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: Tinea Pedis - H&P

Description: Itchy red rash on feet - Tinea Pedis
(Medical Transcription Sample Report)

CHIEF COMPLAINT (1/1): This 24 year-old female presents today complaining of itchy, red rash on feet. Associated signs and symptoms: Associated signs and symptoms include tingling, right. Context: Patient denies any previous history, related trauma or previous treatments for this condition. Duration: Condition has existed for 4 weeks. Location: She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe. Modifying factors: Patient indicates ice improves condition. Quality: Quality of the itch is described by the patient as constant. Severity: Severity of condition is unbearable. Timing (onset/frequency): Onset was after leaving on sweaty socks.

ALLERGIES: Patient admits allergies to adhesive tape resulting in severe rash.

MEDICATION HISTORY: None.

PAST MEDICAL HISTORY: Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.

PAST SURGICAL HISTORY: Patient admits past surgical history of ear tubes.

SOCIAL HISTORY: Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.

FAMILY HISTORY: Patient admits a family history of cataract associated with maternal grandmother,
headaches/migraines associated with maternal aunt.

REVIEW OF SYSTEMS: Unremarkable with exception of chief complaint.

PHYSICAL EXAM: BP Sitting: 110/64 Resp: 18 HR: 66 Temp: 98.6
Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Cardiovascular: Skin temperature of the lower extremities is warm to cool, proximal to distal.
DP pulses palpable bilateral.
PT pulses palpable bilateral.
CFT immediate.
No edema observed.
Varicosities are not observed. Skin: Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.
Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.
Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.

TEST RESULTS: No tests to report at this time

IMPRESSION: Tinea pedis.

PLAN: Obtained fungal culture of skin from right toes. KOH prep performed revealed no visible microbes.

PRESCRIPTIONS: Lotrimin AF Dosage: 1% cream Sig: apply qid Dispense: 4oz tube Refills: 0 Allow Generic: Yes

Keywords: consult - history and phy., red rash, itchy, feet, rash, tinea pedis, fungal culture, koh prep, rash on feet, tinea, pedis, toe,
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