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: Possible Spider Bite

Description: A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.
(Medical Transcription Sample Report)

SUBJECTIVE: This 47-year-old white female presents with concern about possible spider bite to the left side of her neck. She is not aware of any specific injury. She noticed a little tenderness and redness on her left posterior shoulder about two days ago. It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck. She has had no fever. The area is very minimally tender, but not particularly so.

CURRENT MEDICATIONS: Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.

ALLERGIES: No known medicine allergies.

OBJECTIVE:
Vital Signs: Weight is 150 pounds. Blood pressure 122/82.
Extremities: Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter. In the center is a tiny mark which could certainly be an insect or spider bite. There is no eschar there, but just a tiny marking. There are a couple of erythematous streaks extending towards the neck.

ASSESSMENT: Possible insect bite with lymphangitis.

PLAN:
1. Duricef 1 g daily for seven days.
2. Cold packs to the area.
3. Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.
4. Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper onesí and the lower lateral areas. I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.

Keywords: general medicine, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite,
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