ER Medical Transcription Sample Reports For Medical Transcriptionists


CHIEF COMPLAINT:  Right earache.
 
HISTORY OF PRESENT ILLNESS:  This is an 8-year-old child who presents to the emergency room.  Brought in by his parents with the complaint of an earache, which began yesterday, with increasing pain and pressure all evening long.  The patient began complaining of acute and increasing pain approximately 30 minutes prior to arrival.  The patient now states that his pain has significantly subsided and is down to minimum, and he basically does not feel any pain at this time.  There is no recent illness, injury or trauma.  He has had a cold, however, per his mother.  He is currently sitting on the cart in no acute distress and has no other complaints.
 
PAST MEDICAL HISTORY:  Significant for recurrent asthma and for otitis media.
 
CURRENT MEDICATIONS:  Prednisone one teaspoon b.i.d., which he stopped today; Singulair 5 mg daily; and albuterol and Advair p.r.n.
 
ALLERGIES:  None.
 
SOCIAL HISTORY:  Lives at home.  They state there is no tobacco or smoking in the house; however, there is an odor of tobacco about the parents.
 
REVIEW OF SYSTEMS:  He has had a cold for the past two to three days.
 
PHYSICAL EXAMINATION
VITALS:  Blood pressure is 113/64, pulse 76, respirations 16, temperature 98 degrees, and O2 saturation 96% on room air.
SKIN:  Pale, warm, and dry.  Turgor is good.  There are no lesions, rashes or ecchymosis.
HEENT:  Normocephalic.  TMs:  The left is clear.  The right is thick, red.  There is blood in the external canal and signs of perforation.  There is opacification of the right TM.  Nasal is clear.  Oropharynx, mucosa is moist and pink.  No exudate, plaques or lesions.  Copious oral secretions.
NECK:  Supple and symmetric.  Trachea is midline.  There is no lymphadenopathy.
CHEST:  Clear with good breath sounds in all.
CARDIAC:  Regular rate and rhythm without murmur, gallop or rub.
ABDOMEN:  Soft.  Bowel sounds are normoactive.  No mass, guarding, rigidity, or rebound tenderness.
NEUROLOGIC:  Without focal or local defects.
 
INTERVENTION:  Discussion was held with the patient and with his parents.  He will be discharged to home at this time.  We will place him on amoxicillin suspension 250 mg t.i.d.  He was given Tylenol with Codeine elixir to be used as directed and also alternating with Tylenol.  They are to cover the ear before he takes his shower.  Recheck in approximately 7-10 days.  May return at any time as needed.  The patient is discharged to home.
 
DIAGNOSES:
1.  Right otitis media.
2.  Perforation of the right tympanic membrane.


 
CHIEF COMPLAINT:  MVA.
 
HISTORY OF PRESENT ILLNESS:  This is a 30-year-old male transported in full immobilization from an accident.  The patient was involved in a two-car accident this morning.  Was the driver of the vehicle which was hit on the driver's side, right at the door, by another vehicle traveling at a high rate of speed.  The car skidded sideways and spun once.  It did not roll over.  The patient had no loss of consciousness.  He was involved in a prolonged extrication at the scene.  Per EMS, the patient has been stable.  His blood pressure was initially low.  He was bolused with normal saline with multiple IVs instilled.  He does have open laceration, probable fracture of the right thigh.  There is an open laceration, questionable fracture of the left thigh, left lower leg, and some pain in his hip.  There is no headache, neck pain, chest pain or shortness of breath and no abdominal complaints.  There are no GI or GU complaints.  No nausea.  No emesis.  He is alert, active, oriented x4, complaining only of pain in his left leg.  He is moving his upper extremities and his right extremity, although there are no other complaints at this time.
 
PAST MEDICAL HISTORY:  None.
 
CURRENT MEDICATIONS:  None.
 
ALLERGIES:  NONE.
 
TETANUS:  Up-to-date.
 
SOCIAL HISTORY:  He does not use alcohol or tobacco products.
 
REVIEW OF SYSTEMS:  He has had cold symptoms, otherwise negative.
 
