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Write a clinical note about a patient with the following chief complaint: Urinary retention. | CHIEF COMPLAINT: Urinary retention. HISTORY OF PRESENT ILLNESS: This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time. Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably secondary to dehydration. He was seen by urology again at this visit for urinary retention. He had been seen by urology during a previous hospitalization and he passed his voiding trial at the time of his stent removal on 01/22/08. Cystoscopy showed at that time obstructive BPH. He was started on Flomax at the time of discharge from the hospital. During the most recent readmission on 02/04/08, he went back into urinary retention and he had had a Foley placed at the outside hospital. REVIEW OF SYSTEMS: Positive for blurred vision, nasal congestion, and occasional constipation. Denies chest pain, shortness of breath or any rashes or lesions. All other systems were reviewed and found to be negative. PAST MEDICAL HISTORY: 1. End-stage renal disease, now status post deceased donor kidney transplant in 12/07. 2. Hypertension. 3. History of nephrolithiasis. 4. Gout. 5. BPH. 6. DJD. PAST SURGICAL HISTORY: 1. Deceased donor kidney transplant in 12/07. 2. Left forearm and left upper arm fistula placements. FAMILY HISTORY: Significant for mother with an unknown type of cancer, possibly colon cancer or lung and prostate problems on his father side of the family. He does not know whether his father side of the family had any history of prostate cancer. HOME MEDICATIONS: 1. Norvasc. 2. Toprol 50 mg. 3. Clonidine 0.2 mg. 4. Hydralazine. 5. Flomax. 6. Allopurinol. 7. Sodium bicarbonate. 8. Oxybutynin. 9. Coumadin. 10. Aspirin. 11. Insulin 70/30. 12. Omeprazole. 13. Rapamune. 14. CellCept. 15. Prednisone. 16. Ganciclovir. 17. Nystatin swish and swallow. 18. Dapsone. 19. Finasteride. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: GENERAL: This is a well-developed, well-nourished male, in no acute distress. VITAL SIGNS: Temperature 98, blood pressure 129/72, pulse 96, and weight 175.4 pounds. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm with a 3/6 systolic murmur. ABDOMEN: Right lower quadrant incision site scar well healed. Nontender to palpation. Liver and spleen not enlarged. No hernias appreciated. PENIS: Normal male genitalia. No lesions appreciated on the penis. Previous DRE showed the prostate of approximately 40 grams and no nodules. Foley in place and draining clear urine. The patient underwent fill and pull study, in which his bladder tolerated 120 ml of sterile water passively filling his bladder. He spontaneously voided without the Foley 110 mL. ASSESSMENT AND PLAN: This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since the kidney transplant in 12/07. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again. We discussed with Mr. Barker that he has a urologist closer to his home and he lives approximately 3 hours away; however, he desires to continue follow up with the urology clinic at MCG and has been set up for followup in 6 weeks. He was also given a prescription for 6 months of Flomax and Proscar. He did not have a PSA drawn today as he had a catheter in place, therefore his PSA could be falsely elevated. He will have PSA level drawn either just before his visit for followup. |
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Write a clinical note about a patient with the following chief complaint: Right distal ureteral calculus. | CHIEF COMPLAINT: Right distal ureteral calculus. HISTORY OF PRESENT ILLNESS: The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement. PAST MEDICAL HISTORY: 1. Prostatism. 2. Coronary artery disease. PAST SURGICAL HISTORY: 1. Right spermatocelectomy. 2. Left total knee replacement in 1987. 3. Right knee in 2005. MEDICATIONS: 1. Coumadin 3 mg daily. 2. Fosamax. 3. Viagra p.r.n. ALLERGIES: NONE. REVIEW OF SYSTEMS: CARDIOPULMONARY: No shortness of breath or chest pain. GI: No nausea, vomiting, diarrhea or constipation. GU: Voids well. MUSCULOSKELETAL: No weakness or strokes. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL APPEARANCE: An alert male in no distress. HEENT: Grossly normal. NECK: Supple. LUNGS: Clear. HEART: Normal sinus rhythm. No murmur or gallop. ABDOMEN: Soft. No masses. GENITALIA: Normal penis. Testicles descended bilaterally. RECTAL: Examination benign. EXTREMITIES: No edema. IMPRESSION: Right distal ureteral calculus. PLAN: Right ureteroscopy, ureteral lithotripsy. Risks and complications discussed with the patient. He signed a true informed consent. No guarantees or warrantees were given. |
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Write a clinical note about a patient with the following chief complaint: Testicular pain. | CHIEF COMPLAINT: Testicular pain. HISTORY OF PRESENT ILLNESS: The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning. He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it. Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful. He had no voiding or stooling problems. No nausea, vomiting or fever. Family denies trauma or dysuria. At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved. He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning. He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation. He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago. He is on no medications and he is here for evaluation. PAST MEDICAL HISTORY: The patient has no known allergies. He is term delivery via spontaneous vaginal delivery. He has had no problems or hospitalizations with circumcision. PAST SURGICAL HISTORY: He has had no previous surgeries. REVIEW OF SYSTEMS: All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago. IMMUNIZATIONS: Up-to-date. FAMILY HISTORY: The patient lives at home with both parents who are Spanish speaking. He is not in school. MEDICATIONS: He is on no medications. PHYSICAL EXAMINATION: VITAL SIGNS: On physical exam, weight is 15.9 kg. GENERAL: The patient is a cooperative little boy. HEENT: Normal head and neck exam. No oral or nasal discharge. NECK: Without masses. CHEST: Without masses. LUNGS: Clear. CARDIAC: Without murmurs or gallops. ABDOMEN: Soft. No masses or tenderness. His scrotum did not have any swelling at the present time. There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted. No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only. His left testis was slightly harder than the right, but this was not very significant. EXTREMITIES: He had full range of motion in all 4 extremities. SKIN: Warm, pink, and dry. NEUROLOGIC: Grossly intact. LABORATORY DATA: Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left. This is personally reviewed by me. The right was normal. No masses were appreciated. There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study. ASSESSMENT/PLAN: The patient has a possibly torsion detorsion versus other acute testicular problem. If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found. I discussed the pre and postsurgical care with the parents. Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure. The parents understand and wished to proceed. We will schedule this later today emergently. |
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Write a clinical note about a patient with the following chief complaint: "Bloody bump on penis.", | CHIEF COMPLAINT: "Bloody bump on penis.",HISTORY OF PRESENT ILLNESS: This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis. The patient states that he has had a large bump on the end of his penis for approximately a year and a half. He states that it has never bled before. It has never caused him any pain or has never been itchy. The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years. He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice. The patient does state that last night he was "trying to get some," meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis. The patient said that there is a large amount of blood from this injury. This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding. The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed. The patient denies any drainage or discharge from his penis. He denies fevers or chills recently. He also denies nausea or vomiting. The patient has not had any discharge from his penis. He has not had any other skin lesions on his penis that are new to him. He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years. The patient has never had these checked out. He denies fevers, chills, or night sweats. He denies unintentional weight gain or loss. He denies any other bumps, rashes, or lesions throughout the skin on his body. PAST MEDICAL HISTORY: No significant medical problems. PAST SURGICAL HISTORY: Surgery for excision of a bullet after being shot in the back. SOCIAL HABITS: The patient denies illicit drug usage. He occasionally smokes tobacco and drinks alcohol. MEDICATIONS: None. ALLERGIES: No known medical allergies. PHYSICAL EXAMINATION: GENERAL: This is an African-American male who appears his stated age of 29 years. He is well nourished, well developed, in no acute distress. The patient is pleasant. He is sitting on a Emergency Department gurney. VITAL SIGNS: Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air. HEART: Regular rate and rhythm. Clear S1, S2. No murmur, rub, or gallop is appreciated. LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. ABDOMEN: Soft, nontender, nondistended, and positive bowel sounds throughout. GENITOURINARY: The patient's external genitalia is markedly abnormal. There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus. This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter. The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well. There are no open lesions at this point. There is a small tear of the skin where the mass attaches to the glans near the urethral meatus. Bleeding is currently stanch, and there is no sign of secondary infection at this time. Bilateral testicles are descended and normal without pain or mass bilaterally. There is no inguinal adenopathy. EXTREMITIES: No edema. SKIN: Warm, dry, and intact. No rash or lesion. DIAGNOSTIC STUDIES: Non-emergency department courses. It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass. ASSESSMENT AND PLAN: Penile mass. The patient does have a large pedunculated penile mass. He will be referred to the urologist who is on-call today. The patient will need this mass excised and biopsied. The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER. |
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Write a clinical note about a patient with the following chief complaint: Penile discharge, infected-looking glans. | CHIEF COMPLAINT: Penile discharge, infected-looking glans. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for wet gangrene. The patient was transferred to Nursing Home and presents today from the nursing home with complaints of bleeding from the right AKA stump and penile discharge. As per the patient during his hospitalizations over here, he had indwelling Foley catheter for a few days and when he was discharged at the nursing home he was discharged without the catheter. However, the patient was brought back to the ED today when he suffered fall yesterday and started bleeding from his stump. While placing the catheter in the ED on retraction of foreskin purulent discharge was seen from the penis and the glans appeared infected, so urology consult was placed. REVIEW OF SYSTEMS: Negative except as in the HPI. PAST MEDICAL HISTORY: Significant for end-stage renal disease on dialysis, hypertension, peripheral vascular disease, coronary artery disease, congestive heart failure, diabetes, and hyperlipidemia. PAST SURGICAL HISTORY: Right AKA,MEDICATIONS: Novolin, Afrin, Nephro-Vite, Neurontin, lisinopril, furosemide, Tums, labetolol, Plavix, nitroglycerin, Aricept, omeprazole, oxycodone, Norvasc, Renagel, and morphine. ALLERGIES: PENICILLIN and ADHESIVE TAPE. FAMILY HISTORY: Significant for hypertension, hyperlipidemia, diabetes, chronic renal insufficiency, and myocardial infarction. SOCIAL HISTORY: The patient lives alone. He is unemployed, disabled. He has history of tobacco use in the past. He denies alcohol or drug abuse. PHYSICAL EXAMINATION: GENERAL: A well-appearing African-American male lying comfortably in bed, in acute distress. NECK: Supple. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: S1 and S2, normal. ABDOMEN: Soft, nondistended, and nontender. GENITOURINARY: Penis is not circumcised. Currently, indwelling Foley catheter in place. On retraction of the foreskin, pale-looking glans tip with areas of yellow-white tissue. The proximal glans appeared pink. The patient currently has indwelling Foley catheter and glans slightly tender to touch. However, no purulent discharge was seen on compression of the glans. Otherwise on palpation, no other deformity noticed. Bilateral testes descended. No palpable abnormality. No evidence of infection in his perineal area. EXTREMITIES: Right AKA. NEUROLOGIC: Awake, alert, and oriented. No sensory or motor deficit. LABORATORY DATA: I independently reviewed the lab work done on the patient. The patient had a UA done in the ED which showed few bacteria, white blood cells 6 to 12, and a few epithelial cells which were negative. His basic metabolic panel with creatinine of 7.2 and potassium of 5, otherwise normal. CBC with a white blood cell count of 11.5, hemoglobin of 9.5, and INR of 1.13. IMPRESSION: A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. I think it is due to chronic ischemic changes. RECOMMENDATIONS: Our recommendation would be: 1. To remove the Foley catheter. 2. Local hygiene. 3. Local application of bacitracin ointment. 4. Antibiotic for urinary tract infection. 5. Follow up as needed. Of note, it was explained to the patient that the appearance of this glans may improve or may get worsened but at this point, there is no indication to operate on him. If increased purulent discharge, the patient was asked to call us sooner, otherwise follow up as scheduled. |
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Write a clinical note about a patient with the following chief complaint: Penile cellulitis status post circumcision. | CHIEF COMPLAINT: Penile cellulitis status post circumcision. HISTORY OF PRESENT ILLNESS: The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin. He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago. The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103. He was seen at Hospital, transferred to Children's Hospital for further care. Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant. He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother. I was requested a consultation by Dr. X because of the appearance of penis. The patient has been voiding without difficulty throughout. PAST MEDICAL HISTORY: The patient has no known allergies. He was a term delivery via vaginal delivery. Surgeries; he has had 2 circumcisions. No other hospitalizations. He has had no heart murmurs, seizures, asthma, or bronchitis. REVIEW OF SYSTEMS: A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned. He also had an ear infection about 1 to 2 weeks before his circumcision. SOCIAL HISTORY: The patient lives with both parents and no siblings. There are smokers at home. MEDICATIONS: Clindamycin and bacitracin ointment. Also Bactrim. PHYSICAL EXAMINATION: VITAL SIGNS: Weight is 14.9 kg. GENERAL: The patient was sleepy but easily arousable. HEAD AND NECK: Grossly normal. His neck and chest are without masses. NARES: He had some crusted nares; otherwise, no other discharge. LUNGS: Clear. CARDIAC: Without murmurs or gallops. ABDOMEN: Soft without masses or tenderness. GU: He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema. There was some induration around the penis; however, there were no signs of active infection. He has a buried appearance of the penis after recent circumcision with a normal appearing glans. The tissue itself, however, was quite dull and is soft or readily retractable at this time. The scrotum was normal, and there was no erythema, there was no tenderness. Both testes were descended without hydroceles. EXTREMITIES: He has full range of motion of all 4 extremities. SKIN: Warm, pink, and dry. NEUROLOGIC: Grossly intact. BACK: Normal. IMPRESSION/PLAN: The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis. This is being treated, but it is most likely Staph and pending sensitivities. I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad. I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day. I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely. Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so. He has a scheduled followup appointment with his urologist and he should keep that appointment or followup sooner if there is any other problem arising. |
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Write a clinical note about a patient with the following chief complaint: Foul-smelling urine and stomach pain after meals. | CHIEF COMPLAINT: Foul-smelling urine and stomach pain after meals. HISTORY OF PRESENT ILLNESS: Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time. She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI. This visit was in July 2010. REVIEW OF SYSTEMS: HEENT: No headaches. No visual disturbances, no eye irritation. No nose drainage or allergic symptoms. No sore throat or masses. Respiratory: No shortness of breath. No cough or wheeze. No pain. Cardiac: No palpitations or pain. Gastrointestinal: Pain and cramping. Denies nausea, vomiting, or diarrhea. Has some regurgitation with gas after meals. Genitourinary: "Smelly" urine. Musculoskeletal: No swelling, pain, or numbness. MEDICATION ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: General: Unremarkable. HEENT: PERRLA. Gaze conjugate. Neck: No nodes. No thyromegaly. No masses. Lungs: Clear. Heart: Regular rate without murmur. Abdomen: Soft, without organomegaly, without guarding or tenderness. Back: Straight. No paraspinal spasm. Extremities: Full range of motion. No edema. Neurologic: Cranial nerves II-XII intact. Deep tendon reflexes 2+ bilaterally. Skin: Unremarkable. LABORATORY STUDIES: Urinalysis was done, which showed blood due to her period and moderate leukocytes. ASSESSMENT: 1. UTI. 2. GERD. 3. Dysphagia. 4. Contraception consult. PLAN: 1. Cipro 500 mg b.i.d. x five days. Ordered BMP, CBC, and urinalysis with microscopy. 2. Omeprazole 20 mg daily and famotidine 20 mg b.i.d. 3. Prescriptions same as #2. Also referred her for a barium swallow series to rule out a stricture. 4. Ortho Tri-Cyclen Lo. |
