Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Pediatrics - Neonatal

The medical practice that deals with the development, care and diseases of children. Refers to specialists for additional care when appropriate.



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Gastrostomy
Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.

Goldenhar Syndrome - Discharge Summary
Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.

H&P - Infant with fever
Irritable baby, 6-week-old, with fever for approximately 24 hours.

Head Injury
Head injury, anxiety, and hypertensive emergency.

Hyperbilirubinemia - 4-day-old
4-day-old with hyperbilirubinemia and heart murmur.

Infant Not Gaining Weight
A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.

Infantile Spasms
A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.

Inguinal Hernia & Hydrocele Repair
Left communicating hydrocele. Left inguinal hernia and hydrocele repair. The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.

Kawasaki Disease - Discharge Summary
This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR.

Mastoiditis - Discharge Summary
Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving. The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples