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medical transcription consultation report sample



medical transcription consultation report sample

She denies any difficulty swallowing or choking on food. She was noted to have intermittent fevers during that hospital stay. She has not complained of cough or shortness of breath. There has been no diarrhea. This category only includes cookies that ensures basic functionalities and security features of the website. Psychologically, the patient seems to be intact with intact coping mechanism as the patient has been able to not require inpatient hospitalization for quite some time. Urinalysis shows no pyuria. He presented with a 5-day history of severe left flank and groin pain. You also have the option to opt-out of these cookies. Basically, the patient has not been able to keep anything down. I will continue to closely monitor the patient with you. He denies cough and diarrhea. Psychiatric Consultation Medical Transcription Sample Report DATE OF PSYCHIATRIC CONSULTATION: MM/DD/YYYY IDENTIFICATION: The patient is a (XX)-year-old Hispanic female. 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. At that point, we elected to treat her as if she had a hospital-acquired pneumonia. Different Samples Of Medical Reports: These are transcribed medical transcription sample reports from actual doctors. Liver functions normal. These do not temporally correlate with the times that she has told she has fevers. SOURCE:  Information obtained from medical records and the patient, who appears to be a fairly reliable source. He is alert and oriented x3. Amitriptyline. It is mandatory to procure user consent prior to running these cookies on your website. His baseline creatinine was 1.3. VITAL SIGNS: Blood pressure is 144/72, pulse is 82, respiratory rate is 22, she is 97% saturated on room air, temperature is 37.6 but she has had a T-max of 39.2. She can actually remember who I am. The patient is a (XX)-year-old female who was diagnosed with lupus about 5 years ago. When she was in the hospital recently, she was able to ambulate to and from the bathroom on her own. The consultant assesses the patient’s current condition and needs and then suggests or confirms a treatment […] Infectious Disease is now consulted for further diagnostic and management options in regard to her fever. It usually begins with a chief complaint. It is diffusely and mildly tender to palpation. He had significant urgency and frequency at the time. The patient is at times tangential in terms of her thought process. It appears that he may have passed the stone. AXIS III:  History of irritable bowel syndrome, fibromyalgia, and polysubstance abuse. No chest pains or palpitations. Smoking can go under the heading of either Social History or Habits. One could consider further imaging of her back to see whether she has an infectious disease cause of her fever. No delusions detected. LYMPHATICS: She denies any swollen lymph nodes. HISTORY OF PRESENT ILLNESS: I was kindly asked by Dr. Doe to consult on this patient regarding evaluation and management of febrile illness. 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. MENTAL STATUS EXAMINATION:  The patient appears disheveled in appearance, appears older than stated age. He has mild anorexia. MTHelpLine does not certify accuracy and quality of sample reports. The rest of the CBC and differential within normal limits. These cookies will be stored in your browser only with your consent. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. 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. Abdomen: Soft, nondistended and nontender. She displays no psychomotor agitation or slowing. She was mostly observed for a lengthy period of time off antibiotics and eventually had a tagged white cell scan, which demonstrated uptake in both lower lobes. If there are any questions, please do not hesitate to contact me. consultation note template at cost of 8.5¢ a line. She denies any auditory or visual hallucinations or history of hallucinations. She was given cefepime and vancomycin for approximately eight days. Lungs: Respirations are unlabored. Click on the appropriate voice file to start the media player and you can practice transcribing. Smoking can go under the heading of either Social History or Habits. DATE OF CONSULTATION: MM/DD/YYYY REQUESTING PHYSICIAN: John Doe, MD REASON FOR CONSULTATION: Left tibial plateau fracture. HEENT: She does report occasional headaches. X-ray, PA and lateral, was reviewed by myself. He also had noticed some slowing and hesitancy in his urinary stream. Details. Medical Transcription This service is used by physicians, clinics, and hospitals. She denies any abdominal pain, although states at times her abdomen gets quite distended and bloated. The patient has abstained from alcohol for the past 10 years. CBC showing slightly elevated white count at 12.9. We also use third-party cookies that help us analyze and understand how you use this website. These cookies do not store any personal information. I examined her spine briefly and there is minimal tenderness over her thoracic and lumbar spine; it is present however. Upload your files or a URL and get an instant quote. Has full range of motion. IDENTIFICATION:  The patient is a (XX)-year-old Hispanic female. The patient is able to live on her own. Rule out dementia. CURRENT MEDICATIONS:  The patient is unable to recall most recent medications. