Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic

The branch of surgery and medicine concerned with the correction or reconstruction of skeletal and spinal deformities.

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Phalanx Amputation
Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.

Physical Therapy - Ankle Sprain
Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.

Physical Therapy - Back Pain
Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient would benefit from skilled physical therapy intervention.

Physical Therapy - Low Back Pain
The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back.

Physical Therapy - Osteoarthritis
The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.

Physical Therapy - Synovitis
Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor.

Pilon Fracture External Fixation
External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.

Pinning - Hip
Revision and in situ pinning of the right hip.

Pinning - Ulna
Closed reduction and pinning of the right ulna with placement of a long-arm cast.

PMT Halo Crown & Vest
Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.

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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