Medical Reports Samples With Audio (4)

Medical Transcription Reports With Audio:

When you first start out typing a medical transcription report it can be overwhelming because you might not hear words that are said or know what medical words the doctor is using. I can tell you from experience that it all gets easier. When I first started out I felt like the doctors were talking in their own language, but with practice and experience I can tell you that I catch mistakes when the doctors dictate now and also know what words are missing when they dictate.

When you are typing a report and get stuck on a word that you do not understand or the doctor mumbled that word, don’t get frustrated and don’t spend too much time trying to figure it out. Highlight the word so that you can come back to it. Most likely the doctor will repeat that word again later on in the dictation and then you can go back and type it correctly. This has happened to me many times and I have learned not to waste my time trying to figure out what that word is. Test your abilities doing these medical transcription reports.

History And Physical Report Sample #1

SUBJECTIVE: 59-year-old woman who presents for evaluation of “facial skin problems”. I saw her one year ago. She has been using Retin-A Micro. She has noticed an improvement in the texture of her skin and the brown spots on her face. She is interested in options for further treatment of the brown spots. She also has several growths on her legs. They are asymptomatic.

MEDICATIONS: Prograf, acyclovir, trazodone, Premarin, lorazepam, Ambien, and Bactrim.

ALLERGIES: CLINDAMYCIN, CHLORAMPHENICOL, CODEINE, COMPAZINE, TALWIN, ERYTHROMYCIN, EPINEPHRINE, AND FLAGYL.

PAST MEDICAL HISTORY: She has Fitzpatrick type 1 skin. Her lateral cheeks have several scattered brown to tan macules. Her right medial cheek has three 1 mm dark blue to gray macules. Her mid upper lip has a 2/3 mm pearly papule. Both lower legs have a few scattered tan “stuck-on” papules.

PHYSICAL EXAMINATION: She has Fitzpatrick type 1 skin. Her lateral cheeks have several scattered brown to tan macules. Her right medial cheek has three 1 mm dark blue to gray macules. Her mid upper lip has a 2/3 mm pearly papule. Both lower legs have a few scattered tan “stuck-on” papules.

IMPRESSION:

  1. Lentigines. I discussed the risks, benefits, and options for treatment. She will consider treatment using the V-Beam laser with a Q-switched 532 nanometer laser.
  2. Thrombosed angioma versus exogenous pigment, right medial cheek. I discussed the risks, benefits, and options for treatment. She will consider a test using the VersaPulse laserh.
  3. Seborrheic keratoses, legs. No treatment is needed.
  4. Possible basal cell carcinoma, upper lip. I discussed the risk, benefits, and options for treatment. She did not want to do a biopsy today. She will consider doing this in the near future.




History And Physical Report Sample #2

CHIEF COMPLIANT: The patient is referred for Gemini Study.

HISTORY OF PRESENT ILLNESS: A 54-year-old African American female with a long-standing history of hypertension and dyslipidemia. She experiences occasional chest discomfort described as sharp in nature and on one occasion radiating through to her back, symptoms are always attributed to indigestion. Recently worse with movement and associated with an inability to take a deep breath. She denies dyspnea on exertion, shortness of breath, orthopnea, or lower extremity edema. She does experience occasional palpitations at night unrelated to any other symptoms.

PAST MEDICAL HISTORY: In addition to above, diabetes mellitus for two years, osteoarthritis, and hormone replacement therapy since 1999.

SURGICAL HISTORY: Partial hysterectomy 1997.

SOCIAL HISTORY: She is married and has two children. She is a housewife. Abstains from alcohol, tobacco, or drugs. She does not exercise regularly. Follows a regular diet with no restrictions. Caffeine, drinks decaffeinated coffee one to two cups per month and drinks a glass of tea three times per week.

FAMILY HISTORY: Mother deceased at age 68 with congestive heart failure.

REVIEW OF SYSTEMS: She has gained approximately 20 pounds within the last eight months. Positive for occasional seasonal allergy symptoms. Restless at night and sleeps poorly. Joint pain particularly of the hips and knees secondary to osteoarthritis. Low back pains of the last four months radiating into the buttocks, on Naproxen therapy with some relief.

CURRENT MEDICATIONS: Glucotrol 1½ every day, Actos one every day, Prinzide 20/25 1½ every day, Gemfibrozil 2 every day, and Cenestin 0.625 mg every day.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAMINATION: Weight 290 pounds, height 5’4” tall.

GENERAL: Overweight, well-developed African American female in no acute distress.

SKIN: Warm and dry.

VITAL SIGNS: Blood pressure 144/82. Epical pulse 80. Respiratory rate 18.

PHYSICAL EXAM: Unremarkable, except for soft S4 gallop. Otherwise, please insert template #5.

IMPRESSION: Mother deceased at age 68 with congestive heart failure.

  1. Hypertension.
  2. Diabetes mellitus type 2.
  3. Dyslipidemia.
  4. Obesity.

DISCUSSION: We will obtain records according to the patient; she had stress testing and echo done. The patient will be referred back to research nurse for enrollment in a Gemini Study and will be followed up for a research protocol.




