Medical Specialty:
Consult - History and Phy.

Sample Name: Gen Med Consult - 21


Description: A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis
(Medical Transcription Sample Report)


SUBJECTIVE: The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage. She does take Zyrtec on a fairly regular basis. Mom is having some allergy trouble herself right now. She does not know her colors. She knows some of her shapes. She speaks in sentences. She is not showing much interest in the potty. She is in the 80th percentile for height and weight, and still over 95th percentile for head circumference. Mom has no other concerns.

ALLERGIES: Eggs and peanuts.

OBJECTIVE:
General: Alert, very talkative little girl.
HEENT: TMs clear and mobile. Eyes: PERRL. Fundi benign. Pharynx clear. Mouth moist. Nasal mucosa is pale with clear discharge.
Neck: Supple without adenopathy.
Heart: Regular rate and rhythm without murmur.
Lungs: Clear. No tachypnea, wheezing, rales or retractions.
Abdomen: Soft and nontender without mass or organomegaly.
GU: Normal female genitalia. Tanner stage I.
Extremities: No clubbing, cyanosis or edema. Pulses 2+ and equal.
Hips: Intact.
Neurological: Normal. DTRs are 2+. Gait was normal.
Skin: Warm and dry. No rashes noted.

ASSESSMENT: Allergic rhinitis. Otherwise healthy 2-year-old young lady.

PLAN: In addition to her Zyrtec, I put her on Nasonex spray one spray each nostril daily. If this works for her, certainly she can do it through the ragweed season. Otherwise she is doing well. I talked about ways to improve her potty training. She is a very good eater. I will see her yearly or p.r.n. Unfortunately she is not able to get the flu shot due to her egg allergy.

Keywords: consult - history and phy., allergic rhinitis, nasal drainage, stuffiness, congestion, drainage,