ER Medical Transcription Sample Report #1
CHIEF COMPLAINT: Severe abdominal pain.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presents to the ER with a history of onset of left flank pain. The patient claims this is similar to what she has experienced many times before. It is slightly worse. It is also concerning because it was experienced 9 days ago and then treated as she normally would with Cipro 500 mg 1 b.i.d., which she has again taken for 9 days, but then it occurred again today while taking Cipro. Today, she experienced fairly sudden onset, lasting approximately 30 minutes, associated with nausea and vomiting and has relapsed and is continuing. She also claims some difficulty with urination, having to strain. No dysuria, no fever or chills. No further symptomatology. Again, nausea and vomiting as of today. Negative for hematemesis. Negative for fever or chills. Negative for hematuria. Negative for change in bowels.
PAST MEDICAL HISTORY:
1. History of urethral stricture, status post dilatation.
2. Cholecystectomy.
3. History of arthritis.
4. History of diverticulosis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Cipro 500 mg 1 b.i.d. times last 9 days.
2. Ibuprofen.
SOCIAL HISTORY: Negative history of recreational drug use.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Please see HPI. Further history is negative.
CARDIAC: Negative history of chest pain or palpitations.
RESPIRATORY: Negative shortness of breath, cough, sputum production.
GASTROINTESTINAL: Negative history of nausea, vomiting and abdominal pain with exception of HPI.
GENITOURINARY: Please see HPI.
GYN: The patient claims last menstrual period 1 week ago. She denies pregnancy. She denies any vaginal discharge, pelvic pain.
PHYSICAL EXAMINATION:
GENERAL: Revealed a pleasant female. She is alert and oriented x3.
VITAL SIGNS: Temperature 98.4, blood pressure 162/82, pulse initially 122, respirations 21, O2 saturation 98%.
HEENT: Head is atraumatic. Eyes: Pupils equal, round, reactive to light. Sclerae nonicteric. Oral mucosa is moist.
NECK: Supple.
LUNGS: Clear to A&P bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. Negative MRG.
ABDOMEN: Soft, normoactive bowel sounds. Negative palpable organomegaly. No masses. There is some tenderness along the left side of the abdomen, left CVA tenderness. No further abnormalities noted. This is not an acute or surgical abdomen by exam today.
EXTREMITIES: The ankles are negative for edema.
SKIN: Without dermatitis.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING:
The patient was seen and evaluated by myself as well as consultation obtained with Dr. Doe. The patient was obviously in discomfort; for this, IV was started. She was given Phenergan 12.5 mg and morphine 4 mg IV. One liter of normal saline was given during her stay. Morphine was repeated x 1. Toradol was added at 30 mg. Phenergan was repeated, and later following removal of her IV, Dilaudid 1 mg IM. The patient did rest comfortably with these medications. She also expressed desire to be discharged to home. Her workup included a Foley catheter placement by nursing. Nursing notes were reviewed. The patient subsequently underwent CT abdomen without contrast. Reading per radiologist revealed moderate obstructive uropathy, left, secondary to 3.8 mm calculus 1 cm from left UV junction, Foley in place, status post cholecystectomy. EKG was done, read by Dr. Doe. Today’s reading revealed normal sinus rhythm, rate 62, no concerning ischemic or interval pattern changes, minimal ST elevation in the inferior lead; however, this is compared to past EKG and not felt to be significant. CBC: WBC count elevated at 16.6, H&H 13.2 and 38.8, platelet count 274; differential, neutrophil elevated at 87.5, lymphocytes low at 9.2. Absolute neutrophil is elevated at 14.6, otherwise unremarkable. Sodium 142, potassium 3.7, chloride 110, BUN 15, creatinine 1.4, glucose 114. SGOT 14, SGPT 12, total bilirubin 0.3, direct bilirubin 0.1, protein 6.4, albumin 4.4, lipase 22, alkaline phosphatase 45. UA: Specific gravity greater than 1.020, pH 7.2, protein negative, ketone negative, sugar negative, leukocyte esterase negative, nitrite negative, wbc’s 0-3, blood trace, rbc’s 0-3, bilirubin negative, urobilinogen 0.2, squamous epithelial cells 0-3. HCG qualitative urine was negative. Again, it was noted her creatinine was 1.4. This is felt secondary to fluids, and therefore, she was given 1 liter normal saline. Again, the patient subjectively was doing well. She wished to go home. It was felt that the patient could be discharged to home to follow up with Dr. Doe as soon as possible. She was to take medications as provided for pain. She was given Dilaudid 2 mg 1 q. 4-6 hours with warning of drowsiness, #30 total. She was given Phenergan to take as needed for nausea, vomiting. She was told to increase fluids. To return to ED if increasing signs or symptoms, difficulty with urination, fever, chills, nausea, vomiting, uncontrolled pain, any other problems or concerns. She indicated understanding and agreement with this. She was discharged to home in good condition.
