Sample Medical Transcription Report

Sample Medical Transcription Report:

PATIENT NAME:                                 LOREN, JOHN

MEDICAL RECORD#:                          12345

DATE OF ADMISSION:                        01/02/06

ATTENDING PHYSICIAN:                     Max Morgan, M.D.

CHIEF COMPLAINT: Anemia, constipation, no diarrhea or hematochezia, no pyrosis, anorexia.  Weight loss for several weeks.  The patient has microcytic anemia.  Bilateral BKA.

MEDICATIONS: Monopril 10 mg q.d, aspirin b.i.d., ferrous sulfate. 

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Diabetes mellitus, artheriosclerotic heart disease.

SOCIAL HISTORY: Denies using tobacco or alcohol.  Does not use non-steroidal anti-inflammatories or recreational drugs. 

Vital Signs: Blood pressure is 112/70.  Pulse is 46.  Respirations 18.  Afebrile.

HEENT:    Within normal limits.

Neck :  Supple, no asymmetry, no masses, no thyromegaly or bruits.

Chest :  No wheezes, rales, rhonchi.  Percussion dullness.

Heart :  S1, S2 diminished.  Regular rhythm.  Soft systolic murmur at the left sternal border.

Abdomen : Soft, non-distended, non-tender.  There is no guarding, rebound, masses, hepatosplenomegaly, hernias, or ascites.

Lymphatics :  Negative, post amputation.

Genitalia :  Normal.

Rectal : Positive stool.

PLAN:   The patient will need colonoscopy and gastroscopy in view of his cardiopulmonary status and amputation status.  He will need a 24 hour admit on IV fluids and careful observation.

Max Morgan, M.D.

D: 01/02/06    T: 01/03/06

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