Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.

Consultations, initial evaluations, new patient visits, history and physicals, etc.



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Hypergranulation - Consult
Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.

Hypersensitivity to Coumadin
Probable Coumadin hypersensitivity.

Hypertension - Consult
An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation.

Hypertension & Cardiomyopathy
Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.

Hyperthyroidism Following Pregnancy
Chief complaint of chest pain, previously diagnosed with hyperthyroidism.

Iliopsoas Hematoma - 1
Left Iliopsoas hematoma. Gait difficulty.

Iliopsoas Hematoma - 2
Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.

Impairment Rating
Right shoulder impingement syndrome, right suprascapular neuropathy.

Infant Not Gaining Weight
A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.

Infantile Spasms
A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.

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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