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Write a clinical note about a patient with the following chief complaint: The patient comes for her well-woman checkup.

CHIEF COMPLAINT: The patient comes for her well-woman checkup. HISTORY OF PRESENT ILLNESS: She feels well. She has had no real problems. She has not had any vaginal bleeding. She had a hysterectomy. She has done fairly well from that time till now. She feels like she is doing pretty well. She remains sexually active occasionally. She has not had any urinary symptoms. No irregular vaginal bleeding. She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well. She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves. She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep. She does not report any swelling or inflammation, or pain. She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis. MEDICATIONS: Tetracycline 250 mg daily, Inderal LA 80 mg every other day. ALLERGIES: Sulfa. PAST MEDICAL HISTORY: She had rosacea. She also has problems with “tremors” and for that she takes Inderal LA. Hysterectomy in the past. SOCIAL HISTORY: She drinks four cups of coffee a day. No soda. No chocolate. She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much. They walk every evening for one hour. FAMILY HISTORY: Her mother is in a nursing home; she had a stroke. Her father died at age 86 in January 2004 of congestive heart failure. She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict. REVIEW OF SYSTEMS: Patient denies headache or trauma. No blurred or double vision. Hearing is fine, no tinnitus, or infection. Infrequent sore throat, no hoarseness, or cough. Neck: No stiffness, pain, or swelling. Respiratory: No shortness of breath, cough, or hemoptysis. Cardiovascular: No chest pain, ankle edema, palpitations, or hypertension. GI: No nausea, vomiting, diarrhea, constipation, melena, or jaundice. GU: No dysuria, frequency, urgency, or stress incontinence. Locomotor: No weakness, joint pain, tremor, or swelling. GYN: See HPI. Integumentary: Patient performs self-breast examinations and denies any breast masses or nipple discharge. No recent skin or hair changes. Neuropsychiatric: Denies depression, anxiety, tearfulness, or suicidal thought. PHYSICAL EXAMINATION: VITAL SIGNS: Height: 62 inches. Weight: 134 pounds. Blood pressure: 116/74. Pulse: 60. Respirations: 12. Age 59. 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 fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her. She wears glasses. Neck: Full range of motion. No lymphadenopathy or thyromegaly. Chest: Clear to auscultation and percussion. Heart: Normal sinus rhythm, no murmur. Integumentary: Breasts are without masses, tenderness, nipple retraction, or discharge. Reviewed self-breast examination. No axillary nodes are palpable. Abdomen: Soft. Liver, spleen, and kidneys are not palpable. No masses felt, nontender. Femoral pulses strong and equal. Back: No CVA or spinal tenderness. No deformity noted. Pelvic: BUS negative. Vaginal mucosa atrophic. Cervix and uterus are absent. No Pap was taken. No adnexal masses. Rectal: Good sphincter tone. No masses. Stool guaiac negative. Extremities: No edema. Pulses strong and equal. Reflexes are intact. Romberg and Babinski are negative. She is oriented x 3. Gait is normal. ASSESSMENT: Middle-aged woman, status post hysterectomy, recent urinary tract infection. PLAN: We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture. I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today. We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available. Continue same meds. Recheck annually unless she has problems sooner.

Write a clinical note about a patient with the following chief complaint: I need refills.

CHIEF COMPLAINT: I need refills. HISTORY OF PRESENT ILLNESS: The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain. She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office. She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try. OBJECTIVE: Well developed and well nourished. She does not appear to be in any acute distress. Cardiovascular: Regular rhythm. No murmurs, gallops, or rubs. Capillary refill less than 3 seconds. Peripheral pulses are 2+ bilaterally. Respiratory: Her lungs are clear to auscultation bilaterally with good effort. No tenderness to palpation over chest wall. Musculoskeletal: She has full range of motion of all four extremities. No tenderness to palpation over long bones. Skin: Warm and dry. No rashes or lesions. Neuro: Alert and oriented x3. Cranial nerves II-XII are grossly intact. No focal deficits. PLAN: I did refill her medications. I have requested that she have her primary doctor forward her records to me. I have discussed Chantix and its use and success rate. She was given a prescription, as well as a coupon. She is to watch for any worsening signs or symptoms. She verbalized understanding of discharge instructions and prescriptions. I would like to see her back to proceed with her preventive health measures.

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.

Write a clinical note about a patient with the following chief complaint: Vaginal discharge with a foul odor.

CHIEF COMPLAINT: Vaginal discharge with a foul odor. HISTORY OF PRESENT ILLNESS: This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration. The patient states that she has also had frequency of urination. The patient denies any burning with urination. She states that she is sexually active and does not use condoms. She does have three sexual partners. The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again. The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years. The patient does state that she has never had HIV testing. The patient states that she has not had any vaginal bleeding and does not have any abdominal pain. The patient denies fevers or chills, nausea or vomiting, headaches or head trauma. The patient also denies skin rashes or lesions. She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin. The patient is G2 P2. She has had some irregular Pap smears in the past. Her last Pap smear was approximately 6 to 12 months ago. The patient has had frequent urinary tract infections in the past. PAST MEDICAL HISTORY: 1. Bronchitis. 2. Urinary tract infections. 3. Vaginal candidiasis. PAST SURGICAL HISTORY: Cyst removal of the right breast. SOCIAL HISTORY: The patient does smoke approximately half a pack of cigarettes per day. She denies alcohol or illicit drug use. MEDICATIONS: None. ALLERGIES: No known medical allergies. PHYSICAL EXAMINATION: GENERAL: This is an African-American female who appears her stated age of 25 years. She is well nourished, well developed, and in no acute distress. The patient is pleasant. VITAL SIGNS: Afebrile. Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air. HEART: Regular rate and rhythm. Clear S1 and S2. No murmur, rub or gallop is appreciated. LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi. ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds throughout. SKIN: Warm, dry and intact. No rash or lesion. PSYCH: Alert and oriented to person, place, and time. NEUROLOGIC: Cranial nerves II through XII are intact bilaterally. No focal deficits are appreciated. GENITOURINARY: The pelvic exam done shows external genitalia without abnormalities or lesions. There is a white-to-yellow discharge. Transformation zone is identified. The cervix is mildly friable. Vaginal vault is without lesions. There is no adnexal tenderness. No adnexal masses. No cervical motion tenderness. Cervical swabs and vaginal cultures are obtained. DIAGNOSTIC STUDIES: Urinalysis shows 3+ bacteria, however, there are no wbc's. No squamous epithelial cells and no other signs of infection. There is no glucose. The patient's cervical swabs and cultures are obtained and there are positive clue cells. Negative Trichomonas. Negative fungal elements and Chlamydia and gonorrhea are pending at this time. Urinalysis is sent for culture and sensitivity. ASSESSMENT: : Gardnerella bacterial vaginosis. PLAN: The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days. The patient will follow up with her primary care provider.

Write a clinical note about a patient with the following chief complaint: The patient comes for her first Pap smear, complaining of irregular periods.

CHIEF COMPLAINT: The patient comes for her first Pap smear, complaining of irregular periods. HISTORY OF PRESENT ILLNESS: The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods. She notes that her periods are out of weck. She says that she has cramping and pain before her period starts. Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks. She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed. The cramping is worse. She said her flow has increased. She has to change her pad every half to one hour and uses a super tampon sometimes. She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad. She also notes that her headaches have been worsening a little bit. She has had quite a bit of stress. She had a headache on Wednesday again after having had one on the weekend. She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them. She avoids caffeine. She only eats chocolate when she is near her period and she usually drinks one can of cola a day. MEDICATIONS: None. ALLERGIES: None. SOCIAL HISTORY: She is a nonsmoker. She is not sexually active. PAST MEDICAL HISTORY: She has had no surgery or chronic illnesses. FAMILY HISTORY: Mother has hypertension, depression. Father has had renal cysts and sometimes some stomach problems. Both of her parents have problems with their knees. REVIEW OF SYSTEMS: Patient denies headache or trauma. No blurred or double vision. Hearing is fine, no tinnitus or infection. Infrequent sore throat, no hoarseness or cough. HEENT: See HPI. Neck: No stiffness, pain or swelling. Respiratory: No shortness of breath, cough or hemoptysis. She is a nonsmoker. Cardiovascular: No chest pain, ankle edema, palpitations or hypertension. GI: No nausea, vomiting, diarrhea, constipation, melena or jaundice. GU: No dysuria, frequency, urgency or stress incontinence. Locomotor: No weakness, joint pain, tremor or swelling. GYN: See HPI. Integumentary: Patient performs self-breast examinations and denies any breast masses or nipple discharge. No recent skin or hair changes. Neuropsychiatric: Denies depression, anxiety, tearfulness or suicidal thought. PHYSICAL EXAMINATION: VITALS: Height 64.5 inches. Weight: 162 pounds. Blood pressure 104/72. Pulse: 72. Respirations: 16. LMP: 08/21/04. Age: 19. 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. Neck: Full range of motion. No lymphadenopathy or thyromegaly. Chest: Clear to auscultation and percussion. Heart: Normal sinus rhythm, no murmur. Integumentary: Breasts are without masses, tenderness, nipple retraction or discharge. Reviewed self-breast examination. No axillary nodes are palpable. Abdomen: Soft. Liver, spleen, and kidneys are not palpable. No masses felt, nontender. Femoral pulses strong and equal. Back: No CVA or spinal tenderness. No deformity noted. Pelvic: BUS negative. Vaginal mucosa pink, scanty discharge. Cervix without lesion. Pap was taken. Uterus normal size. Adnexa: No masses. She does have some pain on palpation of the uterus. Rectal: Good sphincter tone. No masses. Stool is guaiac negative. Extremities: No edema. Pulses strong and equal. Reflexes are intact. Rectal: No mass. ASSESSMENT: Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods. PLAN: We will evaluate with a CBC, urinalysis and culture, and TSH. The patient has what she describes as migraine headaches of a new onset. Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram. We will evaluate with a CT scan of the brain with and without contrast. We will try Anaprox DS one every 12 hours for the headache. At this point, she could also use that for menstrual cramping. Prescription written for 20 tablets. If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow. The lab x-ray and urinalysis results will be reported to her as soon as they are available.

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:

Write a clinical note about a patient with the following chief complaint: Transient visual loss lasting five minutes.

CHIEF COMPLAINT: Transient visual loss lasting five minutes. HISTORY OF PRESENT ILLNESS: This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible lumbar stenosis. He reports he experienced a single episode of his vision decreasing "like it was compressed from the top down with a black sheet coming down". The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car. He was able to pull the car over to the side of the road safely. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale and ashen during the episode. He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable. It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker. He has had no further similar events. He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem. He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis. The question has arisen as to whether he should have a CT myelogram to further evaluate this process. He has no back pain or pain of any type, he denies bowel or bladder incontinence or frank lower extremity weakness. He is extremely active and plays tennis at least three times a week. He denies recent episodes of unexpected falls. REVIEW OF SYSTEMS: He only endorses hypothyroidism, the episode of visual loss described above and joint pain. He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative. A copy is in his clinic chart. PAST MEDICAL HISTORY: As above. He has had bilateral knee replacement three years ago and experiences some pain in his knees with this. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He is retired from the social security administration x 20 years. He travels a lot and is extremely active. He does not smoke. He consumes alcohol socially only. He does not use illicit drugs. He is married. MEDICATIONS: The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago. He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d. PHYSICAL EXAMINATION: Vital Signs: BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds. He denies any pain. General: This is a pleasant white male in no acute distress. HEENT: He is normocephalic and atraumatic. Conjunctivae and sclerae are clear. There is no sinus tenderness. Neck: Supple. Chest: Clear to auscultation. Heart: There are no bruits present. Extremities: Extremities are warm and dry. Distal pulses are full. There is no edema. NEUROLOGIC EXAMINATION: MENTAL STATUS: He is alert and oriented to person, place and time with good recent and long-term memory. His language is fluent. His attention and concentration are good. CRANIAL NERVES: Cranial nerves II through XII are intact. VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline. MOTOR: He has normal bulk and tone throughout. There is no cogwheeling. There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5. Otherwise he is 5/5 throughout including hip adductors and abductors. SENSORY: He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration. COORDINATION: There is no dysmetria or tremor noted. His Romberg is negative. Note that he cannot rise from the chair without using his arms. GAIT: Upon arising, he has a normal step, stride, and toe, heel. He has difficulty with tandem and tends to fall to the left. REFLEXES: 2 at biceps, triceps, patella and 1 at ankles. The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection. He has had full labs for cholesterol and stroke for risk factors although he does not have those available here. IMPRESSION: 1. TIA. The character of his brief episode of visual loss is concerning for compromise of the posterior circulation. Differential diagnoses include hypoperfusion, stenosis, and dissection. He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system. He has recently been started on Paxil by his primary care physician and this should be continued. Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup. The patient and his wife assure me that the workup was complete and that nothing was found at that time. 2. Lumbar stenosis. His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability. In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this time. Therefore we would defer further evaluation with CT myelogram as he does not want surgery. PLAN: 1. We will get a CT angiogram of the cerebral vessels. 2. Continue Plavix. 3. Obtain copies of the workup done at the outside hospital. 4. We will follow the lumbar stenosis for the time being. No further workup is planned.

Write a clinical note about a patient with the following chief complaint: Severe back pain and sleepiness. The patient is not a good historian and history was obtained from the patient's husband at bedside.

CHIEF COMPLAINT: Severe back pain and sleepiness. The patient is not a good historian and history was obtained from the patient's husband at bedside. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain. As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection. The patient has severe pain and all in all, the patient cries at home. As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation. The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria. While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control. The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli. The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked. The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode. PAST MEDICAL CONDITIONS: Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine. No history of diabetes, stroke or coronary artery disease. SURGICAL HISTORY: Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age. ALLERGIES: DENIED. CURRENT MEDICATIONS: According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day. The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily. SOCIAL HISTORY: She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking. PHYSICAL EXAMINATION: GENERAL: Currently lying in the bed without apparent distress, very lethargic. VITAL SIGNS: Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58. CHEST: Shows bilateral air entry present, clear to auscultate. HEART: S1 and S2 regular. ABDOMEN: Soft, nondistended, and nontender. EXTREMITIES: Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain. IMAGING: The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease. LABORATORY DATA: The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range. IMPRESSION: The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure. 1. Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants. 2. Osteoporosis of the spine with L1 compression fracture causing the patient severe pain. 3. Hypertension, now hypotension. 4. Incontinence of the bladder. 5. Dementia, most likely Alzheimer type. PLAN AND SUGGESTION: Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept. I will hold the patient's hydrocodone. I will hold the Flexeril and I will also hold gabapentin at this moment. We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed. Also give the patient calcium with vitamin D and physical therapy. We will also order a blood test and further management will be based on the patient's all test results. I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.

Write a clinical note about a patient with the following chief complaint: Status epilepticus.

CHIEF COMPLAINT: Status epilepticus. HISTORY OF PRESENT ILLNESS: The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. At baseline, he can put about 2 to 4 words together in brief sentences. His speech is not always easily understood; however, he is in a special education classroom in kindergarten. He ambulates independently, but falls often. He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left. Mother reports he postures the left upper extremity when running. He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X. He has not received Botox or any other interventions with regard to his cerebral palsy. The patient did require one shunt revision, but since then his shunt has done well. The patient developed seizures about 2 years ago. These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side. His events, however, always tend to be prolonged. He has had seizures as long as an hour and a half. He tends to require multiple medications to stop them. He has been followed by Dr. Y and was started on Trileptal. At one point, The patient was taken off his medication for presumed failure to prevent his seizures. He was more recently placed on Topamax since March 2007. His last seizures were in March and May respectively. He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point. The patient was in his usual state of health until early this morning and was noted to be in seizure. His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right. Family administered Diastat 7.5 mg x1 dose. They did not know they could repeat this dose. EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin. His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline. He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally. REVIEW OF SYSTEMS: At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise. He does have some fevers after his prolonged seizures. He denies any respiratory or cardiovascular complaints. There is no numbness or loss of skills. He has no rashes, arthritis or arthralgias. He has no oropharyngeal complaints. Visual or auditory complaints. PAST MEDICAL HISTORY: Also positive for some mild scoliosis. SOCIAL HISTORY: The patient lives at home with mother, father, and 2 other siblings. There are no ill contacts. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is a well-nourished, well-hydrated male, in no acute distress. VITAL SIGNS: His vital signs are stable and he is currently afebrile. HEENT: Atraumatic and normocephalic. Oropharynx shows no lesions. NECK: Supple without adenopathy. CHEST: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm, no murmurs. ABDOMEN: Benign without organomegaly. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: The patient is alert and will follow instructions. His speech is very dysarthric and he tends to run his words together. He is about 50% understandable at best. He does put words and sentences together. His cranial nerves reveal his pupils are equal, round, and reactive to light. His extraocular movements are intact. His visual fields are full. Disks are sharp bilaterally. His face shows left facial weakness postictally. His palate elevates midline. Vision is intact bilaterally. Tongue protrudes midline. Motor exam reveals clearly decreased strength on the left side at baseline. His left thigh is abducted at the hip at rest with the right thigh and leg straight. He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria. Right upper extremity is much more on target. His sensations are intact to light touch bilaterally. Deep tendon reflexes are 2+ and symmetric. When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis. He also shows some scoliotic curve of the spine, which is mild at this point. Gait was not tested today. IMPRESSION: This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage. He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day. At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently. The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily. Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence. I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance. The plan from CT standpoint is to continue stretching program, continue with medical therapy unit. He may benefit from Botox. In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before. They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time. Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them. Other medication options would include Keppra, Zonegran or Lamictal. FOLLOWUP: Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.

Write a clinical note about a patient with the following chief complaint: Neck and lower back pain.

CHIEF COMPLAINT: Neck and lower back pain. VEHICULAR TRAUMA HISTORY: Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released. NECK AND LOWER BACK PAIN HISTORY: The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.

Write a clinical note about a patient with the following chief complaint: Headaches.

CHIEF COMPLAINT: Headaches. HEADACHE HISTORY: The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain. PAST MEDICAL HISTORY: No significant past medical problems. PAST SURGICAL HISTORY: ,No significant past surgical history. FAMILY MEDICAL HISTORY: ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather. ALLERGIES: Codeine. CURRENT MEDICATIONS: See chart. PERSONAL/SOCIAL HISTORY: Marital status: Married. The patient smokes 1 pack of cigarettes per day. Denies use of alcohol. NEUROLOGIC DRUG HISTORY: The patient has had no help with the headaches from over-the-counter analgesics. REVIEW OF SYSTEMS: ROS General: Generally healthy. Weight is stable. ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal. ROS Ears Nose and Throat: The patient notes some sinus congestion. ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems. ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems. ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system. EXAM: Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill. Sex and Race: Male, Caucasian. Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation. Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion. Exam Cranial Nerves: Sense of smell was intact. Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm. No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits. Exam Back: Back range of motion was normal in all directions. Exam Sensory: Position and vibratory sense was normal. Exam Reflexes: Active and symmetrical. There were no pathological reflexes. Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally. Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities. No lesions identified. IMPRESSION DIAGNOSIS: Migraine without aura (346.91),COMMENTS: The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d. OTHER TREATMENT: The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle. RATIONALE FOR TREATMENT PLAN: The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives. FOLLOW UP INSTRUCTIONS:

Write a clinical note about a patient with the following chief complaint: Headache.

CHIEF COMPLAINT: Headache. HPI: This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. He has had headaches since the 13th and complains now of some worsening of his pain. He denies photophobia, fever, vomiting, and weakness of the arms or legs. PMH: As above. MEDS: Vicodin. ALLERGIES: None. PHYSICAL EXAM: BP 180/110 Pulse 65 RR 18 Temp 97.5. Mr. P is awake and alert, in no apparent distress. HEENT: Pupils equal, round, reactive to light, oropharynx moist, sclera clear. ,Neck: Supple, no meningismus. Lungs: Clear. Heart: Regular rate and rhythm, no murmur, gallop, or rub. ,Abdomen: Benign. Neuro: Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal. Cranial nerves normal. ,COURSE IN THE ED: Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. I recommended an LP but he prefers not to have this done. He received morphine for pain and his headache improved. I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. He left the ED against my advice. ,IMPRESSION: Headache, improved. Intracranial aneurysm. PLAN: The patient will return tomorrow am for his angiogram.

Write a clinical note about a patient with the following chief complaint: Right shoulder pain.

