Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Epidural Hematoma

Description: Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.
(Medical Transcription Sample Report)

CC: Fall with questionable associated loss of consciousness.

HX: This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.

MEDS: Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, "Ginsana" (Ginseng) 100mg bid.

PMH: 1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.

FHX: Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.

SHX: Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.

EXAM: BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2

MS: A&O to person, place, time. Speech fluent and without dysarthria.

CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.

Motor: 5/5 strength throughout with normal muscle tone and bulk.

Sensory: unremarkable.

Coord: unremarkable.

Station/Gait: not mentioned in chart.

Reflexes: symmetric. Plantar responses were flexor, bilaterally.

Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.

HEENT: abrasion over the right forehead.

Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.

COURSE: 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.

Keywords: consult - history and phy., loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma,
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