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Cough and Congestion ER Medical Transcription Sample

DATE OF ADMISSION:  MM/DD/YYYY

MODE OF ARRIVAL:  Private vehicle.

CHIEF COMPLAINT:  Cough and congestion.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old male with a history of coronary artery disease, hypertension, and hypercholesterolemia, who presents with 3 days of sore throat, nasal congestion and cough. The patient stated that he began to become a little bit short of breath and had some tactile fevers at home. He has pain in his chest associated with cough. There is no exertional chest pain noted. There is no nausea, vomiting or diarrhea. No headache. The patient also states that his wife is sick right now with the same symptoms, although much less significant.

PAST MEDICAL HISTORY:  Myocardial infarction 1 year ago with a stent placed, hypertension, hypercholesterolemia.

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Over-the-counter cough medications, Plavix, lisinopril, aspirin and Zocor.

ALLERGIES:  NKDA.

SOCIAL HISTORY:  Noncontributory.

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:  As per HPI, otherwise unremarkable. All systems reviewed and are negative.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE:  The patient is alert and oriented, nontoxic-appearing male.
VITAL SIGNS:  Blood pressure 152/102, pulse 94, respiratory rate 20, temperature 98.6, pulse oximetry 95% on room air, interpreted as normal. Pain is 6/10.
HEENT:  Normocephalic and atraumatic. Pupils are equally round and reactive to light. Tympanic membranes are normal. Nasal mucosa is boggy. Turbinates with clear nasal discharge and postnasal drip. Oral mucosa is moist. There is some mild oropharyngeal erythema. There is no exudate noted.
NECK:  Supple. Full range of motion. There is no thyromegaly.
LYMPHATICS:  Increased anterior cervical lymphadenopathy.
HEART:  Regular rate. No murmur, 2+ pulses x4 extremities.
LUNGS:  Normal respiratory effort. There are bilateral coarse breath sounds. There is no rhonchi noted. No wheezes appreciated.
ABDOMEN:  Soft, nontender, nondistended. Positive bowel sounds.
EXTREMITIES:  No clubbing, cyanosis, or edema. Full range of motion of all extremities.
NEUROLOGIC:  Cranial nerves II through XII are grossly intact. No focal motor or sensory deficits were appreciated.
PSYCHIATRIC:  Normal mood and mentation. Alert and oriented x4.
SKIN:  Warm and dry with no rashes or lesions noted. No petechiae or bruising noted diffusely.

LABORATORY AND DIAGNOSTIC DATA:
EKG:  Normal sinus rhythm with a ventricular rate of 88 with incomplete right bundle branch block with no ST or T-wave changes.
Chest x-ray:  Normal cardiac silhouette. No infiltrate. No effusion. No bony abnormalities.
CPK 72, troponin less than 0.01. WBC 10.6, hemoglobin 14.8. INR is 1.0. LFTs are normal. Chemistry is normal.

EMERGENCY DEPARTMENT COURSE:  The patient was given IV hydration in the emergency department as well as Levaquin 750 mg p.o. The patient remained afebrile, normotensive. No tachycardia, no hypoxia in the emergency department and remained stable throughout the emergency department stay.

ASSESSMENT:
1.  Bronchitis.
2.  Chest wall pain.

PLAN:
1.  Return to the emergency department immediately for worsening symptoms.
2.  The patient was given a list of providers in the area for followup as soon as possible.
3.  The patient was given Z-Pak as directed, Phenergan with Codeine and Motrin 800.
4.  The patient was stable and improved at the time of discharge.

DISPOSITION:  Discharged to home.

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