The patient was involved in a two-car accident this morning. HISTORY OF PRESENT ILLNESS: This is a 30-year-old male transported in full immobilization from an accident. Perforation of the right tympanic membrane.ĮR Medical Transcription Sample Report #2 They are to cover the ear before he takes his shower. He was given Tylenol with Codeine elixir to be used as directed and also alternating with Tylenol. We will place him on amoxicillin suspension 250 mg t.i.d. He will be discharged to home at this time. INTERVENTION: Discussion was held with the patient and with his parents. NEUROLOGIC: Without focal or local defects. No mass, guarding, rigidity, or rebound tenderness. There is no lymphadenopathy.ĬHEST: Clear with good breath sounds in all.ĬARDIAC: Regular rate and rhythm without murmur, gallop or rub.ĪBDOMEN: Soft. There is blood in the external canal and signs of perforation. There are no lesions, rashes or ecchymosis. VITALS: Blood pressure is 113/64, pulse 76, respirations 16, temperature 98 degrees, and O2 saturation 96% on room air. REVIEW OF SYSTEMS: He has had a cold for the past two to three days. They state there is no tobacco or smoking in the house however, there is an odor of tobacco about the parents. PAST MEDICAL HISTORY: Significant for recurrent asthma and for otitis media.ĬURRENT MEDICATIONS: Prednisone one teaspoon b.i.d., which he stopped today Singulair 5 mg daily and albuterol and Advair p.r.n. He is currently sitting on the cart in no acute distress and has no other complaints. He has had a cold, however, per his mother. There is no recent illness, injury or trauma. The patient now states that his pain has significantly subsided and is down to minimum, and he basically does not feel any pain at this time. The patient began complaining of acute and increasing pain approximately 30 minutes prior to arrival. Brought in by his parents with the complaint of an earache, which began yesterday, with increasing pain and pressure all evening long. HISTORY OF PRESENT ILLNESS: This is an 8-year-old child who presents to the emergency room. ER Medical Transcription Sample Reports For Medical TranscriptionistsĮR Medical Transcription Sample Report #1
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