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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Cardiac Consultation - 5
Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.

Cardiac Consultation - 6
Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.

Cardiac Consultation - 7
The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.

Cardiomyopathy & Hypotension - Consult
Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.

Cervical Cord Lesion - Consult
Patient reports a six to eight-week history of balance problems with later fatigue and weakness.

Cervical Spondylosis - Neuro Consult
Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe.

Chest discomfort & palpitations - Consult.
Patient with palpitations and rcent worsening of chronic chest discomfort.

Chest Pain - Cardiac Consult
Chest pain, possible syncopal spells. She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.

Chest Wall Lump - Consult
Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor.

Cholangiocarcinoma Consult
Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.

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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