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Write a clinical note about a patient with the following chief complaint: Left flank pain and unable to urinate. | CHIEF COMPLAINT: Left flank pain and unable to urinate. HISTORY: The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels much better today. I was consulted by Dr. X. MEDICATIONS: Ritalin 50 a day. ALLERGIES: To penicillin. PAST MEDICAL HISTORY: ADHD. SOCIAL HISTORY: No smoking, alcohol, or drug abuse. PHYSICAL EXAMINATION: She is awake, alert, and quite comfortable. Abdomen is benign. She points to her left flank, where she was feeling the pain. DIAGNOSTIC DATA: Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones. LABORATORY WORK: Showed white count 6200, hematocrit 44.7. Liver function tests and amylase were normal. Urinalysis 3+ bacteria. IMPRESSION: 1. Left flank pain, question etiology. 2. No evidence of surgical pathology. 3. Rule out urinary tract infection. PLAN: 1. No further intervention from my point of view. 2. Agree with discharge and followup as an outpatient. Further intervention will depend on how she does clinically. She fully understood and agreed. |
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Write a clinical note about a patient with the following history of present illness: This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. Timing (onset/frequency): Onset was 6 months ago. Patient denies fever and chills and denies flank pain. | CHIEF COMPLAINT: This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. Timing (onset/frequency): Onset was 6 months ago. Patient denies fever and chills and denies flank pain. ALLERGIES: Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia. MEDICATION HISTORY: Patient is not currently taking any medications. PAST MEDICAL HISTORY: Childhood Illnesses: (+) asthma, Cardiovascular Hx: (-) angina, Renal / Urinary Hx: (-) kidney problems. PAST SURGICAL HISTORY: Patient admits past surgical history of appendectomy in 1992. SOCIAL HISTORY: Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use. FAMILY HISTORY: Patient admits a family history of gout attacks associated with father. REVIEW OF SYSTEMS: Unremarkable with exception of chief complaint. PHYSICAL EXAM: BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6,The patient is a pleasant, 61-year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus. Neck: Neck is normal and symmetrical, without swelling or tenderness. Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted. Respiratory: Respirations are even without use of accessory muscles and no intercostal retractions noted. Breathing is not labored, diaphragmatic, or abdominal. Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted. Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks. Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness. Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted. Liver and/or Spleen: no abnormalities, tenderness, or masses noted. Stool specimen not indicated. Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, or tenderness noted. Scrotum: no abnormalities. No lesions, rash, or sebaceous cyst noted. Epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness. Testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted. Urethral Meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted. Penis: no abnormalities; circumcised; no phimosis, Peyronie's, condylomata, or lumps noted. Prostate: size 60 gr, RT>LT and firm. Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted. Sphincter tone: no abnormalities; good tone; without hemorrhoids or masses. Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed. Neurological/Psychiatric: Oriented to person, place and time. Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation. TEST RESULTS: No tests to report at this time. IMPRESSION: Elevated prostate specific antigen (PSA). PLAN: Cystoscopy in the office. DIAGNOSTIC & LAB ORDERS: Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA). Ordered ultrasound of prostate. I have discussed the findings of this follow-up evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP surgical procedure; risks, complications, benefits, and alternative measures discussed. There are no activity restrictions . Instructed Ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. Questions answered. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at 327-8850. PRESCRIPTIONS: Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: No,PATIENT INSTRUCTIONS: Patient completed benign prostatic hypertrophy questionnaire. |
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Write a clinical note about a patient with the following chief complaint: Recurrent bladder tumor. | CHIEF COMPLAINT: Recurrent bladder tumor. HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006. This was followed by bladder instillation of BCG. At this time, the patient denies any voiding symptoms or hematuria. The patient opting for TUR and electrofulguration of the recurrent tumors. ALLERGIES: None known. MEDICATIONS: Atenolol 5 mg daily. OPERATIONS: Status post bilateral knee replacements and status post TUR of bladder tumors. REVIEW OF SYSTEMS: Other than some mild hypertension, the patient is in very, very good health. No history of diabetes, shortness of breath or chest pain. PHYSICAL EXAMINATION: Well-developed and well-nourished woman, alert and oriented. Her lungs are clear. Heart, regular sinus rhythm. Back, no CVA tenderness. Abdomen, soft and nontender. No palpable masses. IMPRESSION: Recurrent bladder tumors. PLAN: The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand. |
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Write a clinical note about a patient with the following chief complaint: Blood in urine. | CHIEF COMPLAINT: Blood in urine. HISTORY OF PRESENT ILLNESS: This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine. The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool. The patient has not had any fever. There is no abdominal pain and the patient is still able to pass urine. The patient has not had any melena or hematochezia. There is no nausea or vomiting. The patient has already completed chemotherapy and is beyond treatment for his cancer at this time. The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer. The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever or chills. The patient does report generalized fatigue and weakness over the past several days. HEENT: No headache, no neck pain, no rhinorrhea, no sore throat. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days. GASTROINTESTINAL: The patient denies any abdominal pain. No nausea or vomiting. No changes in the bowel movement. No melena or hematochezia. GENITOURINARY: A gross hematuria since yesterday as previously described. The patient is still able to pass urine without difficulty. The patient denies any groin pain. The patient denies any other changes to the genital region. MUSCULOSKELETAL: The chronic lower back pain which has not changed over these past few days. The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either. SKIN: No rashes or lesions. No easy bruising. NEUROLOGIC: No focal weakness or numbness. No incontinence of urine or stool. No saddle paresthesia. No dizziness, syncope or near-syncope. ENDOCRINE: No polyuria or polydipsia. No heat or cold intolerance. HEMATOLOGIC/LYMPHATIC: The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria. PAST MEDICAL HISTORY: Prostate cancer with metastatic disease as previously described. PAST SURGICAL HISTORY: TURP. CURRENT MEDICATIONS: Morphine, Darvocet, Flomax, Avodart and ibuprofen. ALLERGIES: VICODIN. SOCIAL HISTORY: The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be pale, but otherwise looks well. The patient is calm, comfortable. The patient is pleasant and cooperative. HEENT: Eyes normal with clear conjunctivae and corneas. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx normal without any sign of infection. Mucous membranes are moist. NECK: Supple. Full range of motion. No JVD. CARDIOVASCULAR: Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop. Peripheral pulses are +2. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruit. No masses or pulsatile masses. GENITOURINARY: The patient has normal male genitalia, uncircumcised. There is no active bleeding from the penis at this time. There is no swelling of the testicles. There are no masses palpated to the testicles, scrotum or the penis. There are no lesions or rashes noted. There is no inguinal lymphadenopathy. Normal male exam. MUSCULOSKELETAL: Back is normal and nontender. There are no abnormalities noted to the arms or legs. The patient has normal use of the extremities. SKIN: The patient appears to be pale, but otherwise the skin is normal. There are no rashes or lesions. NEUROLOGIC: Motor and sensory are intact to the extremities. The patient has normal speech. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: There is no evidence of bruising noted to the body. No lymphadenitis is palpated. EMERGENCY DEPARTMENT TESTING: CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6. Neutrophils were 81%. The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable. Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable. Alkaline phosphatase was 770 and albumin was 2.4. Rest of the values all are within normal limits of the LFTs. Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's. The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen. Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3. EMERGENCY DEPARTMENT COURSE: The patient was given normal saline 2 liters over 1 hour without any adverse effect. The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect. The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department. The patient did not have an adverse reaction to these medicines either. Phenergan resolved his nausea and morphine did relieve his pain and make him pain free. I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion. It was all a matter of what the patient wished to do given the advanced stage of his cancer. Dr. X was willing to assist in any way the patient wished him to. I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion. The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight. The patient's son felt comfortable with his father's choice. This was done. The patient was transfused 2 units of packed red blood cells after appropriately typed and match. The patient did not have any adverse reaction at any point with his transfusion. There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength. Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction. Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder. The patient was given a leg bag and the Foley catheter was left in place. DIAGNOSES,1. HEMATURIA. 2. PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE. 3. SIGNIFICANT ANEMIA. 4. URINARY OBSTRUCTION. CONDITION ON DISPOSITION: Fair, but improved. DISPOSITION: To home with his son. PLAN: We will have the patient follow up with Dr. X in his office in 2 days for reevaluation. The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight. The patient was encouraged to drink extra water. The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern. |
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Write a clinical note about a patient with the following chief complaint: The patient comes for bladder instillation for chronic interstitial cystitis. | CHIEF COMPLAINT: The patient comes for bladder instillation for chronic interstitial cystitis. SUBJECTIVE: The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not think she can take any more pain. She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help. They seem to be intensifying her pain. She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine. So, she has to have somebody come with her and that is kind of troublesome to her. We discussed this at length. I did suggest that it was completely appropriate for her to decide. She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality. She had Hysterectomy in the past. MEDICATIONS: Premarin 1.25 mg daily, Elmiron 100 mg t.i.d. Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily. ALLERGIES: Compazine and Allegra. OBJECTIVE: Vital Signs: Weight: 140 pounds. Blood pressure: 132/90. Pulse: 102. Respirations: 18. Age: 27. PLAN: We discussed going for another evaluation by Dr. XYZ and seeking his opinion. She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete. The instillations give that a full trial and then he would be willing to see her back. As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her. She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend. I thought that was reasonable and agreed that that would work out. PROCEDURE: : She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine. We waited about 20 minutes. The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed. The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder. She seemed to tolerate it moderately well. She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it. If not, she will cancel and will start over next week or she will see Dr. Friesen. |
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Write a clinical note about a patient with the following chief complaint: Bladder cancer. | CHIEF COMPLAINT: Bladder cancer. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall. Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan. This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement. All of this workup was found to be grossly negative. Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis. The patient presents today for evaluation by Dr. Y. PAST MEDICAL HISTORY: Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication. The patient denies coronary artery disease. PAST SURGICAL HISTORY: Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2. The patient denies any bowel resection or GU injury at that time; however, he is unsure. CURRENT MEDICATIONS: 1. Metoprolol 100 mg b.i.d. 2. Diltiazem 120 mg daily. 3. Hydrocodone 10/500 mg p.r.n. 4. Pravastatin 40 mg daily. 5. Lisinopril 20 mg daily. 6. Hydrochlorothiazide 25 mg daily. FAMILY HISTORY: Negative for any GU cancer, stones or other complaints. The patient states he has one uncle who died of lung cancer. He denies any other family history. SOCIAL HISTORY: The patient smokes approximately 2 packs per day times greater than 40 years. He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month. He denies any drug use. He is a retired liquor store owner. PHYSICAL EXAMINATION: GENERAL: He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age. VITAL SIGNS: Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds. HEAD AND NECK: Normocephalic atraumatic. LUNGS: Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. The liver and spleen are not palpably enlarged. There is a large midline defect covered by skin, of which the fascia has numerous holes poking through. These small hernias are of approximately 2 cm in diameter at the largest and are nontender. GU: The penis is circumcised and there are no lesions, plaques, masses or deformities. There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place. Testes are bilaterally descended and there are no masses or tenderness. There is bilateral mild atrophy. Epididymidis are grossly within normal limits bilaterally. Spermatic cords are grossly within normal limits. There are no palpable inguinal hernias. RECTAL: The prostate is mildly enlarged with a small focal firm area in the midline near the apex. There is however no other focal nodules. The prostate is grossly approximately 35 to 40 g and is globally firm. Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault. EXTREMITIES: Demonstrate no cyanosis, clubbing or edema. There is dark red urine in the Foley bag collection. LABORATORY EXAM: Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42. Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup. CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam. There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted. IMPRESSION: Bladder cancer. PLAN: The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery. Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop. The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia. The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging. The patient understands these instructions and also agrees to quit smoking prior to his next visit. This patient was seen in evaluation with Dr. Y who agrees with the impression and plan. |
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Write a clinical note about a patient with the following chief complaint: Non-healing surgical wound to the left posterior thigh. | CHIEF COMPLAINT: Non-healing surgical wound to the left posterior thigh. HISTORY OF PRESENT ILLNESS: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control. PAST MEDICAL HISTORY: Essentially negative other than he has had C. difficile in the recent past. ALLERGIES: None. MEDICATIONS: Include Cipro and Flagyl. PAST SURGICAL HISTORY: Significant for his trauma surgery noted above. FAMILY HISTORY: His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father. SOCIAL HISTORY: He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney. REVIEW OF SYSTEMS: CARDIAC: He denies any chest pain or shortness of breath. GI: As noted above. GU: As noted above. ENDOCRINE: He denies any bleeding disorders. PHYSICAL EXAMINATION: GENERAL: He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress. HEENT: Unremarkable. NECK: Supple. There is no mass, adenopathy, or bruit. CHEST: Normal excursion. LUNGS: Clear to auscultation and percussion. COR: Regular. There is no S3, S4, or gallop. There is no murmur. ABDOMEN: Soft. It is nontender. There is no mass or organomegaly. GU: Unremarkable. RECTAL: Deferred. EXTREMITIES: His right lower extremity is unremarkable. Peripheral pulse is good. His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. There is one small area right essentially within the graft site, and there is one small area down lower on the calf area. The patient has an external fixation on that comes out laterally on his left thigh. Those pin sites look clean. NEUROLOGIC: Without focal deficits. The patient is alert and oriented. IMPRESSION: Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. PLAN: Plan would be for chemical cauterization of these areas. Series of treatment with chemical cauterization till these are closed. |
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Write a clinical note about a patient with the following chief complaint: The patient comes for three-week postpartum checkup, complaining of allergies. | CHIEF COMPLAINT: The patient comes for three-week postpartum checkup, complaining of allergies. HISTORY OF PRESENT ILLNESS: She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish. She has not yet had sexual intercourse. She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding. She has not been particularly constipated but her husband says she is not eating her vegetables like she should. Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears. MEDICATIONS: Prenatal vitamins. ALLERGIES: She thinks to Benadryl. FAMILY HISTORY: Mother is 50 and healthy. Dad is 40 and healthy. Half-sister, age 34, is healthy. She has a sister who is age 10 who has some yeast infections. PHYSICAL EXAMINATION: VITALS: Weight: 124 pounds. Blood pressure 96/54. Pulse: 72. Respirations: 16. LMP: 10/18/03. Age: 39. HEENT: Head is normocephalic. Eyes: EOMs intact. PERRLA. Conjunctiva clear. Fundi: Discs flat, cups normal. No AV nicking, hemorrhage or exudate. Ears: TMs intact. Mouth: No lesion. Throat: No inflammation. She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes. Abdomen: Soft. No masses. Pelvic: Uterus is involuting. Rectal: She has one external hemorrhoid which has inflamed. Stool is guaiac negative and using anoscope, no other lesions are identified. ASSESSMENT/PLAN: Satisfactory three-week postpartum course, seasonal allergies. We will try Patanol eyedrops and Allegra 60 mg twice a day. She was cautioned about the possibility that this may alter her milk supply. She is to drink extra fluids and call if she has problems with that. We will try ProctoFoam HC. For the hemorrhoids, also increase the fiber in her diet. That prescription was written, as well as one for Allegra and Patanol. She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon. She will call and return if she continues to have problems with allergies. Meantime, rechecking in three weeks for her final six-week postpartum checkup. |
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Write a clinical note about a patient with the following chief complaint: Essential thrombocytosis. | CHIEF COMPLAINT: Essential thrombocytosis. HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis. He was first diagnosed when he first saw a hematologist on 07/09/07. At that time, his platelet count was 1,240,000. He was initially started on Hydrea 1000 mg q.d. On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis. He was positive for the JAK-2 mutation. On 11/06/07, his platelets were noted to be 766,000. His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days. He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis. Overall, he is doing well. He has a good energy level, and his ECOG performance status is 0. He denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. CURRENT MEDICATIONS: Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week, Flomax q.d. vitamin D q.d, saw palmetto q.d. aspirin 81 mg q.d. and vitamin C q.d. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: As per the HPI, otherwise negative. PAST MEDICAL HISTORY: 1. He is status post an appendectomy. 2. Status post a tonsillectomy and adenoidectomy. 3. Status post bilateral cataract surgery. 4. BPH. SOCIAL HISTORY: He has a history of tobacco use, which he quit at the age of 37. He has one alcoholic drink per day. He is married. He is a retired lab manager. FAMILY HISTORY: There is no history of solid tumor or hematologic malignancies in his family. PHYSICAL EXAM: VIT: |
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Write a clinical note about a patient with the following chief complaint: Polycythemia rubra vera. | CHIEF COMPLAINT: Polycythemia rubra vera. HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied. CURRENT MEDICATIONS: Levothyroxine 200 mcg q.d. Nexium 40 mg q.d. Celebrex 200 mg q.d. vitamin D3 2000 IU q.d. aspirin 81 mg q.d. selenium 200 mg q.d. Aricept 10 mg q.d. Skelaxin 800 mg q.d. ropinirole 1 mg q.d. vitamin E 1000 IU q.d. vitamin C 500 mg q.d. flaxseed oil 100 mg daily, fish oil 100 units q.d. Vicodin q.h.s. and stool softener q.d. ALLERGIES: Penicillin. REVIEW OF SYSTEMS: The patient's chief complaint is her weight. She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key. She has questions as to whether or not there would be any contra indications to her going on the diet. Otherwise, she feels great. She had family reunion in Iowa once in four days out there. She continues to volunteer Hospital and is walking and enjoying her summer. She denies any fevers, chills, or night sweats. She has some mild constipation problem but has had under control. The rest of her review of systems is negative. PHYSICAL EXAM: VITALS: |
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Write a clinical note about a patient with the following diagnosis: Polycythemia vera with secondary myelofibrosis. | DIAGNOSIS: Polycythemia vera with secondary myelofibrosis. REASON FOR VISIT: Followup of the above condition. CHIEF COMPLAINT: Left shin pain. HISTORY OF PRESENT ILLNESS: A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health. At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped. The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1. PHYSICAL EXAMINATION: VITAL SIGNS: He is afebrile. Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute. GENERAL: He is in no acute distress. HEENT: There is no pallor, icterus or cervical adenopathy that is noted. Oral cavity is normal to exam. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. ABDOMEN: Soft and nontender with no hepatomegaly. Spleen is palpable 4 fingerbreadths below the left costal margin. There is no guarding, tenderness, rebound or rigidity noted. Bowel sounds are present. EXTREMITIES: Reveal no edema. Palpation of the left tibia revealed some mild tenderness. However, I do not palpate any bony abnormalities. There is no history of deep venous thrombosis. LABORATORY DATA: CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000. ASSESSMENT AND PLAN: 1. JAK-2 positive myeloproliferative disorder. The patient has failed pretty much all available options. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial. Hopefully, we can get a JAK-2 inhibitor trial quickly on board. 2. I am concerned about the risk of thrombosis with his elevated white count. He is on aspirin prophylaxis. The patient has been told to call me with any complaints. 3. Left shin pain. I have ordered x-rays of the left tibia and knee today. The patient will return to the clinic in 3 weeks. He is to call me in the interim for any problems. |
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Write a clinical note about a patient with the following chief complaint: The patient is here for followup visit and chemotherapy. | CHIEF COMPLAINT: The patient is here for followup visit and chemotherapy. DIAGNOSES: 1. Posttransplant lymphoproliferative disorder. 2. Chronic renal insufficiency. 3. Squamous cell carcinoma of the skin. 4. Anemia secondary to chronic renal insufficiency and chemotherapy. 5. Hypertension. HISTORY OF PRESENT ILLNESS: A 51-year-old white male diagnosed with PTLD in latter half of 2007. He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. He did not seek medical attention immediately. He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma. He was discussed at the hematopathology conference. Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. First cycle of chemotherapy was complicated by sepsis despite growth factor support. He also appeared to have become disoriented either secondary to sepsis or steroid therapy. The patient has received 5 cycles of chemotherapy to date. He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well. His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection. The patient is here for the sixth and final cycle of chemotherapy. He states he feels well. He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. He denies any tingling or numbness in his fingers. Review of systems is otherwise entirely negative. Performance status on the ECOG scale is 1. PHYSICAL EXAMINATION: VITAL SIGNS: He is afebrile. Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. There is mild pallor noted. There is no icterus, adenopathy or petechiae noted. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. Systolic flow murmur is best heard in the pulmonary area. ABDOMEN: Soft and nontender with no organomegaly. Renal transplant is noted in the right lower quadrant with a scar present. EXTREMITIES: Reveal no edema. LABORATORY DATA: CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000. ASSESSMENT AND PLAN: 1. Diffuse large B-cell lymphoma following transplantation. The patient is to receive his sixth and final cycle of chemotherapy today. PET scan has been ordered to be done within 2 weeks. He will see me back for the visit in 3 weeks with CBC, CMP, and LDH. 2. Chronic renal insufficiency. 3. Anemia secondary to chronic renal failure and chemotherapy. He is to continue on his regimen of growth factor support. 4. Hypertension. This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. His CMP is pending from today. 5. Squamous cell carcinoma of the skin. The scalp is well healed. He still has an open wound on the right posterior aspect of his trunk. This has no active drainage, but it is yet to heal. This probably will heal by secondary intention once chemotherapy is finished. Prescription for prednisone as part of his chemotherapy has been given to him. |
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Write a clinical note about a patient with the following chief complaint: Right knee. , | CHIEF COMPLAINT: Right knee. ,HISTORY OF THE PRESENT ILLNESS: The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Pain: Localized to the bilateral knees right worse than left. Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. ,Duration: Months. Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. ,Hip Pain: None. ,Back pain: None. ,Radicular type pain: None. ,Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change. VISCOSUPPLEMENTATION IN PAST: No Synvisc. VAS PAIN SCORE: 10 bilaterally. WOMAC SCORE: 8,A-1 WOMAC SCORE: 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living. ,REVIEW OF SYSTEMS: No change. Constitutional: Good appetite and energy. No fever. No general complaints. HEENT: No headaches, no difficulty swallowing, no change in vision, no change in hearing. CV - RESP: No shortness of breath at rest or with exertion. No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum. No chest pain on exertion. GI: |
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Write a clinical note about a patient with the following chief complaint: MGUS. | CHIEF COMPLAINT: MGUS. HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS. I initially saw him for thrombocytopenia when his ANC was 1300. A bone marrow biopsy was obtained. Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000. His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. All his tests came back as consistent with an MGUS. Overall, he is doing well. Since I last saw him, he tells me that he has had onset of atrial fibrillation. He has now started going to the gym two times per week, and has lost over 10 pounds. He has a good energy level and his ECOG performance status is 0. He denies any fever, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. CURRENT MEDICATIONS: Multivitamin q.d. aspirin one tablet q.d. Lupron q. three months, Flomax 0.4 mg q.d. and Warfarin 2.5 mg q.d. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: As per the HPI, otherwise negative. PAST MEDICAL HISTORY: 1. He is status post left inguinal hernia repair. 2. Prostate cancer diagnosed in December 2004, which was a Gleason 3+4. He is now receiving Lupron. SOCIAL HISTORY: He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married. FAMILY HISTORY: His brother had prostate cancer. PHYSICAL EXAM: VIT: |
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Write a clinical note about a patient with the following chief complaint: Follicular non-Hodgkin's lymphoma. | CHIEF COMPLAINT: Follicular non-Hodgkin's lymphoma. HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma. From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy. In 1990, his CT scan showed retroperitoneal lymphadenopathy. Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP. In 1999, he was treated with m-BACOD. He also received radiation to his pelvis. On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma. His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck. Overall, he is doing well. He has a good energy level, his ECOG performance status is 0. He denies any fever, chills or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. CURRENT MEDICATIONS: Avelox 400 mg q.d. p.r.n. cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d. Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d. Coreg 6.25 mg b.i.d. Vasotec 2.5 mg b.i.d. Zantac 150 mg q.d. Claritin D q.d. Centrum q.d. calcium q.d. omega-3 b.i.d. Metamucil q.d. and Lasix 40 mg t.i.d. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: As per the HPI, otherwise negative. PAST MEDICAL HISTORY: 1. He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation. 2. He had bilateral ureteral obstruction and is status post a stent placement. The obstruction was secondary to his pelvic radiation. 3. History of congestive heart failure. 4. History of schwannoma resection. It was resected from T12 to L1 in 1991. 5. He has chronic obstruction of his inferior vena cava. 6. Recurrent lower extremity cellulitis. SOCIAL HISTORY: He has no tobacco use. No alcohol use. He is married. He is a retired Methodist minister. FAMILY HISTORY: His mother just died two days ago. There is no history of solid tumors or hematologic malignancies in his family. PHYSICAL EXAM: VIT: |
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Write a clinical note about a patient with the following chief complaint: 1. Extensive stage small cell lung cancer. 2. Chemotherapy with carboplatin and etoposide. 3. Left scapular pain status post CT scan of the thorax. | CHIEF COMPLAINT: 1. Extensive stage small cell lung cancer. 2. Chemotherapy with carboplatin and etoposide. 3. Left scapular pain status post CT scan of the thorax. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment with carboplatin and etoposide. She completed her fifth cycle on 08/12/10. She has had ongoing back pain and was sent for a CT scan of the thorax. She comes into clinic today accompanied by her daughters to review the results. CURRENT MEDICATIONS: Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d. Vicodin 5/500 mg one to two tablets q.6 hours p.r.n. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: The patient continues to have back pain some time she also take two pain pill. She received platelet transfusion the other day and reported mild fever. She denies any chills, night sweats, chest pain, or shortness of breath. The rest of her review of systems is negative. PHYSICAL EXAM: VITALS: |
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Write a clinical note about a patient with the following chief complaint: Leg pain. | CHIEF COMPLAINT: Leg pain. HISTORY OF PRESENT ILLNESS: This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasionally. She has had a little bit of fever and nausea. She has noticed her blood sugars have been low. She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita. She has noticed her fasting blood sugars have been ranging from 100 to 120. Blood sugars one and a half hours after meals have been 185. She is coming in for a diabetic checkup in one month and wants lab prior to that time. She has been eating more meat recently and has not been on a diet for cholesterol. CURRENT MEDICATIONS: Include Lipitor 80 mg q.d. discontinued today, Vioxx 25 mg q.d. Maxzide 37/25 q.d. Protonix 40 mg q.d. hydroxyzine pamoate 50 mg at h.s. aspirin 81 mg q.d. Glucovance 1.25/250 b.i.d. decreased to one a day today, Monopril 20 mg q.d. estradiol one mg q.d. and glucosamine 1000 mg q.d. ALLERGIES: Cipro, sulfa, Bactrim, and Demerol. OBJECTIVE: Vital Signs: Weight is 248 pounds which is a 12-pound drop from January. Blood pressure 120/70. Pulse 68. General: This is a well-developed adult female, awake, alert, and in no acute distress. HEENT: Oropharynx and HEENT are within normal limits. Lungs: Clear. Heart: Regular rhythm and rate. Abdomen: Soft, nontender, and nondistended without organomegaly. GU: Palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain. Neurologic: Deep tendon reflexes are normal. Extremities: Pulses in lower extremities are normal. Straight leg lifts are normal. ASSESSMENT/PLAN: 1. Leg pain/bone pain, I am going to check her CMP. I think this possibly is a side effect from Lipitor. We will stop Lipitor, have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time. Certainly if her pain improves might consider something like Crestor, which is more water soluble, which may cause less adverse effects. We will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay, may need an x-ray of back, hip, and legs at that time if symptoms are not gone. 2. Hypercholesterolemia, this is somewhat bothersome as she is a diabetic. Did discuss with her that we need to stick to the diet especially after going off of Lipitor. We will see how she does with her bone pain/leg pain off of Lipitor. If she has improvement may consider Crestor in one month. I am going to check her lipid panel and a CMP. Apparently, she is going to get this at a different site, Mapleridge in Wichita. 3. Type II diabetes. We will decrease her Glucovance because she is having frequent low blood sugars. Her previous hemoglobin A1c was 5.6 so we will see if this improves her symptoms. I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment. |
