Pediatric Chart Note Medical Transcription Sample Reports
Pediatric Chart Note Medical Transcription Sample Report #1
SUBJECTIVE: The patient was seen for his 1-month visit. He is here today with both of his parents. He is taking 2 to 4 ounces of soy every few hours with still slight spitting but not every feed. He seems fussy a bit. Bowel movements are yellow, once a day, but they can be thick, like peanut butter. Peeing well. Sibling is fine. His sister is fine with him. He is not sleeping great. He has been up every 20 minutes, especially at night. He likes to be upright. Mylicon helped a bit initially. The mother is saying again that he is fussy quite a bit. We discussed the possibilities and wondering whether he could have some reflux and that is why he is fussy.
REVIEW OF SYSTEMS: His mother says his right eye is goopy. It was goopy initially. Now, both eyes are goopy. We discussed a blocked tear duct.
PAST MEDICAL HISTORY: Noncontributory.
MEDICATIONS: Some occasional Mylicon.
PHYSICAL EXAMINATION: His height is 21-1/2 inches, which is 49th percentile. Weight is 9 pounds 1 ounce, which is the 31st percentile. It is up a pound and a half from his last visit, which was approximately 3 weeks ago, so he is certainly gaining an ounce a day. Head circumference is 14-3/4, which is the 34th percentile. He is an alert male in no acute distress. Skin is pink. No jaundice. Anterior fontanelle open and flat. TMs normal bilaterally. Red reflex bilaterally. Pupils are equal and reactive to light. Throat: Negative. Neck: Negative. Heart: Regular rate and rhythm with equal femoral pulses. Lungs: Clear to auscultation. Abdomen: Soft, positive bowel sounds. No hepatosplenomegaly. Genitalia show descended testes. Hips are negative. Neurologic: He is alert. He has got good tone, nonfocal.
IMPRESSION: A well 1-month-old male.
PLAN:
1. Ranitidine was e-prescribed to CVS.
2. Erythromycin eye ointment was also e-prescribed for presumptive conjunctivitis.
3. Hepatitis B #2 was given.
4. Physical examination at 2 months.
5. Hip ultrasound will be ordered as he was breeched just to rule out DHD.
6. Mother is to call if the fussiness persists and certainly to let us know if the ranitidine is helping.
Pediatric Chart Note Medical Transcription Sample Report #2
The patient was seen for his 2-week checkup. He is here today with both his parents.
FAMILY HISTORY: Dad is 6 feet 2 inches. Mom is 5 feet 2 inches. This is dad’s first child. Mom has an older daughter from another relationship. Dad has a history of recently elevated blood pressure. They both have no other medical history. No asthma. No allergies. The patient lives with his sibling and his mom and his dad.
BIRTH HISTORY: The child was born with Apgars of 8 and 9. Birth weight was 6 pounds 12 ounces. Hep B was given on MM/DD/YYYY. His newborn screen was done; it was completely normal. Mom was O+, baby O- and Coombs negative. The OB history is significant for SGA breech and HSV. Baby was born via repeat C-section for breech. Discharge weight was not recorded. Diet: Baby is taking Good Start anywhere from 2 to 4 ounces every 3 hours. Mom says it is really up and down. He really takes 4 ounces and then only 2. He has some spitting more recently. His urination is fine. Bowel movements are almost every feed. They go anywhere from yellow to green. We told him to watch if it really stays green. Sleeping: He sleeps in bassinet; basically, he does not really like it. He likes to be held. We reviewed ways of adjusting the bassinet to make it more like the car seat with a little elevation and maybe he would like it more. His siblings are doing fine with him. Concerns: Dad has had some questions about hiccups and the cord came off about 2 days ago. No one smokes at home. Grandmother smokes in neighboring home.
PHYSICAL EXAMINATION: His height is 20 inches and his weight 7.625 pounds, which is above birth weight. Head circumference is 14.25 inches. His weight is 45th percentile. His length is in the 62nd percentile. His head circumference is in the 58th percentile. He is an alert male in no acute distress. Skin shows no jaundice. There is a slight hemangioma on the left eyelid. No other birth marks. Red reflexes bilaterally. Throat negative; although, his chin is a little recessed. TMs are normal bilaterally. His right earlobe has a significant increase in it. Neck: Negative. Heart: Regular rate and rhythm with equal femoral pulses. Lungs: Clear to auscultation. Abdomen: Soft, positive bowel sounds. No hepatosplenomegaly. Nondistended. Cord is a healing cord. Genitalia show a small scrotum. Had difficulty palpating left testis. The right testis, I could palpate easily. Hips are negative. Neurologic: He is very alert. He has got good tone. DTRs are equal, nonfocal.