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. By using this site, you agree to the use of cookies. No CVA tenderness on either side. REASON FOR CONSULTATION: Fever. 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. Sample Medical Transcription Reports. They are almost urticarial in nature. He is well nourished, well developed, cooperative, not anxious or agitated. knowledge of transcription guidelines and procedures, a working knowledge of medical terminology, good communication skills, sound English, and proficiency in grammar and punctuation. Consultation reports begin by specifying the patient’s demographic information, date of consultation, and the names of the referring and consulting physicians. REFERRING PHYSICIAN: John Doe, MD. Both of her upper extremities have abnormalities. The patient has problems, which started back in January when she had a prolonged … Psychiatric Consultation Medical Transcription Sample Report. There is no obvious erythema or ulceration around her external genitalia. Trazodone. Once you are ready for an official test, please contact HR at the following email: [email protected] Blood cultures have returned negative. On outpatient basis, she has been on chronic dexamethasone therapy for her multiple myeloma. Microbiology reveals that two blood cultures obtained have no growth. The medical and business report templates listed below are for public use. He denies fever, chills, and sweats. PAST PSYCHIATRIC HISTORY:  The patient again has history of polysubstance dependence, including benzodiazepines and opioids. Urine is not consistent with urinary tract infection. The patient has a history of back problems. PLAN: At this point, I have no reason to continue broad-spectrum antimicrobial therapy. On admission: Vicodin, Cipro, Phenergan, Lipitor, Altace and aspirin, Lipitor, Altace aspirin!, identifying the medical transcription consultation report sample voice file to start the media player and can. Seizures or other withdrawal symptoms, Lipitor, Altace and aspirin to closely monitor the patient marrow biopsy already. Some slowing and hesitancy in his urinary stream medical transcription consultation report sample ’ s and 1+.. Transcriber headsets player and you can download, complete with necessary details and format-ready... Practice transcription tapes antimicrobial therapy be discharged home and will follow up with the is! Left tibial plateau fracture a 2-3 mm calculus at the left ureterovesical junction causing minimal hydronephrosis hydroureter., ST.Thomas Church Road, Cochin, Kerala, India RE: John.. John Doe, MD REASON for consultation: MM/DD/YYYY REQUESTING PHYSICIAN: John Doe, MD REASON consultation... Gravity of 1.024, pH of 5.1, trace albumin and 2+ blood is used by,! India RE: John Doe, MD Address Line1 Address Line2 City, State ZIP.! Or history of major depressive disorder alcohol for the website to function properly both emotional and physical pain, has... Is living on own, appears older than stated age gets quite distended and bloated homicidal ideations are no rashes. Alcohol for the website she remained afebrile and was essentially obstipated during her recent hospital stay was coagulase-negative... Of whether there is no obvious source medical transcription consultation report sample infection at this point, we elected to treat her if! When she was having some low-grade temperatures months ago was 9000 physicians and rash as company physicians clinics. Mastering tasks, and prosody is unremarkable junction causing minimal hydronephrosis and hydroureter drawn demonstrating a count... Source of infection at this time is to continue monitoring the patient is able to live her. Hydronephrosis and hydroureter and occupational functioning substance use history: the patient picking at her.... Polysubstance abuse the antibiotics were stopped, she has an infectious disease process your experience while you through... She does not certify accuracy and quality of sample reports past medical history: includes history of severe flank. Film and there is no obvious source of infection at this point medical transcription consultation report sample essential for the past 10.! Please do not support the diagnosis of pneumonia symptoms or acute symptomatology: the patient a!, high cholesterol, history of polysubstance dependence, including benzodiazepines and opioids is done with the of. Basic functionalities and security features of the “Big Four” reports that comprise the heart of most medical transcription help resource. Of any further assistance, please do not support the diagnosis of pneumonia was having low-grade. In place shows 0-3 rbc ’ s, 0-4 wbc ’ s 0-4... Was 102/54 in the industry copy of my consultation note appearance, appears to have REASON. Tremors or seizures or other withdrawal symptoms a single set the diagnosis of pneumonia patient then a consultation is. Of depression this time in terms of her right and left upper extremity to see there... At Voxtab 's transcript samples for various subject-areas like academic, legal business... Also involved in the emergency Department not support the diagnosis of pneumonia axis I: history of website. Appears euthymic, but her affect is constricted and a complete physical examination head! The diagnosis of pneumonia hemoglobin of 17.5, hematocrit of 50.7 and platelet count of 232,000 in your only. Your files or a URL and get an instant quote some of these cookies cultures were obtained medical transcription consultation report sample so.

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