Emergency Room Medical Transcription Sample Report
CHIEF COMPLAINT: Cellulitis and shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with history of hypertension, obstructive sleep apnea requiring CPAP machine use, morbid obesity, chronic cellulitis, and poor healing ulceration of the right lower extremity for approximately 6 months. The patient was evaluated in the emergency department yesterday and was prescribed ciprofloxacin for a secondary right lower extremity cellulitis. Labs were fairly unremarkable; however, one blood culture has returned positive for gram-positive cocci in clusters. The second blood culture so far is negative. The patient was asked to return to the emergency department today for further evaluation.
On arrival, the patient denies any new symptoms. Has not had any fevers or chills. Denies any worsening redness or pain to the right lower extremity. He states again that the poor healing ulcer and surrounding redness has been present for approximately 6 months without significant improvement, however, without significant worsening either. He reports chronic shortness of breath associated with his obstructive sleep apnea. He has been homeless for about 3 months and not been able to use his CPAP machine regularly as he usually does.
He otherwise denies any cough or sputum. Has not had any chest pain, palpitations, or lightheadedness. He denies any orthopnea or PND; however, because of his morbid obesity, he does sleep sitting upright. He has had no exertional worsening of his symptoms. No chest pain on exertion or dyspnea on exertion, worse than his baseline. He has had no change in exercise tolerance.
He was unable to pick up his prescription for ciprofloxacin and Silvadene because he could not get to the pharmacy reportedly. He has otherwise had no headache, visual disturbances, focal weakness, numbness, or any gait disturbances. He denies any trauma. Has had no joint pain, rash, or back pain. He has had no abdominal pain, vomiting, diarrhea, constipation, hematochezia, melena or any change in appetite. He has had no dysuria, hematuria, increased urinary frequency or urgency. Denies any upper respiratory infection symptoms, sore throat, or odynophagia.
REVIEW OF SYSTEMS: As stated in HPI. All other systems are reviewed and otherwise negative.
PAST MEDICAL HISTORY: Hypertension, obstructive sleep apnea, asthma, morbid obesity, chronic nonhealing right lower extremity ulcer, and long-standing cellulitis.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Ciprofloxacin, not been taking; lisinopril; diltiazem; aspirin; lovastatin; multivitamin.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Denies tobacco, alcohol, or illicit drug use.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 148/90, pulse 92, respiratory rate 21, temperature 97.5 degrees Fahrenheit oral, O2 95% on room air. Pain is 0/10.
GENERAL: This is a well-developed morbidly obese male, ambulating, and sitting upright comfortably in stretcher. Alert and oriented x3. Speaking clearly in full sentences, in no acute respiratory distress.
SKIN: Warm and dry.
HEENT: Atraumatic, normocephalic. Pupils equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are moist. Oropharynx is clear.
NECK: No JVD. Supple. Respiratory effort is normal.
LUNGS: Clear to auscultation bilaterally. No wheezes or rales.
HEART: Regular rate and rhythm. Normal S1, S2.
ABDOMEN: Obese. Soft, nontender to deep palpation in all quadrants. No rebound or guarding. Normoactive bowel sounds.
BACK: No CVA tenderness.
EXTREMITIES: Skin thickening and chronic venous stasis changes of the bilateral lower extremities. There are chronic shallow nonhealing ulcers on the lateral aspect of the right lower extremity with some surrounding erythema, however, without significant warmth. There is no fluctuance or induration. No active drainage. No proximal lymphangitic streaking. No inguinal lymphadenopathy is present. Full range of motion in all joints.
NEUROLOGICAL: Alert and oriented x3. Strength is 5/5. Sensation is intact to light touch. Gait is normal and narrow based.
MEDICAL DECISION MAKING: This is a (XX)-year-old male with history of hypertension, asthma, obstructive sleep apnea, morbid obesity, chronic lower extremity venous stasis with nonhealing ulcer and secondary infection which has been ongoing for 6 months. The patient was evaluated here yesterday where blood cultures were done, and one set of blood cultures is positive for gram-positive cocci in clusters. Given his history and to evaluate for possible worsening infectious process and bacteremia, labs will again be checked with the CBC and basic metabolic panel. Due to his chronic lower extremity swelling and complaint of shortness of breath, a BNP as well as chest x-ray will be obtained. The patient otherwise denies any chest pain. Does not appear to represent an acute coronary syndrome or cardiac etiology. Two additional repeat blood cultures were obtained and sent and they are still pending.
LABORATORY DATA/IMAGING STUDIES: CBC within normal limits. Basic metabolic panel within normal limits. Serum glucose is 120, BNP 22. Chest x-ray, single-view, portable, was read by me and shows no evidence of acute infiltrate or effusion. This appears unchanged when compared to prior chest x-ray.
EMERGENCY DEPARTMENT COURSE: The patient was treated with one dose of IV ciprofloxacin. The results were reviewed along with the patient’s recent chart, and it is felt that the single blood culture likely represents a skin contaminant. The patient is otherwise afebrile with stable vital signs and does not appear toxic otherwise. Lab work does not show significant leukocytosis or left shift and the patient does not appear to have significant underlying diabetes to suggest an immunocompromised state. Otherwise, he appears nontoxic. The patient’s complaint of shortness of breath is due to his morbid obesity and underlying obstructive sleep apnea. There is no evidence of significant fluid overload or wheezing on examination and he is not otherwise significantly hypoxic. A prescription was sent to pharmacy and the patient will be provided with a 3-day supply of antibiotics. The patient’s cousin is at the bedside and states that he will assist the patient in obtaining his medications and he does still have the prescriptions provided to him yesterday. He will follow up in 2 days for repeat wound check. The wound is shallow and does appear to have clean granulation tissue at the base. He will apply his usual dressings. He does appear stable for discharge.
CLINICAL IMPRESSION:
1. Cellulitis of leg.
2. Dyspnea, obstructive sleep apnea.
3. Medication noncompliance.
DISPOSITION: Discharged to home.
DISCHARGE INSTRUCTIONS: As stated, he will follow up in 2 days for repeat wound check. He has been given a 3-day supply of antibiotics to take as directed and will return to the emergency department for any worsening symptoms including worsening redness, fevers, chills, vomiting, or any other concerning symptoms.
CONDITION ON DISCHARGE: Stable.
