Dizziness Discharge Summary Medical Transcription Sample Report

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

CHIEF COMPLAINT: Dizziness.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with complaint of dizziness and diaphoresis episodes for one day. The patient stated that she awoke on the morning of admission feeling nauseous, and she had taken her blood pressure medication after she felt extremely weak and lightheaded. She had a left-sided headache, and she said that she had left facial numbness and left arm numbness. She had no loss of consciousness. She had no visual problems. She denied any chest pain, palpitation or shortness of breath. On her way to the hospital, her symptoms did improve.

PAST MEDICAL HISTORY: TIA and hyponatremia.

PAST SURGICAL HISTORY: Hernia.

ALLERGIES: No known drug allergies.

HOME MEDICATIONS: Diovan, Toprol, and aspirin.

SOCIAL HISTORY: Negative smoker, negative alcohol.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4 degrees, pulse 82, respiratory rate 20, and blood pressure 132/82. GENERAL: The patient appeared comfortable in no acute distress. HEENT: Normocephalic and atraumatic. Pupils were round and reactive to light. Extraocular muscles were intact, anicteric. TMs were clear and without erythema. NECK: Supple and nontender. Negative lymphadenopathy, negative masses, negative JVD. CARDIAC: Regular rate and rhythm, S1 and S2. Negative murmurs. RESPIRATORY: Clear to auscultation. Negative rales, negative rhonchi, negative wheezes. ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds. EXTREMITIES: Negative cyanosis, negative edema. NEUROLOGIC: There were no focal neurologic deficits.

LABORATORY DATA: Initial labs showed an ESR of 30 with serum sodium of 124, BUN of 11, and creatinine of 1.3. Hemoglobin 9.6 and hematocrit 29.

ASSESSMENT: The patient was admitted with what appeared to be an episode of transient ischemic attack with unilateral facial numbness as well as arm numbness and weakness with headache and weakness. Symptoms did resolve. The patient was admitted to telemetry to monitor for arrhythmias. Serial cardiac enzymes and EKGs were requested, as well as an echocardiogram and carotid Doppler. Due to the finding of hyponatremia upon admission, sodium was 124 and this was also evaluated with renal ultrasound, a nephrology consultation was requested. Serial stool hemoccults were requested due to the finding of anemia as well as abdominal ultrasound.

HOSPITAL COURSE: The patient’s hospital course was relatively uncomplicated. The patient did have nephrology consultation due to the finding of hyponatremia. The patient also had a cardiology consultation and a neurology consultation. Due to the finding of anemia, the patient also had a gastrointestinal consultation. Not only did the patient have anemia, but the patient also had elevation in liver enzymes and a CAT scan finding, which was reported to show fatty liver changes.

Laboratory tests during this hospitalization showed the patient to have, as stated before, low sodium with sodium of 124. This low sodium was noted to resolve and the number did improve throughout the hospitalization. The patient had normal BUN with creatinine between 1.1 and 1.2. The patient had total cholesterol of 240 with HDL of 136 and an LDL of 86. Cardiac enzymes were negative for myocardial infarction. B-type natriuretic peptide was slightly elevated at 120 with normal being between 0 and 100. CK-MB fractions were negative. Amylase as well as lipase were both within normal limits. Iron was 60. Urine sodium was low at 22. CA-125 was normal at 21.2. Alpha-fetoprotein was normal at 7.5. TSH was normal at 3.7. CEA was normal at 0.6. Folic acid was normal at 7.4. Vitamin B12 level was normal at 526. Hepatitis viral profile was negative for hepatitis B, hepatitis A, and hepatitis C. Urine osmolality was low at 148 with blood osmolality normal at 262. Urinalysis was negative for finding of urinary tract infection. Hemoglobin was ranging between 9.6 and 8.7, with the lowest being 8.7. This number did improve throughout the hospitalization. Hemoglobin electrophoresis was normal with no hemoglobin variation.

The patient had an MRI of the brain performed, which showed no acute ischemia identified. There was mild age-related chronic small vessel ischemic disease. Noncontrast CAT scan of the head showed no evidence of acute infarct. There was no mass effect or midline shift. Chest x-ray showed eventration of the right hemidiaphragm, otherwise unremarkable. Abdominal ultrasound showed fatty liver changes and normal gallbladder. CAT scan of the abdomen performed showed liver, gallbladder, biliary tree, and pancreas was unremarkable. The spleen was normal in size. There were no adrenal lesions. The kidneys were normal in size. There was no renal calcification seen. There was no hydronephrosis. There was no evidence of any retroperitoneal bleeding. The CAT scan of the pelvis performed showed what appeared to be routine IUD in place. There was right colonic diverticulum. Echocardiogram performed showed preserved left ventricular systolic function with evidence of possible diastolic compliance changes. There was trivial valvular flow abnormality. There were no gross mural thrombi or vegetations.

This patient did slowly improve throughout the hospitalization and sodium did correct itself. She had no further episodes of transient ischemic attack, and it was felt that the patient’s low sodium was due to excess fluid oral hydration, and the patient had been drinking excessive amount of water, and as a result, this had resulted in the low sodium. The patient’s sodium did improve. The patient was also made aware that she needed to follow up for further workup and followup of the low hemoglobin, and she also needed further followup and workup for fatty liver changes. With the patient feeling improved, the patient was discharged to home. The patient was discharged with instructions to follow up as an outpatient.

PRINCIPAL DIAGNOSIS: Transient cerebral ischemia.

SECONDARY DIAGNOSES:
1. Hyponatremia.
2. Acute renal failure.
3. Hypertensive heart disease.
4. Iron-deficiency anemia.
5. Chronic nonalcoholic liver disease.