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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Gen Med Consult - 41
Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.

Gen Med Consult - 42
Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea. Medifast does fatigue

Gen Med Consult - 43
A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.

Gen Med Consult - 44
An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.

Gen Med Consult - 45
For evaluation of left-sided chest pain, 5 days post abdominal surgery.

Gen Med Consult - 46
Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.

Gen Med Consult - 47
The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.

Gen Med Consult - 48
The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain.

Gen Med Consult - 49
A female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.

Gen Med Consult - 5
Patient with swelling of lips and dysphagia and Arthritis.

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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