Sample Type / Medical Specialty: Consult - History and Phy.
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.

SOCIAL HISTORY: He is single. He has 2 children. He drinks 4-8 beers per night and smokes half a pack per day for 30 years. He was born in Salt Lake City. He works in an electronic assembly for Harmony Music. He has no history of hepatitis or blood transfusions.

PHYSICAL EXAMINATION:
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.
LUNGS: Clear.
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.

DIAGNOSTIC STUDIES: Normal sinus rhythm on EKG, prolonged QT. Chest x-ray was negative. The abdominal x-rays were read as being negative. His electrolytes were normal. Creatinine was 0.9. White count was 6.5, hematocrit was 48, and platelet count was 307.

ASSESSMENT AND PLAN: Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.

Keywords: consult - history and phy., sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent,