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Tiger Research 69

Write a clinical note about a patient with the following chief complaint: Weak and shaky.

CHIEF COMPLAINT: Weak and shaky. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky. When questioned further, she described shortness of breath primarily with ambulation. She denies chest pain. She denies cough, hemoptysis, dyspnea, and wheeze. She denies syncope, presyncope, or palpitations. Her symptoms are fairly longstanding but have been worsening as of late. PAST MEDICAL HISTORY: She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a history of hypertension and type II diabetes but is not currently taking any medication. She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair. CURRENT MEDICATIONS: She is on two different medications, neither of which she can remember the name and why she is taking it. ALLERGIES: She has no known medical allergies. FAMILY HISTORY: Remarkable for coronary artery disease, stroke, and congestive heart failure. SOCIAL HISTORY: She is a widow, lives alone. Denies any tobacco or alcohol use. REVIEW OF SYSTEMS: Dyspnea on exertion. No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling. PHYSICAL EXAMINATION: General: She is alert but seems somewhat confused and is not able to provide specific details about her past history. Vital Signs: Blood pressure: 146/80. Pulse: 68. Weight: 147 pounds. HEENT: Unremarkable. Neck: Supple without JVD, adenopathy, or bruit. Chest: Clear to auscultation. Cardiovascular: Regular rate and rhythm. Abdomen: Soft. Extremities: No edema. LABORATORY: O2 sat 100% at rest and with exertion. Electrocardiogram was normal sinus rhythm. Nonspecific S-T segment changes. Chest x-ray pending. ASSESSMENT/PLAN: 1. Dyspnea on exertion, uncertain etiology. Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors. We will have the patient sign a release of records so that we can review her previous history. Consider setting up for a stress test. 2. Hypertension, blood pressure is acceptable today. I am not certain as to what, if the patient’s is on any antihypertensive agents. We will need to have her call us what the names of her medications, so we can see exactly what she is taking. 3. History of diabetes. Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C. I have to obtain some further history and review records before proceeding with treatment recommendations.

Write a clinical note about a patient with the following chief complaint: Questionable foreign body, right nose. Belly and back pain. ,

CHIEF COMPLAINT: Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper. PAST MEDICAL HISTORY: Otherwise negative. ALLERGIES: No allergies. MEDICATIONS: No medications other than recent amoxicillin. SOCIAL HISTORY: Parents do smoke around the house. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. He is afebrile. GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance. HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative. NECK: Without lymphadenopathy. No other findings. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted. BACK: Without any findings. Diaper area normal. GU: No rash or infections. Skin is intact. ED COURSE: He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings. ASSESSMENT: 1. Infected foreign body, right naris. 2. Mild constipation. PLAN: As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode.

Write a clinical note about a patient with the following chief complaint: Left flank pain and unable to urinate.

CHIEF COMPLAINT: Left flank pain and unable to urinate. HISTORY: The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels much better today. I was consulted by Dr. X. MEDICATIONS: Ritalin 50 a day. ALLERGIES: To penicillin. PAST MEDICAL HISTORY: ADHD. SOCIAL HISTORY: No smoking, alcohol, or drug abuse. PHYSICAL EXAMINATION: She is awake, alert, and quite comfortable. Abdomen is benign. She points to her left flank, where she was feeling the pain. DIAGNOSTIC DATA: Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones. LABORATORY WORK: Showed white count 6200, hematocrit 44.7. Liver function tests and amylase were normal. Urinalysis 3+ bacteria. IMPRESSION: 1. Left flank pain, question etiology. 2. No evidence of surgical pathology. 3. Rule out urinary tract infection. PLAN: 1. No further intervention from my point of view. 2. Agree with discharge and followup as an outpatient. Further intervention will depend on how she does clinically. She fully understood and agreed.

Write a clinical note about a patient with the following chief complaint: 1. Infection. 2. Pelvic pain. 3. Mood swings. 4. Painful sex.

