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Scalp Injury ER Medical Transcription Sample Report


CHIEF COMPLAINT:  Scalp injury.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who apparently was at a party tonight when he slipped on something on the floor, fell down, hit the back of his head, noted some blood, and came in complaining of some mild sharp scalp pain since.

The patient denies any loss of consciousness. The patient denies any neck pain and denies any chest pain or trouble breathing.

PAST MEDICAL HISTORY:  History of hernia repair.



SOCIAL HISTORY:  The patient reports drinking one to two beers daily. The patient denies tobacco or illicit drug use.

REVIEW OF SYSTEMS:  As above in HPI. The patient denies any other recent illness. All other systems are negative.

GENERAL:  The patient is a pleasant, well-nourished young male. The patient does not appear to be in any distress.
VITAL SIGNS:  Blood pressure 120/76, pulse 72, respirations 18, temperature 98, and O2 sat is 97% on room air.
HEENT:  Head is normocephalic. He is noted to have a small posterior scalp laceration that is approximately 1 cm. This is a relatively superficial scalp laceration. Pupils are equal and reactive. Extraocular muscles are intact. Oropharynx is clear.
NECK:  Supple.
LUNGS:  Clear to auscultation.
HEART:  Regular rhythm.
ABDOMEN:  Soft, nontender.
EXTREMITIES:  There is no edema.
NEUROLOGIC:  The patient is awake, alert, and oriented x4. Gait is within normal limits. Exam is nonfocal.

EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING:  The patient was seen and examined as above. His wound was copiously irrigated. We used three staples to reapproximate the wound after using some lidocaine for topical anesthesia. The patient tolerated the procedure well. He was given a tetanus shot here today.

The patient will be discharged home with instructions to have his staples removed in 7 to 10 days and otherwise return as needed.

DISCHARGE DIAGNOSIS:  Scalp laceration.

PLAN:  The patient is discharged home with instructions as above.



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