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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Tongue Swelling
A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.

Toothache - ER Visit
Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..

Tracheostomy Tube Consult
Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.

Trouble Breathing - H&P
History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.

Ureteral Calculus - Consult
Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.

URI & Eustachian Congestion
Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.

Urinary Retention
This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.

Urology Consut - 1
Blood in urine - Transitional cell cancer of the bladder.

Uveitis
The patient with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.

Ventricular Ectopy - Consult
Ventricular ectopy and coronary artery disease. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.

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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