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Write a clinical note about a patient with the following problem list: 1. HIV stable. 2. Hepatitis C chronic. 3. History of depression, stable off meds. 4. Hypertension, moderately controlled. | PROBLEM LIST: 1. HIV stable. 2. Hepatitis C chronic. 3. History of depression, stable off meds. 4. Hypertension, moderately controlled. CHIEF COMPLAINT: The patient comes for a routine followup appointment. HISTORY OF PRESENTING ILLNESS: This is a 34-year-old African American female who comes today for routine followup. She has no acute complaints. She reports that she has a muscle sprain on her upper back from lifting. The patient is a housekeeper by profession. It does not impede her work in anyway. She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication. No other associated complaints. No neurological deficits or other specific problems. The patient denies any symptoms associated with opportunistic infection. PAST MEDICAL HISTORY: 1. Significant for HIV. 2. Hepatitis. 3. Depression. 4. Hypertension. CURRENT MEDICATIONS: 1. She is on Trizivir 1 tablet p.o. b.i.d. 2. Ibuprofen over-the-counter p.r.n. MEDICATION COMPLIANCE: The patient is 100% compliant with her meds. She reports she does not miss any doses. ALLERGIES: She has no known drug allergies. DRUG INTOLERANCE: There is no known drug intolerance in the past. NUTRITIONAL STATUS: The patient eats regular diet and eats 3 meals a day. REVIEW OF SYSTEMS: Noncontributory except as mentioned in the HPI. LABORATORY DATA: Most recent labs from 11/07. RADIOLOGICAL DATA: She has had no recent radiological procedures. IMMUNIZATIONS: Up-to-date. SEXUAL HISTORY: She has had no recent STDs and she is not currently sexually active. PPD status was negative in the past. PPD will be placed again today. Treatment adherence counseling was performed by both nursing staff and myself. Again, the patient is a 100% compliant with her meds. Last dental exam was in 11/07, where she had 2 teeth extracted. Last Pap smear was 1 year ago was negative. The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram. She has no family history of breast cancer. MENTAL HEALTH AND SUBSTANCE ABUSE: The patient has a history of depression. No history of substance abuse. ADVANCED DIRECTIVE: Unknown. PHYSICAL EXAMINATION: GENERAL: This is a thinly built female, not in acute distress. VITAL SIGNS: Temperature 36.5, blood pressure 132/89, pulse of 82, and weight of 104 pounds. HEAD AND NECK: Reveals bilaterally reactive pupils. Supple neck. No thrush. No adenopathy. HEART: Heart sounds S1 and S2 regular. No murmur. LUNGS: Clear bilaterally to auscultation. ABDOMEN: Soft and nontender with good bowel sounds. NEUROLOGIC: She is alert and oriented x3 with no focal neurological deficit. EXTREMITIES: Peripheral pulses are felt bilaterally. She has no pitting pedal edema, clubbing or cyanosis. GU: Examination of external genitalia is unremarkable. There are no lesions. LABORATORY DATA: From 11/07 shows hemoglobin and hematocrit of 16 and 46. Creatinine of 0.6. LFTs within normal limits. Viral load of less than 48 and CD4 count of 918. ASSESSMENT: 1. Human immunodeficiency virus, stable on Trizivir. 2. Hepatitis C with stable transaminases. 3. History of depression, stable off meds. |
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Write a clinical note about a patient with the following chief complaint: One-month followup. | CHIEF COMPLAINT: One-month followup. HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I think the last steroid injection that she had with Dr. XYZ really did help. The patient denies any shortness of breath or cough. Has no nausea, vomiting, abdominal pain. No diarrhea or constipation. She states her appetite is good. She clears her plate at noon. She has had no fevers, chills, or sweats. The friend with her states she is doing very well. Seems to eat excellently at noontime, despite this, the patient continues to lose weight. When I asked her what she eats for breakfast and for supper, she states she really does not eat anything. Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time. She states she is really not hungry the rest of the time except at lunchtime. She denies any fevers, chills, or sweats. We did do some lab work at the last office visit and CBC was essentially normal. Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3. This is fairly stable for her. Liver enzymes were normal. TSH was normal. Free albumin was normal at 23. She is on different antidepressants and that may be causing some difficulties with unintentional weight loss. MEDICATIONS: Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications. SOCIAL HISTORY: The patient is widow. She is a nonsmoker, nondrinker. She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal. REVIEW OF SYSTEMS: As above in HPI. PHYSICAL EXAM: General: This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face. States are clothes are fitting more loosely. Vital Signs: Weight: 123, down 5 pounds from last month and down 11 pounds from May 2004. Blood pressure: 128/62. Pulse: 60. Respirations: 20. Temperature: 96.8. Neck: Supple. Carotids are silent. Chest: Clear to auscultation. Cardiovascular: Regular rate and rhythm. Abdomen: Soft and nontender, nondistended with positive bowel sounds. No organomegaly or masses are appreciated. Extremities: Free of edema. ASSESSMENT: 1. Unintentional weight loss. I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her. 2. Depression, doing well. 3. Paranoia, doing well. 4. Dementia, stable. 5. Osteoarthritis of the knees, pain is much improved. PLAN: 1. Continue on current medications. 2. I did call and talk with doctor at hospital. We discussed different options. We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time. Connie will weigh the patient once a week and I will go ahead and see the patient in one month. We can see how she is doing at that time. If she continues to lose weight despite eating better, then I think we will need to do further evaluation. |
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Write a clinical note about a patient with the following chief complaint: Followup on hypertension and hypercholesterolemia. | CHIEF COMPLAINT: Followup on hypertension and hypercholesterolemia. SUBJECTIVE: This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise. He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. He sees Dr. Ferguson. He is known to have Crohn's and he takes care of that for him. He sees Dr. Roszhart for his prostate check. He is a nonsmoker and denies swelling in his ankles. MEDICATIONS: Refer to chart. ALLERGIES: Refer to chart. PHYSICAL EXAMINATION: ,Vitals: Wt; 172 lbs, up 2 lbs, B/P; 150/60, T; 96.4, P; 72 and regular. ,General: A 78-year-old male who does not appear to be in any acute distress. Glasses. Good dentition. CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around. Lungs: Diminished with increased AP diameter. ,Abdomen: Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted. Extremities: Well-healed surgical scar on the right knee. No edema. Hand grasps are strong and equal. Back: Surgical scar on the lower back. Neuro: Intact. A&O. Moves all four with no focal motor or sensory deficits. IMPRESSION: 1. Hypertension. 2. Hypercholesterolemia. 3. Osteoarthritis. 4. Fatigue. PLAN: We will check a BMP, lipid, liver profile, CPK, and CBC. Refill his medications x 3 months. I gave him a copy of Partners in Prevention. Increase his Altace to 5 mg day for better blood pressure control. Diet, exercise, and weight loss, and we will see him back in three months and p.r.n. |
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Write a clinical note about a patient with the following chief complaint: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. , | CHIEF COMPLAINT: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE: A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly. ,PAST MEDICAL HISTORY: Refer to chart. MEDICATIONS: Refer to chart. ALLERGIES: Refer to chart. PHYSICAL EXAMINATION: Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular. General: A 70-year-old female who does not appear to be in acute distress. ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull. |
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Write a clinical note about a patient with the following chief complaint: The patient is here for two-month followup. | CHIEF COMPLAINT: The patient is here for two-month followup. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old Caucasian female. She has hypertension. She has had no difficulties with chest pain. She has some shortness of breath only at walking up the stairs. She has occasional lightheadedness only if she bends over then stands up quickly. She has had no nausea, vomiting, or diarrhea. She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year. The patient is wanting to lose weight before her surgery. She is concerned about possible coronary disease or stroke risk. She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable. She has had fairly normal lipid panel, last being checked on 11/26/2003. Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129. The patient is a nonsmoker. Her fasting glucose in November 2003 was within normal limits at 94. Her fasting insulin level was normal. Repeat nonfasting glucose was 109 on 06/22/2004. She does not have history of diabetes. She does not exercise regularly and is not able to because of knee pain. She also has had difficulties with low back pain. X-ray of the low back did show a mild compression fracture of L1. She has had no falls that would contribute to a compression fracture. She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan. She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis. CURRENT MEDICATIONS: Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n. ALLERGIES: Bactrim, which causes nausea and vomiting, and adhesive tape. PAST MEDICAL HISTORY: 1. Hypertension. 2. Depression. 3. Myofascitis of the feet. 4. Severe osteoarthritis of the knee. 5. Removal of the melanoma from the right thigh in 1984. 6. Breast biopsy in January of 1997, which was benign. 7. History of Holter monitor showing ectopic beat. Echocardiogram was normal. These were in 1998. 8. Compression fracture of L1, unknown cause. She had had no injury. Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting. SOCIAL HISTORY: The patient is married. She is a nonsmoker and nondrinker. REVIEW OF SYSTEMS: As per the HPI. PHYSICAL EXAMINATION: General: This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight. Vital signs: Weight: Refused. Blood pressure: 148/82, on recheck by myself with a large cuff, it was 125/60. Pulse: 64. Respirations: 20. Temperature: 96.3. Neck: Supple. Carotids are silent. Chest: Clear to auscultation. Cardiovascular: Revealed a regular rate and rhythm without murmur, S3, or S4. Extremities: Revealed no edema. Neurologic: Grossly intact. RADIOLOGY: EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads. ASSESSMENT: 1. Hypertension, well controlled. 2. Family history of cerebrovascular accident. 3. Compression fracture of L1, mild. 4. Osteoarthritis of the knee. 5. Mildly abnormal chest x-ray. PLAN: 1. We will get a C-reactive protein cardiac. 2. We discussed weight loss options. I would recommend Weight Watchers or possibly having her see a dietician. She will think about these options. She is not able to exercise regularly right now because of knee pain. 3. We would recommend a screening colonoscopy. She states that we discussed this in the past and she canceled her appointment to have that done. She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy. 4. We will start Fosamax 70 mg once weekly. She is to take this in the morning on an empty stomach with full glass of water. She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax. 5. I would like to see her back in one to two months. At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing. One would also consider preoperative beta-blocker for cardiac protection. |
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Write a clinical note about a patient with the following chief complaint: Followup on diabetes mellitus, status post cerebrovascular accident. | CHIEF COMPLAINT: Followup on diabetes mellitus, status post cerebrovascular accident. SUBJECTIVE: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage. MEDICATIONS: Refer to chart. ALLERGIES: Refer to chart. PHYSICAL EXAMINATION: Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular. ,General: A 70-year-old male who does not appear to be in acute distress but does look older than his stated age. He has some missing dentition. Skin: Dry and flaky. ,CV: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal pulse on the left and 1+ on the right. Lungs: Diminished but clear. Abdomen: Scaphoid. Rectal: His prostate check was normal per Dr. Gill. Neuro: Sensation with monofilament testing is better on the left than it is on the right. IMPRESSION: 1. Diabetes mellitus. 2. Neuropathy. 3. Status post cerebrovascular accident. PLAN: Refill his medications x 3 months. We will check an A1c and BMP. I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n. |
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Write a clinical note about a patient with the following chief complaint: 1. Stage IIIC endometrial cancer. 2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. | CHIEF COMPLAINT: 1. Stage IIIC endometrial cancer. 2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. Four of 30 lymph nodes were positive for disease. The left ovary was positive for metastatic disease. Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. Of note, we had sent off genetic testing which was denied back in June. I have been trying to get this testing completed. CURRENT MEDICATIONS: Synthroid q.d. ferrous sulfate 325 mg b.i.d. multivitamin q.d. Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime. ALLERGIES: |
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Write a clinical note about a patient with the following chief complaint: Followup diabetes mellitus, type 1. , | CHIEF COMPLAINT: Followup diabetes mellitus, type 1. ,SUBJECTIVE: Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago. Reports that his blood sugar dropped too low which caused the accident. Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer. ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time. Reports that he had some indications of kidney damage when first diagnosed. His urine microalbumin today is 100. His last hemoglobin A1C drawn at the end of December is 11.9. Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7. His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker. Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today. Patient also has a history of gastroparesis and impotence. Patient requests Nexium and Viagra, neither of which are covered under the Health Plan. , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head. Was not wearing a helmet. Reports that he did not go to the emergency room and had a headache for several days after this incident. Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room. Patient did not comply. Reports that the headache has resolved. Denies any dizziness, nausea, vomiting, or other neurological abnormalities. ,PHYSICAL EXAMINATION: WD, WN. Slender, 34-year-old white male. VITAL SIGNS: Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16. Microalbumin 100. SKIN: There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long. No signs of infection. Wound is closed with new granulation tissue. Appears to be healing well. HEENT: Normocephalic. PERRLA. EOMI. TMs pearly gray with landmarks present. Nares patent. Throat with no redness or swelling. Nontender sinuses. NECK: Supple. Full ROM. No LAD. CARDIAC: |
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Write a clinical note about a patient with the following chief complaint: Septal irritation. | CHIEF COMPLAINT: Septal irritation. HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation. The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a "stretching" like pressure. She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose. She has no other complaints at this time. PHYSICAL EXAM: GENERAL: This is a pleasant African-American female resting in the examination room chair in no apparent distress. ENT: External auditory canals are clear. Tympanic membrane shows no perforation, is intact. NOSE: The patient has a slightly deviated right septum. Septum has a large perforation in the anterior 2/3rd of the septum. This appears to be well healed. There is no sign of crusting in the nose. ORAL CAVITY: No lesions or sores. Tonsils show no exudate or erythema. NECK: No cervical lymphadenopathy. VITAL SIGNS: Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73. ASSESSMENT AND PLAN: The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation. At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis. At this time, I counseled the patient on the risks and benefits of surgery. She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip. We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time. |