History And Physical Report Sample #3

HISTORY OF PRESENT ILLNESS: 78-year-old male with a history of carcinoma of the bladder diagnosed in March of 1999, who present for preoperative evaluation. The patient has undergone periodic cystoscopies and on the recent cystoscopy a lesion was found. This has since been shown to be a recurrent bladder carcinoma and the patient is now scheduled for cystoscopic removal.

MEDICATIONS: None.

ALLERGIES: NONE

PAST MEDICAL HISTORY:

  1. Carcinoma of the bladder as noted above.
  2. A status post right cataract extraction in 03/95.
  3. History of pilonidal cyst, 40 years ago.

FAMILY HISTORY:Mother deceased at age 68 with congestive heart failure.

REVIEW OF SYSTEMS:
HEENT: Unremarkable.
RESPIRATORY: No cough, shortness of breath, or wheezing.
CARDIOVASCULAR: No chest pain, palpitations, dyspnea on exertion. The patient does not exercise regularly but he is very active.
GI: He denies any constipation, diarrhea, nausea, vomiting, or abdominal pain. He denies reflux symptoms. He had a flexible sidmoidoscopy in April of 1995.
GU: Remarkable for history of a bladder cancer and nocturia one time per night.
NEUROLOGIC: Unremarkable.
MUSCULOSKELETAL: Unremarkable.

PYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 142/72. Pulse is 80. Temperature is 97.5 F.
HEENT: Unremarkable.
NECK: Neck is supple without JVD, adenopathy, thyromegaly, or bruit.
LUNGS: Lungs are clear.
CARDIAC: Regular rate without murmur.
ABDOMEN: Soft, nontender without a hepatosplenomegaly. No abdominal bruits are noted.
GU: Exam was deferred.
MUSCULOSKELETAL: Unremarkable.
EXTREMITIES: Distal pulses are 2+. There is no edema.
NEUROLOGIC: Nonfocal.

ASSESSMENT AND PLAN:

  1. Recurrent bladder carcinoma. The patient’s chest x-ray, EKG, and labs have been reviewed and he is cleared for surgery.
  2. Hypercholesterolemia. This was discussed at length with the patient, as his C-reactive protein and homocysteine are normal, the patient will attempt six months of diet and exercise. A diet sheet has been given for the patient to review. This will be checked in six months.
  3. The labs were reviewed with the patient. He has also been instructed to set up a colonoscopy. The patient will return for a full follow-up in one year.




History And Physical Report Sample #4

CHIEF COMPLIANT: Chest pain.

HISTORY OF PRESENT ILLNESS: A 55-year-old white female referred today for follow up for recent exercise stress testing. She was recently evaluated for atypical chest pain and had exercise stress testing, she exercised for 9 minutes and 26 seconds and the test was clinically negative. She continues to have some atypical chest pain complaint, no PND, no orthopnea, no lower extremity edema, no palpations, or dyspnea on exertion.

PAST MEDICAL HISTORY: Hypothyroidism.

PAST SURGICAL HISTORY: Partial hysterectomy, lumbar laminectomy, benign bony tumor removed from sinus cavity.

SOCIAL HISTORY: She is married and has a 28-year-old son. She is self-employed. She makes custom draperies.

FAMIL HISTORY: Father deceased at age 83 with congestive heart failure. Mother living at age 86 with history of hypertension and CVA. She has three sisters who are healthy. Smokes one to one-half pack per day for 25 years. She quit 10-15 years ago. She drinks on a social basis, one to two mixed drinks per week. Caffeine intake, two to three diet Rite Cola’s per day. Three to five eight-ounce glasses of water per day. She exercises regularly, walks one to one-and-one-half miles per day five days a week. She follows a regular diet with no restrictions.

REVIEW OF SYSTEMS: She has lost 16 pounds since January. Positive for easy bruising. She does experience occasional seasonal allergy symptoms. Positive for occasional nocturia. Positive for stress innocence and urinary urgency. Positive for hyperkeratosis. Other review of systems negative.

CURRENT MEDICATIONS: Premarin every day, Synthroid every day, and oxybutnin p.r.n.

ALLERGIES: SULFA DRUGS, RASH.

PHYSICAL EXAMINATION: Weight 169 pounds. Height 5’8½” tall.
VITAL SIGNS: In the right arm blood pressure 140/80 and in the left arm 130/80, applicable at 60. Respiratory rate 16.
GENERAL: A 56-year-old white female in no acute distress.
SKIN: Warm and dry.
PHYSICAL EXAM: Unremarkable, please insert template #5.
EKG: Normal sinus rhythm.

IMPRESSION:

  1. Atypical chest pain with negative exercise stress testing 09/11/02.
  2. Reformed smokere.
  3. Unknown lipid status.
  4. Hypertension.

DISCUSSION: At this time, chest pain appears to be costochondritis. We will treat with Motrin. Check fasting lipids. We will see patient back in the office in four weeks and reevaluate blood pressure readings at that time, as to whether or not medical therapy will be necessary.