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Lip Laceration ER Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:  Lip laceration and abdominal pain.

HISTORY OF PRESENT ILLNESS:  This patient is a (XX)-year-old Hispanic female with two complaints. Her first complaint is a lip laceration. She says she was assaulted by her husband two days ago and at that time sustained a lip laceration. She did not seek medical care at that time. She says she has been starting to have increasing pain as well as drainage from that wound. She denies any other injuries from the assault. The second complaint is of abdominal pain. She says she has been having abdominal pain and burning with urination for the last several days and is concerned she may have a STD. She denies any vomiting and denies any diarrhea. She says she is sexually active and does not use protection.

PAST MEDICAL AND SURGICAL HISTORY:  History of schizophrenia.

CURRENT MEDICATIONS:  Cogentin and Prolixin.

ALLERGIES:  She has no known drug allergies.

FAMILY HISTORY:  Unremarkable.

SOCIAL HISTORY:  The patient does admit to smoking two packs of cigarettes a day. Admits to daily ETOH use. Denies any illicit drug use.

REVIEW OF SYSTEMS:
CONSTITUTIONAL:  The patient denies fever, chills, dizziness, weakness.
CARDIOVASCULAR:  The patient denies chest pain or palpitations.
RESPIRATORY:  The patient denies shortness of breath or cough.
All other review of systems negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 128/88, pulse 102, respiratory rate 16, temperature 100.4, and O2 sat 100% on room air.
GENERAL:  Well-developed, well-nourished Hispanic female, in no acute distress, appears comfortable lying in bed.
HEENT:  Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. No nystagmus. No scleral icterus. Oral mucosa is moist and pink without erythema or exudate. On the right angle of her upper and lower lips, she has a laceration starting at the vermilion border extending back into the anterior aspect of the oral mucosa that is relatively large. There is purulent drainage present. There is also erythema and induration present, but no fluctuance present. The teeth are normally aligned.
NECK:  Supple with no JVD, no cervical lymphadenopathy noted, no midline C-spine tenderness or step-offs.
RESPIRATORY:  Lungs are clear bilaterally with equal breath sounds.
CARDIAC:  Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES:  No clubbing, cyanosis or edema noted.
GENITOURINARY:  Normal female external genitalia. The patient does have a mild yellowish discharge present from the cervix. The uterus is normal size. There are no adnexal masses or tenderness. There is no cervical motion tenderness.
NEUROLOGIC:  The patient is GCS 15. Cranial nerves II through XII intact. No focal neurological deficits.

EMERGENCY DEPARTMENT COURSE:  The case was discussed with the face surgeons on call, who agreed to follow up with the patient in five days in order to better evaluate the lip. The patient was given 500 mg of Cipro, a gram of azithromycin, and 2 grams of Flagyl while in the emergency department. She was also given two Percocets for her pain, and her tetanus was updated.

MEDICAL DECISION MAKING:  The patient is a middle-aged woman with two complaints. The first complaint is of a lip laceration. She has a rather large lip laceration that would have been primarily repaired if she had come in when she had the initial injury, but at this point, the laceration is large and appears to be infected, so we do not want to close it so that an abscess does not develop. Therefore, at this point, the patient will be covered with antibiotics and will follow up the ENT Clinic on Friday, which is five days from now. As for the patient's second complaint of lower abdominal pain, she does have what appears to be a cervicitis. Her urine also appears to be infected, so we will treat her for a urinary tract infection as well as cervicitis. Her beta hCG was negative.

DIAGNOSES:
1.  Lip laceration with infection.
2.  Urinary tract infection.
3.  Cervicitis.

PLAN:
1.  The patient was given a prescription for Cipro 500 mg p.o. b.i.d. x 6 days.
2.  The patient was given a prescription for clindamycin 300 mg p.o. q.i.d. x 10 days.
3.  The patient was given a prescription for Peridex mouthwash 10 mL swish and spit after meals and before bed.
4.  The patient was given a prescription for Percocet one p.o. q 4 hours p.r.n., total #20.
5.  The patient was instructed to follow up with her primary care physician and follow up with ENT Clinic on Friday.

DISPOSITION:  The patient was discharged home in good condition.

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