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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Kyphosis
A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture.

Laparoscopic Gastric Bypass Consult - 1
Consult for laparoscopic gastric bypass.

Laparoscopic Gastric Bypass Consult - 2
Consult for laparoscopic gastric bypass.

Leaking Nephrostomy Tube
Urine leaked around the ostomy site for his right sided nephrostomy tube. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.

Left Lower Quadrant Pain - ER Visit
The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain.

Lesions - Adrenal and Pancreatic
Pancreatic and left adrenal lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.

Lightheaded & Dizziness
Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia.

Lightheadedness
The patient comes in today because of feeling lightheaded and difficulty keeping his balance.

Limbic Encephalitis
Patient with a 1-year history of progressive anterograde amnesia

Lobar Holoprosencephaly
A 21-month-old male presented for delayed motor development, "jaw quivering" and "lazy eye."

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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