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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Bladder Instillation
Bladder instillation for chronic interstitial cystitis.

Bladder Tumor
Recurrent bladder tumor. The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.

Blood In Toilet
Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

Blood in Urine - ER Visit
Patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria.

Brain Tumor - Consult
The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.

Breast Augmentation Consult
Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,

Breast Calcifications - Preop Consult
Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.

Breast Reconstruction
Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.

Bunion & Pes Planovalgus Deformity
Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.

Burn - Consult
First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

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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