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Medical Specialty:
Consult - History and Phy.
Sample Name: Viral Gastroenteritis
Description: Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine." She states after vomiting, she felt "fine through the night," but woke with more nausea and vomiting and diaphoresis. She states she has vomited approximately 20 times today and has also had some slight diarrhea. She denies any sore throat or cough. She states no one else at home has been ill. She has not taken anything for her symptoms.
MEDICATIONS: Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.
ALLERGIES: SHE HAS NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient is married and is a nonsmoker, and lives with her husband, who is here with her.
REVIEW OF SYSTEMS
Patient denies any fever or cough. She notes no blood in her vomitus or stool. The remainder of her review of systems is discussed and all are negative.
Nursing notes were reviewed with which I agree.
PHYSICAL EXAMINATION
VITAL SIGNS: Temp is 37.6. Other vital signs are all within normal limits.
GENERAL: Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.
HEENT: Head is normocephalic and atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. NECK: No enlarged anterior or posterior cervical lymph nodes. There is no meningismus.
HEART: Regular rate and rhythm without murmurs, rubs, or gallops.
LUNGS: Clear without rales, rhonchi, or wheezes.
ABDOMEN: Active bowel sounds. Soft without any focal tenderness on palpation. There are no masses, guarding, or rebound noted.
EXTREMITIES: No cyanosis, clubbing, or edema.
LABORATORY DATA: CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential. Hematocrit is 33.8, but the indices are normochromic and normocytic. BMP is remarkable for a random glucose of 147. All other values are unremarkable. LFTs are normal. Serum alcohol is less than 5.
TREATMENT: Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea. She was given two capsules of Imodium with some apple juice, which she was able to keep down. The patient did feel well enough to be discharged home.
ASSESSMENT: Viral gastroenteritis.
PLAN: Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea. She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet. Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours. If she is unimproved in the next two days, she was urged to follow up with her PCP back home.
See More Samples on Consult - History and Phy.
A 5-month-old boy with cough
Abdominal Pain - Consult
Abnormal Echocardiogram
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Acne Vulgaris - H&P
Acute Cystitis & Diabetes Type II
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Lumbar Spine HNP - Consult
Lumbosacral Polyradiculopathy
Lung Cancer & MI - Hospice Cosult
Lymphoblastic Leukemia - Consult
Lymphoma - Consult
Major Depressive Disorder - IME Consult
Malignant Meningioma - Consult
Mantle Cell Lymphoma - Consult
Marginal Zone Lymphoma
MCA Aneurysm
Medical Management Consult Request
Meningioma
Mental Status Changes - Consult
Mesothelioma - Consult
Metastatic Ovarian Cancer - Consult
Microhematuria - Consult
Migraine without Aura - Consult
Multilobar Pneumonia
Multiple Meningiomas
Multiple Neurological Symptoms
Murmur & Bacteremia.
Neck & Back Pain
Neck & Lower Back Pain - Consult
Neonatal Consult
Nephrology Consultation - 1
Nephrology Consultation - 2
Nephrology Consultation - 3
Nephrology Consultation - 4
Neuro Consult - Depression & Dementia
Neuro Consult - Leg Weakness
Neuroblastoma - Consult
Neurogenic Bladder - Consult
Neurologic Consultation
Neurologic Consultation - 1
Neurologic Consultation - 2
Neurologic Consultation - 3
Neurologic Consultation - 4
Neurologic Consultation - 5
Neurologic Examination
Neuropsychological Evaluation
Neuropsychological Evaluation - 1
Neuropsychological Evaluation - 2
Neuropsychological Evaluation - 3
Neuropsychological Evaluation - 4
Neuropsychological Evaluation - 5
New Onset Seizure
Non-Q-wave Myocardial Infarction
Non-Small Cell Lung Cancer - Consult
Normal Child Exam Template
Normal ENT Exam
Normal ENT Exam - 1
Normal Female Exam Template
