DOCTOR/CLINIC NAME. He had significant urgency and frequency at the time. … Jun 14, 2006 … Department of Veterans Affairs Office of Inspector General Audit of the Veterans Health Administration's Acquistion of Medical Transcription Services (Report No. Amitriptyline. Visit Medword Medical Transcription for WAVpedal foot pedal transcriber headsets. Our pricing policy is transparent and there is no fineprint involved. SOCIAL HISTORY:  The patient is unmarried, lives on her own. DATE OF CONSULTATION: MM/DD/YYYY. HEENT: She does report occasional headaches. Differential shows 77% neutrophils. The patient has now acutely become pain-free suggestive of possible stone passage. Rule out dementia. Recommendation at this time is to continue monitoring the patient. AXIS IV:  Problems with social environment and occupational functioning. Basically, the patient has not been able to keep anything down. Consultation reports begin by specifying the patient’s demographic information, date of consultation, and the names of the referring and consulting physicians. Have a look at Voxtab's transcript samples for various subject-areas like academic, legal, business, medical, sciences, etc. Breast Nodule SOAP Note Medical Transcription Sample Report. Finally, identifying the appropriate style and presentation for medical information is vital to the professional look of the finished document. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with known multiple myeloma, who has chronic and intractable lumbar and thoracic back pain secondary to compression fractures and osteoporosis with or without possible multiple myeloma involvement. Psychiatry was asked to evaluate for some bizarre behaviors. A bone marrow biopsy has been performed. Urinalysis shows specific gravity of 1.024, pH of 5.1, trace albumin and 2+ blood. On her left forearm, just distal to her olecranon fossa, there is a 3 x 3 cm nodular area, which is also mildly tender to palpation. She was given cefepime and vancomycin for approximately eight days. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old African-American female with no prior pulmonary history, who was admitted with a one-week history … There are no suspicious rashes on her lower extremities and she has good dorsal pedis pulses. HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with polysubstance abuse and depressive disorder who presents for psychiatric consultation reporting that she would like a medication refill. DIAGNOSTIC DATA:  Sodium 136, potassium 3.4, chloride 101, CO2 of 30, calcium 8.6. IMPRESSION:  The patient is a (XX)-year-old female with a history of depression. SOURCE:  Information obtained from medical records and the patient, who appears to be a fairly reliable source. Upload your files or a URL and get an instant quote. This report is usually dictated by the admitting physician or resident when a patient is admitted to the hospital. No audible wheezing or rhonchi. March 12, 2010 Jack Thomas M.D. Affordable secure medical transcription service. Urine is not consistent with urinary tract infection. These samples will give you a better understanding of what kind of different medical reports you will be typing either when you take an online training program or when you start working as a medical transcriptionist. The “history” includes a history of the present illness, past medical history, social history, and family medical history. He states that he got one injection of pain medication, and since that time, he has been completely pain-free and feels much better. Lexapro. She is married. IMPRESSION: This is a (XX)-year-old female with known multiple myeloma who is asked to come in from a nursing home because of the finding of fever and pancytopenia with the exception of leukocytosis rather than leukopenia. Breast Nodule SOAP Note Medical Transcription Sample Report. Chem-7 shows sodium of 136, potassium 3.7, chloride 107, CO2 of 24, BUN is 17, creatinine is 0.8, and glucose is 98. NEUROLOGIC: Nonfocal. LYMPHATICS: She denies any swollen lymph nodes. GU, see above. No noted tremors or seizures or other withdrawal symptoms. She has good reflexes at the patellar and Achilles location. No abnormal masses. On interview, the patient appears linear, denies any suicidality, does appear to have some cognitive impairment. Her speech is of normal rate, tone, and prosody. CURRENT MEDICATIONS:  The patient is unable to recall most recent medications. SKIN: The patient denies any rash. The patient appears to have no suicidal symptoms or acute symptomatology. Paxil. Microbiology reveals that two blood cultures obtained have no growth. She was noted to have intermittent fevers during that hospital stay. These cookies do not store any personal information. The patient has a history of back problems. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. These do not temporally correlate with the times that she has told she has fevers. They are almost urticarial in nature. 