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Abdominal Pain Emergency Room Transcription Sample

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:
Abdominal pain.

HISTORY OF PRESENT ILLNESS:
This is a (XX)-year-old female who presents to the emergency department by squad for evaluation. Apparently, the patient has a history of chronic pancreatitis. She took her blood pressure at home, and it was noted to be high. She has not been taking any medications for the last six months. The patient states that she just has not gotten around to going back to see her doctor. Her blood sugars have been running high. The patient has had pain in the left upper quadrant. It radiates into her back and it feels similar to her previous pancreatitis, 6/10 in intensity. No treatment prior to arrival. The patient has had diarrhea for the last few days. She has had no vomiting. The patient has had some nausea. She has had a tactile fever, a little nonproductive cough. The patient’s pain occasionally radiates up into her chest and is intermittent.

PAST MEDICAL HISTORY:
1.  Chronic pancreatitis.
2.  SVT.
3.  Asthma.
4.  Tubal ligation.
5.  Whipple procedure, which was aborted.
6.  Left knee surgery.
7.  Diabetes.
8.  Hypertension.

SOCIAL HISTORY:
The patient smokes a pack of cigarettes per day. Denies alcohol use.

ALLERGIES:
None.

MEDICATIONS:
1.  Verapamil.
2.  Insulin.
3.  Vicodin.

REVIEW OF SYSTEMS:
All systems are reviewed and otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  BP 154/80, temperature 97.6, pulse 84, respirations 18, O2 sat 100% on room air.
GENERAL:  The patient is a well-developed (XX)-year-old, in no distress.
HEENT:  Moist mucous membranes.
NECK:  Supple, no JVD.
HEART:  Regular rate and rhythm, S1, S2.
LUNGS:  The patient has an occasional end-expiratory wheeze, good air exchange.
ABDOMEN:  Soft, positive bowel sounds. Slight tenderness in the left upper and left lower quadrants. No rebound, no guarding, no masses.
EXTREMITIES:  Trace edema of the lower extremities.
RECTAL:  Heme negative, no masses.

DIAGNOSTIC STUDIES:
Chest x-ray shows chronic findings by my reading. EKG shows a normal sinus rhythm with a rate of 80. Occasional PVCs. Otherwise, no acute findings by my reading.

LABORATORY DATA:
Amylase and lipase normal. Chem-7 is normal except for glucose of 160. WBC is 7.2, hemoglobin 10.2, hematocrit 30.8, platelet count 348. Troponin normal.

EMERGENCY DEPARTMENT COURSE:
The patient was seen and examined. She underwent workup. She was given a dose of morphine and Phenergan for her discomfort here in the emergency department. A subsequent rectal examination was done, which was heme negative. The patient was reexamined and was discharged in good condition.

MEDICAL DECISION MAKING:
The patient is a (XX)-year-old female with abdominal pain. We will discharge her to home. Lortab #10. She is to follow up with her primary care physician this week. Clear liquid diet for next one to two days. Return if symptoms worsen.

DISPOSITION:
Home.

DIAGNOSES:
1.  Acute exacerbation of chronic abdominal pain.
2.  Anemia.

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