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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Infantile Spasms
A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.

Insect Sting
Local reaction secondary to insect sting. Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today.

Intractable Epilepsy
Intractable epilepsy, here for video EEG.

Iron deficiency anemia
Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.

Ischemic Cecum - Consult
Pneumatosis coli in the cecum. Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.

Itchy Rash - ER Visit
This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.

Jaw Pain - ER Visit
Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.

Knee DJD - Consult
Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.

Knee Injury
Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling.

Kyphoplasty - Consult
The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time.

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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