Transcribed Medical Transcription Sample Reports and Examples

Sample Type / Medical Specialty: Consult - History and Phy.

Consultations, initial evaluations, new patient visits, history and physicals, etc.

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

Abdominal Pain - Consult
The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.

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.

Abnormal Stress Test
Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.

Abrasions & Lacerations - ER Visit
A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.

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.

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.
Transcribed Medical Transcription Sample Reports and Examples


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