Sample Name: Gen Med Consult - 19
Description: 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.
(Medical Transcription Sample Report)
SUBJECTIVE: This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet. The patient is in foster care, has a long history of the prematurity, born at 22 weeks. She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic. She is on 2-1/2 liters of oxygen and does require that. Her diet has been fluctuating. They have been trying to figure out what works best with her. She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her. They have been doing more pureed foods and that seems to loosen her up, so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure. She was hospitalized a couple of weeks back for the distension she had in the abdomen. Dr. XYZ has been working with her G-tube, increasing her Mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her G-tube site is looking. She also has been seen Dr. Eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.
CURRENT MEDICATIONS: Flagyl, vitamins, Zyrtec, albuterol, and some Colace.
ALLERGIES TO MEDICINES: None.
FAMILY SOCIAL HISTORY: As mentioned, she is in foster care. Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient. Biological Mom and Grandma do visit on Thursdays for about an hour.
REVIEW OF SYSTEMS: The patient has been eating fairly well, sleeping well, doing well with her sprints. A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.
Vital Signs: She is 28 pounds 8 ounces today, 33-1/2 inches tall. She is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.
HEENT: Sclerae and conjunctivae are clear. TMs are clear. Nares are patent. Oropharynx is clear. Trach site is clear of any signs of infection.
Chest: Coarse. She has got little bit of wheezing going on, but she is moving air fairly well.
Abdomen: Positive bowel sounds and soft. The G-tube site looks fairly clean today and healthy. No signs of infection. Her tone is good. Capillary refill is less than three seconds.
ASSESSMENT: A 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.
PLAN: At this point is to continue with the Isomil and pureed baby foods, a little bit of Pediasure. They are going to see Dr. XYZ towards the end of this month and follow up with Dr. Eisenbaum. I would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand. She is just doing wonderful progression on her development. Each time I see her, I am very impressed, that relayed to foster mom. Approximately 25 minutes spent with the patient, most of it counseling.
Keywords: general medicine, chronic lung disease, signs of infection, breathing status, foster mom, foster care, pediasure,