Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine 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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Congestion - 21-day-old
Congestion, tactile temperature.

Congestion & Cough - 5-month-Old
A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot.

Congestion & Fever - 2-month-old
A 2-month-old female with 1-week history of congestion and fever x2 days.

Connective Tissue Disorder
She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.

Consult - Abnormal EKG
Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.

Consult - Alzheimer disease
Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.

Consult - Atrial Fibrillation
Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.

Consult - Atrial Fibrillation - 1
Atrial fibrillation and shortness of breath. The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.

Consult - Back & Leg Pain
The patient has been suffering from intractable back and leg pain.

Consult - Breast Cancer
Patient presents with complaint of lump in the upper outer quadrant of the right breast

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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