Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: General Medicine

A branch of medicine that deals with diagnosis and treatment of nonsurgical diseases.

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Perioperative Elevated Blood Pressure
Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.

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.

Possible Spider Bite
A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.

Post Thyroidectomy - Discharge Summary
Symptomatic thyroid goiter. Total thyroidectomy.

Pressure decubitus
Pressure decubitus, right hip

Pyelonephritis - Discharge Summary
Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.

Recurrent Abscesses - Consult
Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used.

Refractory Hypertension - Followup
Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.

Renal Insufficiency - Consult
Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.

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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