Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Podiatry
Sample Name: Onychomycosis - 1

Description: Onychomycosis present, #1, #2, #3, #4, and #5 right and left.
(Medical Transcription Sample Report)

S: The patient presents to podiatry clinic today at the request of her primary physician, Dr. XYZ for initial examination, evaluation, and treatment of her nails. The patient has last seen primary in December 2006.

PRIMARY MEDICAL HISTORY: Edema, venous insufficiency, schizophrenia, and anemia.

ALLERGIES: THE PATIENT HAS NO KNOWN ALLERGIES.

MEDICATIONS: Refer to chart.

O: The patient presents in wheelchair, verbal and alert. Vascular: She has absent pedal pulses bilaterally. Trophic changes include absent hair growth and mycotic nails. Skin texture is dry. Skin color is rubor. Classic findings include temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.

A:
1. Onychomycosis present, #1, #2, #3, #4, and #5 right and left.
2. Peripheral vascular disease as per classic findings.
3. Pain on palpation.

P: Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided for length and thickness. The patient will be seen again at the request of the nursing staff for treatment of painful mycotic nails.

Keywords: podiatry, debrided, thickness, mycotic nails, onychomycosis, nails,
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