Sample Type / Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 18
1-year-old male who comes in with a cough and congestion. Clinical sinusitis and secondary cough.
(Medical Transcription Sample Report)
This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks. Started off as a congestion but then he started coughing about a week ago. Cough has gotten worsen. Mother was also worried. He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened. He is not running any fevers.PAST MEDICAL HISTORY:
Otherwise, reviewed. Fairly healthy.CURRENT MEDICATIONS:
None.ALLERGIES TO MEDICINES:
None.FAMILY SOCIAL HISTORY:
The sister is in today with clinical sinusitis. Mother and father have been healthy.REVIEW OF SYSTEMS:
He has been congested for about three weeks ago. Coughing now but no fevers. No vomiting. Review of systems is otherwise negative.PHYSICAL EXAMINATION:
General: Well-developed male in no acute distress, afebrile.
Vital Signs: Weight: 22 pounds 6 ounces.
HEENT: Sclerae and conjunctivae are clear. Extraocular muscles are intact. TMs are clear. Nares are very congested. Oropharynx has drainage in the back of the throat. Mucous membranes are moist. Mild erythema though.
Neck: Some shotty lymphadenopathy. Full range of motion. Supple.
Chest: Clear. No crackles. No wheezes.
Cardiovascular: Regular rate and rhythm. Normal S1, S2.
Abdomen: Positive bowel sounds and soft.
Dermatologic: Clear. Tone is good. Capillary refill less than 3 seconds.RADIOLOGY:
Chest x-ray: No foreign body noted as well. No signs of pneumonia.ASSESSMENT:
Clinical sinusitis and secondary cough.PLAN:
Amoxicillin a teaspoon twice daily for 10 days. Plenty of fluids. Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving.
general medicine, congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis,
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.