Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Viral Gastroenteritis
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.
SKIN: No rash.
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:
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.
consult - history and phy., nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill,
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