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: Onychomycosis - H&P

Description: Toenails are discolored, thickened, and painful - Onychomycosis
(Medical Transcription Sample Report)

CHIEF COMPLAINT (1/1): This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.

ALLERGIES: Patient admits allergies to dairy products, penicillin.


PAST MEDICAL HISTORY: Past medical history is unremarkable.

PAST SURGICAL HISTORY: Patient admits past surgical history of eye surgery in 1999.

SOCIAL HISTORY: Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.

FAMILY HISTORY: Unremarkable.

REVIEW OF SYSTEMS: Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.

PHYSICAL EXAM: Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.
Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed. Varicosities are not observed.
Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.
Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.
Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.

TEST RESULTS: No tests to report at this time.

IMPRESSION: Onychomycosis.

PLAN: Debrided 10 nails.

PRESCRIPTIONS: Penlac Dosage: 8% Topical Solution Sig: Dispense: Refills: 0 Allow Generic: No

Keywords: consult - history and phy., toenails, discolored, thickened, painful, onychomycosis,
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