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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Adult Hydrocephalus
The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.

Agitation - ER Visit
Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.

Air Under Diaphragm - Consult
Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.

Airway Compromise & Foreign Body - ER Visit
The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.

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

Anemia - Consult
Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.

Angina - Consult
Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.

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

Annual Health Maintenance Exam
Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.

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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