CHIEF COMPLAINT: Right shoulder pain. HISTORY: The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002. She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy. He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms. He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03. She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X. She comes to me for impairment rating. She has no chronic health problems otherwise, fevers, chills, or general malaise. She is not working. She is right-hand dominant. She denies any prior history of injury to her shoulder. PAST MEDICAL HISTORY: Negative aside from above. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Please see above. REVIEW OF SYSTEMS: Negative aside from above. PHYSICAL EXAMINATION: A pleasant, age appropriate woman, moderately overweight, in no apparent distress. Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right. She has decreased motion in the right shoulder as follows. She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation. She has a positive impingement sign on the right. ASSESSMENT: Right shoulder impingement syndrome, right suprascapular neuropathy. DISCUSSION: With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition. The reason for this impairment is the incident of 01/01/02. For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit. This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity. For her lack of motion in the shoulder she also has additional impairment on the right. She has a 1% impairment of the upper extremity due to lack of shoulder flexion. She has a 1% impairment of the upper extremity due to lack of shoulder abduction. She has a 1% impairment of the upper extremity due to lack of shoulder adduction. She has a 1% impairment of the upper extremity due to lack of shoulder extension. There is no impairment for findings in shoulder external rotation. She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation. Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity. This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty.

Write a clinical note about a patient with the following chief complaint: Intractable epilepsy, here for video EEG.

CHIEF COMPLAINT: Intractable epilepsy, here for video EEG. HISTORY OF PRESENT ILLNESS: The patient is a 9-year-old male who has history of global developmental delay and infantile spasms. Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis. He has had severe global developmental delay, and is nonverbal. He can follow objects with his eyes, but has no ability to interact with his environment to any great degree. He has noted if any purposeful use of the hands. He has abnormal movements constantly, which are more choreiform and dystonic. He has spastic quadriparesis, which is variable at times. The patient is unable to sit or stand, and receives all his nutrition via G-tube. The patient began having seizures in infancy presenting as infantile spasms. I began seeing him at 20 months of age. At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms. The patient had benefit from this medication, and was doing well at that time with regard to that seizure type. He initially was on phenobarbital, which failed to give him benefit. He continued on phenobarbital; however, for a long period time thereafter. The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly. Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2. Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense. It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day. These events manifest as tonic spells with eye deviation and posturing. Mother reports flexion of the upper extremities, extension with lower extremities. During that time, he is not able to cry or say any sounds. These events last from seconds to minutes, and occur at least multiple times per week. There are times where he has none for a few days and other times where he has multiple days in a row with events. He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout. He may vomit after these episodes, then seems to calm down. It is unclear whether this is a seizure or whether the patient is still responsive. MEDICATIONS: The patient's medications include Lamictal for a total of 200 mg twice a day. It is a 150 mg tablet and 25 mg tablets. He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day. He has other medications including the Xopenex and Atrovent. REVIEW OF SYSTEMS: At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias. No respiratory or cardiovascular complaints. He has no change in his skills at this point. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is a slender male who is microcephalic. He has EEG electrodes in place and is on the video EEG at that time. HEENT: His oropharynx shows no lesions. NECK: Supple without adenopathy. CHEST: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. ABDOMEN: Benign with G-tube in place. EXTREMITIES: Reveal no clubbing, cyanosis, or edema. NEUROLOGICAL: The patient is alert and has bilateral esotropia. He is able to fix and follow objects briefly. He is unable to reach for objects. He exhibits constant choreiform movements when excited. These are more prominent in the upper extremities and lower extremities. He has some dystonic posture with flexion of the wrist and fingers bilaterally. He also has plantar flexion at the ankles bilaterally. His cranial nerves reveal that his pupils are equal, round, and reactive to light. Extraocular movements are intact other than bilateral esotropia. His face moves symmetrically. Palate elevates in midline. Hearing appears intact bilaterally. Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above. He has clonus at the ankles bilaterally, and some valgus contracture of the ankles. His sensation is intact to light touch bilaterally. Deep tendon reflexes are 2 to 3+ bilaterally. IMPRESSION/PLAN: This is a 9-year-old male with congenital brain malformation and intractable epilepsy. He has microcephaly as well as dystonic cerebral palsy. He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort. He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types. He will remain hospitalized for probably at least 48 hours to 72 hours. He could be discharged sooner if multiple events are captured. His medications, we will continue his current dose of Zonegran and Lamictal for now. Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.

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.

Write a clinical note about a patient with the following chief complaint: Followup of hospital discharge for Guillain-Barre syndrome.

CHIEF COMPLAINT: Followup of hospital discharge for Guillain-Barre syndrome. HISTORY OF PRESENT ILLNESS: This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis. She was admitted to the hospital. The MRI showed only an old right basal ganglion infarct. She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP. The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms. Her vital capacities were normal during the hospitalization. Her chest x-ray was negative for any acute process. She was discharged to rehab from July 12, 2006 to July 20, 2006. She made some progress in which she notes that her walking is definitely better. However, she notes that she still has some problems with eye movement and her vision. This is possibly her main problem. She also reports tightness and pain in her mid back. REVIEW OF SYSTEMS: Documented in the clinic note. The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus. 3. Stroke involving the right basal ganglion. 4. Guillain-Barre syndrome diagnosed in June of 2006. 5. Bilateral knee replacements. 6. Total abdominal hysterectomy and cholecystectomy. FAMILY HISTORY: Multiple family members have diabetes mellitus. SOCIAL HISTORY: The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs. MEDICATIONS: Percocet 5/325 mg 4-6 hours p.r.n. Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d. Norvasc 10 mg q.d. glipizide ,10 mg q.d. fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d. and Zocor 1 mg q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds. Pain scale 5/10. Please see the written note for details. General exam is benign other than mild obesity. On neuro examination, mental status is normal. Cranial nerves are significant for full visual fields and pupils are equal and reactive. However, extraocular movements are very limited. She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move. Face is symmetric. Sensation is intact. Tongue and uvula are in midline. Palate is elevated symmetrically. Shoulder shrug is strong. The patient's muscle exam shows normal bulk and tone throughout. She has no weakness of the left upper extremity. In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5. There is no drift or orbit. Reflexes are absent throughout. Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal. There is no dysmetria. Gait is somewhat limited possibly by her vision and possibly also by her balance problems. PERTINENT DATA: As reviewed previously. DISCUSSION: This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant. The patient has shown some improvement with IVIG and continues to show some gradual improvement. I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement. I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now. She is scheduled to see an ophthalmologist. I think it is reasonable for close followup of her visual symptoms progress. However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually. I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further. I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week. She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further. She was apparently given some baclofen by her internist and I think this is not unreasonable. I definitely hope to get her off the Percocet in the future. IMPRESSION: 1. Guillain-Barre Miller-Fisher variant. 2. Hypertension. 3. Diabetes mellitus. 4. Stroke. RECOMMENDATIONS: 1. The patient is to start taking aspirin 162 mg per day. 2. Followup with ophthalmology. 3. Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d. 4. Followup by phone in three to four weeks. 5. Followup in this clinic in approximately two months' time. 6. Call for any questions or problems.

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.

Write a clinical note about a patient with the following admitting diagnosis: Encephalopathy related to normal-pressure hydrocephalus.

ADMITTING DIAGNOSIS: Encephalopathy related to normal-pressure hydrocephalus. CHIEF COMPLAINT: Diminished function secondary to above. HISTORY: This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed. He had a shunt placed and was stabilized medically. He has gotten a return of function to the legs and was started on some early therapy. Significant functional limitations have been identified and ongoing by the rehab admission team. Significant functional limitations have been ongoing. He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home. PAST MEDICAL HISTORY: Positive for prostate cancer, intermittent urinary incontinence and left hip replacement. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS,1. Tylenol as needed. ,2. Peri-Colace b.i.d. SOCIAL HISTORY: He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family relatives intermittently available. Goal is to return home to an independent fashion to that home setting. FUNCTIONAL HISTORY: Prior to admission was independent with activities of daily living and ambulatory skills. Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living. Memory at minimal assist. Walking at supervision. REVIEW OF SYSTEMS: Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently. He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain. PHYSICAL EXAMINATION,VITAL SIGNS: The patient is afebrile with vital signs stable. HEENT: Oropharynx clear, extraocular muscles are intact. CARDIOVASCULAR: Regular rate and rhythm, without murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Nontender, nondistended, positive bowel sounds. EXTREMITIES: Without clubbing, cyanosis, or edema. The calves are soft and nontender bilaterally. NEUROLOGIC: No focal, motor or sensory losses through the lower extremities. He moves upper and lower extremities well. Bulk and tone normal in the upper and lower extremities. Cognitively showing intact with appropriate receptive and expressive skills. IMPRESSION ,

Write a clinical note about a patient with the following chief complaint: Recurrent dizziness x1 month.

CHIEF COMPLAINT: Recurrent dizziness x1 month. HISTORY OF PRESENT ILLNESS: This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness. She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. She is not able to describe what direction she feels like she is spinning. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes. She does note that it is worse when she turns to the right and when she turns to the left. She also complains that she gets similar sensations when she looks up. She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches. She also notes occasional tinnitus to her right ear. PAST MEDICAL HISTORY: 1. CHF (uses portable oxygen). 2. Atrial fibrillation. 3. Gout. 4. Arthritis (DJD/rheumatoid). 5. Diabetes mellitus. 6. Hypothyroidism. 7. Hypertension. 8. GERD. 9. Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is married. She does not smoke, use alcohol or use illicit drugs. MEDICATIONS: Please see medication sheet in the chart. It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness). REVIEW OF SYSTEMS: Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented. Tinnitus in the right ear. Diabetes and hypothyroidism. Chronic nausea. Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back. Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking. She says her mood is sad and may be depressed and she is also extremely anxious. She has chronic shortness of breath and coughs easily when has to breathe deeply. She also endorses poor sleep. PHYSICAL EXAMINATION: VITAL SIGNS: Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66. Respiratory rate is 20. Weight is 257 pounds. Pain scale is 7. GENERAL: This is a somewhat anxious elderly African-American female who tends to amplify findings on examination. It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw. She is obese. HEENT: She is normocephalic and atraumatic. Conjunctivae and sclerae are clear. Tympanic membranes were visualized bilaterally. There is tenderness to palpation of any sinus region. There are no palpable cervical nodes. NECK: Supple although she complains of pain when rotating her neck. CHEST: Clear to auscultation bilaterally. HEART: Heart sounds are distant. There are no carotid bruits. EXTREMITIES: She has 1-2+ pitting edema to the mid shins bilaterally. NEUROLOGIC EXAMINATION: MENTAL STATUS: She is alert and oriented x3. Her speech is fluent; however, she is extremely tangential. She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation. CRANIAL NERVES: Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline. MOTOR: This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity. There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout. Her tone is normal throughout. SENSORY: She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg. She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact. COORDINATION: There is no obvious dysmetria. GAIT: She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker. There are some mild right lower extremity circumduction present. REFLEXES: Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent. Toes are equivocal. OTHER: Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, "Oh my back, oh my back", and was unable to complete the maneuver. Brief inspection of her eyes failed to show any nystagmus at that time. IMPRESSION AND PLAN: This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology. Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings. I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise. I agree with symptomatic treatment with Antivert. We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency. In addition, we will attempt to get further objective data by ENG testing. I will see the patient again after these tests are completed and she has a trial of the Antivert.

Write a clinical note about a patient with the following chief complaint: Worsening seizures.

CHIEF COMPLAINT: Worsening seizures. HISTORY OF PRESENT ILLNESS: A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. The patient stated she was in her normal state of well being when she was experiencing having frequent seizures. She lives in assisted living. She has been falling more frequently. The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this. There was no head trauma, but apparently she was doing that many times and there was no responsiveness. The patient has no memory of the event. She is now back to her baseline. She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred. She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems. The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome. PAST MEDICAL HISTORY: Include dyslipidemia and hypertension. FAMILY HISTORY: Positive for stroke and sleep apnea. SOCIAL HISTORY: No smoking or drinking. No drugs. MEDICATIONS AT HOME: Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember. REVIEW OF SYSTEMS: The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning. The patient also has excessive daytime sleepiness with EDS of 16. PHYSICAL EXAMINATION: VITAL SIGNS: Last blood pressure 130/85, respirations 20, and pulse 70. GENERAL: Normal. NEUROLOGICAL: As follows. Right-handed female, normal orientation, normal recollection to 3 objects. The patient has underlying MR. Speech, no aphasia, no dysarthria. Cranial nerves, funduscopic intact without papilledema. Pupils are equal, round, and reactive to light. Extraocular movements intact. No nystagmus. Her mood is intact. Symmetric face sensation. Symmetric smile and forehead. Intact hearing. Symmetric palate elevation. Symmetric shoulder shrug and tongue midline. Motor 5/5 proximal and distal. The patient does have limp on the right lower extremity. Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left. Sensory, the patient does have sharp, soft touch, vibration intact and symmetric. The patient has trouble with ambulation. She does have ataxia and uses a walker to ambulate. There is no bradykinesia. Romberg is positive to the left. Cerebellar, finger-nose-finger is intact. Rapid alternating movements are intact. Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding. Neck more than 16 to 17 inches, BMI elevated above 33. Head and neck circumference very high. IMPRESSION: 1. Cerebral palsy, worsening seizures. 2. Hypertension. 3. Dyslipidemia. 4. Obstructive sleep apnea. 5. Obesity. RECOMMENDATIONS: 1. Admission to the EMU, drop her Carbatrol 200 b.i.d. monitor for any epileptiform activity. Initial time of admission is 3 nights and 3 days. 2. Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated. Continue her other medications. 3. Consult Dr. X for hypertension, internal medicine management. 4. I will follow this patient per EMU protocol.

Write a clinical note about a patient with the following chief complaint: Leaking nephrostomy tube.

CHIEF COMPLAINT: Leaking nephrostomy tube. HISTORY OF PRESENT ILLNESS: This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube. The leaking began this a.m. The patient denies any pain, does not have fever and has no other problems or complaints. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure. The patient states he feels like his usual self and has no other problems or concerns. The patient denies any fever or chills. No nausea or vomiting. No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs. REVIEW OF SYSTEMS: Review of systems otherwise negative and noncontributory. PAST MEDICAL HISTORY: Metastatic prostate cancer, anemia, hypertension. MEDICATIONS: Medication reconciliation sheet has been reviewed on the nurses' note. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient is a nonsmoker. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well. HEENT: Eyes are normal with clear sclerae and cornea. NECK: Supple, full range of motion. CARDIOVASCULAR: Heart has regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +2. No dependent edema. 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. Normal benign abdominal exam. MUSCULOSKELETAL: The patient has nontender back and flank. No abnormalities noted to the back other than the bilateral nephrostomy tubes. The nephrostomy tube left has no abnormalities, no sign of infection. No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it. There is no obvious active leak from the ostomy site. No sign of infection. No erythema, swelling or tenderness. The collection bag is full of clear urine. The patient has no abnormalities on his legs. SKIN: No rashes or lesions. No sign of infection. NEUROLOGIC: Motor and sensory are intact to the extremities. The patient has normal ambulation, normal speech. PSYCHIATRIC: Alert and oriented x4. Normal mood and affect. HEMATOLOGIC AND LYMPHATIC: No bleeding or bruising. EMERGENCY DEPARTMENT COURSE: Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes. There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes. Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X. Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow. This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood. DIAGNOSES: 1. WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE. 2. PROSTATE CANCER, METASTATIC. 3. URETERAL OBSTRUCTION. The patient on discharge is stable and dispositioned to home. PLAN: We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X. The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.

Write a clinical note about a patient with the following chief complaint: Right hydronephrosis.

CHIEF COMPLAINT: Right hydronephrosis. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation. Again, she is scheduled for mastectomy in two weeks. She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney. There was no dilation of the right ureter noted. Urinalysis today is microscopically negative. PAST MEDICAL HISTORY: Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension. PAST SURGICAL HISTORY: Lumpectomy, hysterectomy. MEDICATIONS: Diovan HCT 80/12.5 mg daily, metformin 500 mg daily. ALLERGIES: None. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is retired. Does not smoke or drink. REVIEW OF SYSTEMS: I have reviewed his review of systems sheet and it is on the chart. PHYSICAL EXAMINATION: Please see the physical exam sheet I completed. Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness. IMPRESSION AND PLAN: Marked right hydronephrosis without hydruria. She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005. I will try to obtain the report to see if the right kidney was evaluated at that time. She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney. She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed. She will call us back to schedule the x-rays. She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer. There is also a question of a stone present in the kidney. She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.

Write a clinical note about a patient with the following chief complaint: Aching and mid back pain.

DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury. CHIEF COMPLAINT: Aching and mid back pain. HISTORY OF PRESENT INJURY: Based upon the examinee's perspective: Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was "slammed from behind" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact. During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage. He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be "okay to walk." He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain. He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that "these things can take a long time." He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better. He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8. Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program. The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist. He denies any previous history of symptomatology or injuries involving his back. CURRENT SYMPTOMS: He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant. When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that "I can power through it." "I have learned how to manage the pain, using exercise, stretching, and diversion techniques." It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis. He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness. Again, aggravating activities include prolonged sitting, greater than approximately two hours. Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain. He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent. He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years. With regards to recreational activities, he states that he has not limited his activities due to his back pain. He denies bowel or bladder dysfunction. FILES REVIEW: October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center. October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as "unknown." The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as "no acute bony process." Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets. October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable. November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial. December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor. December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday. December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain. During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes. During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion. December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week. December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better. December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms. December 26, 2000: A no-show was documented at the Chiropractic Wellness Center. April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened. April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center. April 16, 2001: He did not show up for his chiropractic treatment. April 19, 2001: He did not show up for his chiropractic treatment. April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed. September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6. May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner. June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of "a little compression of what appears to be T7 and T8 on the lateral view." Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that "the patient's symptoms are so mild as to almost not warrant intervention." He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.

Write a clinical note about a patient with the following chief complaint: Worker’s compensation injury.

CHIEF COMPLAINT: Worker’s compensation injury. HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old Hispanic female. She comes in today with her boyfriend. The patient speaks English fairly well, but her primary language is Spanish. Her boyfriend does help to make sure that she understands what we are talking about. The patient seems to understand our conversation fairly well. She works at Norcraft and injured her right thumb on 09/10/2004 at 12:15 a.m. She was pushing a cart and mashed her thumb between the cart and the wall. This was at the finishing room in Norcraft. She went ahead and went to work yesterday, which was the 14th, but was not able to work on the 13th. She has swelling in her thumb. It hurt only if it is pushed on. It was the distal end of her thumb that was mashed. She has not noticed any numbness or tingling or weakness. She has not sought any treatment for this, is not taking any pain medications. She did try soaking it in warm salt water and did not notice any improvement. MEDICATIONS: None. ALLERGIES: None. PAST MEDICAL HISTORY: Possible history of chicken pox, otherwise no other medical illnesses. She has never had any surgery. FAMILY HISTORY: Parents and two siblings are healthy. She has had no children. SOCIAL HISTORY: The patient is single. She lives with her boyfriend and his father. She works at Norcraft. She wears seatbelt 30% of the time. I encouraged her to use them all of the time. She is a nonsmoker, nondrinker. VACCINATIONS: She thinks she got a tetanus vaccine in childhood, but does not know for sure. She does not think she has had a tetanus booster recently. REVIEW OF SYSTEMS: Constitutional: No fevers, chills, or sweats. Neurologic: She has had no numbness, tingling, or weakness. Musculoskeletal: As above in HPI. No other difficulties. PHYSICAL EXAMINATION: General: This is a well-developed, well-nourished, very pleasant Hispanic female, in no acute distress. Vital Signs: Weight: 121.4. Blood pressure: 106/78. Pulse: 64. Respirations: 20. Temperature: 96. Extremities: Examination of the right hand reveals the distal end of the thumb to be swollen especially just proximal to the nail bed. The nail bed is pushed up. I can see hematoma below the nail bed, although it does appear to be intact. She has some blue fingernail polish on her nail also, but that is starting to come off. She is able to bend her thumb normally at the DIP joint. She has no discomfort doing that. Sensation is intact over the entire thumb. She has normal capillary refill. There is some erythema and swelling noted especially over the posterior thumb just proximal to the nail bed. I am not feeling any fluctuance. I do not think it is a collection of pus. There is no drainage. She does have some small fissures in the skin where I think she did injure it with this smashing injury, but no deep lacerations at all. It looks like there may be some mild cellulitis at the site of her injury. LABORATORY: X-ray of the thumb was obtained and I do not see any sign of fracture or foreign body. ASSESSMENT: Blunt trauma to the distal right thumb without fracture. I think there is some mild cellulitis developing there. PLAN: 1. We will give a tetanus diphtheria booster. 2. We will start Keflex 500 mg one p.o. q.i.d. x 7 days. I would recommend that she can return to work, but she is not to do any work that requires the use of her right thumb. I would like to see her back on Monday, the 20th in the morning and we can see how her thumb is doing at that time. If she is noticing any difficulties with increased redness, increased warmth, increased pain, pus-like drainage, or any other difficulties, she is to go ahead and give us a call. Otherwise I will be seeing her back on Monday.

