Sample Name: Gen Med Consult - 41
Description: Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night.
PAST MEDICAL HISTORY: She denies sexual activities since two years ago. Her last menstrual period was 06/01/2004. Her periods have been irregular. She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family. Mom and maternal aunt have had total hysterectomies. She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen. She avoids decongestants. She is limited on her activity secondary to her heart condition.
ALLERGIES: No known drug allergies.
Vital Signs: Blood pressure is 124/72. Temperature 99.2. Respirations 20 unlabored. Weight: 137 pounds.
Neck: Supple. Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.
Respiratory: Clear. No wheezes, no crackles, no tachypnea, and no retractions.
Cardiovascular: Regular rate and rhythm. S1 and S2 normal, no murmur.
Abdomen: Soft. No organomegaly. She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable. She has no suprapubic tenderness.
Extremities: She has good range of motion of upper and lower extremities. Good ambulation.
Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria. Culture and sensitivity is pending. Her Strep test is negative. Culture is pending.
1. Urinary dysuria.
PLAN: A 1 g of Rocephin IM was given. Call Dr. B's office tomorrow morning incase a second IM dose is needed. If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug. Push fluids. Await strep culture report. Follow up with Dr. XYZ if no better or symptoms worsen.
Keywords: general medicine, backache, stomachache, dysuria, cylert, urinary dysuria, pharyngitis, culture and sensitivity, tenderness, urinary, infection,