Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine 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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Dural AVM
Patient with episode of lightheadedness and suddenly experienced vertigo.

Dysphagia & Hematemesis
Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis

Ear Pain - Drainage
Right ear pain with drainage - otitis media and otorrhea.

Ear pain - Pediatric Consult
13 years old complaining about severe ear pain - Chronic otitis media.

Ecstasy Ingestion - ER Visit
Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.

Elbow Pain - Consult
Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.

Elevated BNP - Consult
Elevated BNP. Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.

Elevated Cardiac Enzymes
Abnormal cardiac enzyme profile. The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile.

Elevated PSA - H&P
Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.

Encephalopathy - Rehab Consult
Encephalopathy related to normal-pressure hydrocephalus.

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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