Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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as on 3/19/2014

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Sample Type / Medical Specialty: Cardiovascular / Pulmonary

Field of medicine related to heart, blood vessels and blood circulation system and conditions that affect the lungs such as asthma, bronchitis, or chronic lung diseases.

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Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.

Pneumonia - Discharge Summary
Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.

Pneumonia & COPD - Discharge Summary
Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture.

Pneumothorax & Subcutaneous Emphysema
Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.

Port-A-Cath Insertion
Port-A-Cath insertion template. Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.

Port-A-Cath Insertion - 5
Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.

Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure. The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncontrolled blood pressure.

Preop Cardiac Consult
Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery

Pulmonary - Followup Note
Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.

Pulmonary Atresia
The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.

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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