Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: General Medicine
Sample Name: Nausea & Vomiting - ER Visit

Description: She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.
(Medical Transcription Sample Report)

HISTORY OF PRESENT ILLNESS: She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.

PAST MEDICAL HISTORY: Nonsignificant.

PAST SURGICAL HISTORY: None.

SOCIAL HISTORY: No alcohol, drugs, or tobacco.

PAST OBSTETRICAL HISTORY: This is her first pregnancy.

PAST GYNECOLOGICAL HISTORY: Not pertinent.

While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2. Her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria. H and H stable at 14.1 and 48.7. She was then admitted after giving some Phenergan and Zofran IV. As started on IV, given hydration as well as given a dose of Rocephin to treat bladder infection. She was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving Maalox, tolerated fluids as well as p.o. food. Followup chemistry was obtained for AST, ALT and we will plan for discharge if lab variables resolve.

ASSESSMENT AND PLAN:
1. This is a 28-year-old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup.
2. Slightly elevated ALT, questionable, likely due to the nausea and vomiting. We will recheck for followup.

Keywords: general medicine, iv hydration, elevated alt, emergency, nausea, vomiting,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples