Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Gastroenterology
Sample Name: Constipation - 1

Description: Patient complains of constipation. Has not had BM for two days.
(Medical Transcription Sample Report)

Patient complains of constipation, severe at times. Has not had BM for two days. Denies chest pain. Has been ambulating well. No history suggestive of angina. Will be seeing cardiologist this afternoon.

Patient was informed by Dr. ABC that he does not need sleep study as per patient.

PHYSICAL EXAMINATION:
General: Pleasant, brighter.
Vital signs: 117/78, 12, 56.
Abdomen: Soft, nontender. Bowel sounds normal.

ASSESSMENT AND PLAN:
1. Constipation. Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.
2. CAD/angina. See cardiologist this afternoon.

Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.



Keywords: gastroenterology, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema,
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