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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Psychiatric Consult
Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.

Psychiatric Consult - 1
Bipolar disorder, apparently stable on medications. Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.

Psychiatric Consult - 2
She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.

Pubic Cellulitis
A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.

Pulmonary Consultation - 1
Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.

Pulmonary Consultation - 2
Patient with complaints of significant coughing and wheezing.

Pulmonary Edema - Consult
This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure.

Pulmonary Embolism
Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.

Pulmonary Hypertension - Pediatric Consult
Increasing oxygen requirement. Baby boy has significant pulmonary hypertension.

Records Review - Epicondylitis
Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.

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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