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I have done a lot of medical voice files transcribed to documents. Here is an example

PATIENT’S NAME: GILL, THOMAS F. D.O.S: 11/18/2003

D.O.B: 05/13/1938 NUMBER: ----------

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OFFICE VISIT

CHIEF COMPLAINT: Follow-up acute renal failure and chronic renal insufficiency.

INTERVAL HISTORY: I last saw Mr. Gill on November 3. He has a very difficult clinical problem in that he has severe cardiomyopathy, chronic renal insufficiency and a predisposition for intermittent hemodynamic acute renal failure. Usually he goes into acute renal failure when he gets over diuresed. Over the last few visits, we have been trying to fine-tune his diuretics to find his therapeutic sweet spot. I think he may have found the right nix. He denies any symptoms of orthopnea or PND. He is able to lay flat without any shortness of breath. He continues to have some dyspnea on exertion but he also has some element of primary lung disease. For the last 10 days, he has been on spironolactone 25 mg p.o. b.i.d. and Lasix 80 mg p.o. b.i.d. He continues to tolerate Altace as well.

Previous office notes were reviewed along with correspondence from other treating physicians.

PMFSH reviewed and unchanged except as noted in the interval history.

ROS performed and documented with pertinent findings included in the interval history.

Since I last saw him there have been no significant interval renal events. On close questioning, the patient has not had nephrolithiasis, flank pain, or hematuria. There has been no exposure to NSAID’S, COX-2 inhibitors, or intravenous contrast. The patient has not undergone any percutaneous endovascular procedures, and has not had any symptoms of obstruction. There have been no documented episodes of ARF or malignant hypertension. There have been no changes in dosing or frequency of ACE-inhibitors, angiotensin receptor blockers, or diuretics.

PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure of 95/50. Pulse 64. Temperature 97.1. Weight is 206#.

HEAD & NECK: Moist mucous membranes.

LUNGS: Clear.

CARDIOVASCULAR: Regular rate and rhythm.

ABDOMEN: Soft with positive bowel sounds.

EXTREMITIES: About 2+ pretibial edema.

LABORATORY INFORMATION: Most recently available was from 10th November, which showed a BUN of 75, creatinine of 2.5, glucose of 174, sodium 137, potassium 5.0, chloride 90, bicarbonate of 28, calcium of 8.6, phosphors of 4.2, uric acid was 10.3, white count 6.3, H&H 9.6 and 29, platelet count 182. We do have a recent iron saturation from October 27th, which showed 22% with a TIBC of 386 and serum iron of 84.

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I have done a lot of medical voice files transcribed to documents. Here is an example

PATIENT’S NAME: GILL, THOMAS F. D.O.S: 11/18/2003

D.O.B: 05/13/1938 NUMBER: ----------

------

OFFICE VISIT

CHIEF COMPLAINT: Follow-up acute renal failure and chronic renal insufficiency.

INTERVAL HISTORY: I last saw Mr. Gill on November 3. He has a very difficult clinical problem in that he has severe cardiomyopathy, chronic renal insufficiency and a predisposition for intermittent hemodynamic acute renal failure. Usually he goes into acute renal failure when he gets over diuresed. Over the last few visits, we have been trying to fine-tune his diuretics to find his therapeutic sweet spot. I think he may have found the right nix. He denies any symptoms of orthopnea or PND. He is able to lay flat without any shortness of breath. He continues to have some dyspnea on exertion but he also has some element of primary lung disease. For the last 10 days, he has been on spironolactone 25 mg p.o. b.i.d. and Lasix 80 mg p.o. b.i.d. He continues to tolerate Altace as well.

Previous office notes were reviewed along with correspondence from other treating physicians.

PMFSH reviewed and unchanged except as noted in the interval history.

ROS performed and documented with pertinent findings included in the interval history.

Since I last saw him there have been no significant interval renal events. On close questioning, the patient has not had nephrolithiasis, flank pain, or hematuria. There has been no exposure to NSAID’S, COX-2 inhibitors, or intravenous contrast. The patient has not undergone any percutaneous endovascular procedures, and has not had any symptoms of obstruction. There have been no documented episodes of ARF or malignant hypertension. There have been no changes in dosing or frequency of ACE-inhibitors, angiotensin receptor blockers, or diuretics.

PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure of 95/50. Pulse 64. Temperature 97.1. Weight is 206#.

HEAD & NECK: Moist mucous membranes.

LUNGS: Clear.

CARDIOVASCULAR: Regular rate and rhythm.

ABDOMEN: Soft with positive bowel sounds.

EXTREMITIES: About 2+ pretibial edema.

LABORATORY INFORMATION: Most recently available was from 10th November, which showed a BUN of 75, creatinine of 2.5, glucose of 174, sodium 137, potassium 5.0, chloride 90, bicarbonate of 28, calcium of 8.6, phosphors of 4.2, uric acid was 10.3, white count 6.3, H&H 9.6 and 29, platelet count 182. We do have a recent iron saturation from October 27th, which showed 22% with a TIBC of 386 and serum iron of 84.

Noman1981