Sample Name: Gen Med Consult - 29
Description: Patient with intermittent episodes of severe nausea and abdominal pain.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: This is a previously healthy 45-year-old gentleman. For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia. He was able to reduce this, with relief of pain. He is now being admitted for definitive repair.
PAST MEDICAL HISTORY: Significant only for hemorrhoidectomy. He does have a history of depression and hypertension.
MEDICATIONS: His only medications are Ziac and Remeron.
ALLERGIES: No allergies.
FAMILY HISTORY: Negative for cancer.
GENERAL: Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.
HEENT: No scleral icterus.
NECK: No cervical, supraclavicular, or axillary adenopathy.
HEART: Regular. No murmurs or gallops.
ABDOMEN: As noted, obese with mildly visible bulging in the umbilicus at the superior position. With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.
ASSESSMENT AND PLAN: Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.
Keywords: general medicine, sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent,