Medical Transcription Services Company

EMERGENCY ROOM NOTE:

HPI:   This is a 2 year-old male brought to the ER because of cough. The sister has a history of recent pneumonia and has been treated with Ceclor He has had a cough, fever; and vomiting for the last three days and also some slight diarrhea. His only medication is Tylenol.

PE:   On exam, he has a temp of 99.4, pulse 112, respirations 28, blood pressure 80/palp. His TMs are clear and mobile bilaterally. Throat is nonerythematous. Neck is supple without adenopathy. Chest is clear to auscultation. Breath sounds are equal bilaterally. Abdomen is soft and nontender.

IMPRESSION:  Bronchitic-type cough, probable upper respiratory tract infection with bronchitis. Will need to rule out pneumonia.

Quick Inquiry
Name
Phone
Email
Description
Type the code shown below

Bookmark-www.brainstormworld.com