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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Buttock Abscess
Left buttock abscess, status post incision and drainage. Recommended some local wound care

C. Diff Colitis Consult
The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.

Cancer of the nasopharynx
T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.

Carbohydrate Counting
Dietary consultation for carbohydrate counting for type I diabetes.

Cardiac Consult & Cardioversion
Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.

Cardiac Consultation
A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD.

Cardiac Consultation - 1
To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.

Cardiac Consultation - 2
To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.

Cardiac Consultation - 3
Patient with atrial fibrillation with slow ventricular response, partially due to medications.

Cardiac Consultation - 4
Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.

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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