Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.

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



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Consult - Breast Cancer - 1
The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.

Consult - Cerebral Peduncle Infarction
Patient with a history of right upper pons and right cerebral peduncle infarction.

Consult - Chest Pain
Patient with multiple problems, main one is chest pain at night.

Consult - Chest Pain - 1
A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors.

Consult - CHF & Lymphedema
The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.

Consult - Congestive Heart Failure
Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.

Consult - Coronary Artery Disease
Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.

Consult - Enlarged Tonsils
Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.

Consult - Facial Twitching
The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.

Consult - Hydronephrosis
Marked right hydronephrosis without hydruria.

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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