Sample Type: Consult - History and Phy.

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A 5-month-old boy with cough
A 5-month-old boy brought by his parents because of 2 days of cough.

Abnormal Echocardiogram
Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. The patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.

Acne Vulgaris - H&P
Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris

Acute Cystitis & Diabetes Type II
The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

Acute Inferior Myocardial Infarction
Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.

Adjustment Disorder & Encopresis
The patient was referred due to concerns regarding behavioral acting out as well as encopresis.

Admission History & Physical - Nausea
Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.

Allergy Evaluation Consult
Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.

Ankle Pain - Consult
The patient was running and twisted her right ankle - right ankle sprain.

Ankle Sprain - H&P
History and Physical for right ankle sprain

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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