Emergency Room Medical Transcription Transcribed Sample Reports

DATE OF ADMISSION: MM/DD/YYYY

CHIEF COMPLAINT: Frequency and urgency and a growth on the labia.

HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presents to the emergency room with complaints of 3 days of increased frequency, urgency and dysuria. The patient states she has had a history of urinary tract infections in the past and she knows when she has another one. She is not complaining of nausea, vomiting, muscle aches, chills and no backache. For the past 3 to 4 months, she has noticed a tag on her labia. This morning, it seems to be somewhat more enlarged and painful and would like that evaluated. There are no other complaints or symptomatology.

PAST MEDICAL HISTORY: Significant for frequent UTIs. She has had 4 in the last year. The last one was in November. She is status post uterine endometrial ablation, and her last menstrual period was light and approximately 2 weeks ago. She has had frequent labial tags; the last one, she was cutting off with the knife on her own but has opted not to do that anymore.

CURRENT MEDICATIONS: None.

ALLERGIES: NONE.

SOCIAL HISTORY: Does not use alcohol, drugs or tobacco products.

REVIEW OF SYSTEMS: As above. Otherwise, noncontributory.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 140/88, pulse 80, respirations 18, temperature 98.5 and O2 saturation 94% on room air.
SKIN: On physical examination, skin is pale, warm and dry. There was a small thrombosed skin tag on the right labia minora.
CHEST: Clear with good breath sounds.
CARDIAC: Regular rate and rhythm without murmur, gallop or rub.
BACK: There is no CVA tenderness.
ABDOMEN: Soft. Minimal tenderness in the suprapubic area. Bowel sounds are normoactive in all quadrants. No mass, guarding, rigidity or rebound tenderness.
PELVIC: Normal female external genitalia with a skin tag as described above. Her bimanual exam was negative. There are no adnexal masses and cervix is closed.

INTERVENTION: Urinalysis was obtained which shows specific gravity 1.020, pH 5, white cells are too numerous to count, 3+ bacteria, small leukocytes. Culture was sent. Skin tag was treated with pursestring suture at the base of the stalk, which has been used per the patient in the past. At this time, she will be discharged to home. She is to start on Bactrim DS one b.i.d. She is on Pyridium 200 mg t.i.d. She is to increase her fluid intake, finish the antibiotics, have her urine rechecked and have the tag rechecked at that time if it has not avulsed itself. The patient was discharged to home.

DIAGNOSES:
1. Urinary tract infection.
2. Thrombosed skin tag of the labia minora.

Emergency Room History and Physical Sample Report # 2

DATE OF ADMISSION: MM/DD/YYYY

CHIEF COMPLAINT: Fussiness.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-month-old child. Family notes that since last night, the patient was fussy and irritable, possibly pulling at her ears. No obvious pain or discomfort with urination. No chest pain, cough. No abdominal pain. No nausea, vomiting or diarrhea and is having usual stool and wet diapers. Child, however, has been much more fussy at times and now comes to the ER for further evaluation. This is the mother’s first child. The child is consolable and not constantly crying in the ER and is able to be addressed and approached by me without being upset. Family notes the child has been fully immunized and is compliant with scheduled appointments.

REVIEW OF SYSTEMS: Unavailable.

ALLERGIES: NONE.

MEDICATIONS: None.

PAST MEDICAL/SURGICAL HISTORY: None.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: No complications with development, pregnancy or delivery. Fully immunized and has been compliant with medical followup.

