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: Pressure decubitus

Description: Pressure decubitus, right hip
(Medical Transcription Sample Report)

CHIEF COMPLAINT: Pressure decubitus, right hip.

HISTORY OF PRESENT ILLNESS: This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a wheelchair. She relates recently she has been spending up to 16 hours a day in a wheelchair. She has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. She is now presenting for evaluation and management of same. Denies any chills or fever, any other symptoms.

PAST MEDICAL HISTORY: Back closure for spina bifida, hysterectomy, breast reduction, and a shunt.

SOCIAL HISTORY: She denies the use of alcohol, illicits, or tobacco.

MEDICATIONS: Pravachol, Dilantin, Toprol, and Macrobid.


REVIEW OF SYSTEMS: Other than the above aforementioned, the remaining ROS is unremarkable.

GENERAL: A pleasant female with deformity of back.
HEENT: Head is normocephalic. Oral mucosa and dentition appear to be normal.
CHEST: Breath sounds equal and present bilateral.
CVS: Sinus.
GI: Obese, nontender, no hepatosplenomegaly.
EXTREMITIES: Deformity of lower extremities secondary to spina bifida.
SKIN: She has a full-thickness pressure decubitus involving the right hip which is 2 x 6.4 x 0.3, moderate amount of serous material, appears to have good granulation tissue.

PLAN: Daily applications of Acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week.

DIAGNOSIS: Sequelae of spina bifida; pressure decubitus of right hip area.

Keywords: general medicine, pressure decubitus, acticoat, sequelae, breast reduction, decubitus, hysterectomy, ischial area, pressure, spina bifida, trochanter, wheelchair, bifida,
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