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: Flank Pain - Consult

Description: Left flank pain and unable to urinate.
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Left flank pain and unable to urinate.

HISTORY: The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels much better today. I was consulted by Dr. X.

MEDICATIONS: Ritalin 50 a day.

ALLERGIES: To penicillin.

PAST MEDICAL HISTORY: ADHD.

SOCIAL HISTORY: No smoking, alcohol, or drug abuse.

PHYSICAL EXAMINATION: She is awake, alert, and quite comfortable. Abdomen is benign. She points to her left flank, where she was feeling the pain.

DIAGNOSTIC DATA: Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.

LABORATORY WORK: Showed white count 6200, hematocrit 44.7. Liver function tests and amylase were normal. Urinalysis 3+ bacteria.

IMPRESSION:
1. Left flank pain, question etiology.
2. No evidence of surgical pathology.
3. Rule out urinary tract infection.

PLAN:
1. No further intervention from my point of view.
2. Agree with discharge and followup as an outpatient. Further intervention will depend on how she does clinically. She fully understood and agreed.

Keywords: general medicine, flank pain, unable to urinate, urinary tract infection, flank,
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