REVIEW OF SYSTEMS: RESPIRATORY: No asthma, TB or cough. CARDIOVASCULAR: No heart problems. GASTROINTESTINAL: No stomach problems. NEUROLOGIC: No growth or developmental problems. All review of systems is negative except as noted above. Healthy infant without hospitalizations.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 108/72, pulse 98, respirations 26, temperature 98.2 rectal, saturation 92% on room air.
GENERAL APPEARANCE: The child is dysphoric, in no respiratory distress, consolable child.
HEENT: Positive light reflex. NC/AT. No tonsillar erythema or exudates. TMs with positive light reflex. No discharge. No erythema.
NECK: Supple. No lymphadenopathy.
CHEST: Good air entry with stable carotids with no wheezing, rhonchi or crackles.
CARDIOVASCULAR: S1, S2, regular rate and rhythm. No murmurs, gallops or rubs.
ABDOMEN: Positive bowel sounds, soft, nontender.
BACK: Nontender.
EXTREMITIES: No vascular lesion noted.
GENITOURINARY: Normal female external genitalia with positive erythema along pudendum and inguinal region with no lymphadenopathy. No urinary discharge and no pain.
NEUROLOGIC: The patient is able to move extremities with good tone; however, does not want to stand for me and lowers herself to the ground, otherwise is consolable regarding parents, appropriately reaching out to be picked up, etc. and is not constantly crying.

ED COURSE: Rectal temperature is evaluated. The patient is also tolerating p.o. No signs of systemic infection at this time and child has been immunized. At this point, she does not appear to be inconsolable. I advised to give Tylenol in appropriate weight dose every 4 hours as needed for further irritation and may need to be evaluated for fever. Otherwise, as long as child is yielding wet diapers and tolerating p.o. liquids and is consolable after been given Tylenol, the patient is appropriate for followup for reevaluation. Return p.r.n. lethargy, altered mental status, dehydration, unable to tolerate p.o., exacerbation of condition.

CLINICAL IMPRESSION:
1. Fussy infant.
2. Crying – presently due to occult upper respiratory infection.

DISPOSITION: Discharged home.

Emergency Room History and Physical Sample Report # 3

DATE OF ADMISSION: MM/DD/YYYY

CHIEF COMPLAINT: Right ear pain.

HISTORY OF PRESENT ILLNESS: This (XX)-year-old very pleasant gentleman presents to the emergency room with a one day complaint of pain in his right ear. The patient states last evening he thought he had wax. He used a wax softener. He has had lots of drainage from his ear today. He is still having pain. He attributes it to his new hearing aid. He also is complaining of pain now in the right side of his head. There is no nausea, no vomiting, no tinnitus, visual, olfactory or auditory changes. He states the headache is behind the ear, and it is related directly to the pain in his ear. There is no chest pain, no shortness of breath, nausea, vomiting. No other complaints. He is very affable and in no apparent distress.

PAST MEDICAL HISTORY: Significant for hypertension and occasional anxiety.

CURRENT MEDICATIONS: Diazepam, Avapro, calcium, potassium and Tylenol.

ALLERGIES: NONE.

SOCIAL HISTORY: Occasional alcohol. Does not use tobacco products.

REVIEW OF SYSTEMS: The patient states he has been having some problems with his dentures, causing some pain in his gums. He is seeing a dentist for this problem.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 146/80, pulse 96, respirations 21, temperature is 97.5 and O2 saturation is 94% on room air.
SKIN: Skin is pale, warm and dry. Turgor is good. There are no lesions, rashes or ecchymoses.
HEENT: Normocephalic. TMs: Left is clear. Right is clear. The right canal is erythematous, and there is a white exudate noted in the canal. Left canal is clear. Nasopharynx, oropharynx is clear. Mucosa is moist and pink without exudates, plaques or lesions. There was no tenderness to palpation over the sinus areas.
NECK: Supple and symmetric. Trachea is midline.
CHEST: Clear with good breath sounds, inspiratory and expiratory.
CARDIAC: Regular rate and rhythm without murmur, gallop or rub.
Rest of the physical exam is within normal limits.

INTERVENTION: The patient will be discharged to home. We will start him on Cortisporin otic solution 4 drops 3times a day in the right ear. He was also given Darvocet to be used for pain, 1 every 4 to 6 hours. He is to use Tylenol or Advil instead of Darvocet, if the pain is unrelieved. He is to be rechecked in 5 to 7 days. He is to return at any time if symptoms change, worsen or alter; otherwise, follow up with his personal physician. The patient was discharged to home.

DIAGNOSES:
1. Otalgia.
2. Suppurative external otitis.