Write a clinical note about a patient with the following chief complaint: Right shoulder pain.

CHIEF COMPLAINT: Right shoulder pain. HISTORY: The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002. She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy. He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms. He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03. She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X. She comes to me for impairment rating. She has no chronic health problems otherwise, fevers, chills, or general malaise. She is not working. She is right-hand dominant. She denies any prior history of injury to her shoulder. PAST MEDICAL HISTORY: Negative aside from above. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Please see above. REVIEW OF SYSTEMS: Negative aside from above. PHYSICAL EXAMINATION: A pleasant, age appropriate woman, moderately overweight, in no apparent distress. Normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right. She has decreased motion in the right shoulder as follows. She has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation. She has a positive impingement sign on the right. ASSESSMENT: Right shoulder impingement syndrome, right suprascapular neuropathy. DISCUSSION: With a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition. The reason for this impairment is the incident of 01/01/02. For her suprascapular neuropathy, she is rated as a grade IV motor deficit which I rate as a 13% motor deficit. This is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity. For her lack of motion in the shoulder she also has additional impairment on the right. She has a 1% impairment of the upper extremity due to lack of shoulder flexion. She has a 1% impairment of the upper extremity due to lack of shoulder abduction. She has a 1% impairment of the upper extremity due to lack of shoulder adduction. She has a 1% impairment of the upper extremity due to lack of shoulder extension. There is no impairment for findings in shoulder external rotation. She has a 3% impairment of the upper extremity due to lack of shoulder internal rotation. Thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity. This combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the AMA Guide to the Evaluation of Permanent Impairment, Fifth Edition, stated with a reasonable degree of medical certainty.

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.

Write a clinical note about a patient with the following chief complaint: Aching and mid back pain.

DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury. CHIEF COMPLAINT: Aching and mid back pain. HISTORY OF PRESENT INJURY: Based upon the examinee's perspective: Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was "slammed from behind" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact. During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage. He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be "okay to walk." He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain. He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that "these things can take a long time." He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better. He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8. Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program. The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist. He denies any previous history of symptomatology or injuries involving his back. CURRENT SYMPTOMS: He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant. When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that "I can power through it." "I have learned how to manage the pain, using exercise, stretching, and diversion techniques." It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis. He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness. Again, aggravating activities include prolonged sitting, greater than approximately two hours. Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain. He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent. He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years. With regards to recreational activities, he states that he has not limited his activities due to his back pain. He denies bowel or bladder dysfunction. FILES REVIEW: October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center. October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as "unknown." The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as "no acute bony process." Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets. October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable. November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial. December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor. December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday. December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain. During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes. During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion. December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week. December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better. December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms. December 26, 2000: A no-show was documented at the Chiropractic Wellness Center. April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened. April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center. April 16, 2001: He did not show up for his chiropractic treatment. April 19, 2001: He did not show up for his chiropractic treatment. April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed. September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6. May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner. June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of "a little compression of what appears to be T7 and T8 on the lateral view." Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that "the patient's symptoms are so mild as to almost not warrant intervention." He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.

Write a clinical note about a patient with the following past medical condition: None.

PAST MEDICAL CONDITION: None. ALLERGIES: None. CURRENT MEDICATION: Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain. CHIEF COMPLAINT: Back injury with RLE radicular symptoms. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male who is here for independent medical evaluation. The patient states that he works for ABC ABC as a temporary worker. He worked for ABCD too. The patient's main job was loading and unloading furniture and appliances for the home. The patient was approximately there for about two and a half weeks. Date of injury occurred back in October. The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load. Unfortunately at this particular event, the patient had sharp pain in his lower back. Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. This became progressively worse. He also states that some of his radiating pain went down to his left leg as well. He noticed increase in buttock spasm and also noticed spasm in his buttocks. He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe. The patient states that after this treatment, his symptoms still persisted. At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April. After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids. He was put on restricted duty. The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement. Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral. The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief. The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD. The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. He has difficulty sleeping at nighttime because of increase in pain. Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June. The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms. PHYSICAL EXAMINATION: The patient was examined with the gown on. Lumbar flexion was moderately decreased. Extension was normal. Side bending to the right was decreased. Side bending to the left was within normal limits. Rotation and extension to the right side was causing increasing pain. Extension and side bending to the left was within normal limits without significant pain on the left side. While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°. There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position. In supine position, straight leg was negative in the LLE and also negative on the RLE. Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits. Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side. Medial hamstring reflex was 2+/4 on both hamstrings as well. On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side. Increase in pain at deep palpatory examination in midline of the L5 and S1 level. MEDICAL RECORD REVIEW: I had the opportunity to review Dr. XYZ's medical records. Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December. Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal. The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc. DIAGNOSIS: Residual from low back injury with right lumbar radicular symptomatology. EVALUATION/RECOMMENDATION: The patient has an impairment based on AMA Guides Fifth Edition and it is permanent. The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck. Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left. The patient also has increase in back pain with lumbar flexion and rotational movement to the right side. With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function. Therefore, the patient is assigned 8% impairment of the whole person. We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide. Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury. In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy. The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI. In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back. His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain. The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management. The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.

Write a clinical note about a patient with the following chief complaint: Burn, right arm.

CHIEF COMPLAINT: Burn, right arm. HISTORY OF PRESENT ILLNESS: This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care. PAST MEDICAL HISTORY: Noncontributory. MEDICATIONS: None. ALLERGIES: None. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine. FINAL DIAGNOSIS: 1. First-degree and second-degree burns, right arm secondary to hot oil spill. 2. Workers' Compensation industrial injury. TREATMENT: The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed. DISPOSITION: Home.

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:

Write a clinical note about a patient with the following chief complaint: Newly diagnosed T-cell lymphoma.

CHIEF COMPLAINT: Newly diagnosed T-cell lymphoma. HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess. Prior to this event, in March of 2010, he was treated for strep throat. The pain at that time was on the right side. About a month ago, he started having night sweats. The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. All these symptoms were preceded by overwhelming fatigue and exhaustion. He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. He also reports occasional headaches with some stabbing and pain in his feet and legs. He also complains of some left groin pain. PAST MEDICAL HISTORY: Significant for HIV diagnosed in 2000. He also had mononucleosis at that time. The patient reports being on anti-hepatitis viral therapy period that was very intense. He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. He reports no other history of transfusions. He has history of spontaneous pneumothorax. The first episode was 1989 on his right lung. In 1990 he had a slow collapse of the left lung. He reports no other history of pneumothoraces. In 2003, he had shingles. He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy. FAMILY HISTORY: Notable for his mother who is currently battling non-small cell lung cancer. She is a nonsmoker. His sister is Epstein-Barr virus positive. The patient's mother also reports that she is Epstein-Barr virus positive. His maternal grandfather died from complications from melanoma. His mother also has diabetes. SOCIAL HISTORY: The patient is single. He currently lives with his mother in house for several both in New York and here in Colorado. His mother moved out to Colorado eight years ago and he has been out here for seven years. He currently is self employed and does antiquing. He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed. He is homosexual, currently not sexually active. He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. He does not use alcohol or illicit drugs. REVIEW OF SYSTEMS: As mentioned above his weight has been fairly stable. Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. He has had fevers as well. The rest of his review of systems is negative. PHYSICAL EXAM: VITALS:

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.

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.

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:

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:

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:

Write a clinical note about a patient with the following chief complaint: Marginal zone lymphoma.

CHIEF COMPLAINT: Marginal zone lymphoma. HISTORY OF PRESENT ILLNESS: This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass. On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma). Overall, she is doing 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. She has normal bowel and bladder habits. No melena or hematochezia. CURRENT MEDICATIONS: Macrobid 100 mg q.d. ALLERGIES: Sulfa, causes nausea and vomiting. REVIEW OF SYSTEMS: As per the HPI, otherwise negative. PAST MEDICAL HISTORY: 1. She is status post a left partial nephrectomy as a new born. 2. In 2008 she had a right ankle fracture. SOCIAL HISTORY: She has a 20-pack year history of tobacco use. She has rare alcohol use. She has no illicit drug use. She is in the process of getting divorced. She has a 24-year-old son in the area and 22-year-old daughter. FAMILY HISTORY: Her mother had uterine cancer. Her father had liver cancer. PHYSICAL EXAM: VIT:

Write a clinical note about a patient with the following history of present illness: Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.

CHIEF COMPLAINT: Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter. HISTORY OF PRESENT ILLNESS: The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon. History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual "lump" posteriorly. The left testicle has continued to be painful off and on since. In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain. Physical therapy was prescribed and the discomfort temporarily improved. In December, he noted onset of increasing fatigue. He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities. He has lost 10 pounds since December and feels his appetite has decreased. Night sweats and cough began in December, for which he was treated with a course of Augmentin. However, both of these problems have continued. He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007). Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist). The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain. He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000. CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found. He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis. Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT). Continuous intravenous unfractionated heparin infusion was continued. Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected. Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation. This study showed moderately increased diffuse bone marrow metabolic activity. Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D. and flow cytometry was performed on the peripheral blood. These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia. The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL). ALLERGIES: NO KNOWN DRUG ALLERGIES. HE DOES SEEM TO REACT TO CERTAIN ADHESIVES. CURRENT MEDICATIONS: 1. Lovenox 60 mg subcutaneously q.12h. initiated. 2. Coumadin 5 mg p.o. was administered on 02/19/2007 and 02/22/2007. 3. Protonix 40 mg intravenous (IV) daily. 4. Vicodin p.r.n. 5. Levaquin 750 mg IV on 02/23/2007. IMMUNIZATIONS: Up-to-date. PAST SURGICAL HISTORY: The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007. FAMILY HISTORY: Two half-brothers, ages 26 and 28, both in good health. Parents are in good health. A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s. A maternal great-uncle developed leukemia around age 50. A maternal great-grandfather had bone cancer around age 80. His paternal grandfather died of colon cancer at age 73, which he had had since age 68. Adult-onset diabetes is present in distant relatives on both sides. SOCIAL HISTORY: The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well. REVIEW OF SYSTEMS: He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above. PHYSICAL EXAMINATION: GENERAL: Alert, cooperative, moderately ill-appearing young man. VITAL SIGNS: At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%. HAIR AND SKIN: Mild facial acne. HEENT: Extraocular muscles (EOMs) intact. Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal. CARDIOVASCULAR: A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR). LUNGS: Clear to auscultation with an occasional productive cough. ABDOMEN: Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins. MUSCULOSKELETAL: Mild swelling of the dorsal aspect of the right foot and distal right leg. Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh. GENITOURINARY: Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle. NEUROLOGIC: Exam showed him to be oriented x4. Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs). LABORATORY DATA: White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets. Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal. LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively. Calcium was also slightly low at 8.8 mg/dL. Low molecular weight heparin test was low at 0.27 units/mL. PT was 11.8, INR 1.2, and fibrinogen 374. Urinalysis was normal. ASSESSMENT: 1. Newly diagnosed high-risk acute lymphoblastic leukemia. 2. Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation. 3. Probable chronic left epididymitis. PLAN: 1. Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status. 2. Prompt reassessment of the status of the deep venous thrombosis with Doppler studies. 3. Ultrasound/Doppler of the testicles. 4. Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.

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:

Write a clinical note about a patient with the following chief complaint: Newly diagnosed mantle cell lymphoma.

CHIEF COMPLAINT: Newly diagnosed mantle cell lymphoma. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old woman who presented with abdominal pain in September 2006. On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone. Symptoms improved temporarily, but did not completely resolve. By the end of September, her pain had worsened and she was seen in the emergency room at ABC. Chest x-ray was compatible with pleurisy and she was treated with Percocet. Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea. Eventually, she was seen by Dr. X and noted to have splenomegaly. Repeat ultrasound was done and showed the spleen enlarged at 19 cm. In retrospect, this was not changed in comparison to an ultrasound that was done in September. She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged. The patient underwent lymph node biopsy on the right neck on 10/27/2006. Pathology is consistent with mantle cell lymphoma. On 10/31/2006, she had a bone marrow biopsy. This does show involvement of bone marrow with lymphoma. She was noted to have circulating lymphoma cells on peripheral smear as well. Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency. ALLERGIES: NONE. MEDICATIONS: 1. Estradiol/Prometrium. ,2. Ultram p.r.n. ,3. Baby aspirin. ,4. Lunesta for sleep. ,5. She has been started on iron supplements. PAST MEDICAL HISTORY: 1. Tubal ligation in 1986. 2. Possible cyst removed from the left neck in 1991. 3. Tonsillectomy. 4. Migraines, which are rare. SOCIAL HISTORY: She does not smoke cigarettes and drinks alcohol only occasionally. She is married and has two children, ages 24 and 20. She works as a project administrator. FAMILY HISTORY: Father is deceased. He had emphysema and colon cancer at age 68. Mother has arrhythmia and hypertension. Her sister has hypertension and her brother is healthy. PHYSICAL EXAMINATION: GENERAL: She is in no acute distress. VITAL SIGNS: Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse. HEENT: The oropharynx is benign. SKIN: The skin is warm and dry and shows no jaundice. NECK: There is shotty adenopathy in the neck. CARDIAC: Regular rate without murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin. EXTREMITIES: No peripheral edema is noted. LABORATORY DATA: CBC and chemistry panel are pending. CBC was normal last week. PT/INR was normal as well. IMPRESSION: Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc. Written materials were provided to her last week. PLAN: Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells. She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome. Plan will be to have her evaluated for bone marrow transplant in first remission. I will have Dr. Y see her while she is in the hospital. The patient is anxious, and will be given Ativan as needed. We will discontinue aspirin for now, but continue estradiol/Prometrium. Iron deficiency will be treated with oral iron supplements and we will follow her counts. She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma. After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.

Write a clinical note about a patient with the following chief complaint: Iron deficiency anemia.

CHIEF COMPLAINT: Iron deficiency anemia. HISTORY OF PRESENT ILLNESS: This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis. On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells. Her iron levels were 5 and her percent transferrin was 2. There was no evidence of hemolysis. Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth. She currently has an IUD, so she is not menstruating. She was discharged from the hospital on iron supplements. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. She specifically denies melena or hematochezia. CURRENT MEDICATIONS: Iron supplements and Levaquin. ALLERGIES: Penicillin. REVIEW OF SYSTEMS: As per the HPI, otherwise negative. PAST MEDICAL HISTORY: She is status post birth of a baby girl 5 months ago. She is G1, P1. She is currently using an IUD for contraception. SOCIAL HISTORY: She has no tobacco use. She has rare alcohol use. No illicit drug use. FAMILY HISTORY: Her maternal grandmother had stomach cancer. There is no history of hematologic malignancies. PHYSICAL EXAM: GEN:

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:

Write a clinical note about a patient with the following diagnoses: 1. Disseminated intravascular coagulation. 2. Streptococcal pneumonia with sepsis.

DIAGNOSES: 1. Disseminated intravascular coagulation. 2. Streptococcal pneumonia with sepsis. CHIEF COMPLAINT: Unobtainable as the patient is intubated for respiratory failure. CURRENT HISTORY OF PRESENT ILLNESS: This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy. PAST MEDICAL HISTORY: Otherwise nondescript as is the past surgical history. SOCIAL HISTORY: There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister. FAMILY HISTORY: Otherwise noncontributory. REVIEW OF SYSTEMS: Not otherwise pertinent. PHYSICAL EXAMINATION: GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated. VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16. HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place. NECK: No jugular venous pressure distention. CHEST: Coarse breath sounds bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line. EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet. LABORATORY STUDIES: The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13. IMPRESSION/PLAN: At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time.

Write a clinical note about a patient with the following chief complaint: Left breast cancer.

CHIEF COMPLAINT: Left breast cancer. HISTORY: The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center. On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial). The biopsy returned showing infiltrating ductal carcinoma high histologic grade. The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging. She prior to that area, denied any complaints. She had no nipple discharge. No trauma history. She has had been on no estrogen supplementation. She has had no other personal history of breast cancer. Her family history is positive for her mother having breast cancer at age 48. The patient has had no children and no pregnancies. She denies any change in the right breast. Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y. I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy. The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning. The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact. CT scan of the neck, chest, and abdomen is negative for metastatic disease. PAST MEDICAL HISTORY: Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987. MEDICATIONS: She is currently on omeprazole for reflux and indigestion. ALLERGIES: SHE HAS NO KNOWN DRUG ALLERGIES. REVIEW OF SYSTEMS: Negative for any recent febrile illnesses, chest pains or shortness of breath. Positive for restless leg syndrome. Negative for any unexplained weight loss and no change in bowel or bladder habits. FAMILY HISTORY: Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure. SOCIAL HISTORY: The patient works as a school teacher and teaching high school. PHYSICAL EXAMINATION,GENERAL: The patient is a white female, alert and oriented x 3, appears her stated age of 57. HEENT: Head is atraumatic and normocephalic. Sclerae are anicteric. NECK: Supple. CHEST: Clear. HEART: Regular rate and rhythm. BREASTS: Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle. There are no nipple retractions. No skin dimpling. There is some, at the time of the office visit, ecchymosis from recent biopsy. There is no axillary adenopathy. The remainder of the left breast is without abnormality. The right breast is without abnormality. The axillary areas are negative for adenopathy bilaterally. ABDOMEN: Soft, nontender without masses. No gross organomegaly. No CVA or flank tenderness. EXTREMITIES: Grossly neurovascularly intact. IMPRESSION: The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma. RECOMMENDATIONS: I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy. We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection. The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient. The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained. Local numbness, paresthesias or chronic pain was explained. The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers. She was certainly encouraged to obtain further surgical medical opinions prior to proceeding. I believe the patient has given full informed consent and desires to proceed with the above.

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:

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:

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:

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:

Write a clinical note about a patient with the following diagnosis: Refractory anemia that is transfusion dependent.

DIAGNOSIS: Refractory anemia that is transfusion dependent. CHIEF COMPLAINT: I needed a blood transfusion. HISTORY: The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias. PAST MEDICAL HISTORY: Diabetes. PAST SURGICAL HISTORY: Hernia repair. ALLERGIES: He has no allergies. MEDICATIONS: Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol. SOCIAL HISTORY: He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him. FAMILY HISTORY: Negative for blood or cancer disorders according to the patient. PHYSICAL EXAMINATION: GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately. VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds. HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear. NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration. EXTREMITIES: No clubbing, but there is some edema, but no cyanosis. NEUROLOGIC: Noncontributory. DERMATOLOGIC: Noncontributory. CARDIOVASCULAR: Noncontributory. IMPRESSION: At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia. RECOMMENDATIONS: At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization. As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.

Write a clinical note about a patient with the following chief complaint: "Trouble breathing.",

CHIEF COMPLAINT: "Trouble breathing.",HISTORY OF PRESENT ILLNESS: A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly. PAST MEDICAL HISTORY: Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis. Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed. Psoriasis. She denied any history of miscarriage. PAST SURGICAL HISTORY: IVC filter placement 1999.

Write a clinical note about a patient with the following chief complaint: "I have had trouble breathing for the past 3 days",

CHIEF COMPLAINT: "I have had trouble breathing for the past 3 days",HISTORY: 69-year-old Caucasian male complaining of difficulty breathing for 3 days. He also states that he has been coughing accompanying with low-grade type fever. He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing. Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since. PMH: DM, HTN, COPD, CAD,PSH: CABG, appendectomy, tonsillectomy,FH: Non-contributory,SOCH: Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren. He smokes 1 pack a day of Newport for 30 years and is a social drinker. He denies any illicit drug use. TRAVEL HISTORY: Denies any recent travel overseas,ALLERGIES: Denies any drug allergies,HOME MEDICATIONS: Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd,REVIEW OF SYSTEMS REVEALS: Same as above,PHYSICAL EXAM: Vital signs are: Temp. 99.3 F / BP 138/92, Resp. 22, P 88,General: Patient is in mild acute respiratory distress,HEENT: Head: Atraumatic, normocephalic,Eyes:

Write a clinical note about a patient with the following chief complaint: Toothache.