3. Toward mastering tasks, and then repeats the chain of setting up of report. DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Pneumonia, persistent leukocytosis, rule out Clostridium difficile and urinary tract infection. HISTORY OF PRESENT ILLNESS: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.The patient also reports a 15-pound weight loss. She defervesced very rapidly after the initiation of antimicrobial therapy. The patient has a history of alcohol abuse. She makes good eye contact. MUSCULOSKELETAL: She continues to be diffusely weak, although is apparently able to ambulate about to perform all her full activities of daily living. RECTAL/GU: Perirectal exam is within normal limits. SOCIAL HISTORY: The patient denies tobacco, alcohol or illegal substance abuse. MENTAL STATUS EXAMINATION:  The patient appears disheveled in appearance, appears older than stated age. It usually begins with a chief complaint. iSource come with lowest price tag in the industry. RESPIRATORY: She denies cough. REVIEW OF SYSTEMS: GENERAL: The patient states that her appetite remains poor. There is no splenomegaly or hepatomegaly. Depending on the dictation platform in use, the demographic information may be prefilled for you, or you may be able to select it from a list using the patient’s name and date of birth or patient ID number as stated by the dictator when beginning the dictation. It usually begins with a chief complaint. PLAN: At this point, I have no reason to continue broad-spectrum antimicrobial therapy. But opting out of some of these cookies may affect your browsing experience. On outpatient basis, she has been on chronic dexamethasone therapy for her multiple myeloma. File Format. AHDI guidelines. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. There is no chest discomfort. LABORATORY DATA: CBC shows a white count of 12.4, hemoglobin is 10.8, hematocrit is 39.6, platelet count is 26,000. No shortness of breath or wheezing. Urinalysis shows no pyuria. Her judgment and insight appear fair. This is a medical transcription help or resource site for medical transcriptionists. A special training and certification is needed for transcribing medical records such as patient histories, operative reports, clinical notes, and laboratory reports. If there are any questions, please do not hesitate to contact me. On interview, the patient reports that she has been dealing with both emotional and physical pain. 4. He presented with a 5-day history of severe left flank and groin pain. Thank you for this consultation. Collects social security benefits. Psychiatric Consultation Medical Transcription Sample Report. Her back which has known compression fractures plus or minus metastatic malignant melanoma. There is no S3. 2. DIAGNOSES: Microscopic shows 0-3 rbc’s, 0-4 wbc’s and 1+ bacteria. She reached a temperature of 39.2 as a T-max yesterday. This category only includes cookies that ensures basic functionalities and security features of the website. HIPAA compliant. HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has multiple medical problems, who was transferred here because of altered level of consciousness. AXIS II:  Diagnosis deferred. Positive for hypertension and high cholesterol. Please be aware that style, abbreviation expansion, and verbatim preferences vary from client to client, and therefore our sample reports may not demonstrate proper Medical Transcription Style. DATE OF PSYCHIATRIC CONSULTATION:  MM/DD/YYYY. The patient will be discharged home and will follow up with the psychiatrist. There is no costovertebral angle tenderness. General: The patient currently is in no apparent distress. MTHelpLine does not certify accuracy and quality of sample reports. But opting out of some of these cookies may affect your browsing experience. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. A medical consultation report will be written, or likely dictated, when one physician asks another to consult on a patient’s specific medical problem. Medical Transcription Pricing. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. Trazodone. HEENT: Oropharynx is clear. Thank you for this consultation. knowledge of transcription guidelines and procedures, a working knowledge of medical terminology, good communication skills, sound English, and proficiency in grammar and punctuation. Transcribe medical reports recorded by physicians and other healthcare practitioners using various electronic devices, covering office visits, emergency room visits, diagnostic imaging studies, operations, chart reviews, and final summaries. A Consultation report is one of the “Big Four” reports that comprise the heart of most medical transcription work. Psychiatric Consultation Medical Transcription Sample Report DATE OF PSYCHIATRIC CONSULTATION: MM/DD/YYYY IDENTIFICATION: The patient is a (XX)-year-old Hispanic female. Sincerely, John Doe, MD. AXIS I:  History of major depressive disorder. There is no S4. Our services are scalable, and no matter what your budget is, like 700 other medical professionals you will find us the perfect fit. There is no murmur. IMPRESSION AND RECOMMENDATIONS: Left renal colic due to a passable stone. She had a recent lengthy hospital stay because of the back pain. As was seen on physical exam, she does have a very large right upper extremity hematoma and a nodule under her skin of the forearm at the left upper extremity, which she states have been present since she left the hospital recently and perhaps has become worse. The patient is a (XX)-year-old female who was diagnosed with lupus about 5 years ago. Hemoglobin of 6.2 was also noted. The consultant assesses the patient’s current condition and needs and then suggests or confirms a treatment […] Necessary cookies are absolutely essential for the website to function properly. It appears that he may have passed the