Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Normal Review of Systems Transcription Samples

REVIEW OF SYSTEMS:  No weight changes, no headaches, no dizziness, no fainting, no trouble with hearing or vision, no trouble with swallowing. No cough, no chest pain, no trouble with exertion, shortness of breath, no heartburn. No abdominal pain. Normal bowel movements, no bloody bowel movement. No trouble with urination. No joint pain. No lumps or growths. No sweats or fevers.

REVIEW OF SYSTEMS:  Cardiac:  No chest pain or palpitations. Pulmonary:  No shortness of breath, orthopnea or wheezing. Gastrointestinal:  No constipation, diarrhea, nausea, vomiting. Genitourinary:  No dysuria or discharge. The patient has had no history of clotting disorders. She has no family history of any clotting disorders. She has good exercise capacity.

REVIEW OF SYSTEMS:  Significant for intermittent headaches, not well defined or characterized by the patient. She does not report associated symptoms such as photophobia, phonophobia, osmophobia, nausea, vomiting or visual disturbance. She has memory loss. She has trouble walking due to the severe osteoarthritis in her knees. She has history of depression.

REVIEW OF SYSTEMS:  The patient denies any recent weight loss, decreased appetite, or fatigue. The patient does report significant low back pain, which requires her to ambulate with the use of a cane secondary to her spinal stenosis. She otherwise has no chest pain, dizziness, lightheadedness, nausea, vomiting or abdominal pain. The remainder of the review of systems is otherwise unremarkable.

REVIEW OF SYSTEMS:  No alopecia, sicca or Raynaud's, pleuropericarditis, kidney disease. No eye problems, ear problems, sinus problems, neuropathy, seizure, psychosis, bleeding, bruising, diabetes, abdominal pain, hematemesis or bright blood per rectum.

REVIEW OF SYSTEMS:  No blood clots, pregnancy loss, no hair loss, no Raynaud's, no photosensitivity, no discoid lesions, no pleuropericarditis or nephritis. No seizures, psychosis, depression, wheezing, chest pain, diabetes, thyroid disease, bleeding, bruising, or weight loss. Overall, she said she feels well.

REVIEW OF SYSTEMS:  No changes in his hearing or vision. No cough or shortness of breath. No rashes, abdominal pain, nausea, bowel pain, bright red blood per rectum, hematemesis. No urinary frequency, dysuria, no acute joint issues, no headache, numbness or tingling.

REVIEW OF SYSTEMS:  No chest pain, palpitations, no shortness of breath, no hemoptysis, no cough, no vomiting, no diarrhea, no GI distress, no urinary discomfort, no dysuria, no polyuria, no hematuria, no neurological complaints, no headache, no confusion, no focal neuro symptoms.  No recent weight loss.  She does report that she has had decreased p.o. intake secondary to decreased appetite over the past couple of weeks.  There has been no weight change, no rashes or bruising.

REVIEW OF SYSTEMS:  Significant for multiple symptoms including weight gain/loss, loss of energy, sleep disturbance, loss of interest, heat/cold intolerance, change in hair/nails, headache, abdominal pain, change in bowel/bladder habits, nausea/vomiting, personality change, visual change, hearing loss and dizziness. All other systems are negative.

REVIEW OF SYSTEMS:  Weight loss secondary to exercise and diet. Occasional symptoms of dizziness, feelings of near fainting, no symptoms recently, complained of this previously after a vigorous workout. No loss of consciousness. She wears glasses. She is due to see the dentist. Symptoms of heartburn, indigestion, epigastric discomfort as discussed above. Bowel movements are normal. No blood on stool, toilet tissue or in toilet bowl. No black stool. No urinary problems. No vaginal complaints. Ongoing low back discomfort, notices improvement with working out and stretching. Joints are occasionally stiff and crack. Concerned regarding blemish near her right axilla. Complains of fatigue. Also symptoms of depression. No suicidal or homicidal ideations. Decreased libido. No concerns with menses. All other systems reviewed today and are unremarkable.

REVIEW OF SYSTEMS:  HEENT:  She does have astigmatism.  Cardiovascular:  No anterior neck, chest or arm discomfort.  Her last dobutamine echo was 2 years ago.  Respiratory:  She has shortness of breath when she walks from the bed to the bathroom at night sometimes and occasionally while climbing stairs.  Gastrointestinal:  No change in her bowel habits, blood in her stools, abdominal pain, nausea, vomiting or diarrhea.   Genitourinary:  She has no blood in urine.  She has no history of kidney failure or kidney stones.  Musculoskeletal:  She has some arthritis, which she has had for years, no long bone pain or back pain.  Neurologic:  She had TIAs 2 years ago, she states no TIAs since.  Se has had no stroke.  She had no evidence of syncope or seizure disorder.  Endocrine:  No diabetes or thyroid disease.  Hematology:  No history of anemia or bleeding disorder.

REVIEW OF SYSTEMS:  She is obese and has gained 9 pounds. She is also tired. HEENT:  Eye checkup as she needs glasses. Has decreased hearing. Has occasional headaches. No dizzy or fainting spells. Lungs:  No cough or wheeze. Heart:  See above. Gastrointestinal:  No indigestion or dysphagia, regular bowel movements. Genitourinary:  Nocturia. Increased urination. Bones plus joints:  See above concerning neck and thigh. Allergies:  Penicillin produced vomiting and rash, but she is able to tolerate amoxicillin. Neurologic/Psychiatric:  See above. Gynecologic:  She is going to make an appointment to see Dr. Doe.

REVIEW OF SYSTEMS:  Neurologic:  The patient denies any history of seizures, headaches, muscle weakness or numbness. Respiratory:  He denies any symptoms of asthma, chronic obstructive pulmonary disease or chronic cough. Cardiac:  No symptoms of chest pain, shortness of breath or edema. Abdomen:  He denies any nausea, vomiting, diarrhea, constipation or bleeding per rectum. Urinary:  He denies any burning on urination and no blood in the urine. Musculoskeletal:  He previously had symptoms of left foot pain that has resolved. He has no pain in his back, hips or knees.

REVIEW OF SYSTEMS:  He had an episode of apparent tachycardia.  His heart rate got up to 170 when he went to the emergency room where he was evaluated.  He eventually had a normal Holter and echocardiogram.  He has no history of diabetes, cancer, hypertension, anemia or blood disorder, kidney or bladder disease, liver disease or hepatitis, orthopedic problems, glaucoma or cataracts, thyroid disease, arthritis, migraines, seizures or depression.

REVIEW OF SYSTEMS:  On comprehensive review of systems, he denies any fevers, chills, fatigue, loss of appetite, blurred vision, double vision, chest pain, palpitations, heart attacks or any shortness of breath. Psychologically, he is generally happy. He has never had any severe depression, never considered suicide, never had anxiety and does not have any difficulty sleeping. He has no GI related system issues. He does not have a current PSA to evaluate. His urine dip today showed trace blood.

REVIEW OF SYSTEMS:  The patient describes 3/10 pain that can be sharp, aching and tender, most pronounced when she has to urinate. In general, her symptoms are alleviated with urination. On comprehensive review of systems, she has had fatigue, sore throat, sinus trouble, shortness of breath, anxiety, difficulty sleeping and rash. She has had heartburn, diarrhea, constipation, neck pain, back pain, hematuria, painful urination, frequent urination, difficulty with urination and urinary infections. Urine dip today showed glucose negative, ketones trace, pH 5.6, blood moderate, nitrites negative, leukocytes negative and protein negative. On postvoid residual bladder scan, a urine volume of 90 mL was identified.

REVIEW OF SYSTEMS:  The patient denies any current pain. On comprehensive review of systems, she has had fatigue, loss of appetite, sore throat, sinus trouble, leg pain, shortness of breath, wheezing, anemia, easy bruisability, depression, difficulty sleeping, heartburn, nausea, vomiting, diarrhea, constipation, neck pain, joint pain, back pain and most notable frequent urination. In GU related systems, she does describe some frequency of urination. She gets up 4 times per night to urinate. She will drink 3 coffees in the morning. Occasionally, she does leak with coughing, sneezing and exercise.

REVIEW OF SYSTEMS:  No nasal congestion. No history of jaw trauma. No history of hypothyroidism. Weight as above. He does complain of some memory and attention-concentration problems. History of depression. No anxiety disorder. Cardiovascular review of systems is notable for hypertension only. No history of coronary disease. No history of stroke. Respiratory review of systems is notable for mild exertional dyspnea, but no cough, wheezing, sputum production or hemoptysis. No history of chronic lung disease. No history of recurrent chest infections. Neurologic review of system is negative for history of any cerebrovascular disease. Endocrine review of system is negative as above other than dyslipidemia and diabetes mellitus. He does complain of joint pains.