CHIEF COMPLAINT: Toothache. HISTORY OF PRESENT ILLNESS: This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. The patient denies any other problems or complaints. The patient denies any recent illness or injuries. The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever or chills. No fatigue or weakness. No recent weight change. HEENT: No headache, no neck pain, the toothache pain for the past three days as previously mentioned. There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids. The patient denies any rhinorrhea. No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No focal weakness or numbness. Normal speech. HEMATOLOGIC/LYMPHATIC: No lymph node swelling has been noted. PAST MEDICAL HISTORY: Chronic knee pain. CURRENT MEDICATIONS: OxyContin and Vicodin. ALLERGIES: PENICILLIN AND CODEINE. SOCIAL HISTORY: The patient is still a smoker. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient is a little overweight but otherwise appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Eyes are normal with clear conjunctiva and cornea bilaterally. There is no icterus, injection, or discharge. Pupils are 3 mm and equally round and reactive to light bilaterally. There is no absence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Ears are normal bilaterally without any sign of infection. There is no erythema, swelling of canals. Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it. Nose is normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. NECK: Supple, nontender, and full range of motion. There is no meningismus. No cervical lymphadenopathy. No JVD. Mouth and oropharynx shows multiple denture and multiple dental caries. The patient has tenderness to tooth #12 as well as tooth #21. The patient has normal gums. There is no erythema or swelling. There is no purulent or other discharge noted. There is no fluctuance or suggestion of abscess. There are no new dental fractures. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion or swelling. The buccal membranes are normal. Mucous membranes are moist. The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally without shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to back, arms and legs. The patient has normal use of his extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact to the extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No cervical lymphadenopathy is palpated. EMERGENCY DEPARTMENT COURSE: The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction. DIAGNOSES: 1. ODONTALGIA. 2. MULTIPLE DENTAL CARIES. CONDITION UPON DISPOSITION: Stable. DISPOSITION: To home. PLAN: The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes. The patient was requested to have reevaluation within two days. The patient was given a prescription for Percocet and clindamycin. The patient was given drug precautions for the use of these medicines. The patient was offered discharge instructions on toothache but states that he already has it. He declined the instructions. The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.

Write a clinical note about a patient with the following chief complaint: Severe back pain and sleepiness. The patient is not a good historian and history was obtained from the patient's husband at bedside.

CHIEF COMPLAINT: Severe back pain and sleepiness. The patient is not a good historian and history was obtained from the patient's husband at bedside. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain. As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection. The patient has severe pain and all in all, the patient cries at home. As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation. The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria. While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control. The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli. The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked. The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode. PAST MEDICAL CONDITIONS: Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine. No history of diabetes, stroke or coronary artery disease. SURGICAL HISTORY: Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age. ALLERGIES: DENIED. CURRENT MEDICATIONS: According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day. The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily. SOCIAL HISTORY: She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking. PHYSICAL EXAMINATION: GENERAL: Currently lying in the bed without apparent distress, very lethargic. VITAL SIGNS: Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58. CHEST: Shows bilateral air entry present, clear to auscultate. HEART: S1 and S2 regular. ABDOMEN: Soft, nondistended, and nontender. EXTREMITIES: Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain. IMAGING: The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease. LABORATORY DATA: The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range. IMPRESSION: The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure. 1. Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants. 2. Osteoporosis of the spine with L1 compression fracture causing the patient severe pain. 3. Hypertension, now hypotension. 4. Incontinence of the bladder. 5. Dementia, most likely Alzheimer type. PLAN AND SUGGESTION: Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept. I will hold the patient's hydrocodone. I will hold the Flexeril and I will also hold gabapentin at this moment. We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed. Also give the patient calcium with vitamin D and physical therapy. We will also order a blood test and further management will be based on the patient's all test results. I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.

Write a clinical note about a patient with the following chief complaint: Pressure decubitus, right hip.

CHIEF COMPLAINT: Pressure decubitus, right hip. HISTORY OF PRESENT ILLNESS: This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a wheelchair. She relates recently she has been spending up to 16 hours a day in a wheelchair. She has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. She is now presenting for evaluation and management of same. Denies any chills or fever, any other symptoms. PAST MEDICAL HISTORY: Back closure for spina bifida, hysterectomy, breast reduction, and a shunt. SOCIAL HISTORY: She denies the use of alcohol, illicits, or tobacco. MEDICATIONS: Pravachol, Dilantin, Toprol, and Macrobid. ALLERGIES: SULFA AND LATEX. REVIEW OF SYSTEMS: Other than the above aforementioned, the remaining ROS is unremarkable. PHYSICAL EXAMINATION: GENERAL: A pleasant female with deformity of back. HEENT: Head is normocephalic. Oral mucosa and dentition appear to be normal. CHEST: Breath sounds equal and present bilateral. CVS: Sinus. GI: Obese, nontender, no hepatosplenomegaly. EXTREMITIES: Deformity of lower extremities secondary to spina bifida. SKIN: She has a full-thickness pressure decubitus involving the right hip which is 2 x 6.4 x 0.3, moderate amount of serous material, appears to have good granulation tissue. PLAN: Daily applications of Acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week. DIAGNOSIS: Sequelae of spina bifida; pressure decubitus of right hip area.

Write a clinical note about a patient with the following chief complaint: "My potassium is high",

CHIEF COMPLAINT: "My potassium is high",HISTORY OF PRESENT ILLNESS: A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs drawn there revealed a potassium of 7.0 and he was told to come here for further evaluation. At time of his assessment in the emergency room, he noted general malaise and fatigue for eight months. Over this same time period he had subjective fevers and chills, night sweats, and a twenty-pound weight loss. He described anorexia with occasional nausea and vomiting of non-bilious material along with a feeling of light-headedness that occurred shortly after standing from a sitting or lying position. He denied a productive cough but did note chronic left sided upper back pain located in the ribs that was worse with cough and better with massage. He denied orthopnea or paroxysmal nocturnal dyspnea but did become dyspneic after walking 2-3 blocks where before he had been able to jog 2-3 miles. He also noted that over the past year his left testicle had been getting progressively more swollen and painful. He had been seen for this at the onset of symptoms and given a course of antibiotics without improvement. Over the last several months there had been chronic drainage of yellowish material from this testicle. He denied trauma to this area. He denied diarrhea or constipation, changes in his urinary habits, rashes or skin changes, arthritis, arthralgias, abdominal pain, headache or visual changes. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Mone. MEDICATIONS: Occasional acetaminophen. ALLERGIES: NKDA. SOCIAL HISTORY: He drank a 6 pack of beer per day for the past 30 years. He smoked a pack and a half of cigarettes per day for the past 35 years. He was currently unemployed but had worked as a mechanic and as a carpet layer in the past. He had been briefly incarcerated 5 years prior to admission. He denied intravenous drug use or unprotected sexual exposures. FAMILY HISTORY: There was a history of coronary artery disease and diabetes mellitus in the family. PHYSICAL EXAM: VITAL SIGNS - Temp 98.6° F, Respirations 16/minute Lying down - Blood pressure 109/70, pulse 70/minute Sitting - Blood pressure 78/65, pulse 79/minute Standing - Blood pressure 83/70, pulse 95/minute GENERAL: well developed, well nourished, no acute distress HEENT: Normocephalic, atraumatic. Sclerae anicteric. Oropharynx with hyperpigmented patches on the mucosa of the palate. No oral thrush. No lymphadenopathy. No jugular venous distension. No thyromegaly. Neck supple. LUNGS: Decreased intensity of breath sounds throughout without adventitious sounds. No dullness to percussion or changes in fremitus. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops, or rubs. Normal intensity of heart sounds. Normal peripheral pulses. ABDOMEN: Soft, non-tender, non-distended. Positive bowel sounds. No organomegaly. RECTAL: Normal sphincter tone. No masses. Normal prostate. Guaiac negative stool. GENITOURINARY: Left testicle indurated and painful to palpation with slight amount of pustular drainage expressible on anterior aspect. Right testicle normal. EXTREMITIES: Marked clubbing noted in fingers and toes. No cyanosis or edema. No rash or arthritis. LYMPHATICS: 1 x 1 cm mobile, firm, non-tender lymph node noted in left inguinal region. Otherwise no other palpable lymphadenopathy. CHEST X-RAY: Ill-defined reticular densities in both apices. No pleural effusions. Cardiomediastinal silhouette within normal range. CHEST CT SCAN: Multiple bilateral apical nodules/masses. Largest 3.2 x 1.6 cm in left apex. Several of these masses demonstrate spiculation. There is an associated 1 cm lymph node in the prevascular space as well as subcentimeter nodes in the pretracheal and subcarinal regions. There is a subcarinal node that demonstrates calcifications. ABDOMINAL CT SCAN: Multiple hypodense lesions are noted throughout the liver. The right adrenal gland is full, measuring 1.0 x 2.3 cm. Otherwise the spleen, pancreas, left adrenal, and kidneys are free of gross mass. No significant lymphadenopathy or abnormal fluid collections are seen. TESTICULAR ULTRASOUND: There is an enlarged irregular inhomogenous left epididymis with increased vascularity throughout the left epididymis and testis. There is a large septated hydrocele on the left. The right epididymis and testis is normal. HOSPITAL COURSE: The above-mentioned studies were obtained. Further laboratory tests and a diagnostic procedure were performed.

Write a clinical note about a patient with the following chief complaint: The patient does not have any chief complaint.

CHIEF COMPLAINT: The patient does not have any chief complaint. HISTORY OF PRESENT ILLNESS: This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well. The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well. The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do. The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house. The patient states that she just simply felt funny and does not give any more specific details than this. The patient denies any pain at any time. She did not have any shortness of breath. No nausea or vomiting. No generalized weakness. The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go. The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved. The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF. The patient was discharged home after evaluation in the emergency room. The patient does use home O2. REVIEW OF SYSTEMS: CONSTITUTIONAL: The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician. The patient denies having any other symptoms today. The patient denies any fever or chills. Has not had any recent weight change. HEENT: The patient denies any headache. No neck pain. No rhinorrhea. No sinus congestion. No sore throat. No any vision or hearing change. No eye or ear pain. CARDIOVASCULAR: The patient denies any chest pain. RESPIRATIONS: No shortness of breath. No cough. No wheeze. The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. No change in the bowel movements. There has not been any diarrhea or constipation. No melena or hematochezia. GENITOURINARY: No dysuria, hematuria, urgency, or frequency. MUSCULOSKELETAL: No back pain. No muscle or joint aches. No pain or abnormalities to any portion of the body. SKIN: No rashes or lesions. NEUROLOGIC: The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days. The patient denies any dizziness at this time. No syncope or no near-syncope. The patient denies any focal weakness or numbness. No speech change. No difficulty with ambulation. The patient has not had any vision or hearing change. PSYCHIATRIC: The patient denies any depression. ENDOCRINE: No heat or cold intolerance. PAST MEDICAL HISTORY: COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation. PAST SURGICAL HISTORY: Placement of pacemaker and hysterectomy. CURRENT MEDICATIONS: The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient used to smoke, but quit approximately 30 years ago. The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear sclerae and cornea bilaterally. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx are normal without any sign of infection. Mucous membranes are moist. NECK: Supple and nontender. Full range of motion. There is no JVD. No cervical lymphadenopathy. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +2. The patient does have +1 bilateral lower extremity edema. RESPIRATIONS: The patient has coarse breath sounds bilaterally, but no dyspnea. Good air movement. No wheeze. No crackles. The patient speaks in full sentences without any difficulty. The patient does not exhibit any retractions, accessory muscle use or abdominal breathing. GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy. MUSCULOSKELETAL: No abnormalities noted to the back, arms or legs. SKIN: No rashes or lesions. NEUROLOGICAL: Cranial nerves II through XII are intact. Motor is 5/5 and equal to bilateral arms and legs. Sensory is intact to light touch. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her. The patient has normal mood and affect. HEMATOLOGIC AND LYMPHATIC: There is no evidence of lymphadenopathy. EMERGENCY DEPARTMENT TESTING: EKG is a rate of 72 with evidence of a pacemaker that has good capture. There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08. CBC has no specific abnormalities of issue. Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20. The rest of the values are normal and unremarkable. LFTs are all within normal limits. Cardiac enzymes are all within normal limits. Digoxin level is therapeutic at 1.6. Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago. CAT scan of the head did not identify any acute abnormalities. I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day. I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past. The neighbor is XYZ and he says that he checks on her three times a day every day. ABC is the patient's son and although he lives out of town he calls and checks on her every day as well. He states that he spoke to her yesterday. She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician. She sounded her usual self to him. Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him. He states that he will be able to check on her tomorrow as well. Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements. The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well. The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home. DIAGNOSES,1. EARLY DEMENTIA. 2.

Write a clinical note about a patient with the following chief complaint: Motor vehicle accident.

CHIEF COMPLAINT: Motor vehicle accident. HISTORY OF PRESENT ILLNESS: This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance. The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago. The patient states that she was driving her vehicle at approximately 40 miles per hour. The patient was driving a minivan. The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her. The patient states that she was wearing her seatbelt. She was driving. There were no other passengers in the van. The patient states that she was restrained by the seatbelt and that her airbag deployed. The patient denies hitting her head. She states that she does have some mild pain on the left aspect of her neck. The patient states that she believes she may have passed out shortly after the accident. The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag. The patient denies any pain in her knees, ankles, or feet. She denies any pain in her shoulders, elbows, and wrists. The patient does state that she is somewhat painful throughout the bones of her pelvis as well. The patient did not walk after this accident. She was removed from her car and placed on a backboard and immobilized. The patient denies any chest pain or difficulty breathing. She denies any open lacerations or abrasions. The patient has not had any headache, nausea or vomiting. She has not felt feverish or chilled. The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan. There were no oblique vectors or force placed on this accident. The patient had straight rear-ending of the vehicle in front of her. The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10. The patient states that her last menstrual cycle was at the end of May. She does not believe that she could be pregnant. She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane. PAST MEDICAL HISTORY: No significant medical history other than acne. PAST SURGICAL HISTORY: None. SOCIAL HABITS: The patient denies tobacco, alcohol or illicit drug usage. MEDICATIONS: Accutane. ALLERGIES: No known medical allergies. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL: This is a Hispanic female who appears her stated age of 32 years. She is well-nourished, well-developed, in no acute distress. The patient is pleasant. She is immobilized on a backboard and also her cervical spine is immobilized as well on a collar. The patient is without capsular retractions, labored respirations or accessory muscle usage. She responds well and spontaneously. VITAL SIGNS: Temperature 98.2 degrees Fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air. HEENT: Head is normocephalic. There is no crepitus. No bony step-offs. There are no lacerations on the scalp. Sclerae are anicteric and noninjected. Fundoscopic exam appears normal without papilledema. External ocular movements are intact bilaterally without nystagmus or entrapment. Nares are patent and free of mucoid discharge. Mucous membranes are moist and free of exudate or lesions. NECK: Supple. No thyromegaly. No JVD. No carotid bruits. Trachea is midline. There is no stridor. HEART: Regular rate and rhythm. Clear S1 and S2. No murmur, rub or gallop is appreciated. LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. ABDOMEN: Soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants. There is no organomegaly here. Positive bowel sounds are auscultated throughout. There is no rigidity or guarding. Negative CVA tenderness bilaterally. EXTREMITIES: No edema. There are no bony abnormalities or deformities. PERIPHERAL VASCULAR: Capillary refill is less than two seconds in all extremities. The patient does have intact dorsalis pedis and radial pulses bilaterally. PSYCHIATRIC: Alert and oriented to person, place, and time. The patient recalls all events regarding the accident today. NEUROLOGIC: Cranial nerves II through XII are intact bilaterally. No focal deficits are appreciated. The patient has equal and strong distal and proximal muscle group strength in all four extremities. The patient has negative Romberg and negative pronator drift. LYMPHATICS: No appreciable adenopathy. MUSCULOSKELETAL: The patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists. There are no bony abnormalities identified. The patient does have some mild tenderness over palpation of the bilateral iliac crests. SKIN: Warm, dry, and intact. No lacerations. There are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus. No lacerations and no sites of trauma or bleeding are identified. DIAGNOSTIC STUDIES: The patient does have multiple x-rays done. There is an x-ray of the pelvis, which shows normal pelvis and right hip. There is also a CT scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine. There is some prevertibral soft tissue swelling from C5 through C7. This is nonspecific and could be due to prominence of upper esophageal sphincter. The CT scan of the brain without contrast shows no evidence of acute intracranial injury. There is some mucus in the left sphenoid sinus. The patient also has emergent CT scan without contrast of the abdomen. The initial studies show some dependent atelectasis in both lungs. There is also some low density in the liver, which could be from artifact or overlying ribs; however, a CT scan with contrast is indicated. A CT scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities. The patient has laboratory studies done as well. CBC is within normal limits without anemia, thrombocytopenia or leukocytosis. The patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal. EMERGENCY DEPARTMENT COURSE: The patient was removed from the backboard within the first half hour of her emergency department stay. The patient has no significant bony deformities or abnormalities. The patient is given a dose of Tylenol here in the emergency department for treatment of her pain. Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard. The patient's CT scans of the abdomen appeared normal. She has no signs of bleeding. I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well. The patient is able to stand and walk through the emergency department without difficulty. She has no abrasions or lacerations. ASSESSMENT AND PLAN: Multiple contusions and abdominal pain, status post motor vehicle collision. Plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her CT scans. She has normal scans of the brain and her C-spine as well. The patient is in stable condition. She will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting. The patient is given a prescription for Vicodin and Flexeril to use it at home for her muscular pain.

Write a clinical note about a patient with the following chief complaint: Nausea and feeling faint.

CHIEF COMPLAINT: Nausea and feeling faint. HPI: The patient is a 74-year-old white female brought in by husband. The patient is a vague historian at times. She reports her appetite has been fair over the last several days. Today, she complains of some nausea. She feels weak. No other specific complaints. REVIEW OF SYSTEMS: The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities. CURRENT MEDICATIONS: Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2. ALLERGIES: MORPHINE CAUSES VOMITING. PAST MEDICAL HISTORY: COPD and hypertension. HABITS: Tobacco use, averages two cigarettes per day. Alcohol use, denies. LAST TETANUS IMMUNIZATION: Not sure. LAST MENSTRUAL PERIOD: Status post hysterectomy. SOCIAL HISTORY: The patient is married and retired. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.2, pulse is 105, respirations 20, and BP 137/80. GENERAL: A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated. SKIN: Warm, dry, and good color. EYES: EOMI. PERRL. MOUTH: Clear. Mucous membranes moist. NECK: Supple. No JVD. LUNGS: Reveal faint expiratory wheeze heard in the posterior lung fields. HEART: Slightly tachycardic without murmur. ABDOMEN: Soft, positive bowel sounds, and nontender. No rebound or guarding is appreciated. BACK: No CVA tenderness. EXTREMITIES: Moves all four extremities. No pretibial edema. NEURO: Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal. LABORATORY STUDIES: WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils. Hemoglobin 10.7 and hematocrit 31.2 both are decreased. Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2. Amylase and lipase both normal. Clean catch urinalysis is unremarkable. Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7. It seems to indicate that the patient had previous problems with anemia. RADIOLOGY STUDIES: Chest x-ray indicates chronic changes, reviewed by me, official report is pending. ED STUDIES: O2 sat on room air is 92%, which is satisfactory for this patient with COPD. Monitor indicates sinus tachycardia at rate 103. No ectopy. ED COURSE: The patient was assessed for orthostatic vital sign changes and none were detected by the nurse. The patient was given albuterol unit dose small volume nebulizer treatment. Repeat lung exam reveals resolution of expiratory wheezing. The patient later had normal saline lock started by the nurse. She was given IV fluids of normal saline 1L wide open over approximately one hour. She was able to void urine indicating that she is well hydrated. Rectal examination was performed with female nurse in attendance. Good sphincter tone. No masses. The rectal secretions were heme negative. The patient was reassessed. She feels slightly better. Monitor now shows normal sinus rhythm, rate 81, no ectopy. Blood pressure is 136/66. The patient is stable and will be discharged. MEDICAL DECISION MAKING: This patient presents with the above history. Laboratory evaluation today indicates the following problems, anemia and hyponatremia. This could contribute the patient's feelings of tiredness and not feeling well. There is no evidence of rectal bleeding at this time. The patient was advised that she needs to follow up with Dr. X to further investigate these problems. The patient is hemodynamically stable and will be discharged. ASSESSMENT: 1. Acute tiredness. 2. Anemia of unknown etiology. 3. Acute hyponatremia. PLAN: The patient is advised to put salt on her food for the next week. Should be given discharge instruction sheet for anemia. Recommend follow up with personal physician, Dr. X in two to three days for recheck. Return to ED sooner if condition changes or worsen anyway. Discharged in stable condition.

Write a clinical note about a patient with the following chief complaint: Jaw pain.