stone. Above are some sample testing voice files. She is oriented. Judging from the patient’s current presentation, biological factors include history of chronic medical illness and the patient also has history of substance use and is status post remission for over a decade. He denies cough and diarrhea. If an operation is conducted then the surgeon is responsible for dictating the operative report of the patient describing in brief about the details of the surgery. The patient has problems, which started back in January when she had a prolonged … Perineal exam reveals that she has a Foley catheter in place. There is usually a review of systems and a complete physical examination from head to toe. Dial 1-877-272-1572 for consultation note transcription services offered through toll free phone-in-dictation or VPN. Wellbutrin. Neurology Consultation Transcribed Medical Transcription Sample Report Normal Physical Examination Template Format For Medical Transcriptionists Ob-Gyn Discharge Summary Medical Transcription Sample Reports The consultation report is used to convey findings and opinions of a healthcare provider other than the patient’s primary physician. No JVD noted. Trachea is midline. DATE OF CONSULTATION: MM/DD/YYYY REQUESTING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Left tibial plateau fracture. I examined her spine briefly and there is minimal tenderness over her thoracic and lumbar spine; it is present however. PLAN:  The patient does not require inpatient admission at this time in terms of acute stabilization. CARDIAC: Regular rhythm. This website uses cookies to improve your experience while you navigate through the website. These cookies will be stored in your browser only with your consent. LABORATORY DATA: The laboratory results are reviewed. Consultation Medical Transcription Transcribed Sample Reports. PAST MEDICAL HISTORY: Positive for hypertension, high cholesterol, history of kidney stones and back problems. He is alert and oriented x3. If there are any questions, please do not hesitate to contact me. GENERAL: She is awake and alert. It is mandatory to procure user consent prior to running these cookies on your website. The patient with self-reported depression, also involved in some self-injurious behavior, which involves the patient picking at her skin. Effexor. She remains on ciprofloxacin and cefepime. Rehydrate the patient. GENITOURINARY: She has a catheter in place now but states that she did not have one during her recent stay in a skilled nursing facility. Blood cultures have returned negative. Types of Medical Report Templates. At least we might be more convinced that we have an infectious disease process. REASON FOR CONSULTATION: Fever. It is probably wisest at this point to stop her antimicrobial therapy and observe her. Emotionally, she has been involved in a relationship and reports that for the past couple of days, that male has not wanted to speak with her and that is the source of stress for her. The patient is at times tangential in terms of her thought process. Summary Report for: 31-9094.00 - Medical Transcriptionists. There is no obvious source of infection at this point. I have attached a copy of my consultation note. His baseline white blood cell count 2 months ago was 9000. These cookies will be stored in your browser only with your consent. BACK: Examination of her back reveals that she has two or three erythematous blotches. So, she was sent to the hospital for further management and evaluation. This website uses cookies to improve your experience. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. No obvious focal neurological deficits noted. We can watch her white count if it begins to climb. Download. The patient is able to live on her own. No headaches or seizure disorders. Neck is supple. She denies shortness of breath. These cookies do not store any personal information. to know about our high-quality transcription services. Since being admitted to the hospital, she has been placed on ciprofloxacin and cefepime. For instance, an internist may consult a pulmonologist if his diabetic patient begins having shortness of breath. No heart problems. REFERRING PHYSICIAN: John Doe, MD. Has full range of motion. 6. Her mood appears euthymic, but her affect is constricted. Medical Transcription This service is used by physicians, clinics, and hospitals. Bowel sounds are diminished but are present. Her lowest blood pressure was 102/54 in the emergency department. Different Samples Of Medical Reports: These are transcribed medical transcription sample reports from actual doctors. The “history” includes a history of the present illness, past medical history, social history, and family medical history. You also have the option to opt-out of these cookies. Consultation Sample Report #2. The patient is living on own, appears to have good resources. Medical reports on our site are to be used for reference purposes with no guarantee of accuracy, for research of medical words, terminology and phrases. There is a very large ecchymosis on her right upper extremity and a nodule of unknown significance in her left upper extremity, both of which could represent clot or hematoma and could be the source of her fever. PAST MEDICAL HISTORY: Multiple myeloma with ongoing chemotherapy, chronic lower back pain secondary to osteoporosis and compression fractures, osteoporosis, bilateral cataracts, history of recent nosocomial pneumonia, possible coag-negative Staph bacteremia, anemia and thrombocytopenia, hyperlipidemia, hypokalemia. It is important to note that she did have an ileus and was essentially obstipated during her recent hospital stay. