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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Records Review - Orthopedic
Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.

Rectal Bleeding - 1-year-old
Pediatric Gastroenterology - Rectal Bleeding Consult.

Rectal Bleeding - Consult
A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks.

Recurrent Abscesses - Consult
Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used.

Recurrent nasal obstruction
Patient with suspected nasal obstruction, possible sleep apnea.

Renal Failure - Consult
Acute renal failure, suspected, likely due to multi-organ system failure syndrome.

Renal Failure Evaluation
Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.

Renal Insufficiency - Consult
Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.

Request For Consultation
Request for consultation to evaluate stomatitis, possibly methotrexate related.

Revocation Admission
A 40-year-old male seen today for a 90-day revocation admission. Noncompliant with medications, refusing oral or IM medications, became agitated. History of hyperlipidemia with elevated triglycerides.

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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