CHIEF COMPLAINT: Jaw pain. HISTORY OF PRESENT ILLNESS: This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began. The patient denies any facial swelling. No headache. No swelling to the throat. No sore throat. No difficulty swallowing liquids or solids. No neck pain. No lymph node swelling. The patient denies any fever or chills. Denies any other problems or complaints. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever or chills. No fatigue or weakness. HEENT: No headache. No neck pain. No eye pain or vision change. No rhinorrhea. No sinus congestion, pressure, or pain. No sore throat. No throat swelling. The patient does have the toothache on the left lower side that radiates towards his left ear as previously described. The patient does not have ear pain or hearing change. No pressure in the ear. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath. GASTROINTESTINAL: No nausea or vomiting. No abdominal pain. MUSCULOSKELETAL: No back pain. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No speech change. HEMATOLOGIC/LYMPHATIC: No lymph node swelling. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. CURRENT MEDICATIONS: None. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient smokes marijuana. The patient does not smoke cigarettes. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be healthy. The patient is calm, comfortable in no acute distress, looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear cornea and conjunctivae bilaterally. Nose, normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. Ears are normal without any sign of infection. No erythema or swelling of the canals. Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it. MOUTH: The patient has a dental fracture at tooth #18. The patient states that the fracture is a couple of months old. The patient does not have any obvious dental caries. The gums are normal without any erythema, swelling, or evidence of infection. There is no fluctuance or suggestion of abscess. There is slight tenderness of the tooth #18. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion, or swelling. Mucous membranes are moist. Floor of the mouth is normal without any tenderness or swelling. No suggestion of abscess. There is no pre or post auricular lymphadenopathy either. NECK: Supple. Nontender. Full range of motion. No meningismus. No cervical lymphadenopathy. No JVD. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to the back, arms, or legs. The patient has normal use of the extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. No evidence of clinical intoxification. HEMATOLOGIC/LYMPHATIC: No lymphadenitis is palpated. DIAGNOSES: 1. ACUTE LEFT JAW PAIN. 2. #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE. 3. ELEVATED BLOOD PRESSURE. CONDITION UPON DISPOSITION: Stable. DISPOSITION: Home. PLAN: We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation. The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain. The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain. He was given precautions for drowsiness and driving with the use of this medication. The patient was also given a prescription for pen V. The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.

Write a clinical note about a patient with the following chief complaint: Arm and leg jerking.

CHIEF COMPLAINT: Arm and leg jerking. HISTORY OF PRESENT ILLNESS: The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These movements are without any back arching. They mainly occur during sleep, so mom is unaware of any eye rolling. Mom is able to wake the patient up during this periods and stop the patient's extremity movements. Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast. She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours. She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day. REVIEW OF SYSTEMS: Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups. This patient has developed some upper airway congestion in the past day. She has not had any vomiting or diarrhea. Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds. This patient has not had any rashes. Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit. Otherwise, the above history of present illness and other review of systems negative. BIRTH/PAST MEDICAL HISTORY: The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps. There were no complications during pregnancy such as diabetes or hypertension. Prenatal care started at approximately 3 weeks, and mom maintained all visits. She also denies any smoking, alcohol, or drug use during the pregnancy. Mom was GBS status positive, but denies any other infections such as urinary tract infections. She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis. After delivery, this patient did not receive antibiotics secondary to "borderline labs." She was jaundiced after birth and received photo treatments. Her discharge bilirubin level was approximately 11. Mom and child stayed in the hospital for approximately 3-1/2 days. Mom denies any history of sexually transmitted disease in her or dad. She specifically denies any blistering, herpetic genital lesions. She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago. PAST SURGICAL HISTORY: Negative. ALLERGIES: No known drug allergies. MEDICATIONS: None. SOCIAL HISTORY: At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. All the residents at home are sick currently with cold, cough, runny nose, except for mom. At home also live 2 dogs and 2 outside cats. Mom denies any recent travel history, especially during the recent holidays and no smoke exposures. FAMILY HISTORY: Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently. The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. The maternal grandmother is notable for hypertension and diabetes. There are no other children in the family who see a specialist or no child death less than 1 year of age. PHYSICAL EXAMINATION:

Write a clinical note about a patient with the following chief complaint: Both pancreatic and left adrenal lesions.

CHIEF COMPLAINT: Both pancreatic and left adrenal lesions. HISTORY OF PRESENT ILLNESS: This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland. The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back. He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling. He is now sleeping in an upright position. He was sent for CAT scan originally of his chest. The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion. He was subsequently was sent for a dedicated abdominal CAT scan and MRI. The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma. The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature. Neoplasm could not be excluded. He was referred to us for further assessment. He denies any significant abdominal pain, any nausea or vomiting. His appetite is fine. He has had no significant changes in his bowel habits or any rectal bleeding or melena. He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps. He does have a history of frequent urination. Has been followed by urologist for this. There is no family history of pancreatic cancer. There is a history of gallstone pancreatitis in the patient's sister. PAST MEDICAL HISTORY: Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol. ALLERGIES: ENVIRONMENTAL. MEDICATIONS: Include glipizide 5 mg b.i.d. metformin 500 mg b.i.d. Atacand 16 mg daily, metoprolol 25 mg b.i.d. Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d. and fluticasone spray 50 mcg two sprays daily. PAST SURGICAL HISTORY: He has not had any previous surgery. FAMILY HISTORY: His brothers had prostate cancer. Father had brain cancer. Heart disease in both sides of the family. Has diabetes in his brother and sister. SOCIAL HISTORY: He is a non-cigarette smoker and non-ETOH user. He is single and he has no children. He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical. REVIEW OF SYSTEMS: He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding history. PHYSICAL EXAMINATION: GENERAL: Presents as an obese 60-year-old white male, who appears to be in no apparent 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 or S4 gallop. There is no obvious murmur. HEART: There is distant heart sounds. ABDOMEN: Obese. It is soft. It is nontender. Examination was done as relatively sitting up as the patient was unable to recline. Bowel sounds are present. There is no obvious mass or organomegaly. GENITALIA: Deferred. RECTAL: Deferred. EXTREMITIES: Revealed about 1+ pitting edema. Bilateral peripheral pulses are intact. NEUROLOGIC: Without focal deficits. The patient is alert and oriented. IMPRESSION: Both left adrenal and pancreatic lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy. We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention. Prior to that the patient will undergo an esophagogastroduodenoscopy.

Write a clinical note about a patient with the following chief complaint: Itchy rash.

CHIEF COMPLAINT: Itchy rash. HISTORY OF PRESENT ILLNESS: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day. PAST MEDICAL HISTORY: Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally healthy. REVIEW OF SYSTEMS: As mentioned denies any oropharyngeal swelling. No lip or tongue swelling. No wheezing or shortness of breath. No headache. No nausea. Notes itchy rash, especially on his torso and upper arms. SOCIAL HISTORY: The patient is accompanied with his wife. FAMILY HISTORY: Negative. MEDICATIONS: None. ALLERGIES: TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN. PHYSICAL EXAMINATION: VITAL SIGNS: The patient was afebrile. He is slightly tachycardic, 105, but stable blood pressure and respiratory rate. GENERAL: The patient is in no distress. Sitting quietly on the gurney. HEENT: Unremarkable. His oral mucosa is moist and well hydrated. Lips and tongue look normal. Posterior pharynx is clear. NECK: Supple. His trachea is midline. There is no stridor. LUNGS: Very clear with good breath sounds in all fields. There is no wheezing. Good air movement in all lung fields. CARDIAC: Without murmur. Slight tachycardia. ABDOMEN: Soft, nontender. SKIN: Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms. He noted some on his buttocks as well. Remaining of the exam is unremarkable. ED COURSE: The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortable. IMPRESSION: ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS. ASSESSMENT AND PLAN: The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess. He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off. In the meantime, I think he can be managed with some antihistamine over-the-counter. He is responding already to Benadryl and the epinephrine that we gave him here. He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation. He is discharged in stable condition.

Write a clinical note about a patient with the following history of present illness: Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.

CHIEF COMPLAINT: Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter. HISTORY OF PRESENT ILLNESS: The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon. History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual "lump" posteriorly. The left testicle has continued to be painful off and on since. In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain. Physical therapy was prescribed and the discomfort temporarily improved. In December, he noted onset of increasing fatigue. He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities. He has lost 10 pounds since December and feels his appetite has decreased. Night sweats and cough began in December, for which he was treated with a course of Augmentin. However, both of these problems have continued. He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007). Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist). The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain. He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000. CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found. He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis. Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT). Continuous intravenous unfractionated heparin infusion was continued. Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected. Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation. This study showed moderately increased diffuse bone marrow metabolic activity. Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D. and flow cytometry was performed on the peripheral blood. These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia. The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL). ALLERGIES: NO KNOWN DRUG ALLERGIES. HE DOES SEEM TO REACT TO CERTAIN ADHESIVES. CURRENT MEDICATIONS: 1. Lovenox 60 mg subcutaneously q.12h. initiated. 2. Coumadin 5 mg p.o. was administered on 02/19/2007 and 02/22/2007. 3. Protonix 40 mg intravenous (IV) daily. 4. Vicodin p.r.n. 5. Levaquin 750 mg IV on 02/23/2007. IMMUNIZATIONS: Up-to-date. PAST SURGICAL HISTORY: The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007. FAMILY HISTORY: Two half-brothers, ages 26 and 28, both in good health. Parents are in good health. A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s. A maternal great-uncle developed leukemia around age 50. A maternal great-grandfather had bone cancer around age 80. His paternal grandfather died of colon cancer at age 73, which he had had since age 68. Adult-onset diabetes is present in distant relatives on both sides. SOCIAL HISTORY: The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well. REVIEW OF SYSTEMS: He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above. PHYSICAL EXAMINATION: GENERAL: Alert, cooperative, moderately ill-appearing young man. VITAL SIGNS: At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%. HAIR AND SKIN: Mild facial acne. HEENT: Extraocular muscles (EOMs) intact. Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal. CARDIOVASCULAR: A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR). LUNGS: Clear to auscultation with an occasional productive cough. ABDOMEN: Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins. MUSCULOSKELETAL: Mild swelling of the dorsal aspect of the right foot and distal right leg. Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh. GENITOURINARY: Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle. NEUROLOGIC: Exam showed him to be oriented x4. Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs). LABORATORY DATA: White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets. Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal. LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively. Calcium was also slightly low at 8.8 mg/dL. Low molecular weight heparin test was low at 0.27 units/mL. PT was 11.8, INR 1.2, and fibrinogen 374. Urinalysis was normal. ASSESSMENT: 1. Newly diagnosed high-risk acute lymphoblastic leukemia. 2. Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation. 3. Probable chronic left epididymitis. PLAN: 1. Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status. 2. Prompt reassessment of the status of the deep venous thrombosis with Doppler studies. 3. Ultrasound/Doppler of the testicles. 4. Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.

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.

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.

Write a clinical note about a patient with the following chief complaint: Headache.

CHIEF COMPLAINT: Headache. HISTORY OF PRESENT ILLNESS: This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago. Indicates pressure type of discomfort with throbbing component. It is as high as a 9 on a 0 to 10 scale of intensity. She denies having had similar discomfort in the past. Denies any trauma. Review of systems: No fever or chills. No sinus congestion or nasal drainage. No cough or cold symptoms. No head trauma. Mild nausea. No vomiting or diarrhea. Other systems reviewed and are negative. PMH: Acne. Psychiatric history is unremarkable. PSH: Right knee surgery. SH: The patient is single. Living at home. No smoking or alcohol. FH: Noncontributory. ALLERGIES: No drug allergies. MEDICATIONS: Accutane and Ovcon. PHYSICAL EXAMINATION: VITALS: Temperature of 97.8 degrees F. pulse of 80, respiratory rate of 16, and blood pressure is 131/96. GENERAL: This is a 16-year-old white female. She is awake, alert, and oriented x3. She does appear bit uncomfortable. HEAD: Normocephalic and atraumatic. EYES: The pupils were equal and reactive to light. Extraocular movements are intact. ENT: TMs are clear. Nose and throat are unremarkable. NECK: There is no evidence of nuchal rigidity. She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles. Palpation clearly causes having exacerbation of her discomfort. CHEST: Thorax is unremarkable. GI: Abdomen is nontender. MUSCLES: Extremities are unremarkable. NEURO: Cranial nerves II through XII are grossly intact. Motor and sensory are grossly intact. ,SKIN: Skin is warm and dry. ED COURSE: The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort. DIAGNOSES: 1. Muscle tension cephalgia. 2. Right trapezius and rhomboid muscle spasm. PLAN: Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20. She was instructed to apply warm compresses and perform gentle massage. Follow up with regular provider as needed. Return if any problems.

Write a clinical note about a patient with the following chief complaint: Diarrhea, vomiting, and abdominal pain.

CHIEF COMPLAINT: Diarrhea, vomiting, and abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing. PAST MEDICAL HISTORY: Per the ER documentation is hypertension, diverticulosis, blindness, and sciatica. MEDICATIONS: Lorazepam 0.5 mg, dosing interval is not noted; Tylenol PM; Klor-Con 10 mEq; Lexapro; calcium with vitamin D. ALLERGIES: SHE IS ALLERGIC TO PENICILLIN. FAMILY HISTORY: Unknown. SOCIAL HISTORY: Also unknown. REVIEW OF SYSTEMS: Unobtainable secondary to the patient's condition. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 80. Respiratory rate 18. Blood pressure 130/80. Temperature 97.6. GENERAL: Elderly black female who is initially sleeping upon my evaluation, but is easily arousable. NECK: No JVD. No thyromegaly. EARS, NOSE, AND THROAT: Her oropharynx is dry. Her hearing is very diminished. CARDIOVASCULAR: Regular rhythm. No lower extremity edema. GI: Mild epigastric tenderness to palpation without guarding or rebound. Bowel sounds are normoactive. RESPIRATORY: Clear to auscultation bilaterally with a normal effort. SKIN: Warm, dry, no erythema. NEUROLOGICAL: The patient attempts to answer questions when asked, but is very hard of hearing. She is seen to move all extremities spontaneously. DIAGNOSTIC DATA: White count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, PTT 24, PT 13.3, INR 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, BUN 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, AST 33, ALT 26, alkaline phosphatase 92. Cardiac isoenzymes negative x1. EKG shows sinus rhythm with a rate of 96 and a prolonged QT interval. ASSESSMENT AND PLAN: 1. Pancreatitis. Will treat symptomatically with morphine and Zofran, and also IV fluids. Will keep NPO. 2. Diarrhea. Will check stool studies. 3. Volume depletion. IV fluids. 4. Hyperglycemia. It is unknown whether the patient is diabetic. I will treat her with sliding scale insulin. 5. Hypertension. If the patient takes blood pressure medications, it is not listed on the only medication listing that is available. I will prescribe clonidine as needed. 6. Renal failure. Her baseline is unknown. This is at least partly prerenal. Will replace volume with IV fluids and monitor her renal function. 7. Hypokalemia. Will replace per protocol. 8. Hypercalcemia. This is actually rather severe when adjusted for the patient's low albumin. Her true calcium level comes out to somewhere around 12. For now, I will just treat her with IV fluids and Lasix, and monitor her calcium level. 9. Protein gap. This, in combination with the calcium, may be suggestive of multiple myeloma. It is my understanding that the family is seeking hospice placement for the patient right now. I would have to discuss with the family before undertaking any workup for multiple myeloma or other malignancy.

Write a clinical note about a patient with the following chief complaint: Right-sided weakness.

CHIEF COMPLAINT: Right-sided weakness. HISTORY OF PRESENT ILLNESS: The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Medications are taken from the paperwork from Life Care Center and include: Lortab 3-4 times a day for pain, Ativan 0.25 mg by mouth every 12 hours p.r.n. pain, Depakote ER 250 mg p.o. q nightly, Actos 15 mg p.o. t.i.d. Lantus 35 units subcu q nightly, Glipizide 10 mg p.o. q day, Lanoxin 0.125 mg p.o. q day, Lasix 40 mg p.o. q day, Lopressor 50 mg p.o. b.i.d. insulin sliding scale, Lunesta 1 mg p.o. q nightly, Sorbitol 15 mg p.o. q day, Zoloft 50 mg p.o. q nightly, Dulcolax as needed for constipation. PAST MEDICAL HISTORY: Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal). SOCIAL HISTORY: The patient lives at Life Care Center. She does not smoke, drink or use intravenous drugs. FAMILY HISTORY: Negative for cerebrovascular accident or cardiac disease. REVIEW OF SYSTEMS: As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection. PHYSICAL EXAMINATION: VITAL SIGNS: The patient is currently with a temperature of 99.1, blood pressure 138/59, pulse 69, respirations 15. She is 95% on room air. GENERAL: This is a pleasant elderly female who appears stated age, in mild distress. HEENT: Oropharynx is dry. NECK: Supple with no jugular venous distention or thyromegaly. RESPIRATORY: Clear to auscultation. No wheezes, rubs or crackles. CARDIOVASCULAR: A 4/6 systolic ejection murmur best heard at the 2nd right intercostal space with radiation to the carotids. ABDOMEN: Soft. Normal bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral above knee amputations. NEUROLOGIC: Strength 2/5 in her right hand, 4/5 in her left hand. She does have mild right facial droop and an expressive aphasia. VASCULAR: The patient has good capillary refill in her fingertips. LABORATORY DATA: BUN 52, creatinine 1.3. Normal coags. Glucose 220. White blood cell count 10,800. Urinalysis has 608 white cells, 625 RBCs. Head CT is currently pending. EKG shows normal sinus rhythm with mild ST-depression and biphasic T-waves diffusely. ASSESSMENT AND PLAN: 1. Right-sided weakness with an expressive aphasia, at this time concerning for a left-sided middle cerebral artery cerebrovascular accident/transient ischemic attach given the patient's serious vascular disease. At this point we will hydrate, treat her urinary tract infection, check an MRI, ultrasound of her carotids, and echocardiogram to reevaluate valvular and left ventricular function. Start antiplatelet therapy and ask Neuro to see the patient. 2. Urinary tract infection. Will treat with ceftriaxone, check urine culture data and adjust as needed. 3. Dehydration. Will hydrate with IV fluids and follow p.o. intake while holding diuretics. 4. Diabetes mellitus type 2 uncontrolled. Her sugar is 249. We will continue Lantus insulin and sliding scale coverage, and check hemoglobin A1c to gauge prior control. 5. Prophylaxis. Will institute low molecular weight heparin and follow activity levels.

Write a clinical note about a patient with the following chief complaint: Intractable nausea and vomiting.

CHIEF COMPLAINT: Intractable nausea and vomiting. HISTORY OF PRESENT ILLNESS: This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke. PAST MEDICAL HISTORY: 1. Diabetes mellitus (poorly controlled). 2. Hypertension (poorly controlled). 3. Chronic renal insufficiency. 4. Adrenal mass. 5. Obstructive sleep apnea. 6. Arthritis. 7. Hyperlipidemia. PAST SURGICAL HISTORY: 1. Removal of ovarian cyst. 2. Hysterectomy. 3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis. 4. Colonoscopy in June, 2005, showing diverticular disease. 5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis. 6. Laparoscopic adrenalectomy in January, 2006. MEDICATIONS: 1. Reglan 10 mg orally every 6 hours. 2. Nexium 20 mg orally twice a day. 3. Labetalol. 4. Hydralazine. 5. Clonidine. 6. Lantus 20 units at bedtime. 7. Humalog 30 units before meals. 8. Prozac 40 mg orally daily. SOCIAL HISTORY: She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use. FAMILY HISTORY: Significant for diabetes and hypertension. ALLERGIES: NO KNOWN DRUG ALLERGIES. REVIEW OF SYSTEMS: HEENT: See has had headaches, and some dizziness. She denies any vision changes. CARDIAC: She denies any chest pain or palpitations. RESPIRATORY: She denies any shortness of breath. GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis. NEUROLOGICAL: She denies any neurological deficits. All other systems were reviewed and were negative unless otherwise mentioned in HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98. GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well. HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear. NECK: Supple. No JVD. No lymphadenopathy. LUNGS: Clear to auscultation bilaterally, nonlabored. HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops.

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.

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.

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.

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.

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.

Write a clinical note about a patient with the following chief complaint: Right-sided facial droop and right-sided weakness.

