Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: General Medicine
Sample Name: Acute Cystitis & Diabetes Type II

Description: The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.

PAST MEDICAL HISTORY: There is no significant past medical history noted today.

PHYSICAL EXAMINATION:
HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.
Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.
Resp: Patient denies asthma, lung infections and lung lesions.
GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.
GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.
Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.
Dermatology: Patient denies allergic reactions, rashes and skin lesions.

MEDS: Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.

SOCIAL HISTORY: No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.

FAMILY HISTORY: No significant family history.

REVIEW OF SYSTEMS: Non-contributory.
Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.
Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and conto.
Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.
Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.
Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.
Extremities: There is no clubbing, cyanosis, or edema.

ASSESSMENT: Diabetes type II uncontrolled. Acute cystitis.

PLAN: Endocrinology Consult, complete CBC.

RX: Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.

Keywords: general medicine, bactrim, micronase, abdominal pain, endocrinology, cbc, diabetes type ii, acute cystitis, diabetes, abnormalities,
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