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Write a clinical note about a patient with the following chief complaint: Hip pain. | CHIEF COMPLAINT: Hip pain. HISTORY OF PRESENTING ILLNESS: The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office. She reports moderate to severe pain related to a complicated past medical history. In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23. She was given nonsteroidals at that time, which did help with this discomfort. With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital. She was referred for rehabilitation and strengthening. Most of this was focused on her SI joints. At that time, although she had complained of foot discomfort, she was not treated for it. This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996. She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain. She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back. Medications at that time were salicylate and Ultram. When she returned to Portland in 1996, she was then working for Dr. B. She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case. Subsequently, nuclear bone scans revealed osteoarthritis. Orthotics were provided. She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure. During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle. She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since. She currently does not have an established cardiologist having just changed insurance plans. She is establishing care with Dr. S, of Rheumatology for her ongoing care. Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L. Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis. A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation. She then transferred her care to Ab Cd, FNP under the direction of Dr. K. Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens. Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged. PAST MEDICAL HISTORY: 1. Attention deficit disorder. 2. TMJ arthropathy. 3. Migraines. 4. Osteoarthritis as described above. PAST SURGICAL HISTORY: 1. Cystectomies. 2. Sinuses. 3. Left ganglia of the head and subdermally in various locations. 4. TMJ and bruxism. FAMILY HISTORY: The patient's father also suffered from bilateral hip osteoarthritis. MEDICATIONS: 1. Methadone 2.5 mg p.o. t.i.d. 2. Norco 10/325 mg p.o. q.i.d. 3. Tenormin 50 mg q.a.m. 4. Skelaxin 800 mg b.i.d. to t.i.d. p.r.n. 5. Wellbutrin SR 100 mg q.d. 6. Naprosyn 500 mg one to two pills q.d. p.r.n. ALLERGIES: IV morphine causes hives. Sulfa caused blisters and rash. PHYSICAL EXAMINATION: A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior. VITAL SIGNS: Blood pressure 110/72 with a pulse of 68. HEENT: Normocephalic. Atraumatic. Pupils are equal and reactive to light and accommodation. Extraocular motions are intact. No scleral icterus. No nystagmus. Tongue is midline. Mucous membranes are moist without exudate. NECK: Free range of motion without thyromegaly. CHEST: Clear to auscultation without wheeze or rhonchi. HEART: Regular rate and rhythm without murmur, gallop, or rub. ABDOMEN: Soft, nontender. MUSCULOSKELETAL: There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally. Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side. Toe-heel walking is performed without difficulty. Straight leg raises are negative. Romberg's are negative. NEUROLOGIC: Grossly intact. Intact reflexes in all extremities tested. Romberg is negative and downgoing. ASSESSMENT: 1. Osteoarthritis. 2. Chronic sacroiliitis. 3. Lumbar spondylosis. 4. Migraine. 5. TMJ arthropathy secondary to bruxism. 6. Mood disorder secondary to chronic pain. 7. Attention deficit disorder, currently untreated and self diagnosed. RECOMMENDATIONS: 1. Agree with Rheumatology referral and review. I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies. 2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage. |
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Write a clinical note about a patient with the following chief complaint: 1. Metastatic breast cancer. 2. Enrolled is clinical trial C40502. 3. Sinus pain. | CHIEF COMPLAINT: 1. Metastatic breast cancer. 2. Enrolled is clinical trial C40502. 3. Sinus pain. HISTORY OF PRESENT ILLNESS: She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa, Faslodex, and Aromasin. She was found to have disease progression first noted by rising tumor markers. PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502. She was randomized to the ixabepilone plus Avastin. She experienced dose-limiting toxicity with the fourth cycle. The Ixempra was skipped on day 1 and day 8. She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy. Early in the month she had concerned about possible perforated septum. She was seen by ENT urgently. She was found to have nasal septum intact. She comes into clinic today for day eight Ixempra. CURRENT MEDICATIONS: Zometa monthly, calcium with Vitamin D q.d. multivitamin q.d. Ambien 5 mg q.h.s. Pepcid AC 20 mg q.d. Effexor 112 mg q.d. Lyrica 100 mg at bedtime, Tylenol p.r.n. Ultram p.r.n. Mucinex one to two tablets b.i.d. Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily. ALLERGIES: Compazine. REVIEW OF SYSTEMS: The patient is comfort in knowing that she does not have a septal perforation. She has progressive neuropathy and decreased sensation in her fingertips. She makes many errors when keyboarding. I would rate her neuropathy as grade 2. She continues to have headaches respond to Ultram which she takes as needed. She occasionally reports pain in her right upper quadrant as well as right sternum. He denies any fevers, chills, or night sweats. Her diarrhea has finally resolved and her bowels are back to normal. The rest of her review of systems is negative. PHYSICAL EXAM: VITALS: |
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Write a clinical note about a patient with the following chief complaint: Stage IIA right breast cancer. | CHIEF COMPLAINT: Stage IIA right breast cancer. HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer. She noticed a lump in the breast in November of 2007. A mammogram was obtained dated 01/28/08, which showed a mass in the right breast. On 02/10/08, she underwent an ultrasound-guided biopsy. The pathology showed an infiltrating ductal carcinoma Nottingham grade II. The tumor was ER positive, PR positive and HER-2/neu negative. On 02/22/08, she underwent a lumpectomy and sentinel lymph node biopsy. The pathology showed a 3.3 cm infiltrating ductal carcinoma grade I, one sentinel lymph node was negative. Therefore it was a T2, N0, M0 stage IIA breast cancer. Of note, at that time she was taking hormone replacement therapy and that was stopped. She underwent radiation treatment ending in May 2008. She then started on Arimidex, but unfortunately she did not tolerate the Arimidex and I changed her to Femara. She also did not tolerate the Femara and I changed it to tamoxifen. She did not tolerate the tamoxifen and therefore when I saw her on 11/23/09, she decided that she would take no further antiestrogen therapy. She met with me again on 02/22/10, and decided she wants to rechallenge herself with tamoxifen. When I saw her on 04/28/10, she was really doing quite well with tamoxifen. She tells me 2 weeks after that visit, she developed toxicity from the tamoxifen and therefore stopped it herself. She is not going take to any further tamoxifen. Overall, she is feeling well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. CURRENT MEDICATIONS: Avapro 300 mg q.d. Pepcid q.d. Zyrtec p.r.n. and calcium q.d. ALLERGIES: Sulfa, Betadine, and IV contrast. REVIEW OF SYSTEMS: As per the HPI, otherwise negative. PAST MEDICAL HISTORY: 1. Asthma. 2. Hypertension. 3. GERD. 4. Eczema. 5. Status post three cesarean sections. 6. Status post a hysterectomy in 1981 for fibroids. They also removed one ovary. 7. Status post a cholecystectomy in 1993. 8. She has a history of a positive TB test. 9. She is status post repair of ventral hernia in November 2008. SOCIAL HISTORY: She has no tobacco use. Only occasional alcohol use. She has no illicit drug use. She has two grown children. She is married. She works as a social worker dealing with adult abuse and neglect issues. Her husband is a high school chemistry teacher. FAMILY HISTORY: Her father had prostate cancer. Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer. PHYSICAL EXAM: VIT: |
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Write a clinical note about a patient with the following chief complaint: Aplastic anemia. | CHIEF COMPLAINT: Aplastic anemia. HISTORY OF PRESENT ILLNESS: This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury. Her cyclosporine level was 555. It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held. Overall, she tells me that now she feels quite well since leaving the hospital. She was transfused 2 units of packed red blood cells while in the hospital. Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000. CURRENT MEDICATIONS: Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: As per the HPI, otherwise negative. PAST MEDICAL HISTORY: 1. Hypertension. 2. GERD. 3. Osteoarthritis. 4. Status post tonsillectomy. 5. Status post hysterectomy. 6. Status post bilateral cataract surgery. 7. Esophageal stricture status post dilatation approximately four times. SOCIAL HISTORY: She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired. FAMILY HISTORY: Her sister had breast cancer. PHYSICAL EXAM: VIT: |
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Write a clinical note about a patient with the following chief complaint: 1. Chronic lymphocytic leukemia (CLL). 2. Autoimmune hemolytic anemia. 3. Oral ulcer. | CHIEF COMPLAINT: 1. Chronic lymphocytic leukemia (CLL). 2. Autoimmune hemolytic anemia. 3. Oral ulcer. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. He comes in to clinic today for follow-up and complete blood count. At his last office visit we discontinued this prophylactic antivirals and antibacterial. CURRENT MEDICATIONS: Prilosec 20 mg b.i.d. levothyroxine 50 mcg q.d. Lopressor 75 mg q.d. vitamin C 500 mg q.d. multivitamin q.d. simvastatin 20 mg q.d. and prednisone 5 mg q.o.d. ALLERGIES: Vicodin. REVIEW OF SYSTEMS: The patient reports ulcer on his tongue and his lip. He has been off of Valtrex for five days. He is having some difficulty with his night vision with his left eye. He has a known cataract. He denies any fevers, chills, or night sweats. He continues to have headaches. The rest of his review of systems is negative. PHYSICAL EXAM: VITALS: |
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Write a clinical note about a patient with the following history of present illness: Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years. He denies any gasping, choking, or coughing episodes while asleep at night. His bedtime is between 10 to 11 p.m. has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed. He has two to three episodes of nocturia per night. He denies any morning symptoms. He has mild excess daytime sleepiness manifested by dozing off during boring activities. | CHIEF COMPLAINT: Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years. He denies any gasping, choking, or coughing episodes while asleep at night. His bedtime is between 10 to 11 p.m. has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed. He has two to three episodes of nocturia per night. He denies any morning symptoms. He has mild excess daytime sleepiness manifested by dozing off during boring activities. PAST MEDICAL HISTORY: Hypertension, gastritis, and low back pain. PAST SURGICAL HISTORY: TURP. MEDICATIONS: Hytrin, Motrin, Lotensin, and Zantac. ALLERGIES: None. FAMILY HISTORY: Hypertension. SOCIAL HISTORY: Significant for about a 20-pack-year tobacco use, quit in 1991. No ethanol use or illicit drug use. He is married. He has one dog at home. He used to be employed at Budd Automotors as a die setter for about 37 to 40 years. REVIEW OF SYSTEMS: His weight has been steady over the years. Neck collar size is 17½". He denies any chest pain, cough, or shortness of breath. Last chest x-ray within the past year, per his report, was normal. PHYSICAL EXAM: A pleasant, obese, African-American male in no apparent respiratory distress. T: 98. P: 90. RR: 20. BP: 156/90. O2 saturation: 97% on room air. Ht: 5' 5". Wt: 198 lb. HEENT: A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD. CARDIAC: Regular rate and rhythm without any adventitious sounds. CHEST: Clear lungs bilaterally. ABDOMEN: An obese abdomen with active bowel sounds. EXTREMITIES: No cyanosis, clubbing, or edema. NEUROLOGIC: Non-focal. IMPRESSION: 1. Probable obstructive sleep apnea syndrome. 2. Hypertension. 3. Obesity. 4. History of tobacco use. PLAN: 1. We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome. 2. Encouraged weight loss. 3. Check TSH. 4. Asked not to drive and engage in any activity that could endanger himself or others while sleepy. 5. Asked to return to the clinic one week after sleep the study is done. |
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Write a clinical note about a patient with the following history of present illness: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has existed for 2 weeks. He indicates the problem location is the right hand and left hand. Patient indicates no modifying factors. Severity of condition is slowly worsening. Onset was unknown. | CHIEF COMPLAINT: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has existed for 2 weeks. He indicates the problem location is the right hand and left hand. Patient indicates no modifying factors. Severity of condition is slowly worsening. Onset was unknown. ALLERGIES: Patient admits allergies to aspirin resulting in GI upset, disorientation. MEDICATION HISTORY: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD. PAST MEDICAL HISTORY: Past medical history is unremarkable. PAST SURGICAL HISTORY: Patient admits past surgical history of (+) appendectomy in 1989. FAMILY HISTORY: Patient admits a family history of rheumatoid arthritis associated with maternal grandmother. SOCIAL HISTORY: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. REVIEW OF SYSTEMS: Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) numbness,Musculoskeletal: (-) back pain (chronic) (-) decreased ROM (-) episodic weakness,Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms (-) sleep apnea,PHYSICAL EXAM: BP Standing: 120/84 HR: 79 Temp: 98.6 Height: 5 ft. 8 in. Weight: 168 lbs. Patient is a 26 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Palpation of skin shows no abnormalities. HEENT: Inspection of head and face shows no abnormalities. Hair growth and distribution is normal. Examination of scalp shows no abnormalities. Conjunctiva and lids reveal no signs or symptoms of infection. Pupil exam reveals round and reactive pupils without afferent pupillary defect. Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Bilateral retinas reveal normal color, contour, and cupping. Inspection of ears reveals no abnormalities. Otoscopic examination reveals no abnormalities. Examination of oropharynx reveals no abnormalities and tissues pink and moist. ENT: Inspection of ears reveals no abnormalities. Examination of larynx reveals no abnormalities. Inspection of nose reveals no abnormalities. Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable. Thyroid examination reveals no abnormalities and smooth and symmetric gland with no enlargement, tenderness or masses noted. Lymphatic: Neck lymph nodes are normal. Respiratory: Assessment of respiratory effort reveals even respirations without use of accessory muscles and no intercostal retractions noted. Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion. Auscultation of lungs reveals clear lung fields and no rubs noted. Cardiovascular: Heart auscultation reveals normal S1 and S2 and no murmurs, gallop, rubs or clicks. Examination of peripheral vascular system reveals full to palpation, varicosities absent, extremities warm to touch and no edema. Abdomen: Abdominal contour is slightly rounded. Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities. Palpation of spleen reveals no abnormalities. Musculoskeletal: Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking. Inspection and palpation of bones, joints and muscles is unremarkable. Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Neurologic/Psychiatric: Psychiatric: Oriented to person, place and time. Mood and affect normal and appropriate to situation. Testing of cranial nerves reveals no deficits. Coordination is good. Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal. TEST & X-RAY RESULTS: Rheumatoid factor: 52 U/ml. Sed rate: 31 mm/hr. C4 complement: 19 mg/dl. IMPRESSION: Rheumatoid arthritis. PLAN: ESR ordered; automated. Ordered RBC. Ordered quantitative rheumatoid factor. Return to clinic in 2 week (s). PRESCRIPTIONS: Vioxx Dosage: 12.5 mg tablet Sig: BID Dispense: 30 Refills: 2 Allow Generic: No |
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Write a clinical note about a patient with the following identification of patient: The patient is a 34-year-old Caucasian female. | IDENTIFICATION OF PATIENT: The patient is a 34-year-old Caucasian female. CHIEF COMPLAINT: Depression. HISTORY OF PRESENT ILLNESS: The patient's depression began in her teenage years. Sleep has been poor, for multiple reasons. She has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes. The patient tends to feel irritable, and has crying spells. She sometimes has problems with motivation. She has problems with memory, and energy level is poor. Appetite has been poor, but without weight change. Because of her frequent awakening, her CPAP machine monitor has indicated she is not using it enough, and Medicaid is threatening to refuse to pay for the machine. She does not have suicidal thoughts. ,The patient also has what she describes as going into a "panic mode." During these times, she feels as if her whole body is going to explode. She has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom. These spells may last a couple of hours, but once lasted for about two day. She does not get chest pain. These attacks tend to be precipitated by bills that cannot be paid, or being on a "time crunch." ,PSYCHIATRIC HISTORY: The patient's nurse practitioner had started her on Cymbalta, up to 60 mg per day. This was helpful, but then another physician switched her to Wellbutrin in the hope that this would help her quit smoking. Although she was able to cut down on tobacco usage, the depression has been more poorly controlled. She has used Wellbutrin up to 200 mg b.i.d. and Cymbalta up to 60 mg per day, at different times. At age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do. She has never been hospitalized for psychiatric purposes. She did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services. She has not previously spoken with a psychiatrist, but has been seeing a therapist, Stephanie Kitchen, at this facility. SUBSTANCE ABUSE HISTORY: Caffeine: The patient has two or three drinks per day of tea or Diet Pepsi. Tobacco: She smokes about one pack of cigarettes per week since being on Wellbutrin, and prior to that time had been smoking one-half pack per day. She is still committed to quitting. Alcohol: Denied. Illicit drugs: Denied. In her earlier years, someone once put some unknown drug in her milk, and she "came to" when she was dancing on the table in front of the school nurse. MEDICAL HISTORY/REVIEW OF SYSTEMS: Constitutional: See History of Present Illness. No recent fever or sweats. |