CHIEF COMPLAINT: Right-sided facial droop and right-sided weakness. HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation. While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop. The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications. ALLERGIES: SHE IS ALLERGIC TO PENICILLIN. SOCIAL HISTORY: She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility. FAMILY HISTORY: Noncontributory. PAST MEDICAL HISTORY: 1. Cerebrovascular accident with expressive aphasia and lower extremity weakness. 2. Abnormality of gait and wheelchair bound secondary to #1. 3. Hypertension. 4. Chronic obstructive pulmonary disease, on nasal oxygen. 5. Anxiety disorder. 6. Dementia. PAST SURGICAL HISTORY: Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis. REVIEW OF SYSTEMS: Because of the patient's inability to communicate, is not obtainable, but apparently, she has urine incontinence and also stool incontinence, and is wheelchair bound. PHYSICAL EXAMINATION: GENERAL: She is an 83-year-old patient, awake, and non-communicable lady, currently in bed, follows commands by closing and opening her eyes. VITAL SIGNS: Temperature is 99.6, pulse is 101, respirations 18, and blood pressure is in the 218/97. HEENT: Pupils are equal, round, and reactive to light. External ocular muscles are intact. Conjunctivae anicteric. There is a slight right-sided facial droop. Oropharynx is clear with the missing teeth on the upper and the lower part. Tympanic membranes are clear. NECK: Supple. There is no carotid bruit. No cervical adenopathy. CARDIAC: Regular rate and rhythm with 2/6 systolic murmur, more at the apex. LUNGS: Clear to auscultation. ABDOMEN: Soft and no tenderness. Bowel sound is present. EXTREMITIES: There is no pedal edema. Both knees are passively extendable with about 10-15 degrees of fixed flexion deformity on both sides. NEUROLOGIC: There is right-sided slight facial droop. She moves both upper extremities equally. She has withdrawal of both lower extremities by touching her sole of the feet. SKIN: There is about 2 cm first turning to second-degree pressure ulcer on the right buttocks. LABORATORY DATA: The CT scan of the head shows brain atrophy with no acute events. Sodium is 137, potassium 3.7, chloride 102, bicarbonate 24, BUN of 22, creatinine 0.5, and glucose of 92. Total white blood cell count is 8.9000, hemoglobin 14.4, hematocrit 42.7, and the platelet count of 184,000. The urinalysis was more than 100 white blood cells and 10-25 red blood cells. Recent culture showed more than 100,000 colonies of E. coli, resistant to most of the tested medications except amikacin, nitrofurantoin, imipenem, and meropenem. ASSESSMENT: 1. Recent cerebrovascular accident with right-sided weakness. 2. Hypertension. 3. Dementia. 4. Anxiety. 5. Urinary tract infection. 6. Abnormality of gait secondary to lower extremity weakness. PLAN: We will keep the patient NPO until a swallowing evaluation was done. We will start her on IV Vasotec every 4 hours p.r.n. systolic blood pressure more than 170. Neuro check every 4 hours for 24 hours. We will start her on amikacin IV per pharmacy. We will start her on Lovenox subcutaneously 40 mg every day and we will continue with the Ecotrin as swallowing evaluation was done. Resume home medications, which basically include Aricept 10 mg p.o. daily, Diovan 160 mg p.o. daily, multivitamin, calcium with vitamin D, Ecotrin, and Tylenol p.r.n. I will continue with the IV fluids at 75 mL an hour with a D5 normal saline at the range of 75 mL an hour and adding potassium 10 mEq per 1000 mL and I would follow the patient on daily basis.

Write a clinical note about a patient with the following chief complaint: Abdominal pain.

CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. He described the pain as 8/10 in severity and the intensity varied. The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission. The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting. The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction. The patient was subsequently admitted for possible obstruction. The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.) He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy. PAST HISTORY: Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily. Esophageal reflux treated with Nexium 40 mg daily. Allergic rhinitis treated with Allegra 180 mg daily. Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly. Glaucoma treated with Xalatan drops. History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent. PREVIOUS SURGERIES: Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery. FAMILY HISTORY: Father died at age 85 of "old age," mother died at age 89 of "old age." Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease. Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma. SOCIAL HISTORY: The patient is widowed and a retired engineer. He denies cigarettes smoking or alcohol intake. REVIEW OF SYSTEMS: Denies fevers or weight loss. HEENT: Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat. Neck: Denies neck stiffness, no pain or masses in the neck. Respiratory: Denies cough, sputum production, hemoptysis, wheezing or shortness of breath. Cardiovascular: Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation. Gastrointestinal: See history of the present illness. Urinary: Denies dysuria, frequency, urgency or hematuria. Neuro: Denies seizure, syncope, incoordination, hemiparesis or paresthesias. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics. HEENT: Atraumatic, normocephalic. Eyes, EOMs full, PERRLA. Fundi benign. TMs normal. Nose clear. Throat benign. NECK: Supple with no adenopathy. Carotid upstrokes normal with no bruits. Thyroid is not enlarged. LUNGS: Clear to percussion and auscultation. HEART: Regular rate, normal S1 and S2 with no murmurs or gallops. PMI is nondisplaced. ABDOMEN: Mildly distended with mild diffuse tenderness. There is no rebound or guarding. Bowel sounds are hypoactive. EXTREMITIES: No cyanosis, clubbing or edema. Pulses are strong and intact throughout. GENITALIA: Atrophic male, no scrotal masses or tenderness. Testicles are atrophic. No hernia is noted. RECTAL: Unremarkable, prostate was not enlarged and there were no nodules or tenderness. LAB DATA: WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000. Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44. Alkaline phosphatase, AST and ALT are all normal. UA is negative. Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted. IMPRESSION: 1. Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction. 2. Hypertension. 3. Esophageal reflux. 4. Allergic rhinitis. 5. Glaucoma. PLAN: The patient is admitted to the medical floor. He has been kept NPO and will be given IV fluids. He will also be given antiemetic medications with Zofran and an analgesic as necessary. General surgery consultation was obtained. Abdominal series x-ray will be done.

Write a clinical note about a patient with the following chief complaint: Abdominal pain.

CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is an 86-year-old female who is a patient of Dr. X, who was transferred from ABCD Home due to persistent abdominal pain, nausea and vomiting, which started around 11:00 a.m. yesterday. During evaluation in the emergency room, the patient was found to have a high amylase as well as lipase count and she is being admitted for management of acute pancreatitis. PAST MEDICAL HISTORY: Significant for dementia of Alzheimer type, anxiety, osteoarthritis, and hypertension. ALLERGIES: THE PATIENT IS ALLERGIC TO POLLENS. MEDICATIONS: Include alprazolam 0.5 mg b.i.d. p.r.n. mirtazapine 30 mg p.o. daily, Aricept 10 mg p.o. nightly, Namenda 10 mg p.o. b.i.d. Benicar 40 mg p.o. daily, and Claritin 10 mg daily p.r.n. FAMILY HISTORY: Not available. PERSONAL HISTORY: Not available. SOCIAL HISTORY: Not available. The patient lives at a skilled nursing facility. REVIEW OF SYSTEMS: She has moderate-to-severe dementia and is unable to give any information about history or review of systems. PHYSICAL EXAMINATION: GENERAL: She is awake and alert, able to follow few simple commands, resting comfortably, does not appear to be in any acute distress. VITAL SIGNS: Temperature of 99.5, pulse 82, respirations 18, blood pressure of 150/68, and pulse ox is 90% on room air. HEENT: Atraumatic. Pupils are equal and reactive to light. Sclerae and conjunctivae are normal. Throat without any pharyngeal inflammation or exudate. Oral mucosa is normal. NECK: No jugular venous distention. Carotids are felt normally. No bruit appreciated. Thyroid gland is not palpable. There are no palpable lymph nodes in the neck or the supraclavicular region. HEART: S1 and S2 are heard normally. No murmur appreciated. LUNGS: Clear to auscultation. ABDOMEN: Soft, diffusely tender. No rebound or rigidity. Bowel sounds are heard. Most of the tenderness is located in the epigastric region. EXTREMITIES: Without any pedal edema, normal dorsalis pedis pulsations bilaterally. BREASTS: Normal. BACK: The patient does not have any decubitus or skin changes on her back. LABS DONE AT THE TIME OF ADMISSION: WBC of 24.3, hemoglobin and hematocrit 15.3 and 46.5, MCV 89.3, and platelet count of 236,000. PT 10.9, INR 1.1, PTT of 22. Urinalysis with positive nitrite, 5 to 10 wbc's, and 2+ bacteria. Sodium 134, potassium 3.6, chloride 97, bicarbonate 27, calcium 8.8, BUN 25, creatinine 0.9, albumin of 3.4, alkaline phosphatase 109, ALT 121, AST 166, amylase 1797, and lipase over 3000. X-ray of abdomen shows essentially normal abdomen with possible splenic granulomas and degenerative spine changes. CT of the abdomen revealed acute pancreatitis, cardiomegaly, and right lung base atelectasis. Ultrasound of the abdomen revealed echogenic liver with fatty infiltration. Repeat CBC from today showed white count to be 21.6, hemoglobin and hematocrit 13.9 and 41.1, platelet count is normal, 89% segments and 2% bands. Sodium 132, potassium 4.0, chloride 98, bicarbonate 22, glucose 184, ALT 314, AST 382, amylase 918, and lipase 1331. The cultures are pending at this time. EKG shows sinus rhythm, rate about 90 per minute, multiple ventricular premature complexes are noted. Troponin 0.004 and myoglobin is 39.6. ASSESSMENT: 1. Acute pancreatitis. 2. Leukocytosis. 3. Urinary tract infection. 4. Hyponatremia. 5. Dementia. 6. Anxiety. 7. History of hypertension. 8. Abnormal electrocardiogram. 9. Osteoarthrosis. PLAN: Admit the patient to medical floor, NPO, IV antibiotics, IV fluids, hold p.o. medications, GI consult, pain control, Zofran IV p.r.n. bedrest, DVT prophylaxis, check blood and urine cultures. I have left a message for the patient's son to call me back.

Write a clinical note about a patient with the following chief complaint: Left leg pain.

CHIEF COMPLAINT: Left leg pain. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage IIIC papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on Saturday. The patient noticed the pain in her left groin and left thigh and also noticed swelling in that leg. A Doppler ultrasound of her leg that was performed today noted a DVT. She is currently on course one, day 14 of 21 of Taxol and carboplatin. She is scheduled for intraperitoneal port placement for intraperitoneal chemotherapy to begin next week. She denies any chest pain or shortness of breath, nausea, vomiting, or dysuria. She has a positive appetite and ambulates without difficulty. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Mitral valve prolapse. 3. Stage IIIC papillary serous adenocarcinoma of the ovaries. PAST SURGICAL HISTORY: 1. A D and C. 2. Bone fragment removed from her right arm. 3. Ovarian cancer staging. OBSTETRICAL HISTORY: Spontaneous miscarriage at 3 months approximately 30 years ago. GYNECOLOGICAL HISTORY: The patient started menses at age 12; she states that they were regular and occurred every month. She finished menopause at age 58. She denies any history of STDs or abnormal Pap smears. Her last mammogram was in April 2005 and was within normal limits. FAMILY HISTORY: 1. A sister with breast carcinoma who was diagnosed in her 50s. 2. A father with gastric carcinoma diagnosed in his 70s. 3. The patient denies any history of ovarian, uterine, or colon cancer in her family. SOCIAL HISTORY: No tobacco, alcohol, or drug abuse. MEDICATIONS: 1. Prilosec. 2. Tramadol p.r.n. ALLERGIES: NO KNOWN DRUG ALLERGIES. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.3, pulse 91, respiratory rate 18, blood pressure 142/46, O2 saturation 99% on room air. GENERAL: Alert, awake, and oriented times three, no apparent distress, a well-developed, well-nourished white female. HEENT: Normocephalic and atraumatic. The oropharynx is clear. The pupils are equal, round, and reactive to light. NECK: Good range of motion, nontender, no thyromegaly. CHEST: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur on her left side. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly, a well-healing midline incision. EXTREMITIES: 2+ pulses bilaterally, right leg without swelling, nontender, no erythema, negative Homans' sign bilaterally, left thigh swollen, erythematous, and warm to the touch compared to the right. Her left groin is slightly tender to palpation. LYMPHATICS: No axillary, groin, clavicular, or mandibular nodes palpated. LABORATORY DATA: White blood cell count 15.5, hemoglobin 11.4, hematocrit 34.5, platelets 159, percent neutrophils 88%, absolute neutrophil count 14,520. Sodium 142, potassium 3.3, chloride 103, CO2 26, BUN 15, creatinine 0.9, glucose 152, calcium 8.7. PT 13.1, PTT 28, INR 0.97. ASSESSMENT AND PLAN: Miss Bolen is a 59-year-old gravida 1, para 0-0-1-0 with stage IIIC papillary serous adenocarcinoma of the ovary. She is postop day 21 of an exploratory laparotomy with ovarian cancer staging. She is currently with a left leg DVT. 1. The patient is doing well and is currently without any complaints. We will start Lovenox 1 mg per kg subcu daily and Coumadin 5 mg p.o. daily. The patient will receive INR in the morning; the goal was obtain an INR between 2.5 and 3.0 before the Lovenox is instilled. The patient is scheduled for port placement for intraperitoneal chemotherapy and this possibly may be delayed. 2. Aranesp 200 mcg subcu was given today. The patient's absolute neutrophil count is 14,520.

Write a clinical note about a patient with the following chief complaint: Anxiety, alcohol abuse, and chest pain.

CHIEF COMPLAINT: Anxiety, alcohol abuse, and chest pain. HISTORY OF PRESENT ILLNESS: This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain. The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath. The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates. Aggravated by breathing, coughing, and palpation over the area. The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted. Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5. The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together. The patient has a history prior digoxin overdose of the same nature. MEDICATIONS: Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg. PAST MEDICAL HISTORY: MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure. The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y. SOCIAL HISTORY: History of alcohol use in the past. He is basically requesting for more and more pain medications. He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid. His pain is tolerable. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Alert and oriented x3, no apparent distress. HEENT: Extraocular muscles are intact. CVS: S1, S2 heard. CHEST: Clear to auscultation bilaterally. ABDOMEN: Soft and nontender. EXTREMITIES: No edema or clubbing. NEURO: Grossly intact. Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found. EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes. ASSESSMENT AND PLAN: 1. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. Continue to follow the patient clinically at this time. The patient has been admitted to ICU and will be changed to DOU. 2. Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes. The patient likely has opioid dependence and requesting more and more pain medications. He is also bargaining for pain medications with me. The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days. The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred. We will try to verify his pain medications from his primary doctor and his pharmacy. The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past.

Write a clinical note about a patient with the following diagnoses: 1. Pneumonia. 2. Crohn disease. 3. Anasarca. 4. Anemia.

DIAGNOSES: 1. Pneumonia. 2. Crohn disease. 3. Anasarca. 4. Anemia. CHIEF COMPLAINT: I have a lot of swelling in my legs. HISTORY: The patient is a 41-year-old gentleman with a long history of Crohn disease. He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months. He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers. This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital. He has been treated with IV antibiotics and is growing Streptococcus. At this time, he seems relatively stable although slightly dyspneic. Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities. At this time, he continues to have symptoms consistent with diarrhea and malabsorption. He also has some episodes of nausea and vomiting at times. He currently has a cough and symptoms of dyspnea. Further review of systems was not otherwise contributory. MEDICATIONS: 1. Prednisone. 2. Effexor. 3. Folic acid. 4. Norco for pain. PAST MEDICAL HISTORY: As mentioned above, but he also has anxiety and depression. PAST SURGICAL HISTORY: 1. Small bowel resections. 2. Appendectomy. 3. A vasectomy. ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter. FAMILY HISTORY: Significant for his father who died of IPF and irritable bowel syndrome. REVIEW OF SYSTEMS: As mentioned in the history of present illness and further review of systems is not otherwise contributory. PHYSICAL EXAMINATION: GENERAL: He is a thin appearing man in very mild respiratory distress when his oxygen is off. VITAL SIGNS: His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds. HEENT: Sclerae anicteric. Conjunctivae normal. Nasal and oropharynx are clear. NECK: Supple. No jugular venous pressure distention is noted. There is no adenopathy in the cervical, supraclavicular or axillary areas. CHEST: Reveals some crackles in the right chest, in the base, and in the upper lung fields. His left is relatively clear with decreased breath sounds. HEART: Regular rate and rhythm. ABDOMEN: Slightly protuberant. Bowel sounds are present. He is slightly tender and it is diffuse. There is no organomegaly and no ascites appreciable. EXTREMITIES: There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet. DERMATOLOGIC: Shows thin skin. No ecchymosis or petechiae. LABORATORY STUDIES: Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3. There is no M-spike observed. His B12 is 500 with a folic acid of 11. His white count is 21 with a hemoglobin of 10, and a platelet count 204,000. IMPRESSION AT THIS TIME: 1. Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca. 2. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia. ASSESSMENT AND PLAN: At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate. I believe that he needs a calorie count. We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered. I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist. I will help in anyway that I can to improve the patient's laboratory abnormalities. However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time. I have explained this in detail to the patient and his family. Everybody expresses understanding and all questions were answered. At this time, follow him up during his hospital stay and plan to see him in the office as well.

Write a clinical note about a patient with the following chief complaint: Swelling of lips causing difficulty swallowing.

CHIEF COMPLAINT: Swelling of lips causing difficulty swallowing. HISTORY OF PRESENT ILLNESS: This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics. She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago. She showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty. ,The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate. She has rather diffuse pain involving both large and small joints. ,MEDICATIONS: Prednisone 7.5 mg p.o. q.d. Premarin 0.125 mg p.o. q.d. and Dolobid 1000 mg p.o. q.d. recently discontinued because of questionable allergic reaction. HCTZ 25 mg p.o. q.o.d. Oral calcium supplements. In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had Azulfidine, cyclophosphamide, or chlorambucil. ,ALLERGIES: None by history. ,FAMILY/SOCIAL HISTORY: Noncontributory. PHYSICAL EXAMINATION: This is a chronically ill appearing female, alert, oriented, and cooperative. She moves with great difficulty because of fatigue and malaise. Vital signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22. HEENT: Normocephalic. No scalp lesions. Dry eyes with conjuctival injections. Mild exophthalmos. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosion of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her hard and soft palette. Tonsils not enlarged. No visible exudate. She has difficulty opening her mouth because of pain. SKIN: She has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown. She has some fissuring in the buttocks crease. PULMONARY: Clear to percussion in auscultation. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Protuberant no organomegaly and positive bowel sounds. NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia. MUSCULOSKELATAL: Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis. She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+. I feel no pulse distally in either leg. ,PROBLEMS: 1. Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome. 2. Rheumatoid Arthritis class 3, stage 4. 3. Flare of arthritis after discontinuing methotrexate. 4. Osteoporosis with compression fracture. 5. Mild dehydration. 6. Nephrolithiasis. PLAN: Patient is admitted for IV hydration and treatment of oral ulcerations. We will obtain a dermatology consult. IV leucovorin will be started, and the patient will be put on high-dose corticosteroids.

Write a clinical note about a patient with the following skin: There was no rash or skin lesions.

Chief Complaint: Abdominal pain, nausea and vomiting. History of Present Illness: A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. The patient denied passing any stool or gas per rectum for the previous 24 hours. She had been admitted recently to the hospital from December 19 to December 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin "lumps". She described a total of three "lumps". The first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. They were described as "erythematous nodular lesions on the extensor surface of the left arm." A punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained "multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis". However, one granuloma in the deep dermis, showed a hint of central necrosis. Special stains for acid - fast bacilli and fungi were reported as negative. No atypia or malignancy was noted. A CT scan of the chest was obtained on December 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. No cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. The patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. Minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. They were also able to appreciate intra-alveolar fibrinous exudates. One of the blood cultures drawn on December 19, 2000 grew Streptococcus mitis. The patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd. Past Medical History: 1. Post-streptococcal glomerulonephritis at age 10. 2. End stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996. 3. Cadaveric transplant in October 1996,4. Steroid induced diabetes mellitus,5. Hypertension,Past Surgical History: 1. Total abdominal hysterectomy in January 1996,2. Cesarean section X2 in 1996 and 1997,3. Appendectomy in 1971,4. Insertion of peritoneal dialysis catheter in 1994,5. Cadaveric transplant in October 1996,Social History: The patient denies a history of smoking, drinking or intravenous drug use. She came to the United States in 1973. She works as a nurse in a newborn nursery. Her hobby is gardening. She traveled to Las Vegas on May 2000 and stayed for 6 months. She denied ill contacts or pets. Allergies: Ciprofloxacin and Enteric coated aspirin,Medications: prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch TTS 3 1/week, Prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h. Family History: She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed. Review of systems: Non-contributory. The patient denied fever, chills, ulcers, liver disease or history of gallstones. Vaccines: The patient was vaccinated with BCG before starting elementary school in the Philippines. Physical Examination: At the time of the examination the patient was alert and oriented times three and in no acute distress. She was well nourished. BP 106/60 lying down; HR 86; RR 12; T 96.1° F; Hgt. =5' 2"; Wgt. =121 lbs. SKIN: There was no rash or skin lesions. HEENT: She had no oral lesions and moist mucous membranes. No icterus was noted. NECK: Her neck was supple without lymphadenopathy or thyromegaly. LUNGS: Crackles at the right lower base with normal respiratory excursion and no dullness to percussion. HEART: IV/VI crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck. ABDOMEN: The abdomen was distended. Bowel sounds were normal. No hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination. EXTREMITIES: No cyanosis, clubbing or edema was noted. RECTAL: Normal rectal exam. Guaiac negative. NEUROLOGIC: Normal and non-focal. Hospital Course: The patient was admitted and a nasogastric tube was placed. IV fluids were started. A KUB was obtained showing an abnormal bowel gas pattern. Multiple loops of distended bowel were noted in the mid abdomen. Air and feces were noted within the colon in the right side. An Abdominal CT scan was obtained. There was a small amount of perihepatic fluid noted. The liver and spleen were normal. The kidneys were atrophic. The gallbladder was moderately distended. There was marked dilatation of the small bowel proximally and distally. There was gas and contrast material in the colon. A diagnostic procedure was performed.