Normal Female Exam Template - 1
Normal Female Exam Template - 2
Normal Female ROS Template
Normal Male Exam Template
Normal Male Exam Template - 1
Normal Male Exam Template - 2
Normal Male Exam Template - 3
Normal Male Exam Template - 4
Normal Male ROS Template - 1
Normal Newborn H&P Template
Normal Newborn Infant Physical Exam
Normal Physical Exam Template
Normal Physical Exam Template - 1
Normal Physical Exam Template - 2
Normal Physical Exam Template - 3
Normal Physical Exam Template - 4
Normal Physical Exam Template - 5
Normal Physical Exam Template - 6
Normal Physical Exam Template - 7
Normal ROS Template
Normal ROS Template - 1
Normal ROS Template - 2
Normal ROS Template - 3
Normal ROS Template - 4
Normal ROS Template - 5
Not Feeling Well - ER Visit
OB/GYN - H&P
OB/GYN Consultation - 1
OB/GYN Consultation - 2
OB/GYN Consultation - 3
OB/GYN Consultation - 4
Occupational Medicine Consult
Occupational Medicine Consult - 1
Occupational Medicine Consult - 2
Occupational Medicine Consult - 3
Oligoarticular Arthritis - 1
Oligoarticular Arthritis - 2
Onychomycosis - H&P
Organic Brain Syndrome
Orthopedic Consult
Orthopedic Consult - 1
Orthopedic Consult - 2
Orthopedic Consult - 3
Orthopedic Consult - 4
Orthopedic Consult - 5
Otitis Media - H&P
Pain from Hernia - ER Consult
Pain Management Consult - 1
Pain Management Consult - 2
Paroxysmal Atrial Fibrillation
Pediatric Rheumatology Consult
Penile Cellulitis
Penile Discharge
Pericardial Effusion
Perioperative Elevated Blood Pressure
Peripheral Effusion - Consult
Physical Exam and Pap - 1
Physical Exam and Pap -2
Pneumoconiosis
Pneumothorax & Subcutaneous Emphysema
Postop Medical Management
Preeclampsia
Preop Cardiac Consult
Prostate Adenocarcinoma
Prostate Adenocarcinoma - H&P
Pseudoseizures
Pseudotumor Cerebri
Psych Consult - Alcohol Withdrawal
Psych Consult - Altered Mental Status
Psych Consult - Anxiety
Psych Consult - Assaultive Behavior
Psych Consult - Bipolar Affective Disorder
Psych Consult - Dementia
Psych Consult - Depression - 1
Psych Consult - Depression - 2
Psych Consult - Lethargy
Psych Consult - Pain Meds
Psych Consult - Paranoia
Psych Consult - Psychosis
Psych Consult - Psychosis - 1
Psych Consult - Schizophrenia
Psych Consult - Substance abuse
Psych H&P - 1
Psych H&P - 2
Psychiatric Consult
Psychiatric Consult - 1
Psychiatric Consult - 2
Pubic Cellulitis
Pulmonary Consultation - 1
Pulmonary Consultation - 2
Pulmonary Edema - Consult
Pulmonary Embolism
Pulmonary Hypertension - Pediatric Consult
Records Review - Epicondylitis
Records Review - Orthopedic
Rectal Bleeding - 1-year-old
Rectal Bleeding - Consult
Recurrent Abscesses - Consult
Recurrent nasal obstruction
Renal Failure - Consult
Renal Failure Evaluation
Renal Insufficiency - Consult
Request For Consultation
Revocation Admission
Rheumatoid Arthritis - Consult
Rheumatoid Arthritis - H&P
Rotator cuff syndrome - H&P
School Physical - 1
School Physical - 2
Sepsis - Consult
Shoulder Pain Consult
Sick Sinus Syndrome
Sinus problems - Consult
Sleepiness - Consult
Small Bowel Obstruction
Speech Therapy Evaluation
Speech Therapy Evaluation - 1
Spinal fluid evaluation
Sports Physical - 1
Sports Physical - 2
Sports Physical - 3
Status Epilepticus
Supraclavicular Lymphadenopathy
Supraventricular Tachycardia - Consult
Syncope - ER Visit
Syncope - ER Visit - 1
T-Cell Lymphoma Consult
Tethered Cord Evaluation
Therapeutic Recreation Initial Evaluation
Thrombocytopenia - Consult
Thyroid Mass Consult
TIA - Cosult
TIA & Lumbar Stenosis
Tinea Pedis - H&P
Tongue Swelling
Toothache - ER Visit
Tracheostomy Tube Consult
Trouble Breathing - H&P
Ureteral Calculus - Consult
URI & Eustachian Congestion
Urinary Retention
Urology Consut - 1
Uveitis
Ventricular Ectopy - Consult
Vertigo Consult
Vertigo Consult - 1
Viral Gastroenteritis
Weight Gain and Edema
Weight Loss Evaluation
Well-Child Check - 1
Well-Child Check - 2
Well-Child Check - 3
Well-Child Check - 4
Well-Child Check - 5
Well-Child Check - 6
Well-Child Check - 7
Well-woman checkup
Worker's Compensation Injury
Wound Care Consult
Wrist Pain
Keywords: consult - history and phy., nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill,