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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Discharge Summary - 8
A white female with a history of fevers.

Discharge Summary - 9
A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.

Discharge Summary - Migraine
Intractable migraine with aura. The patient is discharged home. Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.

Discharge Summary - Multiple Trauma
Aftercare of multiple trauma from an motor vehicle accident.

Disseminated Intravascular Coagulation
Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.

Dog Bite
A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.

Down's syndrome
A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.

Ecstasy Ingestion - ER Visit
Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.

Elbow Pain - Consult
Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.

ER Report - Chest Pain & Fever
A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.

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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