Write a clinical note about a patient with the following chief complaint: Altered mental status.

CHIEF COMPLAINT: Altered mental status. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. When asked why he came to the emergency room, the patient replies that it started about 2 PM yesterday. However, he is unable to tell me exactly what started at 2 PM yesterday. The patient's speech is clear, but he speaks nonsensically using words in combinations that don't make any sense. No other history of present illness is available. PAST MEDICAL HISTORY: Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia. PAST SURGICAL HISTORY: Unknown. FAMILY HISTORY: Unknown. SOCIAL HISTORY: The patient denies smoking and drinking. MEDICATIONS: Per the emergency room record, medications are Lotensin 20 mg daily, Toprol 50 mg daily, Plavix 75 mg daily and aspirin 81 mg daily. ALLERGIES: UNKNOWN. REVIEW OF SYSTEMS: Unobtainable secondary to the patient's condition. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature: 97.9. Pulse: 79. Respiratory rate: 20. Blood pressure: 117/84. GENERAL: Well-developed, well-nourished male in no acute distress. HEENT: Eyes: Pupils are equal, round and reactive. There is no scleral icterus. Ears, nose and throat: His oropharynx is moist. His hearing is normal. NECK: No JVD. No thyromegaly. CARDIOVASCULAR: Irregular rhythm. No lower extremity edema. RESPIRATORY: Clear to auscultation bilaterally with normal effort. ABDOMEN: Nontender. Nondistended. Bowel sounds are positive. MUSCULOSKELETAL: There is no clubbing of the digits. The patient's strength is 5/5 throughout. NEUROLOGICAL: Babinski's are downgoing bilaterally. Deep tendon reflexes are 2+ throughout. LABORATORY DATA: By report, head CT from the outlying facility was negative. An EKG showed atrial fibrillation with a rate of 75. There is no indication of any acute cardiac ischemia. A chest x-ray shows no acute pulmonary process, but does show cardiomegaly. Labs are as follows: White count 9.4, hemoglobin 17.2, hematocrit 52.5, platelet count 219. PTT 24, PT 13, INR 0.96. Sodium 135, potassium 3.6, chloride 99, bicarb 27, BUN 13, creatinine 1.4, glucose 161, calcium 9, magnesium 1.9, total protein 7, albumin 3.7, AST 22, ALT 41, alkaline phosphatase 85, total bilirubin 0.7, total cholesterol 193. Cardiac isoenzymes are negative times one with a troponin of 0.09. ASSESSMENT AND PLAN: 1. Probable stroke. The patient has an expressive aphasia. He does not have dysarthria, however. Also, his strength is not affected. I suspect that the patient has had strokes or TIAs in the past because he was taking aspirin and Plavix at home. Head CT is reportedly negative. I will ask our radiologist to re-read the head CT. I will also order MRI and MRA, carotid Doppler ultrasound and echocardiogram in addition to a fasting lipid profile. I will consult neurology to evaluate and continue his aspirin and Plavix. 2. Atrial fibrillation. The patient's rate is controlled currently. I will continue him on his amiodarone 200 mg twice daily and consult CHI to evaluate him. 3. Hypertension. I will continue his home medications and add clonidine as needed. 4. Hyperlipidemia. The patient takes no medications for this currently. I will check a fasting lipid profile. 5. Hyperglycemia. It is unknown whether the patient has a history of diabetes. His glucose is currently 171. I will start him on sliding scale insulin for now and monitor closely. 6. Renal insufficiency. It is also unknown whether the patient has a history of this and what his baseline creatinine might be. Currently he has only mild renal insufficiency. This does not appear to be prerenal. Will monitor for now.

Write a clinical note about a patient with the following heent: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.

Chief Complaint: Confusion and hallucinations. History of Present Illness: The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment. Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices "told him to do good things". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned. The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved. Past Medical History: None. No history of hypertension or of cardiac, renal, lung, or liver disease. Past Surgical History: None,Past Psychological History: None,Social History: The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was "very stressful". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind. Family History: The patient had a second-degree relative with a history of depression and "nervous breakdown". Allergies: There were no known drug allergies. Medications: Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines. Physical Examination: The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute. HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions. NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly. LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi. HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB, no rubs or gallops, PMI nondisplaced, hyperdynamic precordium. ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits. EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses. GENITOURINARY: Normal male phallus, no testicular masses. RECTAL: Guaiac negative, no masses. LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions. SKIN: Acneiform eruption over back and trunk, no papules or vesicles. NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative. PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone. Hospital Course: The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed: Twelve-lead EKG: sinus tachycardia. CXR (PA/lat): normal cardiac silhouette and normal lung fields. CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage. Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative. MRI with gadolinium: no discrete areas of abnormal signal intensity. EEG: no focal or epileptiform activity. The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed.

Write a clinical note about a patient with the following o: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,

Chief Complaint: Abdominal pain, nausea, vomiting, fever, altered mental status. History of Present Illness: 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction. At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief. Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management. Past Medical History: Asthma,Allergic Rhinitis,Medications: loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies: PCN, but has tolerated cephalosporins in the past. Social History: No tobacco use, occasional EtOH, no known drug use, works as a real estate agent. Family History: HTN, father with SLE, uncle with Addison’s Disease. Physical Exam: T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry. Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly. Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages. Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex. Skin: no rash, ecchymosis, or petechiae,STUDIES: EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst. AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible. MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features. Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm. CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus. Hospital Course: The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed.

Write a clinical note about a patient with the following skin: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm.

Chief Complaint: Chronic abdominal pain. History of Present Illness: 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated "with over the counter" antacids and obtained some relief so he did not seek medical attention at that time. Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain. The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems. Past Medical History: No significant past medical history. Past Surgical History: No prior surgeries. Allergies: No known drug allergies. Medications: Omeprazole 40 mg once a day. Denies herbal medications. Family History: Mother, father and siblings were alive and well. Social History: He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs. Physical Examination: The patient was a thin male in no apparent distress. His oral temperature was 98.2 Fahrenheit, blood pressure was 114/67 mmHg, pulse rate of 91 beats per minute and regular, respiratory rate was 14 and his pulse oximetry on room air was 98%. Patient was 52 kg in weight and 173 cm height. SKIN: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm. HEENT: Head was normocephalic and atraumatic. Pupils were equal, round and reactive. Anicteric sclerae. Tympanic membranes had a normal appearance. Normal funduscopic examination. Oral mucosa was moist and pink. Oral/pharynx was clear. NECK: No lymphadenopathy. No carotid bruits. Trachea midline. Thyroid non-palpable. No jugular venous distension. CHEST: Lungs were clear bilaterally with good air movement. HEART: Regular rate and rhythm. Normal S1 and S2 with no murmurs, gallops or rubs. PMI was non-displaced. ABDOMEN: Abdomen was flat. Normal active bowel sounds. Liver span percussed sixteen centimeters, six centimeters below R costal margin with irregular border that was mildly tender to palpation. Slightly tender to palpation in epigastric area. There was no splenomegaly. No abdominal masses were appreciated. No CVA tenderness was noted. RECTAL: No perirectal lesions were found. Normal sphincter tone and no rectal masses. Prostate size was normal without nodules. Guaiac positive. GENITALIA: Testes descended bilaterally, no penile lesions or discharge. EXTREMITIES: No clubbing, cyanosis, or edema. No peripheral lymphadenopathy was noted. NEUROLOGIC: Alert and oriented times three. Cranial nerves II to XII appeared intact. No muscle weakness or sensory deficits. DTRs equal and normal. Radiology/Studies: 2 view CXR: Mild elevation right diaphragm. CT of abdomen and pelvis: Too numerous to count bilobar liver masses up to about 8 cm. Extensive mass in the pancreatic body and tail, peripancreatic region and invading the anterior aspect of the left kidney. Question of vague splenic masses. No definite abnormality of the moderately distended gallbladder, bile ducts, right kidney, poorly seen adrenals, bowel or bladder. Evaluation of the retroperitoneum limited by paucity of fat. Patient underwent several diagnostic procedures and soon after he was transferred to Houston Veterans Administration Medical Center to be near family and to continue work-up and treatment. At the HVAMC these diagnostic procedures were reviewed.

Write a clinical note about a patient with the following gen: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time.

Chief Complaint: Dark urine and generalized weakness. History of Present Illness: 40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed. He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous. Past Medical History: DM II-HbA1c unknown,Past Surgical History: Cholecystectomy without complication,Family History: Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented). Social History: He was unemployed and denied any alcohol or drug use. He was a prior “mild” smoker, but quit 10 years previous. Medications: Insulin (unknown dosage),Allergies: No known drug allergies. Physical Exam: Temperature: 98.2,Blood pressure:118/80,Heart rate: 95,Respiratory rate: 18,GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time. HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx. NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits. CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs,PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes,ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable. RECTAL: Guaiac negative,EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm,NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis,SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata. Hospital Course: The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved. Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis. By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma. By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection. STUDIES (HISTORICAL): CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal. CT neck: No abnormalities noted,CT head: No intracranial abnormalities,RUQ US (for biopsy): Heterogenous liver with lymphadenopathy. ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam.

Write a clinical note about a patient with the following vs: T 100.2F BP 132/85 P 111 RR 20 O2 Sat 95% on room air,

Chief Complaint: coughing up blood and severe joint pain. History of Present Illness: The patient is a 37 year old African American woman with history of chronic allergic rhinitis who presents to an outpatient clinic with severe pain in multiple joints and hemoptysis for 1 day. The patient was at her baseline state of health until 2 months prior to admission when her usual symptoms of allergic rhinitis worsened. In addition to increased nasal congestion and drainage, she also began having generalized fatigue, malaise, and migratory arthralgias involving bilateral wrists, shoulders, elbows, knees, ankles, and finger joints. She also had intermittent episodes of swollen fingers that prevented her from making a fist. Patient denied recent flu-like illness, fever, chills, myalgias, or night sweats. Four weeks after the onset of arthralgias patient developed severe bilateral eye dryness and redness without any discharge. She was evaluated by an ophthalmologist and diagnosed with conjunctivitis. She was given eye drops that did not relieve her eye symptoms. Two weeks prior to admission patient noted the onset of rust colored urine. No bright red blood or clots in the urine. She denied having dysuria, decreased urine output, abdominal pain, flank pain, or nausea/vomiting. Patient went to a community ER, and had a CT Scan of the abdomen that was negative for kidney stones. She was discharged from the ER with Bactrim for possible UTI. During the next week patient had progressively worsening arthralgias to the point where she could hardly walk. On the day of admission, she developed a cough productive of bright red blood associated with shortness of breath and nausea, but no chest pain or dizziness. This prompted the patient to go see her primary care physician. After being seen in clinic, she was transferred to St. Luke’s Episcopal Hospital for further evaluation. Past Medical History: Allergic rhinitis, which she has had for many years and treated with numerous medications. No history of diabetes, hypertension, or renal disease. No history tuberculosis, asthma, or upper airway disease. Past Surgical History: Appendectomy at age 21. C-Section 8 years ago. Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids. Social History: Patient is married and lives with her husband and 2 children. Works in a business office. Denies any tobacco, alcohol, or illicit drug use of any kind. No history of sexually transmitted diseases. Denies exposures to asbestos, chemicals, or industrial gases. No recent travel. No recent sick contacts. Family History: Mother and 2 maternal aunts with asthma. No history of renal or rheumatologic diseases. Medications: Allegra 180mg po qd, Zyrtec 10mg po qd, Claritin 10mg po qd,No herbal medication use. Allergies: No known drug allergies. Review of systems: No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss. Physical Examination: VS: T 100.2F BP 132/85 P 111 RR 20 O2 Sat 95% on room air,GEN: Well-developed woman in no apparent distress. SKIN: No rashes, nodules, ecchymoses, or petechiae. LYMPH NODES: No cervical, axillary, or inguinal lymphadenopathy. HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric sclerae. Erythematous sclerae and pale conjunctivae. Dry mucous membranes. No oropharyngeal lesions. Bilateral tympanic membranes clear. No nasal deformities. NECK: Supple. No increased jugular venous pressure. No thyromegaly. CHEST: Decreased breath sounds throughout bilateral lung fields with occasional diffuse crackles. No wheezes or rales. CV: Tachycardic. Regular rhythm. No murmurs, gallops, or rubs. ABDOMEN: Soft with normal active bowel sounds. Non-distended and non-tender. No masses palpated. No hepatosplenomegaly. RECTAL: Brown stool. Guaiac negative. EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. Tenderness and mild swelling of bilateral wrists, MCPs and PIPs with decreased range of motion and grip function. Bilateral wrists warm without erythema. Bilateral elbows, knees, and ankles tender to palpation with decreased range of motion, but no erythema, warmth, or swelling of these joints. NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation are within normal limits. STUDIES: Chest X-ray (10/03): Suboptimal inspiratory effort. No evidence of pneumonic consolidation, pleural effusion, pneumothorax, or pulmonary edema. Cardiomediastinal silhouette is unremarkable. CT Scan of Chest (10/03): Prominence of the bronchovascular markings bilaterally with a nodular configuration. There are mixed ground glass interstitial pulmonary infiltrates throughout both lungs with a perihilar predominance. Aortic arch is of normal caliber. The pulmonary arteries are of normal caliber. There is right paratracheal lymphadenopathy. There is probable bilateral hilar lymphadenopathy. Trachea and main stem bronchi are normal. The heart is of normal size. Renal Biopsy: Microscopic Description : Ten glomeruli are present. There are crescents in eight of the glomeruli. Some of the glomeruli show focal areas of apparent necrosis with fibrin formation. The interstitium consists of a fairly dense infiltrate of lymphocytes, plasma cells with admixed eosinophils. The tubules for the most part are unremarkable. No vasculitis is identified. Immunofluorescence Description : There are no staining for IgG, IgA, IgM, C3, Kappa, Lambda, C1q, or albumin. Electron Microscopic Description : Mild to moderate glomerular, tubular, and interstitial changes. Mesangium has multifocal areas with increased matrix and cells. There is focal mesangial interpositioning with the filtration membrane. Interstitium has multifocal areas with increased collagen. There are focal areas with interstitial aggregate of fibrin. Within the collagen substrate are infiltrates of lymphocytes, plasma cells, eosinophils, and macrophages. The glomerular sections evaluated show no electron-dense deposits in the filtration membrane or mesangium. Microscopic Diagnosis: Pauci-immune crescentic glomerulonephritis with eosinophilic interstitial infiltrate.

Write a clinical note about a patient with the following chief complaint: Mental changes today.

CHIEF COMPLAINT: Mental changes today. HISTORY OF PRESENT ILLNESS: This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic medication. Today, the patient was found to have decrease in mental alertness, but no other GI symptoms. Some sweating and agitation, but no fever or chills. No other rash. Because of the above symptoms, the patient was treated in the emergency department here. She was found to glucose in 30 range, and hypertension. There was some question whether she also take her blood pressure medication or not. Because of the above symptoms, the patient was admitted to the hospital for further care. The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement. At this time, the patient's glucose was in the 175 range. PAST MEDICAL HISTORY: Diabetes, hypertension. PAST SURGICAL HISTORY: None. FAMILY HISTORY: Unremarkable. ALLERGIES: No known drug allergies. MEDICATIONS: In Spanish label. They are the diabetic medication, and also blood pressure medication. She also takes aspirin a day. SOCIAL HISTORY: The patient is a Mazatlan, Mexico resident, visiting her son here. PHYSICAL EXAMINATION: GENERAL: The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter. HEENT: Clear, atraumatic, normocephalic. No sinus tenderness. No obvious head injury or any laceration. Extraocular movements are intact. Dry mucosal linings. HEART: Regular rate and rhythm, without murmur. Normal S1, S2. LUNGS: Clear. No rales. No wheeze. Good excursion. ABDOMEN: Soft, active bowel sounds in 4 quarters, nontender, no organomegaly. EXTREMITIES: No edema, clubbing, or cyanosis. No rash. LABORATORY FINDINGS: On Admission: CPK, troponin are negative. CMP is remarkable for glucose of 33. BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7. Urinalysis shows specific gravity of 10.30. CT of the brain showed no hemorrhage. Chest x-ray showed no acute cardiomegaly or any infiltrates. IMPRESSION: 1. Hypoglycemia due to not eating her meals on a regular basis. 2. Hypertension. 3. Renal insufficiency, may be dehydration, or diabetic nephropathy. PLAN: Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.

Write a clinical note about a patient with the following chief complaint: Jaw pain this morning.

CHIEF COMPLAINT: Jaw pain this morning. BRIEF HISTORY OF PRESENT ILLNESS: This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease. The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day. Also, history of chronic diverticulitis with recent bouts. The patient has been doing well, seen in my office at the end of December for complete physical examination. I had ordered a stress test for him, then delayed due to a family illness. However, denies any chest pain or chest tightness with exertion. The patient was doing well. He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand. He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain. He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event. The patient's pain resolved. He was given nitroglycerin in the emergency room drawing his blood pressure 67/32. Blood pressure quickly came back to normal with the patient's reverse Trendelenburg. FAMILY HISTORY: Strongly positive for heart disease in his father. He had a bypass at age 60. Both parents are alive. Both have dementia. His father has history of coronary artery disease and multiple vascular strokes. He is in his 80s. His mother is 80, also with dementia. The patient does not smoke or drink. PAST MEDICAL HISTORY: Remarkable for tonsillectomies. MEDICATIONS: Synthroid and Lipitor. ALLERGIES: PENICILLIN AND BIAXIN. REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18. He is afebrile. GENERAL: He is well-developed, well-nourished white male, in no acute distress. HEENT: Pupils equal, round, and reactive to light and accommodation. Extraocular movements were intact. Throat was clear. NECK: Supple. There is no organomegaly or thyromegaly. Carotids are +2 without bruits. CHEST: Lungs are clear to auscultation and percussion. CV: Without any murmurs or gallops. ABDOMEN: Soft. There is no hepatosplenomegaly. Bowel sounds are active. No tenderness. EXTREMITIES: No cyanosis, clubbing, or edema. Peripheral pulses 2+. NEUROLOGICAL: Intact. Motor exam is 5/5. LABORATORY STUDIES: EKG is within normal limits, good sinus rhythm. His axis is somewhat leftward. CBC and BMP were normal and cardiac enzymes were negative x1. IMPRESSION: 1. Jaw pain, sounds musculoskeletal. We will rule out angina equivalent. 2. Hypercholesterolemia. 3. Hypothyroidism. PLAN: Lipitor and thyroid have been ordered. His chest pain unit protocol for the stress thallium that will be done in the morning. If test is negative, we will discharge home. If positive, we will consult Cardiology. The patient requests Dr. ABC.

Write a clinical note about a patient with the following chief complaint: A 74-year-old female patient admitted here with altered mental status.