IMPRESSION:
1. A well 2-week-old, a pound above birth weight.
2. C-section secondary to breech, potential for DHD.
PLAN:
1. Physical examination at 1 month.
2. Call if rectal temperature greater than or equal to 100.4.
3. Anticipatory guidance given about safety, diet, behavior.
4. When I see the patient at a month of age, we will discuss doing just a screening hip ultrasound, as he was breech.
5. Call with any concerns.
Pediatric Chart Note Medical Transcription Sample Report #3
REASON FOR VISIT: The patient was seen due to cold signs and symptoms.
HISTORY OF PRESENT ILLNESS: The patient is here today with her mom and her older sister. She has had a cold for 24 hours. Mom is just starting it as well and her sister is fine. She has a cough and rhinorrhea. Mom says she sounds wheezy. She slept okay, ate fine, drinking fine, peeing fine. No vomiting. No fever. Nasal discharge. Her mood is slightly off.
PAST MEDICAL HISTORY: Noncontributory.
ALLERGIES: She has no known drug allergies.
MEDICATIONS: None.
PHYSICAL EXAMINATION: Her temperature is 99.4. Her weight is 17 pounds 8 ounces. She is an alert female in no acute distress, really quite happy for 99% of the time, very playful, interactive, in no distress. Skin: Normal. Anterior fontanelle open and flat. TMs perfect bilaterally. Throat: Negative. Neck: Negative. Heart: Regular rate and rhythm. Abdomen: Normal. Neurologic: Nonfocal. Lungs: There is some very fine end inspiratory wheezing in the left upper lobe and slightly in the right upper lobe. Her back is more clear. There is no retraction. There is normal respiratory rate, maybe a few rhonchi on the back.
We did a pulse oximetry after the examination. Her heart rate was 165. Her pulse oximetry was at least 94. It ended up getting pulled off, but it ran at least to 94. We think it probably was higher. We gave her 1.25 mg albuterol nebulizer. The nebulizer was given at about 2:30 or 2:45. After the nebulizer, her lungs were very clear to auscultation. There was excellent aeration. We attempted to do a second pulse oximetry, but the patient would not keep it on her finger.
IMPRESSION: Bronchiolitis, questionable respiratory syncytial virus.
PLAN:
1. We reviewed RSV bronchiolitis with the mom, that it might increase her risk for wheezing. Her sister apparently does wheeze with sports.
2. As mentioned, we did a pulse oximeter and a heart rate before the nebulizer.
3. Albuterol 1.25 mg nebulizer was given.
4. Mom has a nebulizer at home from her sister, so we called in albuterol 1.25 mg per 3 mL to CVS and advised mom to do it minimally t.i.d. until she is 100%. She certainly can do it as much as every 4-6 hours as needed.
5. We would like to recheck her in a few days.
6. Mom is going to call with increasing signs and symptoms. We explained that if she needs the nebulizer frequently or the patient seems in distress or if she is not eating or drinking well, to certainly give us a call.
Pediatric Chart Note Medical Transcription Sample Report #4
HISTORY OF PRESENT ILLNESS: The patient was seen due to worsening cold signs and symptoms. We had seen the patient and determined he may have an upper respiratory infection or maybe a very early bronchiolitis. Dad says that he had a low-grade fever since then, increased temperature though today. Increased cough, more raspy. Breathing seems more heavy. His activity was very low until he got to the office. Dad was shocked at the office how happy and playful he is. He slept a lot today, but he is definitely perkier now. Drinking well, not so much solids. Sleeping okay.
PAST MEDICAL HISTORY: Significant for severe hypospadias, which has been repaired and a VSD followed by Cardiology.
MEDICATIONS: At 1:30 p.m., Tylenol. He was seen at about 4:00.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION: Vital Signs: Temperature was 101.4. General: He is a very alert, playful male here in the office, completely non-ill appearing. Left tympanic membrane is perfect. Right tympanic membrane is markedly red. Throat: Negative. Neck: Negative. Skin: Negative. Heart: Regular rate and rhythm. Lungs: Very clear to auscultation. We can hear some noise coming from his nose, but his lungs are very clear. There is no wheeze. There is good respiratory rate. No retractions. Excellent aeration. Abdomen: Normal. Neurological: Nonfocal.
IMPRESSION:
1. Upper respiratory infection.
2. Fever.
3. Right otitis media.
PLAN:
1. Continue with supportive care, pushing fluids.
2. Amoxicillin was e-prescribed to CVS.
3. Call with increasing signs and symptoms, if fever persists more than another couple of days or any concerns.
4. Follow up p.r.n. and recheck his ear at his PE in 5 days or so.
