Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Emergency Room Reports

Close monitoring/treatment of a seriously ill patient (including post surgical care) that enables immediate treatment in a controlled environment such as an intensive care unit.



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Hypertension - Consult
An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.

Intracranial aneurysm - ER Visit
Headache, improved. Intracranial aneurysm.

Itchy Rash - ER Visit
This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.

Jaw Pain - ER Visit
Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.

Leaking Nephrostomy Tube
Urine leaked around the ostomy site for his right sided nephrostomy tube. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.

Left Lower Quadrant Pain - ER Visit
The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.

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.

Melena - ICU Followup
Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.

Motor Vehicle Accident
Multiple contusions and abdominal pain, status post motor vehicle collision.

MRSA Infection - ER Visit
Methicillin-resistant Staphylococcus aureus (MRSA) infection. A 14-day-old was seen by private doctor because of blister.

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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