CHIEF COMPLAINT: 1. Infection. 2. Pelvic pain. 3. Mood swings. 4. Painful sex. HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old female who is here today with the above-noted complaints. She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past. She is requesting antibiotics. She has been squeezing them and some of them are very bruised and irritated. She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again. She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all. She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off. She states she does not wish to be on any medication at the current time. She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she "wants to.",PAST MEDICAL HISTORY: Significant for cleft palate. ALLERGIES: She is allergic to Lortab. CURRENT MEDICATIONS: None. REVIEW OF SYSTEMS: Please see history of present illness. Psychiatric: She has had some suicidal thoughts, but no plans. She denies being suicidal at the current time. Cardiopulmonary: She has not had any chest pain or shortness of breath. GI: Denies any nausea or vomiting. Neurological: No numbness, weakness or tingling. PHYSICAL EXAMINATION: General: The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress. Vital signs: Weight: 160 pounds. Blood pressure: 100/60. Pulse: 62. Psychiatric: I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that. Extremities: Her inner thighs are covered with multiple areas of folliculitis and mild abscesses. They are bruised from her squeezing them. We talked about that in detail. ASSESSMENT: 1. Folliculitis. 2. Pelvic pain. 3. Mood swings. 4. Dyspareunia. PLAN: 1. I would like her to go to the lab and get a CBC, chem-12, TSH and UA. 2. We will put her on cephalexin 500 mg three times a day. 3. We will send her back to see Dr. XYZ regarding the pelvic pain per her request. 4. We will get her an appointment with a psychiatrist for evaluation and treatment. 5. She is to call if she has any further problems or concerns. Otherwise I will see her back for her routine care or sooner if there are any further issues.

Write a clinical note about a patient with the following chief complaint: "I took Ecstasy.",

CHIEF COMPLAINT: "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets. The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis. Mother called the EMS service when the patient vomited. On arrival here, the patient states that she no longer has any nausea and that she feels just fine. The patient states she feels wired but has no other problems or complaints. The patient denies any pain. The patient does not have any auditory of visual hallucinations. The patient denies any depression or suicidal ideation. The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself. The patient denies any homicidal ideation. The patient denies any recent illness or recent injuries. The mother states that the daughter appears to be back to her usual self now. REVIEW OF SYSTEMS: CONSTITUTIONAL: No recent illness. No fever or chills. HEENT: No headache. No neck pain. No vision change or hearing change. No eye or ear pain. No rhinorrhea. No sore throat. CARDIOVASCULAR: No chest pain. No palpitations or racing heart. RESPIRATIONS: No shortness of breath. No cough. GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then. The patient denies any abdominal pain. No change in bowel movements. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No dizziness, syncope, or near syncope. PSYCHIATRIC: The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations. ENDOCRINE: No heat or cold intolerance. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Appendectomy when she was 9 years old. CURRENT MEDICATIONS: Birth control pills. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient denies smoking cigarettes. The patient does drink alcohol and also uses illicit drugs. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal. CONSTITUTIONAL: The patient is well nourished, and well developed, appears to be healthy. The patient is calm and 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 cornea and conjunctiva bilaterally. The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally. No evidence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Nose is normal without rhinorrhea or audible congestion. Ears are normal without any sign of infection. Mouth and oropharynx are normal without any signs of infection. Mucous membranes are moist. NECK: Supple and nontender. Full range of motion. There is no JVD. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +3 and bounding. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, normal and benign. MUSCULOSKELETAL: No abnormalities noted in back, arms, or legs. The patient is normal use of her extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact in all extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. The patient does not have any smell of alcohol and does not exhibit any clinical intoxication. The patient is quite pleasant, fully cooperative. HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted. No bruising is noted. DIAGNOSES: 1. ECSTASY INGESTION. 2. ALCOHOL INGESTION. 3. VOMITING SECONDARY TO STIMULANT ABUSE. CONDITION UPON DISPOSITION: Stable disposition to home with her mother. PLAN: I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation. The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal. The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.

Write a clinical note about a patient with the following chief complaint: Dog bite to his right lower leg.

