Medical Transcription Ramzi Cotran

Topics: Medicine, Childbirth, Physician Pages: 2 (267 words) Published: May 19, 2013

Patient Name: Ramzi S. Cotran

Patient ID: 023672DOB:03/15/----Age: 2Sex: M

Room No.:

Consultant: Jessie D. Smith, MD, Orthopedics

Requesting Physician: Reed Phillips, MD, Pediatrics

Date of Consult: 10/01/----

Reason for Consultation: Infected Finger

HISTORY: Ramzi is an otherwise healthy 2-year-old Lebanese male child who had an injury to the distal failing of his right middle finger the day prior to being seen. The patient is left-hand dominant. The patient was brought to Dr. Phillips of Pediatrics secondary to worsening redness as well as infection of the nail bed. Orthopedics consult was requested on 09/30/---- for possible paronychia. The patient at that time was having no fevers or chills and he was tolerating his antibiotic regiment well.

PAST MEDICAL SURGICAL HISTORY: None other than circumcision shortly after birth.

BIRTH HISTORY: Normal full-term vaginal delivery.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Patient lives with his mother and a sibling, Father deceased.

PHYSICAL EXAMINATION: Ramzi is alert, oriented, playful, and in no apparent distress. The patient does have erythema surrounding the tip of his right distal failings, middle finger.

There is mild purulence from the area. The area is minimally tender to palpation. The nail appears to be lifting off from the nail bed itself. He has good capillary refill and has good flexion and extension of that finger.

ASSESSMENT: This is a 2-year-old male with paronychia.

PLAN: Follow up with me at 9am tomorrow. Mother was given my pager number should the patient’s condition worsen overnight. I will be in touch with Dr. Phillips.
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