ER Medical Transcription Sample Reports for Medical Transcriptionists:
CHIEF COMPLAINT: Fall.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old female who states at approximately 8 a.m. she was putting her pants on, she lost her balance, fell forward and struck her forehead on the handle of a chest of drawers, causing a small laceration. She denies prior dizziness or lightheadedness, chest pain, shortness of breath prior to the fall. She denies loss of consciousness or vomiting. Presents here at the concern of her daughter. She denies any pain. She denies headache, neck pain or back pain. Denies any other injury.
IMMUNIZATIONS: Her tetanus is up-to-date.
ALLERGIES: PENICILLIN AND IODINE.
CURRENT MEDICATIONS: Aggrenox, Avandia, Zocor, Altace, Lasix, Zoloft, Glucotrol, clonidine, allopurinol, clonazepam, oxybutynin, tramadol, levothyroxine, Centrum, and iron.
PAST MEDICAL HISTORY: Neuropathy, retinopathy, diabetes, hypertension, history of skin cancer, history of a CVA with right-sided deficits, primarily weakness.
PAST SURGICAL HISTORY: Right knee replacement recently.
SOCIAL HISTORY: She lives with her daughter.
REVIEW OF SYSTEMS: See HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 180/64, temperature 97.5, pulse 57, respirations 18, pulse oximetry 98%.
GENERAL: The patient is an (XX)-year-old female in no acute distress. She is alert, oriented, pleasant and cooperative throughout the exam.
HEENT: Her head is normocephalic. She has a small laceration noted to the right frontal aspect of the forehead. There was no evidence of a hematoma. She also appears to have a cystic-type structure, probably a sebaceous cyst, along the mid aspect of the forehead. Otherwise, the remainder of the head was atraumatic. Her pupils are round, equal, reactive to light. Her extraocular movements are intact. Bilateral TMs are clear. Nares are patent. Mouth: She has a clear oropharynx.
NECK: She was nontender to palpation on the cervical spine.
BACK: There is no obvious malalignment or trauma, no step-offs or instability on palpating the spine. She denies any pain to palpation along the spine.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and nontender.
EXTREMITIES: She has normal range of motion in all four extremities. She denies any pain to palpation in these areas. Distal pulses were intact. She denied any pain with palpation of the pelvis, was able to flex, extend, internally and externally rotate both hips without difficulty.
EMERGENCY DEPARTMENT COURSE: The patient was discussed with Dr. Doe. The patient was also evaluated by Dr. Doe as well.
DIAGNOSTIC AND LABORATORY TESTS: A C-spine x-ray was obtained, no acute findings but did show diffuse degenerative changes. A CT of the head without contrast was obtained, read as negative by the radiologist. EKG was obtained, read as within normal limits by Dr. Doe. No acute findings. Cardiac panel was obtained as well as a PT/INR. Her INR was 1.1, PT was 13.6, PTT 33.6. CBC showed a red blood cell count of 3.26, hemoglobin 11.2, hematocrit 32.8. Her glucose was 77. Her troponin was less than 0.1.
PROCEDURE: The forehead was prepped with PCMX, irrigated with normal saline, re-evaluated. The laceration measures approximately 4 mm. I recommended closure with Dermabond to which she was agreeable. This was performed.
IMPRESSION: Closed head injury.
PLAN:
1. Wound care sheet was given. Head injury precautions were discussed.
2. Tylenol p.r.n.
3. Follow up with her doctor Tuesday for recheck.
4. Return if worse, i.e. weakness, chest pain, headache, vomiting, lethargy.
DISPOSITION: The patient was treated and released in stable condition.
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