1. We reviewed his blood pressure today in the office is at 174/101. We retook it 2 or 3
times and remained elevated. He is not tachycardic with a pulse rate of 80. His current
regimen consists of amlodipine 10 mg and lisinopril 40 mg. At this point, those are
maxed out. We will add hydrochlorothiazide 25 mg q.d. to be taken with the lisonopril.
2. Monitor blood pressure readings at home 3 to 4 times per week. He also has to follow up
here in about 10 to 14 days. Let us know via telephone if there are any questions,
problems, or blood pressure not responding.
3. Laboratory: He is coming due for his laboratory next month and we ordered a
comprehensive metabolic panel, CBC, urine microalbumin, hemoglobin A1C, and fasting
lipid panel. He may also follow up here after his laboratory results in a month otherwise,
we’ll see him in 10 to 14 days first.

NAME: Kevin Smith
DOB: 12/16/1955
CHIEF COMPLAINT: The patient is here for an annual physical examination.
SUBJECTIVE
HPI-ROS:
The patient is here for an annual physical examination and has no known complaints. He is not
taking any medications at all and feels quite well.
REVIEW OF SYSTEMS:
emesis, no melena.
or numbness.

OBJECTIVE
General: Awake, alert, oriented, and very friendly.
Eyes: Sclera non-icteric, extra-ocular muscles are intact.
Ears: TMs clear, EACs clear.
Nose: Tubrinates normal, nasal mucosa normal, no obstruction, no discharge.
Throat: Pink and moist, without any lesions, oropharynx is clear; he does not have any tonsils
visible.
Neck: Soft, supple, No JVD, no adenopathy, no thyromegaly, ROM normal.
Heart: Regular rhythm and rate. No S3, S4 murmurs or rubs.
Chest: Lungs cleared auscultation bilaterally without rales, rhonchi, or wheezes, no retractions,
and no use of accessory muscles for respiration.
Abdomen: Soft, non-tender, BS normal present x4 quadrants with no organomegaly, no
guarding, no rebound, no rigidity. There are no masses palpable and no abnormal aortic
pulsations.
Extremities: No cyanosis, no clubbing, no edema, pulses are intact distinctly x4 extremities.
Neuro: CN 2-12 intact, no gross sensory or motor deficits noted; full range of motion of all
extremities with no sensory or motor deficits; muscle strength is 5/5 bilaterally; deep tendon
reflexes are 2/4 bilateral upper and lower extremities; lumbar flexion and extension are normal;
gait normal; mentation appropriate with no short-term memory. Difficulties are seen today
during the interview. He has no signs or symptoms of any cognitive dysfunction and no
confusion. He does remain quite active as far as exercise goes as he is walking 2 to 3 miles per
day.
Rectal: No suspicious lesions; he has no hemorrhoids and his prostate feels to be normal-sized
and texture and non-tender.
ASSESSMENT
Annual Physical Examination
Z00.00 Encounter for general adult medical examination without abnormal findings
PLAN

1. Comprehensive metabolic panel, complete blood count with differential, urinalysis
complete with reflex culture sensitivity, and PSA.
2. Encourage him to call us 2 to 3 days after laboratory tests are done.
3. He’s encouraged to get an annual eye exam.
4. He has never had a screening colonoscopy, so a referral for a consult for screening
colonoscopy is given for gastroenterology.
5. Continue a healthy lifestyle and diet as well as regular exercise. May follow up otherwise
observe follow-up annually or sooner PRN. The total time spent is 29 minutes face-to-
face with greater than 50% of the time spent in counseling.

NAME: Harry Jones
DOB: 12/25/1951
CHIEF COMPLAINT: The patient is here for a follow-up on multiple medical issues.
SUBJECTIVE
HPI-ROS:
The patient is here for a follow-up on hypertension, hyperlipidemia, as well as coronary artery
disease, and diabetes. He has known that his blood sugar has been elevated in the morning
running about 250 to 280. He has also been having occasional exertional chest pain with
concomitant shortness of breath. He is not having any swelling on his legs. He has not had any
fevers or chills. He denies any cough though he does continue to smoke. He has also been
struggling to lose weight and he is currently at 322 pounds.
REVIEW OF SYSTEMS:
Chest: Remarkable for exertional chest pains. No dyspnea, no wheezing, no hemoptysis, no
cough.
emesis, no melena.
or numbness.

OBJECTIVE
General: Awake, alert, and oriented; he does ambulate on his own but he is slow due to his
morbid obesity. He is able to transition from sitting to standing position and vice versa without
any assistance.
Eyes: Sclera non-icteric, extra-ocular muscles intact, pupils equal round and reactive, ocular
fundus is benign.
Ears: TMs clear, EACs clear.
Throat: Clear though it does have a narrow oropharynx due to his obesity and mild tonsil
hypertrophy.
Neck: Soft, supple, with some acanthosis nigricans noted, and does have a few scattered skin
tags as well.
Heart: Regular rhythm and rate, heart sounds are somewhat distant due to his morbid obesity, no
obvious murmurs nor S3 or S4 gallops.
Chest: Lungs cleared auscultation bilaterally, without rales, rhonchi, or wheezes.
Abdomen: Morbidly obese, no obvious organomegaly, but difficult due to his morbid obesity.
Bowel sounds are present x4 quadrants.
Extremities: Has trace edema in the bilateral lower extremities to above the medial tibials. No
skin breakdown though his skin is somewhat dry.
Neuro: Neurological examination of the feet with monofilament testing and vibration testing
with a tuning fork is negative for neuropathy.
ASSESSMENT
PLAN
1. We discussed his diabetes and currently, his blood sugar is running above 200 in the
mornings. We told him we need to increase his dose of glipizide to two 5 mg tablets

twice a day. He should continue checking his blood sugar both fasting as well as 1- or 2-
hour postprandial and report what the sugar readings are in the next 10 to 14 days.
2. For his blood pressure goes, continue on his amlodipine but we are going to decrease the
dosage to 5 mg from 10 mg as he may be getting some edema in his legs due to that high
dose of the amlodipine otherwise we will increase his lisinopril from 20 mg to 40 mg to
hopefully keep his blood pressure on good control.
3. He is due for A1C testing as well as a chemistry panel and lipid testing in the next couple
of months. He is also behind on his urine microalbumin testing as well. Laboratory slip to
be given for the next month for the comprehensive metabolic panel, fasting lipid panel,
hemoglobin A1C, and urine microalbumin. He needs to follow up here after those tests
are done. In the meantime, he can leave me a message at the front desk about his glucose
logs so we can let him know if any further adjustments are needed on his diabetic
medications. Also, stress the importance of annual dilated eye exams for his diabetes and
he will not be due for that until this coming June. He understands all that we discussed
and the total time spent is 28 minutes face-to-face with greater than 55% time spent in
counseling.

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