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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Low Back Pain - Consult
New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.

Lower back pain
Lumbar muscle strain and chronic back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.

Lower Quadrant Pain
Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear.

Lumbar Radiculopathy - Consult
Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.

Lumbar Spine HNP - Consult
Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.

Lumbosacral Polyradiculopathy
Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.

Lung Cancer & MI - Hospice Cosult
Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.

Lymphoblastic Leukemia - Consult
Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.

Lymphoma - Consult
Marginal B-cell lymphoma, status post splenectomy. Testicular swelling - possible epididymitis or possible torsion of the testis.

Major Depressive Disorder - IME Consult
Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.

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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