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Write a clinical note about a patient with the following referral data: This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister. She also has a stepsister that is 8 years old. The patient was brought in by her mother after being picked up by Anchorage Police Department (APD). She was brought to our institution for an assessment. ,REASON FOR ADMISSION/ | ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA: This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister. She also has a stepsister that is 8 years old. The patient was brought in by her mother after being picked up by Anchorage Police Department (APD). She was brought to our institution for an assessment. ,REASON FOR ADMISSION/CHIEF COMPLAINT: The patient ran away in the middle of the night on Sunday, 07/19/04, and she has been on the run since then. Her friends report to the parents that she is suicidal and that she had a knife. A friend took a knife away from her to keep her from cutting herself. ,HISTORY OF PRESENT ILLNESS: This is a 16-year-old Caucasian adolescent girl who was brought in by APD and her parents. This is her first admission. APD picked her up from a runaway and brought her at her mother's request after some friends told the mother that she was suicidal. The mother found journals in her room talking about suicide, and that she has been raped. There were no details and the client denies that she was raped. She is sexually active with one boyfriend, also 16 years old, that she met while going to school in Ketchican in the last school year. She has been with the mother only the last two months and the same Ketchican boyfriend, Michael, followed her to Anchorage. She reports symptoms of depression, no energy, initial and middle insomnia, eating more. She is very irritable and has verbal altercations wither sister who is 14. She admits to being sad and also having poor concentration. She had marked drop in school functioning in the last year, and will need to repeat the ninth grade. The mother is very concerned with the patent's safety and feels she is not able to control her. She lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in Ketchican. She went to live with her dad up to age 16. Now she is living with her mother and her mother's boyfriend for the last two months. In December, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed. LEGAL HISTORY: No legal history. TREATMENT/PSYCHIATRIC HISTORY: The patient was evaluated once at XYZ when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family. ,FAMILY PSYCHIATRIC HISTORY: The patient has three siblings with ADHD (Attention Deficit Hyperactivity Disorder) and two of her siblings are in an RTC (Residential Treatment Center) Program, one with the diagnosis of Bipolar Disorder, and the other with ADHD and bipolar condition. PERTINENT MEDICAL HISTORY: She was born with some eczema. At age 4 she was involved in an accident where she cut one of her legs and needed sutures. There is no history of seizure or head injury. She reports loss of consciousness. This will be investigated; there are no details about it. She admits to being sexually active, protecting herself using condoms. Her last menstruation period was 07/20/04. ,ALLERGIES: No allergies. DEVELOPMENT AGE FACTORS: The mother reports she was born with some jaundice and eczema. Early milestones walk and talk. The patient appears to function at the expected age level. ,PERTINENT PSYCHOSOCIAL DATA: Complete pertinent psychosocial will be obtained by our clinician. The patient admits witnessing seeing some domestic violence when she was small, around five years old. There is an allegation of a rape that the mother found in her journal, but this is going to be investigated. ,SCHOOL HISTORY: |
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Write a clinical note about a patient with the following identifying data: The patient is a 36-year-old Caucasian male. | IDENTIFYING DATA: The patient is a 36-year-old Caucasian male. CHIEF COMPLAINT: The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted. HISTORY OF PRESENT ILLNESS: The patient has been receiving services at this facility previously, under the care of ABC, M.D. and later XYZ, M.D. Historically, he has found it very easy to be distracted in the "cubicle" office setting where he sometimes works. He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder. Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful. In the past, probably in high school, the patient recalled being more figidity than now. He tensed to feel anxious. Sleep has been highly variable. He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month. Appetite has been good. He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall. He tends to feel depressed. His energy level is "better now," but this was very problematic in the past. He has problems with motivation. In the past, he had passing thoughts of suicide, but this is no longer a problem. PSYCHIATRIC HISTORY: The patient has never been hospitalized for psychiatric purposes. His only treatment has been at this facility. He tried Adderall for a time, and it helped, but he became hypertensive. Lunesta is effective for his insomnia issues. Effexor has helped to some degree. He has been prescribed Provigil, as much as 200 mg q.a.m. but has been cutting it down to 100 mg q.a.m. with some success. He sometimes takes the other half of the tablet in the afternoon. |
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Write a clinical note about a patient with the following identification of patient: This is a 31-year-old female who was referred by herself. She was formerly seen at Counseling Center. She is a reliable historian. | IDENTIFICATION OF PATIENT: This is a 31-year-old female who was referred by herself. She was formerly seen at Counseling Center. She is a reliable historian. CHIEF COMPLAINT: "I'm bipolar and I have severe anxiety disorder. I have posttraumatic stress syndrome." ,HISTORY OF PRESENT ILLNESS: At age 19, Ms. Abc had a recurrence of memories. Her father had molested her, and the memories returned. In 1992, at the age of 18, she entered her first abusive marriage. She was beaten and her husband shared her sexually with his friends. This lasted until age 24. The second marriage was age 26, her second husband was a drug abuser and "he slapped me around." She had two children during that marriage. In 2001, she was married in Indiana to a military man. This was her third marriage and she stated, "This marriage is good." She had EMDR in Indiana when she was being treated for Posttraumatic Stress Disorder. ,Historically, her first husband threw her down the stairs at age 21, and she had a miscarriage. Her sexual abuse began at age 5, and at that time she lost interest in other activities that normal school children have. Currently, she is unable to have sex with the lights on. She states, "Sometimes I hurt all over." Her husband was deployed three days ago, on April 21, to a foreign theater of operations. She has panic attacks every day. Review of symptoms shows her to have physiological distress at the memory of her trauma, she has psychological distress, and this comes about when she smells Old Spice aftershave. She does not avoid thoughts of her trauma, but she avoids the perpetrators and placements. She is not unable to recall details of her trauma. She does feel detached and isolated. She has restrictive range of affect and she had a foreshortened future. She also had a loss of interest in things, starting at age 5. She has anger, which is uncontrollable at times, she has poor sleep, she has nightmares, flashbacks, she is hypervigilant, she has exaggerated startle reflex, and with respect to concentration, she says, "I don't do as good as I can." Further review of symptoms shows her to have periods of constant cleaning and increased sex drive. She also has had euphoria, poor judgment, distractibility, and inability to concentrate. She has been irritable. She has had a decreased need for sleep, which lasts for six or seven days. She had racing thoughts, rapid speech, but has not had grandiosity. These symptoms of mania occurred in the last week of November 2005 and lasted for seven days from, which she was not hospitalized. Furthermore, she endorses the following symptoms: She states, "When I'm depressed, I have neck pain, jaw pain, abdominal pain. I have migraines and urinary tract pain." She also complains of chest pain, pain during sex, and excess pain during her menstrual period. She has an increased gag reflex, which has caused her to have emesis. She states it is easy to choke. She has had physical symptoms, "for as long as I can remember," and she states, "I've felt like crap most of my life," "it affects my marriage." She has also admitted to having nausea and vomiting, with excess gas. She has constipation and she cannot eat certain foods, mainly broccoli and cauliflower, and she does not have diarrhea. She states that sex is only important to her in mania. Otherwise, she has no desire. She has had irregular periods for two or three weeks at a time. She has had no episodes of excess bleeding. She has had no paralysis, no balance issues, no diplopia, no seizures, no blindness, no deafness, no amnesia, no loss of consciousness, but she does have a lump in her throat on occasion. Currently, she is sleeping from 10 p.m. to 3 a.m. and that is under the influence of Lunesta. Her energy is "not good. Her appetite is "I'm craving crap," stating that she wants to eat carbohydrates. Concentration is poor today. She feels worthless, hopeless, and guilty. Her self-esteem is "I don't have any." She has no anhedonia, and she has no libido. She also has had feelings of chronic emptiness. She feels abandoned. She has had unstable relationships. She self-mutilated, but she stopped at age 22. She has trouble controlling her anger. She did not have stress-related paranoia or dissociative phenomena, but she did have those during the sexual transgressions when she was a child. She has no identity disturbance. ,CURRENT MEDICATIONS: Seroquel 700 mg p.o. q.d.; Wellbutrin XL 300 mg p.o. q.d.; Desyrel 100 mg p.o. q.h.s.; Ativan p.r.n. dosage unknown. In the past, she has been on Prozac, Paxil, lithium, Depakote, Depakene, and Zoloft. ,PSYCHIATRIC HISTORY: She saw Dr. B. She saw Chris. She is diagnosed with Posttraumatic Stress Disorder, depression, and Bipolar Disorder. She had counseling in Indiana in 2001. She had inpatient treatment in Indiana in 2001 also, at age 19. She had three suicide attempts. At age 14, she took too many aspirin; the second one was at age 19, she took pain medication and sleep medication; and when she discussed her third suicide attempt, she began to cry and would not speak of it any more. She has had no psychological testing. ,MEDICAL HISTORY: Significant for migraines, hyperactive and gag reflex. She states she has had cardiovascular workups due to panic disorder, but nothing was found. She also has astigmatism. She states she has stomach pain and may have irritable bowel syndrome, and she had had recurrent kidney infections with a stent in the right kidney during one of her pregnancy. She has no history of head injury or MRI test of the brain. No history of EEG, seizures, thyroid problems, or asthma. There are no drug allergies. She has never had an EKG. She does have musculoskeletal problems and has arthritis-like joint pains on occasion. She has had ear infections and sinus infections intermittently. Hearing test was normal. She is currently not pregnant. She saw her gynecologist four months ago at Elmendorf Air Force Base. ,Surgical history is significant for having a tubal ligation at age 27, an appendectomy at age 19. She had surgery on her right ovary due to pain, a cyst was found; the date on that is unknown. ,She has no hypertension, no diabetes, no glaucoma. FAMILY HISTORY: Significant for her paternal grandmother not being mentally competent. Her mother was depressed and was treated. Her mother is currently age 55. She has a paternal grandmother who may have had Schizophrenia. There is also a family history of the paternal grandfather using substance. He was "an extreme alcoholic." She had maternal aunts who used alcohol, and a maternal uncle use alcohol to excess. The maternal uncle committed suicide; he drowned himself. ,There is no family history of bipolar disorder, anxiety, nor attention deficit, mental netardation, Tourette's syndrome, or learning disabilities. ,Medical history in the family is significant for her son, age 4, who is having seizures ruled out. Her mother and two maternal aunts have thyroid disease. She has a brother, age 32, with diabetes, a maternal uncle with heart disease, and several paternal great aunts had breast cancer. There is no family history of hypertension. ABUSE HISTORY: Significant for being physically abused by her father, her first husband, and her second husband. She was sexually abused by her father from age 5 to age 18. She states, "my first husband gave me away for four years to his friends to be used sexually." She was emotionally abused by her mother, father, and both of her first two husbands. She was neglected by her mother and her father. She never witnessed domestic violence. She has not witnessed traumatic events. ,SUBSTANCE ABUSE: Significant for having used nerve pills, but she stated she has not used them excessively, and never had to get her prescription refilled early. She has never used alcohol, tobacco, marijuana, or any other drugs. PARENT/SIBLING RELATIONSHIP INFORMATION: She had had a poor relationship with her parents. She has no contact with them. She has no contact with her brother. She was married three times, as stated in the history. She has two children with Asperger's and autism. ,HOBBIES/SPIRITUAL: She likes to read and write. She likes to cross-stitch, quilt, and do music, and has found a good church in Anchorage. ,EDUCATIONAL: She states she was teased in school because "I was so depressed." She got good grades otherwise. She finished high school. WORK HISTORY: She has worked in the past managing a Dollar General store. She has been a waitress and an executive secretary. ,LEGAL HISTORY: She has never been arrested. MENTAL STATUS: Significant for a well groomed, well kempt young white female who appears her stated age. She has a pierced nose and has a nose ring. She is cooperative, alert, and attentive. She makes good eye contact. Her speech is normal, prosody is normal, and rate and rhythm are normal. Motor is normal. She has no gait abnormalities. No psychomotor retardation or agitation. Her mood is "I'm sad and depressed." Her affect is restricted. She is tearful at times when discussing the sexual traumas, and she became anxious and panicky at certain points during the interviews. Perception is normal. She denies auditory and visual hallucinations. She denies depersonalization and derealization, except that those occurred when the sexual transgressions occurred. Otherwise, she has not had dissociative phenomena. Thought processes are normal. She has no loosening of association, no flight of ideas, no tangentiality, and no circumstantiality. She is goal directed and oriented. Insight and judgment are good. She is alert and oriented to person, place, and time, stating it was 04/18/06, Tuesday, it was Anchorage in the spring. She is able to register three words and recall them at five minutes. She is able to do simple calculations, stating 2x3 is 6, and 1 dollar 15 cents has 23 nickels. She is given a proverb to interpret. She was asked what judging a book by its cover meant. She said, "You can't always tell what a person is by looking at them on the outside." She is appropriate in her abstraction, and is able to identify the last four presidents. CLINICAL IMPRESSION: Abc is a 31-year-old female with a family history of mood disorder, suicide, alcoholism, and possible psychosis. She has had an extensive history of sexual abuse and emotional abuse. She has not used drugs and alcohol, and she has been treated in the past. She was treated with EMDR and stated that she did not benefit from that. She has an extensive medical history and brought her medical records, and they were thoroughly reviewed. She currently has symptoms of dysthymia and she had had a recent bout of bipolar hypomania, which was in November of 2005. She also has symptoms of somatization, but these are not chronic in the fact that they only exist during her dysphoric periods and do not exist when she has mania. Medical records review a history of dysmenorrhea with surgery to the right cystic ovary. The EMDR did not benefit her in the past. She also has not had good psychotherapeutic consultation. ,DIAGNOSES: AXIS I. 309.81 Posttraumatic Stress Disorder. |
