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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Hypertension & Cardiomyopathy
Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.

Hyperthyroidism Following Pregnancy
Chief complaint of chest pain, previously diagnosed with hyperthyroidism.

Hypothermia - Discharge Summary
Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.

Infantile Spasms
A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.

Insect Sting
Local reaction secondary to insect sting. Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today.

Itchy Rash - ER Visit
This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.

Jaw Pain - ER Visit
Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.

Lesions - Adrenal and Pancreatic
Pancreatic and left adrenal lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.

Lymphoblastic Leukemia - Consult
Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.

Male Exam & ROS
Sample male exam and review of systems.

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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