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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Cellulitis - Discharge Summary
Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.

Chest Pain & Respiratory Insufficiency
A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.

Chest Wall Lump - Consult
Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor.

Chronic Abscesses - Discharge Summary
Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.

Chronic Medical Conditions - Followup
Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis.

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

Congestion & Cough - 5-month-Old
A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot.

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