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 - 2

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

S: The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.

PRIMARY MEDICAL HISTORY: Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.

MEDICATIONS: Refer to chart.

ALLERGIES: PENICILLIN AND ASPIRIN.

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 and shiny. Skin color is rubor. Classic findings are temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, # 1 right and #1 left.

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

P: Nails #1 right and #1 left were debrided for length and thickness. All the nails were reduced. The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails.

Keywords: podiatry, length and thickness, mycotic nails, classic findings, 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