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Write a clinical note about a patient with the following identifying data: The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. | IDENTIFYING DATA: The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. CHIEF COMPLAINT: "I am not sure." The patient has poor insight into hospitalization and need for treatment. HISTORY OF PRESENT ILLNESS: The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas. According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks. The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle. The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail. The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold). PAST PSYCHIATRIC HISTORY: History of schizophrenia, chronic paranoid. The patient as noted has been treated in Houston but has not had recent treatment or medications. PAST MEDICAL HISTORY: No acute medical problems noted. CURRENT MEDICATIONS: None. The patient was most recently treated with Invega and Abilify according to his records. FAMILY SOCIAL HISTORY: The patient resides with his father in Houston. The patient has no known history of substances abuse. The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold. FAMILY PSYCHIATRIC HISTORY: Need to increase database. MENTAL STATUS EXAMINATION: Attitude: Calm and cooperative. Appearance: Shows poor hygiene and grooming. Psychomotor: Behavior is within normal limits without agitation or retardation. No EPS or TDS noted. Affect: Is suspicious. Mood: Anxious but cooperative. Speech: Shows normal rate and rhythm. Thoughts: Disorganized,Thought Content: Remarkable for paranoia "they want to hurt me.",Psychosis: The patient endorses paranoid delusions as above. The patient denies auditory hallucinations. Suicidal/Homicidal Ideation: The patient denies on admission. Cognitive Assessment: Grossly intact. The patient is alert and oriented x 3. Judgment: Poor, shown by noncompliance with treatment. Assets: Include stable physical status. Limitations: Include recurrent psychosis. FORMULATION: The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment. INITIAL IMPRESSION: AXIS I: Schizophrenia, chronic paranoid. AXIS II: None. AXIS III: None. AXIS IV: Severe. AXIS V: 10. ESTIMATED LENGTH OF STAY: 12 days. PLAN: The patient will be restarted on Invega and Abilify for psychosis. The patient will also be continued on Cogentin for EPS. Increased database will be obtained. |
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Write a clinical note about a patient with the following identifying data: The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner. | IDENTIFYING DATA: The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner. CHIEF COMPLAINT: "I'm in jail because I was wrongly arrested." The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability. HISTORY OF PRESENT ILLNESS: The patient has minimal insight into the circumstances that resulted in this admission. He reports being diagnosed with AIDS and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition. Prior to admission, the patient was brought to Emergency Room after he attempted to shoplift from a local department store, during which he apparently slapped his partner. The patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability. On the interview, the patient is still disorganized and confused. He believes that he has been arrested and is in jail. Reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary. I was able to contact his partner by telephone. His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers. His partner estimates the patient spends about 20% of the year in episodes of worse symptoms. His partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons. He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night. He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently. He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home. He reports that the patient has been eating regularly with no recent weight loss. He states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months. His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening. He reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine. He also reports that the patient has expressed the belief in the past that he does not suffer from either condition. PAST PSYCHIATRIC HISTORY: The patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown. The patient was last enrolled in an outpatient mental health treatment in mid 2009. He dropped out of care about six months ago when he moved with his partner. His partner reports the patient was most recently prescribed Seroquel, which, though the patient denied benefiting from, his partner felt was "useful, but not dosed high enough." Past medication trials that the patient reports include Haldol and lithium, neither of which he found to be particularly helpful. MEDICAL HISTORY: The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis. He is currently followed at Clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year. The patient is fairly vague on his history of AIDS related conditions, but does identify the following: Thrush, skin lesions, and lung infections; additional details of these problems are not currently known. CURRENT MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL AND DEVELOPMENTAL HISTORY: The patient lives with his partner. He is unemployed. Details of his educational and occupational history are not currently known. His source of finances is also unknown, though social security disability is presumed. SUBSTANCE AND ALCOHOL HISTORY: The patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month. His partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently. The patient reports smoking marijuana a few times in his life, but not recently. Denies other illicit substance use. LEGAL HISTORY: Unknown. GENETIC PSYCHIATRIC HISTORY: Also unknown. MENTAL STATUS EXAM: Attitude: The patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions. His appearance is cachectic. The patient is poorly groomed. Psychomotor: There is no psychomotor agitation or retardation. No other observed extrapyramidal symptoms or tardive dyskinesia. Affect: His affect is fairly detached. Mood: Describes his mood is "okay.",Speech: His speech is normal rate and volume. Tone, his volume was decreased initially, but this improved during the course of the interview. Thought Process: His thought processes are markedly tangential. Thought content: The patient is fairly scattered. He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time. He denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline. Paranoid delusions are elicited. Homicidal/Suicidal Ideation: He denies suicidal or homicidal ideation. Denies previous suicide attempts. Cognitive Assessment: Cognitively, he is alert and oriented to person and year only. His memory is intact to names of his Madison Clinic providers. Insight/Judgment: His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses. His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions. Assets: His assets include his housing and his history of supportive relationship with his partner over many years. Limitations: His limitations include his AIDS and his history of poor compliance with treatment. FORMULATION: The patient is a 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months. It is unclear to me how much his presentation is a direct expression of an AIDS-related condition, though I suspect the impact of his HIV status is likely to be substantial. DIAGNOSES: AXIS I: Schizophrenia by history. Rule out AIDS-induced psychosis. Rule out AIDS-related cognitive disorder. AXIS II: Deferred. AXIS III: AIDS (stable by his report). Anemia. AXIS IV: Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and HIV-related providers. AXIS V: Global Assessment Functioning is currently 15. PLAN: I will attempt to increase the database, will specifically request records from the last mental health providers. The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis. With the patient's permission, I will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past. I anticipate titrating further for effect during the course of his admission. |
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Write a clinical note about a patient with the following reason for consult: Anxiety. | REASON FOR CONSULT: Anxiety. CHIEF COMPLAINT: "I felt anxious yesterday.",HPI: A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath. The patient was consulted by Psychiatry for anxiety. I know this patient from a previous consult. During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with "syncopal episodes." She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours. The patient was seen by Abc, MD, and Def, Ph.D. The laboratories were reviewed and were positive for UTI, and anemia is also present. The TSH level was within normal limits. She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety. A low dose of Klonopin was also helpful for sedation. PAST MEDICAL HISTORY: Metastatic breast cancer to bone. The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis. PAST PSYCHIATRIC HISTORY: The patient has a history of depression and anxiety. She was taking Remeron 15 mg q.h.s. Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home. FAMILY HISTORY: There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family. SOCIAL HISTORY: The patient is married and lives at home with her husband. She has a history of smoking one pack per day for 18 years. The patient quit in 1967. According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day. MEDICATIONS: 1. Klonopin 0.25 mg p.o. every evening. 2. Fluconazole 200 mg p.o. daily. 3. Synthroid 125 mcg p.o. everyday. 4. Remeron 15 mg p.o. at bedtime. 5. Ceftriaxone IV 1 g in 1/2 NS every 24 hours. P.R.N. MEDICATIONS: 1. Tylenol 650 mg p.o. every 4 hours. 2. Klonopin 0.5 mg p.o. every 8 hours. 3. Promethazine 12.5 mg every 4 hours. 4. Ambien 5 mg p.o. at bedtime. ALLERGIES: No known drug allergies,LABORATORY DATA: These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90. White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000. TSH level 0.88. The urinalysis was positive for UTI. MENTAL STATUS EXAMINATION: GENERAL APPEARANCE: The patient is dressed in a hospital gown. She is lying in bed during the interview. She is well groomed with good hygiene. MOTOR ACTIVITY: No psychomotor retardation or agitation noted. Good eye contact. ATTITUDE: Pleasant and cooperative. ATTENTION AND CONCENTRATION: Normal. The patient does not appear to be distracted during the interview. MOOD: Okay. AFFECT: Mood congruent normal affect. THOUGHT PROCESS: Logical and goal directed. THOUGHT CONTENT: No delusions noted. PERCEPTION: Did not assess. MEMORY: Not tested. SENSORIUM: Alert. JUDGMENT: Good. INSIGHT: Good. IMPRESSION: 1. AXIS I: Possibly major depression or generalized anxiety disorder. 2. AXIS II: Deferred. 3. AXIS III: Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism. 4. AXIS IV: Interpersonal stressors. |
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Write a clinical note about a patient with the following chief complaint: Mental status changes after a fall. | CHIEF COMPLAINT: Mental status changes after a fall. HISTORY: Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes. She was very confused, incomprehensible speech, and was not responding appropriately. She was transported here stable, with no significant changes. She ultimately upon arrival here was unchanged in that she was not responding appropriately. She would have garbled speech, somewhat inappropriate at times, and unable to follow commands. No other history was able to be obtained. All pertinent history is documented within the records. Physical examination also documented in the records, essentially as above. PHYSICAL EXAMINATION: HEENT: Without any obvious signs of trauma. Pupils are equal and reactive. Extraocular movements are difficult to assess with her eyes closed, but she will open to voice. TMs, canals are normal without any signs of hemotympanum. Nasal mucosa and oropharynx are normal. NECK: Nontender, full range of motion, was not examined initially, a collar was placed. HEART: Regular. LUNGS: Clear. CHEST/BACK/ABDOMEN: Without trauma. SKIN: With multiple excoriations from scratching and itching. NEUROLOGIC: Otherwise she has good sensation, withdrawals to pain. When lifting the arm, she will hold them up and draw, let them down slowly. With movement of the legs, she did straighten them back out slowly. DTRs were intact and equal bilaterally. Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change. LABORATORY DATA: CT scan of the head was negative as was cervical spine. She has a history of being on Coumadin. Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands. CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3. ASSESSMENT AND PLAN: Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved. It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved. At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation. I have discussed this with her son, he agrees. Otherwise, she has improved significantly. The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment. |
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Write a clinical note about a patient with the following identifying data: Mr. T is a 45-year-old white male. | IDENTIFYING DATA: Mr. T is a 45-year-old white male. CHIEF COMPLAINT: Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests. He has had suicidal ideation, but this is currently in remission. Furthermore, he continues to have hopeless thoughts and crying spells. Mr. T stated these symptoms appeared approximately two months ago. HISTORY OF PRESENT ILLNESS: On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee." This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him "bitch." Mr. T then retaliated, and went to hit the other employee. Due to this event, Mr. T was fired. It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to "deal with it.",There are no other apparent stressors in Mr. T's life at this time or in recent months. Mr. T stated that work was his entire life and he based his entire identity on his work ethic. It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years. PAST PSYCHIATRIC HISTORY: There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time. Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003. PAST PSYCHIATRIC REVIEW OF SYSTEMS: Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders. He denied any suicide attempts, or profound suicidal or homicidal ideation. Mr. T furthermore stated that his family psychiatric history is unremarkable. SUBSTANCE ABUSE HISTORY: Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years. No other substance abuse was noted. LEGAL HISTORY: Currently, charges are pending over the above described incident. MEDICAL HISTORY: Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia. PERSONAL AND SOCIAL HISTORY: Mr. T was born in Dwyne, Missouri, with no complications associated with his birth. Originally, he was raised by both parents, but they separated at an early age. When he was about seven years old, he was raised by his mother and stepfather. He did not sustain a relationship with his biological father from that time on. He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education. Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old. He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company. He then became a homemaker while his wife worked for Chrysler for approximately two years. Mr. T was married for eleven years, and divorced in 1993. He has a son who is currently 20 years old. After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer. Mental Status Exam: Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense. At times he showed some involuntary movements that would be more akin to a resting tremor. There was no psychomotor retardation, but there was some mild psychomotor excitement. His speech was clear, concise, but pressured. His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger. There was no evidence of euphoria or diurnal mood variation. His affective expression was restricted range, but there was no evidence of lability. At times, his affective tone and facial expressions were inappropriate to the interview. There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations. There was no evidence of illusions, depersonalizations, or derealizations. Mr. T presented with a sequential and goal directed stream of thought. There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking. There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts. There was evidence of concreteness for similarities and proverbs. His intelligence was average. His concentration was mildly impaired, and there was no evidence of distractibility. He was oriented to time, place, person and situation. There was no evidence of clouded consciousness or dissociation. His memory was intact for immediate, recent, and remote events. He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence. There was a moderate preoccupation with his physical health pertaining to his headaches. His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans. Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem. His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments. He has a well-developed empathy for others and capacity for affection. There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation. His credibility seemed good. There was no evidence for potential self-injury, suicide, or violence. The reliability and completeness of information was very good, and there were no barriers to communication. The information gathered was based on the patient's self-report and objective testing and observation. His attitude toward the examiner was neutral and his attitude toward the examination process was neutral. There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder. IMPRESSIONS: Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy. At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment. Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year. As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning. Furthermore, it only appears logical that this would precipitate a major depressive episode. |
