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 - Weankness & Polymyositis
Consultation - an 87-year-old white female with weakness and a history of polymyositis.

Consult for Colostomy Reversal
Patient presents for a colostomy reversal as well as repair of an incisional hernia.

Consult for New Wheelchair
A male referred to Wheelchair Clinic for evaluation for a new wheelchair.

Consult/ER Report - OB/GYN
A female with unknown gestational age who presents to the ED after a suicide attempt.

Conversion Disorder
The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder.

Cough & Abdominal Pain
Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.

Cut on Foot - ER Visit
Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.

CVA Consult - ER Visit
Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.

Cystic Fibrosis
A 10 years of age carries a diagnosis of cystic fibrosis

Decreased Vision Consult
One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.

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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