Sample Type: General Medicine

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Acute Cystitis & Diabetes Type II
The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

Admission History & Physical - Nausea
Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.

Antibiotic Management Consult
Antibiotic management for a right foot ulcer and possible osteomyelitis.

Antibiotic Therapy Consult
Questionable need for antibiotic therapy for possible lower extremity cellulitis.

Asbestos Exposure - Hemoptysis
Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.

Burn - Consult
First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

Congestion - 21-day-old
Congestion, tactile temperature.

Congestion & Fever - 2-month-old
A 2-month-old female with 1-week history of congestion and fever x2 days.

Consult - Chest Pain
Patient with multiple problems, main one is chest pain at night.

Consult - Chest Pain - 1
A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors.

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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