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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Rheumatoid Arthritis - Consult
A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She is not on DMARD, but as she recently had a surgery followed by a probable infection.

Rheumatoid Arthritis - H&P
Patient presents for treatment of suspected rheumatoid arthritis.

Rotator cuff syndrome - H&P
Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.

School Physical - 1
This patient was seen in clinic for a school physical.

School Physical - 2
Well-child check and school physical.

Sepsis - Consult
Sepsis. The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

Shoulder Pain Consult
Consultation for right shoulder pain.

Sick Sinus Syndrome
Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction

Sinus problems - Consult
Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.

Sleepiness - Consult
Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.

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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