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: Headache - Urgent Care Visit

Description: Migraine headache - The patient was seen in the urgent care.
(Medical Transcription Sample Report)

CC: Headache.

HPI: This is a 15-year-old girl presenting with occipital headache for the last six hours. She denies trauma. She has been intermittently nauseated but has not vomited and has some photophobia. Denies fever or change in vision. She has no past history of headaches.

PMH: None.

MEDICATIONS: Tylenol for pain.

ALLERGIES: None.

FAMILY HISTORY: Grandmother died of cerebral aneurysm.

ROS: Negative.

PHYSICAL EXAM:
Vital Signs: BP 102/60 P 70 RR 20 T 98.2
HEENT: Throat is clear, nasopharynx clear, TMs clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender.
Neck: Supple without meningismus.
Chest: Lungs clear; heart regular without murmur.

COURSE IN THE ED: The patient was seen in the urgent care and examined. At this time, her photophobia and nausea make migraine highly likely. She is well appearing and we'll try Tylenol with codeine for her pain. One day off school and follow up with her primary doctor.

IMPRESSION: Migraine headache.

PLAN: See above.

Keywords: general medicine, photophobia, nausea, migraine headache, tylenol, migraine, headache,
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