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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Perioperative Elevated Blood Pressure
Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.

Peripheral Effusion - Consult
Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.

Physical Exam and Pap - 1
A white female presents for exam and Pap.

Physical Exam and Pap -2
A white female who presents for complete physical, Pap and breast exam.

Pneumoconiosis
Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.

Pneumothorax & Subcutaneous Emphysema
Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.

Postop Medical Management
Post-surgical medical management; right total knee replacement.

Preeclampsia
Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure. The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncontrolled blood pressure.

Preop Cardiac Consult
Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery

Prostate Adenocarcinoma
Adenocarcinoma of the prostate. The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.

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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