Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Back Pain Emergency Room ER Transcription Sample

CHIEF COMPLAINT:  Back pain.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Asian male who complains of left lower back pain since last evening. The patient states the pain does radiate to his left testicle. He did have two episodes of the pain overnight and one earlier today. He denies any known injury. He denies any hematuria, fevers or chills. He has had a previous history of kidney stones in the past but states that this does not feel typical of his kidney stone pain. He has not been taking anything at home for the pain. The patient denies any penile discharge.

PAST MEDICAL HISTORY:
1.  Vasectomy.
2.  History of kidney stones.

MEDICATIONS:  None.

ALLERGIES:  None.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  The patient denies alcohol or illicit drug use.

REVIEW OF SYSTEMS:  As above, otherwise, negative per the patient.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 138/90, pulse 72, respirations 18, temperature 98.6, O2 sat is 97% on room air.
GENERAL:  This is a well-developed, well-nourished male, in no acute distress.
HEENT:  Normocephalic, atraumatic. PERRLA. EOMI. Posterior oropharynx is pink and moist without erythema or exudate.
NECK:  Supple. No lymphadenopathy.
HEART:  Regular rate and rhythm. No murmurs, gallops, rubs.
LUNGS:  Clear to auscultation bilaterally.
ABDOMEN:  Soft, nontender, nondistended. Bowel sounds x4.
BACK:  The patient does have slight tenderness to palpation in his left flank area. There is no muscular spasm noted. There is no CVA tenderness.
GENITOURINARY:  The patient does have normal circumcised external genitalia. There is diffuse testicular tenderness to palpation on the left, but there is no erythema or edema. There is no scrotal swelling. The testicles have a normal lie. There is no hernia noted.

EMERGENCY DEPARTMENT COURSE:  The patient's nursing notes were reviewed. He did have urinalysis, which showed 30 protein, many bacteria, negative leukocyte esterase and nitrites, moderate blood, 5-10 wbc’s and 0-3 squamous epithelial cells. Urine was, otherwise, negative. He did have a CT scan of the abdomen and pelvis without contrast, which showed a fatty liver in the right lobe, uncomplicated mild sigmoid diverticulosis, no collecting system calculi, a small left inguinal hernia with fat only. However, upon our read, it did appear that the patient did have a small stone in the left UVJ. There also appeared to be a stone further down, either in the bladder or the urethra.

The patient was given 10 mg of morphine IM and 12.5 mg of Phenergan IM, which did not provide any relief of his pain but did relieve his nausea. He was then given 60 mg of Toradol IM after which he was resting comfortably and stated that his pain was significantly improved.

MEDICAL DECISION MAKING:  It does appear that the patient's pain is related to a renal stone. He has had a history of these in the past, and his symptoms are suggestive of this. The patient also has a moderate amount of blood in his urine, which is also highly suggestive of this. Upon the review of the CAT scan, it did appear that the patient does have a renal stone. We will, therefore, encourage him to follow up with his urologist, and we will give him something to control his pain and nausea at home. There is no evidence of any hydronephrosis or any obstructing stone, and therefore, the patient can be managed on an outpatient basis.

DIAGNOSIS:  Nephrolithiasis.

PLAN:
1.  The patient can take ibuprofen over the counter for pain.
2.  The patient is given Vicodin, #20, for severe pain.
3.  The patient is given Phenergan.
4.  The patient is to drink plenty of fluids.
5.  The patient is to follow up with his urologist.
6.  The patient is to return to the ER for any increased pain, uncontrolled vomiting, fever or any other concerns.

DISPOSITION:  The patient was discharged to home in good condition.

ER Sample Reports       ER Sample Reports # 1

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites