Rash Emergency Room Medical Transcription Sample Report

CHIEF COMPLAINT: Rash.

HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old who was brought to the emergency department today by mom. Apparently, the child developed a rash over the past few days.

Mom states that the child was with her dad. She is not sure if there were different laundry detergent use or soaps; although, he tends to use the same things they do, but she is concerned because the child has developed a rash on her buttocks as well as in the front trunk area.

She thinks it may be spreading to her neck as well. She states the child scratches here and there but not excessively. There has been no fever. No vomiting. No diarrhea. Child has been acting normal. Otherwise, no complaints of pain.

PAST MEDICAL HISTORY: Negative.

MEDICATIONS: None.

IMMUNIZATIONS: Up-to-date.

SOCIAL HISTORY: Here with mom.

REVIEW OF SYSTEMS: As noted in the HPI. The remainder 10 is negative unless otherwise stated.

PHYSICAL EXAMINATION:
GENERAL: Examination reveals a (XX)-year-old who is adorable. She is awake. She is alert. She is age appropriate. She appears in absolutely no distress. She is nontoxic in appearance.
VITAL SIGNS: She is afebrile.
HEENT: Head is normocephalic and atraumatic. Pupils are equal and reactive. Extraocular movements are intact. Nares patent. Throat is clear. TMs are intact.
NECK: Soft and supple.
LUNGS: Clear without wheezes.
HEART: Regular.
ABDOMEN: Soft.
SKIN: She has evidence of a maculopapular pinpoint rash that is noted on the buttocks, somewhat in the groin area. Mom states she sees it on the neck; I really do not see it there. She states she could feel it starting to form on her back. It seems to be in the distribution of her underwear. Mom states that she has not had pull-ups on in a few days as sometimes those can tend to give her a rash.

MEDICAL DECISION MAKING: At this point, I do not know the etiology of this rash. I told mom it does not appear consistent with scabies, bed bugs, cellulitis, MRSA, nothing to suggest chickenpox or roseola. She was using some Aquaphor, which I do not think could hurt. They can use some Benadryl if she is itching; otherwise, they would see the pediatrician. Nothing to suggest anything toxic. The patient is seen in collaboration with Dr. John Doe.

CLINICAL IMPRESSION: Rash.