CHIEF COMPLAINT: A 74-year-old female patient admitted here with altered mental status. HISTORY OF PRESENT ILLNESS: The patient started the last 3-4 days to do poorly. She was more confused, had garbled speech, significantly worse from her baseline. She has also had decreased level of consciousness since yesterday. She has had aphasia which is baseline but her aphasia has gotten significantly worse. She eventually became unresponsive and paramedics were called. Her blood sugar was found to be 40 because of poor p.o. intake. She was given some D50 but that did not improve her mental status, and she was brought to the emergency department. By the time she came to the emergency department, she started having some garbled speech. She was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department. When seen on the floor, she is more awake, alert. PAST MEDICAL HISTORY: Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection. She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place. She has had right-sided CVA. She has had atrial fibrillation status post pacemaker. She is a type 2 diabetic with significant neuropathy. She has also had significant pain on the right side from her stroke. She has a history of hypothyroidism. Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998. She has had a pacemaker placement. ,REVIEW OF SYSTEMS: GENERAL: No recent fever, chills. No recent weight loss. PULMONARY: No cough, chest congestion. CARDIAC: No chest pain, shortness of breath. GI: No abdominal pain, nausea, vomiting. No constipation. No bleeding per rectum or melena. GENITOURINARY: She has had frequent urinary tract infection but does not have any symptoms with it. ENDOCRINE: Unable to assess because of patient's bed-bound status. MEDICATIONS: Percocet 2 tablets 4 times a day, Neurontin 1 tablet b.i.d. 600 mg, Cipro recently started 500 b.i.d. Humulin N 30 units twice a day. The patient had recently reduced that to 24 units. MiraLax 1 scoop nightly, Avandia 4 mg b.i.d. Flexeril 1 tablet t.i.d. Synthroid 125 mcg daily, Coumadin 5 mg. On the medical records, it shows she is also on ibuprofen, Lasix 40 mg b.i.d. Lipitor 20 mg nightly, Reglan t.i.d. 5 mg, Nystatin powder. She is on oxygen chronically. SOCIAL/FAMILY HISTORY: She is married, lives with her husband, has 2 children that passed away and 4 surviving children. No history of tobacco use. No history of alcohol use. Family history is noncontributory. PHYSICAL EXAMINATION: GENERAL: She is awake, alert, appears to be comfortable. VITAL SIGNS: Blood pressure 111/43, pulse 60 per minute, temperature 37.2. Weight is 98 kg. Urine output is so far 1000 mL. Her intake has been fairly similar. Blood sugars are 99 fasting this morning. ,HEENT: Moist mucous membranes. No pallor,NECK: Supple. She has a rash on her neck. ,HEART: Regular rhythm, pacemaker could be palpated. CHEST: Clear to auscultation. ABDOMEN: Soft, obese, nontender. EXTREMITIES: Bilateral lower extremities edema present. She is able to move the left side more efficiently than the right. The power is about 5 x 5 on the left and about 3-4 x 5 on the right. She has some mild aphasia. DIAGNOSTIC STUDIES: BUN 48, creatinine 2.8. LFTs normal. She is anemic with a hemoglobin of 9.6, hematocrit 29. INR 1.1, pro time 14. Urine done in the emergency department showed 20 white cells. It was initially cloudy but on the floor it has cleared up. Cultures from the one done today are pending. The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures. There is a question of her being allergic to Septra that was used for her last UTI. IMPRESSION/PLAN: 1. Cerebrovascular accident as evidenced by change in mental status and speech. She seems to have recovered at this point. We will continue Coumadin. The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home. 2. Recurrent urinary tract infection. Will await culture at this time, continue Cipro. 3. Diabetes with episode of hypoglycemia. Monitor blood sugar closely, decrease the dose of Humulin N to 15 units twice a day since intake is poor. At this point, there is no clear evidence of any benefit from Avandia but will continue that for now. 4. Neuropathy, continue Neurontin 600 mg b.i.d. for pain continue the Percocet that she has been on. 5. Hypothyroidism, continue Synthroid. 6. Hyperlipidemia, continue Lipitor. 7. The patient is not to be resuscitated. Further management based on the hospital course.

Write a clinical note about a patient with the following history of present illness: This is a previously healthy 45-year-old gentleman. For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia. He was able to reduce this, with relief of pain. He is now being admitted for definitive repair.

CHIEF COMPLAINT: This is a previously healthy 45-year-old gentleman. For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia. He was able to reduce this, with relief of pain. He is now being admitted for definitive repair. PAST MEDICAL HISTORY: Significant only for hemorrhoidectomy. He does have a history of depression and hypertension. MEDICATIONS: His only medications are Ziac and Remeron. ALLERGIES: No allergies. FAMILY HISTORY: Negative for cancer. SOCIAL HISTORY: He is single. He has 2 children. He drinks 4-8 beers per night and smokes half a pack per day for 30 years. He was born in Salt Lake City. He works in an electronic assembly for Harmony Music. He has no history of hepatitis or blood transfusions. PHYSICAL EXAMINATION: GENERAL: Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department. HEENT: No scleral icterus. NECK: No cervical, supraclavicular, or axillary adenopathy. LUNGS: Clear. HEART: Regular. No murmurs or gallops. ABDOMEN: As noted, obese with mildly visible bulging in the umbilicus at the superior position. With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus. DIAGNOSTIC STUDIES: Normal sinus rhythm on EKG, prolonged QT. Chest x-ray was negative. The abdominal x-rays were read as being negative. His electrolytes were normal. Creatinine was 0.9. White count was 6.5, hematocrit was 48, and platelet count was 307. ASSESSMENT AND PLAN: Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.

Write a clinical note about a patient with the following chief complaint: Blood-borne pathogen exposure. ,

CHIEF COMPLAINT: Blood-borne pathogen exposure. ,HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam. ,REVIEW OF SYSTEMS: The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat. There was no chest pain or troubled breathing. He did have abdominal symptoms as described above but no abdominal pain. There were no urinary symptoms. No darkening of the skin or eyes. He had no yellowing or darkening of the urine. He had no rash to the skin. There was no local infection at the side of the fingerstick. All other systems were negative. ,PAST MEDICAL HISTORY: Significant for degenerative disc disease in the back. ,MEDICATIONS: Nexium. ,ALLERGIES: IV contrast. ,CURRENT WORK STATUS: He continues on full duty work. ,PHYSICAL EXAMINATION: The patient was awake and alert. He was seated upright. He did not appear ill or toxic, and was well hydrated. His temperature was 97.2 degrees, pulse was 84, respirations 14 and unlabored, and blood pressure 102/70. HEENT exam, the sclerae were clear. Ocular movements were full and intact. His oropharynx was clear. There was no pharyngeal erythema. No tonsillar enlargement. His neck was supple and nontender. He had no masses. There was no adenopathy in his cervical or axillary chain. Breath sounds were clear and equal without wheeze or rales. Heart tones were regular without murmur or gallop. His abdomen was soft, flat, and nontender. There was no enlargement of the liver or spleen. His extremities were without rash or edema. He had normal gait and balance without ataxia. ,ASSESSMENT: The patient presents for evaluation after a contaminated needlestick to the index finger. The source patient was tested and found to be negative for HIV. However, he did test positive for hepatitis C. He was described as a carrier without active disease. The patient has been followed with periodic evaluation including blood testing. He has completed a 3 shot series for hepatitis B and had titers drawn that showed protected antibodies. He also was up-to-date on his immunization including tetanus. The patient has been well during this time except for the onset of a intestinal illness being investigated with some squeakiness and vomiting. He had no other symptoms that were suggestive of acute hepatitis. His abdominal exam was normal. He had no generalized lymphadenopathy and no fever. Blood tests were drawn on 02/07/2005. The results of which were reviewed with the patient. His liver function test was normal at 18. His hepatitis C and HIV, both of which were negative. He had no local signs of infection, and otherwise has been doing well except for his acute intestinal illness as described above. ,IMPRESSION: Blood-borne pathogen exposure secondary to contaminated needlestick. ,PLAN: The patient is now six months out from his injury. He had negative lab studies. There were no physical findings that were suggestive of disease transmission. He was counseled on ways to prevent exposure in the future including use of protective gear including gloves, which he states that he always does. He was counseled that ways to prevent transmission or exposure to intimate contacts. ,WORK STATUS: He was released to regular work. ,CONDITION: He was reassured that no signs of disease transmission had occurred as result of his injury. He therefore was found to be medically stationary without signs of impairment of today's date.

Write a clinical note about a patient with the following chief complaint: Abdominal pain and discomfort for 3 weeks.

CHIEF COMPLAINT: Abdominal pain and discomfort for 3 weeks. HISTORY OF PRESENT ILLNESS: ,The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdominal pain and discomfort which is mostly located in the epigastrium and right upper quadrant. She also complains of indigestion and right scapular pain during this same period. None of these complaints are alleviated or aggravated by food. She denies any NSAIDs use. The patient went to an outside hospital where a right upper quadrant ultrasound showed no gallbladder disease, but was suspicious for a liver mass. A CT and MRI of the abdomen and pelvis showed a 12.5 X 10.9 X 11.1 cm right suprarenal mass and a 7.1 X 5.4 X 6.5 cm intrahepatic mass in the region of the dome of the liver. CT of the chest revealed multiple small (<5 mm) bilateral lung nodules. Total body bone scan had no abnormal uptake. She was transferred to Methodist for further care. The patient reports having a good appetite and denies any weight loss. She denies having any fever or chills. She has noticed increasing dyspnea with moderate exercise, but not at rest. She denies having palpitations. She occasionally has nausea, but no vomiting, constipation, or diarrhea. Over the last 2 months, she has noticed increasing facial hair and a mustache. There is an extensive family history of colon and other cancers in her family. She was told there is a genetic defect in her family but cannot recall the name of the syndrome. She had a colonoscopy and a polyp removed at the age of 14 years old. Her last colonoscopy was 2 months ago and was unremarkable. PAST MEDICAL HISTORY : None. No history of hypertension, diabetes, heart disease, liver disease or cancer. PAST SURGICAL HISTORY: Bilateral tubal ligation in 2001, colon polyp removed at 14 years old. GYN HISTORY: Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal. FAMILY HISTORY: Mother is 61 years old and brother is 39 years old, both alive and well. Father died at 48 of colon cancer and questionable pancreatic cancer. One paternal uncle died at 32 of colon cancer and bile duct cancer. One paternal uncle had colon cancer in his 40s. Thirty cancers are noted on the father’s side of the family, many are colon; two women had breast cancer. The family was told that there is a genetic syndrome in the family, but no one remembers the name of the syndrome. SOCIAL HISTORY: No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children. MEDICATION: None. REVIEW OF SYSTEMS: No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI. PHYSICAL EXAM: VS: T 97.6 BP 121/85 P 84 R 18 O2 Sat 100% on room air,GEN: Pleasant, thin woman in mild distress secondary to abdominal pain and discomfort. HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Sclerae clear. Pink conjunctiva. Moist mucous membranes. No oropharyngeal lesions. NECK: Supple, no masses, jugular venous distention or bruits. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. No murmurs, gallops, rubs. BREASTS: Symmetric, no skin changes, no discharge, no masses,ABDOMEN: Soft with active bowel sounds. There is minimal diffuse tenderness on examination. No masses palpated. There is fullness in the right upper quadrant with negative Murphy’s sign. No rebound or guarding. The liver span is 12 cm by percussion, but not palpable below the costal margin. No splenomegaly. PELVIC: not done,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits. LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions; no tattoos,STUDIES: CT Chest: Multiple bilateral small (<5 mm) pulmonary nodules, no mediastinal mass or hilar adenopathy. MRI Abdomen: 12.5 x 10.9 x 11.1 cm suprarenal mass, 7.1 x 5.4 x 6.5 cm intrahepatic lesion in the region of the dome of the liver, abnormal signal intensity within the inferior vena cava at the level of porta hepatic worrisome for thrombus. Total Body Bone Scan: No abnormal uptake. HOSPITAL COURSE: ,The patient was transferred from an outside hospital for further workup and management. She was taken to the Operating Room for abdominal exploration. A liver biopsy was done.

Write a clinical note about a patient with the following chief complaint: Nausea, vomiting, diarrhea, and fever.

CHIEF COMPLAINT: Nausea, vomiting, diarrhea, and fever. HISTORY OF PRESENT ILLNESS: This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought to the emergency department for evaluation. Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6. She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness. PAST MEDICAL HISTORY: Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism. MEDICATIONS: Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone. SOCIAL HISTORY: The patient has been residing at South Valley Care Center. REVIEW OF SYSTEMS: The patient is unable answer review of systems. PHYSICAL EXAMINATION: GENERAL: This is a very elderly, cachectic woman lying in bed in no acute distress. HEENT: Examination is normocephalic and atraumatic. The pupils are equal, round and reactive to light and accommodation. The extraocular movements are full. NECK: Supple with full range of motion and no masses. LUNGS: There are decreased breath sounds at the bases bilaterally. CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2, and no S3 or S4. ABDOMEN: Soft and nontender with no hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: The patient moves all extremities but does not communicate. DIAGNOSTIC STUDIES: The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000. The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3. IMPRESSION/PLAN: 1. Elevated white count. This patient is admitted to the hospital for treatment of a febrile illness. There is concern that she has a progression of pneumonia. She may have aspirated. She has been treated with ceftriaxone and clindamycin. I will follow her oxygen saturation and chest x-ray closely. She is allergic to penicillin. Therefore, clindamycin is the appropriate antibiotic for possible aspiration. 2. Intractable diarrhea. The patient has been experiencing intractable diarrhea. I am concerned about Clostridium difficile infection with possible pseudomembranous colitis. I will send her stool for Clostridium difficile toxin assay. I will consider treating with metronidazole. 3. Hypokalemia. The patient's profound hypokalemia is likely secondary to her diarrhea. I will treat her with supplemental potassium. 4. DNR status: I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy. ,

Write a clinical note about a patient with the following chief complaint: Headache and pain in the neck and lower back.

CHIEF COMPLAINT: Headache and pain in the neck and lower back. HISTORY OF PRESENT ILLNESS: The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy. Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty. Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup. On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain. Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks. Past Medical History: HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance. PAST SURGICAL HISTORY: Excisional lymph node biopsy (9/03). FAMILY HISTORY: There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes. SOCIAL HISTORY: Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico . MEDICATION: Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid. ALLERGIES: , Sulfa (rash). REVIEW OF SYSTEMS: The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI. PHYSICAL EXAM: VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air. Ht: 5'9" Wt: 159 lbs. GEN: Well developed man in no apparent distress. Alert and Oriented X 3. HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions. NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally. CV: Regular rate and rhythm. No murmurs, gallops, rubs. ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly. EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits. LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES: C-spine/lumbosacral spine (11/30): Within normal limits. CXR (12/8): Normal heart size, no infiltrate. Hila and mediastinum are not enlarged. CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura. HOSPITAL COURSE: The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.

Write a clinical note about a patient with the following chief complaint: "I can’t walk as far as I used to.",

CHIEF COMPLAINT: "I can’t walk as far as I used to.",HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72. He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission. PAST MEDICAL HISTORY : Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear. PAST SURGICAL HISTORY : Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear. FAMILY HISTORY: The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her "heart stopped". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems. SOCIAL HISTORY: The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history. MEDICATIONS: 1. Spironolactone 25 mg po qd. 2. Digoxin 0.125 mg po qod. 3. Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday. 4. Metolazone 10 mg po qd. 5. Captopril 25 mg po tid. 6. Torsemide 40 mg po qam and 20 mg po qpm. 7. Carvedilol 3.125 mg po bid. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits. PHYSICAL EXAM: Temperature: 98.4 degrees Fahrenheit. Blood pressure: 134/84. Heart rate: 98 beats per minute. Respiratory rate: 18 breaths per minute. Pulse oximetry: 92% on 2L O 2 via nasal canula. GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate. HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink. NECK: The neck was supple with 15 cm of jugular venous distension. HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI. LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base. ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding. EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally. NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits. LYMPH: No cervical, axillary, or inguinal lymph nodes were present. SKIN: Warm, no rashes, no lesions; no tattoos. MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout. STUDIES: CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline. ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion. HOSPITAL COURSE: The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed.

Write a clinical note about a patient with the following chief complaint: Fever.

CHIEF COMPLAINT: Fever. HISTORY OF PRESENT ILLNESS: This is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. Mother states he just completed Amoxil several days ago for a sinus infection. Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum. Mother states that his temperature usually elevates at night. Two days his temperature was 102.6. Mother has not taken it since, and in fact she states today he seems much better. He is cutting an eye tooth that causes him to be drooling and sometimes fussy. He has had no vomiting or diarrhea. There has been no coughing. Nose secretions are usually discolored in the morning, but clear throughout the rest of the day. Appetite is fine. PHYSICAL EXAMINATION: General: He is alert in no distress. Vital Signs: Afebrile. HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares patent. Clear secretions present. Oropharynx is clear. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular, no murmur. Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly. Skin: Normal turgor. ASSESSMENT: 1. Allergic rhinitis. 2. Fever history. 3. Sinusitis resolved. 4. Teething. PLAN: Mother has been advised to continue Zyrtec as directed daily. Supportive care as needed. Reassurance given and he is to return to the office as scheduled.

Write a clinical note about a patient with the following history of present illness: Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services. She does have an MBA in business. Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well. She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc. She describes the job is very demanding and high stress. She denies any history of weakness, lethargy, or dizziness. No history of stroke.

CHIEF COMPLAINT: Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services. She does have an MBA in business. Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well. She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc. She describes the job is very demanding and high stress. She denies any history of weakness, lethargy, or dizziness. No history of stroke. CURRENT MEDICATIONS: Vioxx 25 mg daily, HCTZ 25 mg one-half tablet daily, Zoloft 100 mg daily, Zyrtec 10 mg daily. ALLERGIES TO MEDICATIONS: Naprosyn. SOCIAL HISTORY, FAMILY HISTORY, PAST MEDICAL HISTORY AND SURGICAL HISTORY: She has had hypertension very well controlled and history of elevated triglycerides. She has otherwise been generally healthy. Nonsmoker. Please see notes dated 06/28/2004. REVIEW OF SYSTEMS: Review of systems is otherwise negative. PHYSICAL EXAMINATION: Vital Signs: Age: 60. Weight: 192 pounds. Blood pressure: 134/80. Temperature: 97.8 degrees. General: A very pleasant 60-year-old white female in no acute distress. Alert, ambulatory and nonlethargic. HEENT: PERRLA. EOMs are intact. TMs are clear bilaterally. Throat is clear. Neck: Supple. No cervical adenopathy. Lungs: Clear without wheezes or rales. Heart: Regular rate and rhythm. Abdomen: Soft nontender to palpation. Extremities: Moving all extremities well. IMPRESSION: 1. Short-term memory loss, probable situational. 2. Anxiety stress issues. PLAN: Thirty-minute face-to-face appointment in counseling with the patient. At length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn. The current job she is at does sound extremely stressful and demanding. I think her stress reactions to these as far as feeling frustrated are within normal limits. We did complete a mini mental state exam including clock drawing, sentence writing, signature, etc. She does score a maximum score of 30/30 and all other tasks were completed without difficulty or any hesitation. I did spend quite a bit of time reassuring her as well. She is currently on Zoloft 100 mg which I think is an appropriate dose. We will have her continue on that. She did verbalize understanding and that she actually felt better after our discussion concerning these issues. At some point in time; however, I would possibly recommend job change if this one would persist as far as the stress levels. She is going to think about that.

Write a clinical note about a patient with the following chief complaint: Joints are hurting all over and checkup.

CHIEF COMPLAINT: Joints are hurting all over and checkup. HISTORY OF PRESENT ILLNESS: A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema. She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well. The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks. PAST MEDICAL HISTORY: Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization. PAST SURGICAL HISTORY: She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has osteoporosis. SOCIAL HISTORY: The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California. MEDICATIONS: Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d. lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d. Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d. also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin. ALLERGIES: She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins. FAMILY HISTORY: As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment. REVIEW OF SYSTEMS: General: No fever, chills, or night sweats. Weight stable. HEENT: No sudden blindness, diplopia, loss of vision, i.e. in one eye or other visual changes. No hearing changes or ear problems. No swallowing problems or mouth lesions. Endocrine: Hypothyroidism but no polyuria or polydipsia. She watches her blood sugars. They have been doing quite well. Respiratory: No shortness of breath, cough, sputum production, hemoptysis or breathing problems. Cardiovascular: No chest pain or chest discomfort. No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks. GI: As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better. She has had some irritable bowel syndrome and bowel abnormalities for years. GU: No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections. No vaginal bleeding or discharge. Musculoskeletal: As above. Hematological: She has had some anemia in the past. Neurological: No blackouts, convulsions, seizures, paralysis, strokes, or headaches. PHYSICAL EXAMINATION: Vital Signs: Weight is 164 pounds. Blood pressure: 140/64. Pulse: 72. Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table. General: A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly. HEENT: Skull is normocephalic. TMs intact and shiny with good auditory acuity to finger rub. Pupils equal, round, reactive to light and accommodation with extraocular movements intact. Fundi benign. Sclerae and conjunctivae were normal. Neck: No thyromegaly or cervical lymphadenopathy. Carotids are 2+ and equal bilaterally and no bruits present. Lungs: Clear to auscultation and percussion with good respiratory movement. No bronchial breath sounds, egophony, or rales are present. Heart: Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement. PMI normal position. All pulses are 2+ and equal bilaterally. Abdomen: Obese, soft with no hepatosplenomegaly or masses. Breasts: No predominant masses, discharge, or asymmetry. Pelvic Exam: Normal external genitalia, vagina and cervix. Pap smear done. Bimanual exam shows no uterine enlargement and is anteroflexed. No adnexal masses or tenderness. Rectal exam is normal with soft brown stool Hemoccult negative. Extremities: The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well. No real erythema. There is no real swelling of the knees. No new pedal edema. Lymph nodes: No cervical, axillary, or inguinal adenopathy. Neurological: Cranial nerves II-XII are grossly intact. Deep tendon reflexes are 2+ and equal bilaterally. Cerebellar and motor function intact in all extremities. Good vibratory and positional sense in all extremities and dermatomes. Plantar reflexes are downgoing bilaterally. LABORATORY: CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal. Urinalysis is within normal limits. Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3. ASSESSMENT: 1. Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome. I think we need to look at this more closely. 2. Diarrhea that seems to have resolved. Whether this is related to the above is unclear. 3. Diabetes mellitus type II, really fairly well controlled.