PHYSICAL EXAMINATION
Cursory survey shows laceration to the chin with some tenderness over the right TMJ.  There is a very large laceration over the lateral mid anterior left thigh, which is open.  It is contaminated with some debris.  There is also an open laceration approximately 6 inches in length into the muscle layer of the distal lower leg.  The upper lacerations are approximately 3 x 5 inches.  There is no other sign of external trauma.  There are multiple superficial abrasions over the posterior and upper left arm.
HEENT:  Grossly normocephalic.  TMs are clear.  Pupils are equal, round, and reactive to light.  Funduscopic exam was negative.  Extraocular muscles are intact.  There is no nystagmus.  Nasal is clear.  Septum is midline.  Dentition is intact.  Tongue is midline.  There is normal elevation of the palate.  There is again tenderness over the right TMJ.
NECK:  Trachea is midline.  He is in a cervical collar and immobilized.
CHEST:  Shows normal breath sounds, inspiratory and expiratory, bilaterally.  Palpation reveals no tenderness, no deformities, and no signs of crepitus.
ABDOMEN:  Soft.  Bowel sounds are normoactive in all quadrants.  No mass, guarding, rigidity, or rebound tenderness is seen.
CARDIAC:  Regular rate and rhythm without murmur, gallop, or rub.
PELVIC:  There is no tenderness in the pelvis and no deformity in the pelvic structures.  Palpation in the suprapubic area reveals no tenderness. 
GENITALIA:  Normal male external genitalia.  There is no blood at the meatus.  There is no sign of hernia.
EXTREMITIES:  Upper extremity, there is full range of motion; full at the shoulders, elbows, wrists, and digits.  There is a laceration noted over the lateral antecubital fossa of the left elbow.  There is full range of motion at the shoulders, elbows, wrists, and digits.  There is no gross deformity.  Right leg pulses are symmetric and full.  There is no tenderness and no deformity.  Patella is centered.  There is full range of motion.  There is range of motion in the right distal extremity, in all joints.  Left pulses are diminished.  Distal extremity is pink to the touch, somewhat cool however.  Pulses are palpable and auscultable on Doppler.  Wounds again are open and contaminated.
 
INTERVENTION:  Multiple IVs were instilled.  Blood was started.  The patient was given 2 units of universal blood and was given tetanus, 1 gram of Ancef.  He was on multiple IVs.  He was also placed in bare hardware.  EKG was obtained, which shows a normal sinus rhythm.  Chest x-ray, C-spine, portable chest and belly were obtained.  There were no gross fractures.  There was no widening.  There does not appear to be any rib fractures nor there is any sign of pneumothorax.  Cervical spine is basically aligned without any appearance of compression on this alignment or fracture.  Hip, femur, and pelvis were obtained.  Femur and left lower leg, there is comminuted midshaft fracture of the left femur.  There is also comminuted neck fracture of the neck and the left hip.  Lower leg shows no fracture.
 
CAT scans were not obtained.  X-ray of the mandible done.  The CAT scan was not working when the patient originally arrived.  He had been reported to cast with the acceptance to cast.  He was given 2 units of blood.  Vital signs, blood pressure had ranged initially 107/80 with a pulse of 96, respiration 20, and O2 saturation 100%.  He had a Glasgow coma scale of 14.  Pain is 10/10.  Vital signs; blood pressure remained at 136/72, 121/90, 155/91, and 111/65; pulses 89, 86, 65, and 78; respirations 20; and O2 saturations 100%.  Glasgow coma scale reevaluated at 15.  Pupils remain equal at 4 mm bilaterally.  Wounds were re-cleaned and dressed with sterile dressings.  The patient’s toe was splinted.  He was in the tension splint.  On secondary survey,  the back was negative.  Rectal tone was good.  Prostate was intact.  Foley catheter was instilled with good return of urine.  Urinalysis was negative.
 
Laboratories obtained:  Sodium is 138, potassium is 6.4, chloride 111, CO2 of 21, SGOT of 85, LDH 155, GGT 44, calcium is 4.6, alkaline phosphatase 65, SGPT is 77, cholesterol 127, amylase 30, lipase 122, PT 15.3 and PTT 33.14.  White count was 14.1, hemoglobin 15, hematocrit 45.7, and platelets are 195, slight elevation of granulocytes.  Glucose was 290, BUN 11, and creatinine 0.7.  Urinalysis shows specific gravity greater than 1.030, pH 5, large blood, occasional 4-9 white cells, and 2+ bacteria.
 
The patient had been typed.  He was given 2 units of blood in the emergency room.  Even the Life Flight crew was available.  The patient had been stable.  He had no further suggestions or needs at this point of time.  Vital signs are stable.  Further x-rays with CT of the hip, neck, chest, and abdomen will be done.

 
DISCHARGE DIAGNOSES:
1.  Fracture of the left hip.
2.  Open fracture to the left thigh.
3.  He has a lacerated chin.
 
NOTE:  Most ER reports don't have the heading "Discharge diagnoses."  Additional headings dictated in other ER reports are ED COURSE, IMPRESSION, PLAN, DISPOSITION.
 




  
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