DIAGNOSIS:
Ureteral stone.
ER Medical Transcription Sample Report #2
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presents to the ER with a history of chest pain. She claims that this onset was slow, somewhat steady, although has waxing and waning component. She claims that it is similar to reflux pain she has had before, just not lasted this long, and usually responds to Prevacid and Reglan. She denies history of nausea, vomiting and does admit to some reflux of material. She claims this pain remained throughout the night; however, she was able to sleep. However, upon awakening this morning, she experienced similar discomfort, which is in the right anterior chest and into the right upper extremity. No history of trauma. No history of exertional chest pain prior this. Also, should be noted that she denies any exertional exacerbation to her chest pain currently. Again, she has somewhat of a waxing and waning component lasting seconds when present, not exertional. No fevers, no cough, no sputum production, no wheezing. She claims it is not particularly exacerbated by deep breath; however, she feels somewhat stifled to take a deep breath as it does seem to be uncomfortable. She otherwise denies shortness of breath, nausea, vomiting. She denies any abdominal pain and change in stool. She denies hematemesis, hematochezia or melena. She denies any GU symptoms. She now presents for further evaluation and care. She denies any past history of cardiac problems.
PAST MEDICAL HISTORY:
1. History of GERD.
2. Irritable bowel syndrome.
PAST SURGICAL HISTORY:
Status post hysterectomy.
ALLERGIES:
No known drug allergies.
MEDICATIONS:
1. Prevacid p.r.n.
2. Reglan p.r.n.
SOCIAL HISTORY: Negative history of tobacco, alcohol, recreational drug use.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies.
HEENT: The patient denies symptoms. No neck pain, no difficulty swallowing.
CARDIAC: Negative history of palpitations. Please see HPI.
RESPIRATORY: Please see HPI.
GASTROINTESTINAL: Please see HPI.
GENITOURINARY: Please see HPI.
GYN: Status post hysterectomy.
MUSCULOSKELETAL/NEUROLOGIC: As above, otherwise unremarkable.
FAMILY HISTORY: The patient denies a family history of clotting disorders, blood clots, DVT. She denies any family history of coronary artery disease in immediate family.
PHYSICAL EXAMINATION:
GENERAL: Revealed a pleasant female. She is alert and oriented x3.
VITAL SIGNS: Temperature 98.4, blood pressure 118/78, pulse 78, respirations 18, O2 sats 98%.
HEENT: Head is atraumatic. Eyes: Pupils equal, round and reactive to light. Sclerae nonicteric. Oral mucosa is moist.
NECK: Supple. Trach midline and mobile.
LUNGS: Clear to A&P bilaterally.
CARDIOVASCULAR: RRR. Negative MRG.
ABDOMEN: Soft, normoactive bowel sounds. Negative palpable organomegaly, abnormal masses or tenderness. Negative for CVA tenderness.
EXTREMITIES: Ankles negative for edema or venous cords about the upper or lower extremities.
EMERGENCY ROOM COURSE AND MEDICAL DECISION MAKING:
Further discussion was held with the patient with regard to risk for a DVT. There is no recent trip or risk factors concerning for DVT and PE. Also, the patient has had one aspirin today at home. The following workup was undertaken. CBC was done. WBC count was 8.6, H&H 14.2 and 41.9, platelet count 288. PTT 32.8, INR 1.0, prothrombin time 13.4. EKG done and read by Dr. Doe revealed a normal sinus rhythm, rate of 72, normal axis, no concerning interval ischemic changes. CK-MB less than 1.0. Troponin less than 0.05. BNP less than 5. D-dimer less than 100. Sodium was 136, potassium 3.9, chloride 109, CO2 of 22, glucose 105, BUN 9, creatinine 0.9, anion gap 13. The patient was asymptomatic while she was being seen here in the ER. Discussion was held regarding the above labs. Also, chest x-ray was taken and read by Dr. Doe, which was consistent with no acute disease. It was felt that the patient could be safely discharged home with the following advice. She is to stay on Prevacid and Reglan on a regular basis. Return to the ER should she have worsening signs, symptoms or return of chest pain. Otherwise, mandatory followup with her PCP this week. Also was recommended that she follow up with her gastroenterologist in the near future.
DISPOSITION: Discharged home in good condition in care of family.
DIAGNOSIS:
Chest pain, not otherwise specified.
