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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Syncope - ER Visit
Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.

Syncope - ER Visit - 1
The patient had a syncopal episode last night. She did not have any residual deficit. She had a headache at that time. She denies chest pains or palpitations.

T-Cell Lymphoma Consult
Newly diagnosed T-cell lymphoma. The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.

Tethered Cord Evaluation
Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.

Therapeutic Recreation Initial Evaluation
Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.

Thrombocytopenia - Consult
Consultation for evaluation of thrombocytopenia.

Thyroid Mass Consult
Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.

TIA - Cosult
A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours.

TIA & Lumbar Stenosis
Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale.

Tinea Pedis - H&P
Itchy red rash on feet - Tinea Pedis

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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