Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
|

View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note

Description: The patient states that he feels sick and weak.
(Medical Transcription Sample Report)

SUBJECTIVE: The patient states that he feels sick and weak.

PHYSICAL EXAMINATION:
VITAL SIGNS: Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.
GENERAL: The patient looks tired.
HEENT: Oral mucosa is dry.
CHEST: Clear to auscultation. He states that he has a mild cough, not productive.
CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.
ABDOMEN: Soft and nontender. Bowel sounds are positive. Murphy's sign is negative.
EXTREMITIES: There is no swelling.
NEURO: The patient is alert and oriented x 3. Examination is nonfocal.

LABORATORY DATA: White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000. Glucose is in the low 100s. Comprehensive metabolic panel is unremarkable. UA is negative for infection.

ASSESSMENT AND PLAN:
1. Fever of undetermined origin, probably viral since white count is normal. Would continue current antibiotics empirically.
2. Dehydration. Hydrate the patient.
3. Prostatic hypertrophy. Urologist, Dr. X.
4. DVT prophylaxis with subcutaneous heparin.

Keywords: general medicine, fever, dehydration, prophylaxis, white count is normal, white count, sick, weak, temperature,
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.
Home | MedicalTranscriptionSamples | MT911 | MTDictionary | MTSetup | MTHelpLine
Sitemap | Tell a Friend | Contact Us | Disclaimer

Transcribed Medical Transcription Sample Reports and Examples