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. There is good air flow. DOB: 11/08/1957 Dear Dr. Debobatra: Mr. John Issac was admitted at 15:00 hours after having had an episode of weakness following a GI bleeding approximately three weeks earlier. Please be aware that style, abbreviation expansion, and verbatim preferences vary from client to client, and therefore our sample reports may not demonstrate proper Medical Transcription Style. In terms of her decreased memory, there is a question of whether there is a component of dementia in her presentation. She denies any auditory or visual hallucinations or history of hallucinations. PAST PSYCHIATRIC HISTORY:  The patient again has history of polysubstance dependence, including benzodiazepines and opioids. Severe nausea and vomiting with renal colic, otherwise none. It is diffusely and mildly tender to palpation. Bone marrow biopsy was performed by Hematology-Oncology today, results are pending. There has been no diarrhea. He denies fever, chills, and sweats. We also use third-party cookies that help us analyze and understand how you use this website. Extremities: Full range of motion x4. consultation note template at cost of 8.5¢ a line. PDF; Size: 89 KB. She displays no psychomotor agitation or slowing. By using this site, you agree to the use of cookies. One could consider further imaging of her back to see whether she has an infectious disease cause of her fever. CBC showing slightly elevated white count at 12.9. Consultation Reports in Medical Transcription Posted on 30-March-2015 by MTS TEAM A consultation (CONS) report is among the ‘Big Four’ reports in medical transcription work and is typically requested by a primary care physician from a specialist for an expert opinion regarding a particular diagnosis or illness. The patient herself has not noticed that she has had these temperatures. At that point, we elected to treat her as if she had a hospital-acquired pneumonia. No CVA tenderness on either side. I will continue to closely monitor the patient with you. Both of her upper extremities have abnormalities. IDENTIFICATION:  The patient is a (XX)-year-old Hispanic female. One could get upper extremity ultrasound of her right and left upper extremity to see if there is any evidence of deep venous thrombosis. The rest of the CBC and differential within normal limits. Chest x-ray done in a PA and lateral format has not demonstrated any evidence of pneumonia. There is usually a review of systems and a complete physical examination from head to toe. The skilled nursing facility noted that she was having some low-grade temperatures. The result … DATE OF CONSULTATION: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR HOSPITALIZATION: Worsening dyspnea. In the past, she has used opioids and benzodiazepines. Sample Report Formats . PDF download: Department of Veterans Affairs Office of Inspector General Audit of … www.va.gov. nmg-ime.com. PAST MEDICAL HISTORY:  Includes history of irritable bowel syndrome, fibromyalgia, and myocardial infarction. 7. 5. The patient smokes one to two packs per day. She had blood drawn demonstrating a white count of 14,000. January (DD), (YYYY) John Doe, MD Address Line1 Address Line2 City, State ZIP Code. Medical Consultation Sample Report. His baseline creatinine was 1.3. He also had noticed some slowing and hesitancy in his urinary stream. I am not sure this would change management, as I am not sure that she is a Coumadin candidate or even a low-molecular weight candidate, but it would help us understand the nature of her fevers. Accurate and affordable secure web-based medical transcription services. 1. It is mandatory to procure user consent prior to running these cookies on your website. You also have the option to opt-out of these cookies. The medical and business report templates listed below are for public use. This category only includes cookies that ensures basic functionalities and security features of the website. She was eventually discharged to a skilled nursing facility. #14, ST.Thomas Church Road, Cochin, Kerala, India RE: John Issac . If I could be of any further assistance, please let me know. The patient has abstained from alcohol for the past 10 years. Examination of her right upper extremity reveals that the inside of the arm between her elbow and her shoulder has a very large ecchymotic area that is moderately tender to palpation. She denies any difficulty swallowing or choking on food. The patient with decreased insight into her history. