Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Ureteral Calculus - Consult

Description: Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Right distal ureteral calculus.

HISTORY OF PRESENT ILLNESS: The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.

PAST MEDICAL HISTORY:
1. Prostatism.
2. Coronary artery disease.

PAST SURGICAL HISTORY:
1. Right spermatocelectomy.
2. Left total knee replacement in 1987.
3. Right knee in 2005.

MEDICATIONS:
1. Coumadin 3 mg daily.
2. Fosamax.
3. Viagra p.r.n.

ALLERGIES: NONE.

REVIEW OF SYSTEMS: CARDIOPULMONARY: No shortness of breath or chest pain. GI: No nausea, vomiting, diarrhea or constipation. GU: Voids well. MUSCULOSKELETAL: No weakness or strokes.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: An alert male in no distress.
HEENT: Grossly normal.
NECK: Supple.
LUNGS: Clear.
HEART: Normal sinus rhythm. No murmur or gallop.
ABDOMEN: Soft. No masses.
GENITALIA: Normal penis. Testicles descended bilaterally.
RECTAL: Examination benign.
EXTREMITIES: No edema.

IMPRESSION: Right distal ureteral calculus.

PLAN: Right ureteroscopy, ureteral lithotripsy. Risks and complications discussed with the patient. He signed a true informed consent. No guarantees or warrantees were given.

Keywords: consult - history and phy., stent, calcification, ct urogram, ureteral calculus, distal ureteral, kub, teardrop, ureteroscopy, lithotripsy, calculus, hematuria,
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