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: Dystrophic Nails

Description: The patient presents for evaluation at the request of his primary physician for treatment for dystrophic nails.
(Medical Transcription Sample Report)

S: The patient presents for evaluation at the request of his primary physician for treatment for nails. He has last seen the primary physician in December 2006.

PRIMARY MEDICAL HISTORY: Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, and atrial fibrillation.

MEDICATIONS: Refer to chart.

O: The patient presents in wheelchair, verbal and alert. Vascular: He has absent pedal pulses bilaterally. Trophic changes include absent hair growth and dystrophic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings include temperature change and edema +2. Nails: Thickened and hypertrophic, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.

A:
1. Dystrophic nails.
2. Peripheral vascular disease as per classic findings.
3. Pain on palpation.
4. Diabetes.

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

Keywords: podiatry, debrided, nails, dystrophic nails, dystrophic,
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