Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 18
Description: 1-year-old male who comes in with a cough and congestion. Clinical sinusitis and secondary cough.
(Medical Transcription Sample Report)
SUBJECTIVE: 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.
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.
Keywords: consult - history and phy., congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis,