Beginning Medical Transcription
History: Ramses is an otherwise healthy, 2-year-old Lebanese male child, who had an injury to theType your answer here:Type your answer here:of his right middle finger the day prior to being seen. The patient is left hand dominant. The patient was brought to Dr. Phillips ofType your answer here: secondary to worsening redness, as well as infection of the nail bed. Orthopedics consult was requested on 09/30/—- for possibleType your answer here:. The patient at that time was having no fevers or chills, and he was tolerating hisType your answer here: regiment well.
Past Medical/Surgical History: None other thanType your answer here: shortly after birth.
Birth History: Normal, full-term vaginal delivery.
Family History:Type your answer here:
Social History: Patient lives with his mother and a sibling. Father deceased.
Physical Examination: Ramses is alert, oriented, playful, and of no apparentType your answer here: The patient does haveType your answer here:surrounding the tip of his right distal phalanx (middle finger).
There is mildType your answer here: from the area. The area is minimally tender toType your answer here:.The nail appears to be lifting off from the nail bed itself. He has goodType your answer here:refill, and has goodType your answer here: andType your answer here: of that finger.
Assessment: This is a 2-year-old male withType your answer here:
Plan: Follow-up with me at 9 a.m. tomorrow. Mother was given my pager number should the patient’s condition worsen overnight. I will be in touch with Dr. Phillips.
Jesse D. Smith, M.D., Orthopedics