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: Well-Child Check - 7

Description: 1-month-old for a healthy checkup - Well child check
(Medical Transcription Sample Report)

SUBJECTIVE: This is a 1-month-old who comes in for a healthy checkup. Mom says things are gone very well. He is kind of acting like he has got a little bit of sore throat but no fevers. He is still eating well. He is up to 4 ounces every feeding. He has not been spitting up. Voiding and stooling well.

PAST MEDICAL HISTORY: Reviewed, very healthy.



DIETARY: His formula fed on Enfamil Lipil. Voiding and stooling well. Growth chart reviewed with Mom.

DEVELOPMENTAL: He is starting to track with his eyes. He is smiling a little bit, moving hands and feet symmetrically.

PHYSICAL EXAMINATION: In general well-developed, well-nourished male in no acute distress.
DERMATOLOGIC: Without rash or lesion.
HEENT: Head normocephalic and atraumatic. Anterior fontanel soft and flat. Eyes: Pupils equal, round and reactive to light. Extraocular movements intact. Red reflexes present bilaterally. Does appear to have conjugate gaze. Ears: Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility. Nares are patent, pink mucosa, moist. Oropharynx clear with pink mucosa, normal moisture.
NECK: Supple without masses.
CHEST: Clear to auscultation and percussion with easy respirations and no accessory muscle use.
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, heaves or gallops.
ABDOMEN: Soft, nontender, nondistended without hepatosplenomegaly.
GU EXAM: Normal Tanner I male. Testes descended bilaterally. No hernias noted.
EXTREMITIES: Pink and warm. Moving all extremities well. No subluxation of the hips and leg creases appear symmetric.
NEUROLOGIC: Alert, otherwise nonfocal. 2+ deep tendon reflexes at the knees. Fixes and follows appropriately to both voice and face.

ASSESSMENT: Well child check.

1. Diet, growth and safety discussed.
2. Immunizations discussed and updated with hepatitis B.
3. Return to clinic at two months of age. Call if problems.

Keywords: consult - history and phy., 1-month-old, healthy checkup, enfamil lipil, growth chart, immunizations, healthy, child, atraumatic, reflexes, checkup,
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