Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: General Medicine

A branch of medicine that deals with diagnosis and treatment of nonsurgical diseases.



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H&P - Weakness
Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2

Headache - Emergency Visit
Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.

Headache - Office Visit
The patient with continued problems with her headaches.

Headache - Urgent Care Visit
Migraine headache - The patient was seen in the urgent care.

HIV Followup
Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.

HIV Followup - 1
Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds.

Hydrocarbon Aspiration - ER Visit
The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.

Hypergranulation - Consult
Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.

Hypersensitivity to Coumadin
Probable Coumadin hypersensitivity.

Hypertension - Consult
An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.

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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