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Write a clinical note about a patient with the following chief complaint: "A lot has been thrown at me.",The patient is interviewed with husband in room. | CHIEF COMPLAINT: "A lot has been thrown at me.",The patient is interviewed with husband in room. HISTORY OF PRESENT ILLNESS: This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets. She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today. The patient states she had been thinking about suicide for a couple of weeks. Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble. Reports she has been not socializing with her family because of her worsening depression. Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth. They did as they have instructed and husband feels this may have had some factor on her worsening depression. The patient decided to ingest the pills when her husband went to work on Friday. She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened. Her husband left around 7 in the morning and returned around 11 and found her sleeping. About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital. She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene. She does not clearly explain how this has made her suicidality subside. This is the third suicide attempt in the last two months for this patient. About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall. She was taken to Southwest Memorial Hermann Hospital. A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor. Husband locked the gun after that and she was taken to Bellaire Hospital. The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days. She sees Dr. X once or twice weekly. He started seeing her after her first suicide attempt. The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active. Since then she has had worsening of her Huntington symptoms including short-term memory loss. At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath. The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease. The patient's mother passed away 25 years ago from Huntington's. Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's. The patient has told her husband that she does not want to go that way. The patient denies auditory or visual hallucinations, denies paranoid ideation. The husband and the patient deny any history of manic or hypomanic symptoms in the past. PAST PSYCHIATRIC HISTORY: As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression. MEDICATIONS: Her medications on admission, alprazolam 0.5 mg p.o. b.i.d. Artane 2 mg p.o. b.i.d. Haldol 2.5 mg p.o. t.i.d. Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily. Husband has stated that the patient's chorea becomes better when she takes Haldol. Alprazolam helps her with anxiety symptoms. PAST MEDICAL HISTORY: Huntington disease, symptoms of dementia and hypertension. She has an upcoming appointment with the Neurologist. Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y. ALLERGIES: CODEINE AND KEFLEX. FAMILY MEDICAL HISTORY: Strong family history for Huntington disease as per the HPI. Mother and grandmother died of Huntington disease. Two young brothers also had Huntington disease. FAMILY PSYCHIATRIC HISTORY: The patient denies history of depression, bipolar, schizophrenia, or suicide attempts. SOCIAL HISTORY: The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active. MENTAL STATUS EXAM: This is an elderly woman appearing stated age. Alert and oriented x4 with poor eye contact. Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips. She is cooperative. Her speech is of low volume and slow rate and rhythm. Her mood is sad. Her affect is constricted. Her thought process is logical and goal-directed. Her thought content is negative for current suicidal ideation. No homicidal ideation. No auditory or visual hallucinations. No command auditory hallucinations. No paranoia. Insight and judgment are fair and intact. LABORATORY DATA: A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality. U-tox positive for amphetamines and tricyclic antidepressants. Acetaminophen level 206.7, alcohol level 0. The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4. ASSESSMENT: This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. She took 30 tablets of Haldol and 40 tablets of Tylenol. At present, the patient is without suicidal ideation. She reports that her worsening depression has coincided with her worsening Huntington disease. She is more hopeful today, feels that she may be able to get help with her depression. The patient was admitted four days ago to the medical floor and has subsequently been stabilized. Her liver function tests are within normal limits. AXIS I: Major depressive disorder due to Huntington disease, severe. Cognitive disorder, NOS. AXIS II: Deferred. AXIS III: Hypertension, Huntington disease, status post overdose. AXIS IV: Chronic medical illness. AXIS V: 30. PLAN,1. Safety. The patient would be admitted on a voluntary basis to Main-7 North. She will be placed on every 15-minute checks with suicidal precautions. 2. Primary psychiatric issues/medical issues. The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h. Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h. fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d. amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation. 3. Substance abuse. No acute concern for alcohol or benzo withdrawal. 4. Psychosocial. Team will update and involve family as necessary. DISPOSITION: The patient will be admitted for evaluation, observation, treatment. She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy. We will place occupational therapy consult and social work consults. |
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Write a clinical note about a patient with the following chief complaint: Falls at home. | CHIEF COMPLAINT: Falls at home. HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They noted that she frequently came to the emergency room for "attention." The patient denied any chest pain or pressure and no change to exercise tolerance. The patient denied any loss of consciousness or incontinence. She denies any seizure activity. She states that she "tripped" at home. Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating. They stated that she has numerous medications at home, but they were not sure if she was taking them. The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression. The patient denied SI or HI. PHYSICAL EXAMINATION: GENERAL: The patient is pleasant 82-year-old female in no acute distress. VITAL SIGNS: Stable. HEENT: Negative. NECK: Supple. Carotid upstrokes are 2+. LUNGS: Clear. HEART: Normal S1 and S2. No gallops. Rate is regular. ABDOMEN: Soft. Positive bowel sounds. Nontender. EXTREMITIES: No edema. There is some ecchymosis noted to the left great toe. The area is tender; however, metatarsal is nontender. NEUROLOGICAL: Grossly nonfocal. HOSPITAL COURSE: A psychiatric evaluation was obtained due to the patient's increased depression and anxiety. Continue Paxil and Xanax use was recommended. The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls. DISCHARGE DIAGNOSES: 1. Falls ,2. Anxiety and depression. 3. Hypertension. 4. Hypercholesterolemia. 5. Coronary artery disease. 6. Osteoarthritis. 7. Chronic obstructive pulmonary disease. 8. Hypothyroidism. CONDITION UPON DISCHARGE: Stable. DISCHARGE MEDICATIONS: Tylenol 650 mg q.6h. p.r.n. Xanax 0.5 q.4h. p.r.n. Lasix 80 mg daily, Isordil 10 mg t.i.d. KCl 20 mEq b.i.d. lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n. Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n. Advair 250/50 one puff b.i.d. Senokot one tablet b.i.d. Timoptic one drop OU daily, and verapamil 80 mg b.i.d. ALLERGIES: None. ACTIVITY: Per PT. FOLLOW-UP: The patient discharged to a skilled nursing facility for further rehabilitation. |
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Write a clinical note about a patient with the following identifying data: The patient is a 35-year-old Caucasian female who speaks English. | IDENTIFYING DATA: The patient is a 35-year-old Caucasian female who speaks English. CHIEF COMPLAINT: The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband. She then turned on the oven and put her head in the oven and then tried to climb over the second storied balcony. All of these behaviors were interrupted by her husband who called 911. He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period. HISTORY OF PRESENT ILLNESS: The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked. After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium. Her husband states that he restrained her from jumping, "so she would not kill herself," and this was taken as a statement in his affidavit. The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital. She arrives here and is today pacing on the unit and in and out of the large TV room area. She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner. She is highly tangential, delusional, and disorganized. She refused to sign all admit papers and a considerable part of her immediate history is unknown. PAST PSYCHIATRIC HISTORY: The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009. Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present. She is currently treated by Dr. Y. She has been involuntarily detained at least 7 times and revoked at least 6 times. She was on XYZ Inpatient in 2001 and in 01/2009. She states that she "feels invincible" when she becomes manic and this is also the description given by her husband. MEDICAL HISTORY: The patient has a history of a herniated disc in 1999. MEDICATIONS: Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o. AM and 600 mg p.o. q.p.m. Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard. She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc. Of note, she also has a history of abusing Vicodin. ALLERGIES: Said to be PENICILLIN, LAMICTAL, and ZYPREXA. SOCIAL AND DEVELOPMENTAL HISTORY: The patient lives with her husband. There are no children. She reportedly has a college education and has 2 brothers. SUBSTANCE AND ALCOHOL HISTORY: Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin. The X Hospital tox screen of last night was positive for opiates. Her lithium level per last night at X Hospital was 0.42 mEq/L. She smokes nicotine, the amount is not known although she has asked and received Nicorette gum. LEGAL HISTORY: She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated. MENTAL STATUS EXAM: ATTITUDE: The patient's attitude is agitated when asked questions, loud and evasive. APPEARANCE: Disheveled and moderately well nourished. PSYCHOMOTOR: Restless with erratic sudden movements. EPS: None. AFFECT: Hyperactive, hostile, and labile. MOOD: Her mood is agitated, suspicious, and angry. SPEECH: Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real. THOUGHT CONTENT: Delusional, disorganized, psychotic, and paranoid. Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt. COGNITIVE ASSESSMENT: The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital. Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing. JUDGMENT AND INSIGHT: Nil. When asked, are there situations when you lose control, she refuses to answer. When asked, are meds helpful, she refuses to answer. She refuses to give her family information nor release of information to contact them. ASSETS: The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications. LIMITATIONS: The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner. FORMULATION,: The patient has bipolar affective disorder in a manic state at present. She also may be depressed and is struggling with marital issues. DIAGNOSES: |
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Write a clinical note about a patient with the following identifying data: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.", | IDENTIFYING DATA: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan. PRESENT ILLNESS: The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital. PAST PSYCHIATRIC HISTORY: Listed extensively in his admission note and will not be repeated. MEDICAL HISTORY: Includes migraine headaches and a history of concussion. He describes "allergy" to Haldol medication. OUTPATIENT CARE: The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X. DISCHARGE MEDICATIONS: The patient is discharged with: 1. Klonopin 1 mg t.i.d. p.r.n. 2. Extended-release lithium 450 mg b.i.d. 3. Depakote 1000 mg b.i.d. 4. Seroquel 1000 mg per day. SOCIAL HISTORY: The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together. SUBSTANCE ABUSE: The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment. MENTAL STATUS EXAM: Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications. FORMULATION: The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds. DIAGNOSES: AXIS I: 1. Bipolar disorder. 2. Major depression with anxiety and panic attacks. 3. Polysubstance abuse, benzodiazepines, and others street meds. 4. ADHD. AXIS II: Deferred at present, but consider personality disorder traits. AXIS III: History of migraine headaches and past history of concussion. AXIS IV: Stressors are moderate. AXIS V: GAF is 40. PLAN: The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan. |
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Write a clinical note about a patient with the following chief complaint: Foot pain. | CHIEF COMPLAINT: Foot pain. HISTORY OF PRESENT ILLNESS: This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an hour prior to this injury. Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care. He is able to bear weight; however, complains of pain in his toes. The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot. According to the patient, he was at his baseline state of health prior to this acute event. PAST MEDICAL HISTORY: Significant for attention deficit hyperactivity disorder. PAST SURGICAL HISTORY: Positive for wisdom tooth extraction. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He does not use alcohol, tobacco or illicit drugs. He plays water polo for the school team. IMMUNIZATION HISTORY: All immunizations are up-to-date for age. REVIEW OF SYSTEMS: The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative. PRESENT MEDICATIONS: Provigil, Accutane and Rozerem. ALLERGIES: None. PHYSICAL EXAMINATION: GENERAL: This is a pleasant white male in no acute distress. VITAL SIGNS: He is afebrile. Vitals are stable and within normal limits. HEENT: Negative for acute evidence of trauma, injury or infection. LUNGS: Clear. HEART: Regular rate and rhythm with S1 and S2. ABDOMEN: Soft. EXTREMITIES: There are some abrasions across the dorsum of the right foot including the second, third and fourth toes. There is some mild tenderness to palpation. However, there are no clinical fractures. Distal pulses are intact. The left foot notes superficial avulsion lacerations to the third and fourth digit. There are no subungual hematomas. Range of motion is decreased secondary to pain. No obvious fractures identified. BACK EXAM: Nontender. NEUROLOGIC EXAM: He is alert, awake and appropriate without deficit. RADIOLOGY: AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries. On reevaluation, the patient was resting comfortably. He was informed of the x-ray findings. The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair. DISCHARGE MEDICATIONS: Darvocet. The patient's condition at discharge was stable. All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge. The patient/family understood the instructions and was discharged without further incident. |
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Write a clinical note about a patient with the following chief complaint: Ankle pain. | CHIEF COMPLAINT: Ankle pain. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts to move or bear weight. No other injuries noted. He does not think he has had injuries to his ankle in the past. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: He does not drink or smoke. ALLERGIES: Unknown. MEDICATIONS: Adderall and Accutane. REVIEW OF SYSTEMS: As above. Ten systems reviewed and are negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air. GENERAL: |
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Write a clinical note about a patient with the following admission diagnosis: Left hip fracture. | ADMISSION DIAGNOSIS: Left hip fracture. CHIEF COMPLAINT: Diminished function, secondary to the above. HISTORY: This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture identified on x-rays at that time. Pain and inability to ambulate brought him in. He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. His medical issues are under good control. The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions. PAST MEDICAL HISTORY: Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties. ALLERGIES: Zyloprim, penicillin, Vioxx, NSAIDs. CURRENT MEDICATIONS,1. Heparin. 2. Albuterol inhaler. 3. Combivent. 4. Aldactone. 5. Doxepin. 6. Xanax. 7. Aspirin. 8. Amiodarone. 9. Tegretol. 10. Synthroid. 11. Colace. SOCIAL HISTORY: Lives in a 1-story home with 1 step down; wife is there. Speech and language pathology following with current swallowing dysfunction. He is minimum assist for activities of daily living, bed mobility. REVIEW OF SYSTEMS: Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain. PHYSICAL EXAMINATION,HEENT: Oropharynx clear. CV: Regular rate and rhythm without murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Nontender, nondistended. Bowel sounds positive. EXTREMITIES: Without clubbing, cyanosis, or edema. NEUROLOGIC: There are no focal motor or sensory losses to the lower extremities. Bulk and tone normal in the lower extremities. Wound site has healed well with staples out. IMPRESSION ,1. Status post left hip fracture and hemiarthroplasty. 2. History of panic attack, anxiety, depression. 3. Myocardial infarction with stent placement. 4. Hypertension. 5. Hypothyroidism. 6. Subdural hematoma. 7. Seizures. 8. History of chronic obstructive pulmonary disease. Recent respiratory insufficiency. 9. Renal insufficiency. 10. Recent pneumonia. 11. O2 requiring. 12. Perioperative anemia. PLAN: Rehab transfer as soon as medically cleared. |
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ds_sft = datasets.load_dataset('TigerResearch/tigerbot-mt-note-generation-en')
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