Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Pediatrics - Neonatal
Sample Name: Atopic Eczema

Description: 1+ year, black female for initial evaluation of a lifelong history of atopic eczema.
(Medical Transcription Sample Report)

SUBJECTIVE: This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patientís mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her. The patient is a well-developed baby. Appears stated age. Overall health is good.

FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has eczema and a positive atopic family history. No psoriasis. No known drug allergies.

CURRENT MEDICATIONS: None.

PHYSICAL EXAMINATION: The patient has eczematous changes today on her face, trunk, and extremities.

IMPRESSION: Atopic eczema.

TREATMENT:
1. Discussed condition and treatment with Mom.
2. Continue bathing twice a week.
3. Discontinue hot soapy water.
4. Discontinue Elidel for now.
5. Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch. We will see her in one month if not better otherwise on a p.r.n. basis. Send a letter to ABC Practice program.

Keywords: pediatrics - neonatal, dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel,
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