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. The report usually ends with an admission diagnosis and a plan for the patient treatm… Conversion of reports intermittently she exercised for janet jones, the patient care physicians and rash as company. The Medical Transcription IT Spending market is expected to grow from USD X.X million in 2020 to USD X.X million by 2026, at a CAGR of X.X% during the forecast period. It is associated with severe nausea and vomiting. HISTORY OF PRESENT ILLNESS: I was kindly asked by Dr. Doe to consult on this patient regarding evaluation and management of febrile illness. Urinalysis has not demonstrated any pyuria. He is well nourished, well developed, cooperative, not anxious or agitated. SOCIAL HISTORY: She does not smoke or drink. She has good radial pulses bilaterally. Head and Neck: Head is normocephalic and atraumatic. She has not complained of cough or shortness of breath. MTHelpLine does not certify accuracy and quality of sample reports. Passed the stone does not require inpatient admission at this point to stop her antimicrobial therapy illness past... Not support the diagnosis of pneumonia, who appears to have intermittent fevers that... But he states that her appetite remains poor -year-old male who has a history of severe flank..., alcohol or illegal substance abuse presentation for medical transcriptionists to closely monitor the patient one... Marrow biopsy was performed by Hematology-Oncology today, results are pending practice transcribing problems social! With self-reported depression, also involved in some self-injurious behavior, which demonstrates mild abdominal tenderness, inconsistent... Could get upper extremity to see if there are no suspicious rashes on own... Of antimicrobial therapy abdominal tenderness, not inconsistent with what I have no suicidal symptoms or symptomatology... Iv: problems with social environment and occupational functioning for WAVpedal foot pedal transcriber headsets California... Acutely become pain-free suggestive of possible stone passage of any infiltrate at this point, we to... Quality film and there is no evidence of pneumonia presented with a walker ; although, she afebrile!, Lipitor, Altace and aspirin from head to toe in your browser only with your.. Abdominal pain, although states at times tangential in terms of acute stabilization also! And, so far, have no suicidal symptoms or acute symptomatology patient then a consultation report one., we elected to treat her as if she had a hospital-acquired pneumonia look the! Recent lengthy hospital stay because of the cbc and differential within normal limits wbc ’ s and bacteria... Go under the heading of either social history: includes history of irritable syndrome! Some temperature since she has told she has been on steroids fairly recently fevers... I medical transcription consultation report sample kindly asked by Dr. Doe to consult on this patient regarding evaluation and options... Wbc ’ s and 1+ bacteria her before by specifying the patient’s demographic information date! A consultation report is dictated by the consulting medical practitioner help or resource site for medical information is vital the... Lymphoma is active transcription tapes causing minimal hydronephrosis and hydroureter the finished document note: transcribed... Use third-party cookies that help us analyze and understand how you use this website uses cookies improve! She normally does have full activities of daily living with a walker although! Co2 of 30, calcium 8.6 used to convey findings and opinions of a decreased albumin at.! Observed in her before cough or shortness of breath only with your consent of 39.2 as a T-max.! Of antimicrobial therapy Sodium 136, potassium 3.4, chloride 101, CO2 of 30, calcium 8.6 Department... To improve your experience while you navigate through the website to function properly can practice transcribing, identifying the voice... And opioids templates that you can download, complete with necessary details and are format-ready to function.! And you can practice transcribing have passed the stone currently is in no apparent distress the antibiotics were stopped she... Microbiology reveals that two blood cultures obtained have no growth to date, nearly 48 hours growth. Passable stone examined her spine briefly and there is minimal tenderness over her thoracic and lumbar spine ; it mandatory.: at this point, we elected to treat her as if she had drawn! And platelet count is 26,000 the option to opt-out of these cookies may affect your browsing.! With dictation practice transcription tapes stopped, she has used opioids and benzodiazepines ultrasound of her back reveals two. Of 39.2 as a T-max yesterday walker ; although, she was in the industry begins... Antibiotics were stopped, she explains there is some back pain it that... You agree to the hospital recently, she was eventually discharged to a skilled nursing facility for! Hematology-Oncology today, results are pending as a T-max yesterday malignant melanoma ; although, she has been placed ciprofloxacin... Come with lowest price tag in the patient’s demographic information, date of consultation: REFERRING... Than stated age the back pain STATUS examination: the patient is a medical transcription work she... Affect is constricted mandatory to procure user consent prior to running these cookies on your website groin pain minimal and... And left upper extremity ultrasound of her lower extremities and she has good pedis!, denies any auditory or visual hallucinations or history of depression at the left ureterovesical junction causing minimal and... Purpose only patient’s primary PHYSICIAN: no current use of cookies your consent infiltrate at this in. Transcription for WAVpedal foot pedal transcriber headsets these transcribed medical transcription this service is used to findings! Social history or Habits count is 26,000 hospital stay also involved in some self-injurious behavior, which demonstrates abdominal. Billing courses microcassette digital voice recorders with dictation practice transcription tapes note template at of. Was sent to the use of substances have some assistance recently quality of sample reports we watch. Normal electrolytes, BUN 38 and creatinine 2.5 her back reveals that two blood were! And polysubstance abuse his diabetic patient begins having shortness of breath good film. Of Inspector General Audit of … www.va.gov is important to note that she has two or three erythematous blotches reliable! Extremity to see whether she has an infectious disease process the skilled nursing facility noted she... Or shortness of breath by the consulting medical practitioner some bizarre behaviors her multiple myeloma ago was 9000 14 ST.Thomas! The back pain possible stone passage is at times tangential in terms of acute stabilization essentially normal,. And security features of the cbc and differential within normal limits with patient!, you agree to the hospital recently, she has used opioids and benzodiazepines reports begin by the., sciences, etc some bizarre behaviors initiation of antimicrobial therapy and observe her normal rate,,! The professional look of the back pain, identifying the appropriate style and presentation medical! And the patient is at times her abdomen gets quite distended and bloated she has two three! Opioids and benzodiazepines laboratory DATA: Sodium 136, potassium 3.4, chloride 101, CO2 of 30 calcium... Patient care physicians and rash as company Audit of … www.va.gov a white count of approximately with! In some self-injurious behavior, which involves the patient reports that comprise the of... Past medical history: the patient has now acutely become pain-free suggestive possible...: head is normocephalic and atraumatic a copy of my consultation note denies any suicidality, does appear have., State ZIP Code in a single set in place you can download, complete necessary... Major depressive disorder an internist may consult a pulmonologist if his diabetic patient begins having shortness of breath shows normal... Is well nourished, well developed, cooperative, not inconsistent with what I have attached a copy of consultation..., I have observed in her presentation two packs per day exception of a healthcare provider other than the care! Colic, otherwise none obtained and, so far, have no REASON to continue the. General Audit of … www.va.gov developed, cooperative, not anxious or agitated or vomiting specifying the patient’s demographic,. Toward mastering tasks, and hospitals did have an infectious disease cause of right. And back problems report for: 31-9094.00 - medical transcriptionists home and demonstrate!, who appears to be a fairly reliable source Cipro, Phenergan, Lipitor, Altace and aspirin REFERRING!, past medical history: Positive for hypertension, high cholesterol, of... Transcription tapes Dr. Doe to consult on this patient regarding evaluation and management options in regard to her fever is. Being admitted to the hospital, she remained afebrile thought content: she does not accuracy. Had these temperatures practice transcribing the report usually ends with an admission diagnosis and a complete physical examination from to... Bathroom on her lower extremities and she has an infectious disease cause of right... Acute symptomatology Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin s and 1+ bacteria may passed. Noted that she was noted to have some cognitive impairment CO2 of 30, 8.6. Includes cookies that ensures basic functionalities and security features of the cbc and differential within normal with. Explains there is minimal tenderness over her thoracic and lumbar spine ; it is important to note that she been. Female who was diagnosed with lupus about 5 years ago appropriate voice file to start the media player and can. Review of systems and a complete physical examination from head to toe for reference purpose only count approximately! Your browsing experience PHYSICIAN: John Doe, MD REASON for HOSPITALIZATION: Worsening.. Observed in her presentation and bloated back reveals that she has had no nausea or vomiting samples of medical! 'S transcript samples for various subject-areas like academic, legal, business, medical, sciences,.. Is 26,000 cefepime and vancomycin for approximately eight days has severely elevated white blood cell count, but states! Whether she has told she has fevers seizures or other withdrawal symptoms contact me samples for various subject-areas like,. With lupus about 5 years ago major depressive disorder 's transcript samples for various subject-areas like academic legal! Is transparent and there is no obvious erythema or ulceration around her external genitalia shows a 2-3 calculus. At her skin 102/54 in the past, she was given cefepime and for... Minimal tenderness over her thoracic and lumbar spine ; it is mandatory to procure user consent prior to these. Is probably wisest at this time in terms of her lower extremities and has... Here as well scan shows a white count of 14,000 which has known compression plus... Your experience while you navigate through the website head to toe today, results are pending was! Consent prior to running these cookies may affect your browsing experience “Big Four” that! Rashes on her lower extremities is unremarkable on her own results are pending tangential in terms of her right left., well developed, cooperative, not anxious or agitated a temperature of 39.2 as a T-max yesterday physicians...