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Influenza ER Visit Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:  Fever up to 105 at home.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic female who presents with a chief complaint of fever up to 105 at home. Father states the child has had a cough, runny nose, which began over the past four days; however, these signs and symptoms are getting better. The father is worried because the patient's fever is unchecked. She has been alternating between Motrin and Tylenol; however, she has not gotten any significant results. Specifically, the child denies any sore throat, earache, nausea, vomiting, or wheezing. The child has no bowel or bladder problems, and the last diaper was wet just prior to arrival.

PAST MEDICAL HISTORY:  Unremarkable.

PAST SURGICAL HISTORY:  Unremarkable.

FAMILY HISTORY:  Unremarkable.

ALLERGIES:  The patient has no known drug allergies.

MEDICATIONS:  Tylenol and Motrin.

IMMUNIZATION:  All immunizations are up-to-date.

REVIEW OF SYSTEMS:  A 13-point review of systems was conducted and was negative for anything not specifically mentioned in the HPI.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE:  The patient is a well-developed, well-nourished female, alert and oriented x4, nontoxic and in no acute distress.
VITAL SIGNS:  Pulse 150, respirations 24, temperature 103.8 tympanic, pulse oximetry is 94% on room air, and weight is 11.40 kilos.
HEENT:  Head is normocephalic without evidence of trauma. Eyes:  Pupils are equal, round, and reactive to light and accommodation with all extraocular movements intact. There is no injection or icterus. Ears:  Tympanic membranes are pearly gray. All landmarks present. No erythema or exudates. Nose:  Midline without septal deviation. All mucous membranes are moist. Throat:  Palate rises equally on phonation. There is no erythema or exudates.
NECK:  Supple without palpable thyromegaly, nodules, or lymphadenopathy.
LUNGS:  Clear to auscultation bilaterally without wheezes, rales, rhonchi, or stridor.
HEART:  Regular rate and rhythm without murmurs, rubs, clicks, or gallops.
ABDOMEN:  Nondistended. There is no tenderness or guarding.
EXTREMITIES:  Extremities have a range of motion, which is full and equal bilaterally. Muscle strength 5/5.
NEUROLOGIC:  Cranial nerves II through XII are grossly intact bilaterally. All deep tendon reflexes are +2 and equal symmetrically.
SKIN:  Warm, pink, and dry. Turgor is within normal limits. There is no erythema or rash.

LABORATORY DATA:  The patient received a nasopharyngeal swab for influenza, which was positive for influenza A. CBC was performed with white blood cell count of 12.9, RBC of 4.70, hemoglobin 11.8, hematocrit of 35.2, and platelet count of 294,000. Basic metabolic panel showed a sodium of 139, potassium 4.2, chloride 104, carbon dioxide 18, glucose 102, anion gap of 16, BUN of 12, creatinine 0.4. Urinalysis showed a specific gravity of 1.007, negative for leukocyte esterase, nitrites, ketones, or blood. A RSV nasal swab was performed and was negative for RSV.

EMERGENCY DEPARTMENT COURSE:  The patient was given a saline lock, normal saline bolus of 3 mL per kilogram as well as Motrin 10 mg per kilogram.

CLINICAL IMPRESSION:
1.  Influenza.
2.  Fever.
3.  Cough.
4.  Congestion.

PLAN:
1.  Benadryl 12.5 mg/5 mL 3-3/4 teaspoons p.o. q. 6 hours p.r.n. for cough.
2.  Motrin liquid 100 mg/5 mL 3-3/4 teaspoons q. 6 hours.
3.  Tamiflu 60 mg/5 mL, 2.5 mL p.o. q. 12 hours for 5 days.
4.  Tylenol 160 mg/5 mL 3-3/4 teaspoons p.o. q. 4 to 6 hours p.r.n. fever.
5.  The patient is to follow up with the primary care provider.
6.  The patient's father has been educated as to the signs and symptoms that would necessitate an early return to the emergency department.

The patient's father verbalized understanding and states he will comply with our plan.

CONDITION:  Stable.

DISPOSITION:  Discharged.

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