CHIEF COMPLAINT: Dog bite to his right lower leg. HISTORY OF PRESENT ILLNESS: This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment. PAST MEDICAL HISTORY: Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis. ALLERGIES: There are no known allergies. MEDICATIONS: Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin. FAMILY HISTORY: Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has diabetes. SOCIAL HISTORY: He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD. REVIEW OF SYSTEMS: He denies any chest pain. He does admit to exertional shortness of breath. He denies any GI or GU problems. He denies any bleeding disorders. PHYSICAL EXAMINATION,GENERAL: Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild 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. ABDOMEN: Soft. It is nontender. Bowel sounds are present. There is no tenderness. SKIN: He does have like a Chevron incisional scar across his lower chest and upper abdomen. It appears to be well healed and unremarkable. GENITALIA: Deferred. RECTAL: Deferred. EXTREMITIES: He has about 1+ pitting edema to both legs and they have been present since the surgery. In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap. The wound is spread apart about may be a centimeter all along that area and it is relatively clean. There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate. There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc. The flap appeared to be viable. NEUROLOGIC: Without focal deficits. The patient is alert and oriented. IMPRESSION: A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago. He is on multiple medications and he is on chronic Bactrim. We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult. We will see him back in the office early next week to reassess his wound. He is to keep the wound clean with the moist dressing right now. He may shower several times a day.

Write a clinical note about a patient with the following chief complaint: Chest pain and fever.

CHIEF COMPLAINT: Chest pain and fever. HISTORY OF PRESENT ILLNESS: This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating. The patient does have a past medical history of diabetes and hypertension. In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well. The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits. She has not had any musculoskeletal or neurological deficits. She denies any rashes or skin lesions. PAST MEDICAL HISTORY: Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes. PAST SURGICAL HISTORY: Cholecystectomy, appendectomy, oophorectomy. FAMILY HISTORY: Positive for coronary artery disease in her father and brother in their 40s. SOCIAL HISTORY: She is married and does not smoke or drink nor did she ever. PHYSICAL EXAMINATION: On admission, temperature 99.4 degrees F. blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort. In general, she is well developed, well nourished, oriented, and alert and in no apparent distress. Head, ears, eyes, nose, and throat are unremarkable. Neck is supple. No neck vein distention is noted. No bruits are heard. Chest is clear to percussion and auscultation. Heart has a regular rhythm and rate without murmurs or rubs or gallops. Abdomen is soft, obese, and nontender. Musculoskeletal is intact without deformity. However, the patient did develop severe cramp behind her left knee during her treadmill testing. Neurologic: Cranial nerves are intact and she is nonfocal. Skin is warm and dry without rash or lesions noted. LABORATORY FINDINGS: Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2. Liver function panel is normal. CK was 82. MB fraction was 1.0. Troponin was less than 0.1 on three occasions. White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000. Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods. Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0. EKG was normal. DIAGNOSES ON ADMISSION: 1. Urinary tract infection. 2. Chest pain of unclear etiology, rule out myocardial infarction. 3. Neck and back pain of unclear etiology with a negative spinal tap. 4. Hypertension. 5. Diabetes type II, not treated with insulin. 6. Hyperlipidemia treated with TriCor but not statins. 7. Arthritis. ADDITIONAL LABORATORY STUDIES: B-natriuretic peptide was 26. Urine smear and culture negative on 24 and 48 hours. Chest x-ray was negative. Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81. COURSE IN THE HOSPITAL: The patient was placed on home medications. This will be listed at the end of the discharge summary. She was put on rule out acute myocardial infarction routine, and she did in fact rule out. She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70. She has a strong family history of early myocardial disease in the men in their 40s. DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 81 mg one daily. This is new, as the patient was not taking aspirin at home. 2. TriCor 48 mg one daily. 3. Zantac 40 mg one daily. 4. Lisinopril 20 mg one daily. 5. Mobic 75 mg one daily for arthritis. 6. Metformin 500 mg one daily. 7. Macrodantin one two times a day for several more days. 8. Zocor 20 mg one daily, which is a new addition. 9. Effexor XR 37.5 mg one daily. DIET: ADA 1800-calorie diet. ACTIVITY: As tolerated. Continue water exercise five days a week. DISPOSITION: Recheck at Hospital with a regular physician there in 1 week. Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.

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

CHIEF COMPLAINT: Left elbow pain. HISTORY OF PRESENT ILLNESS: This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any passing out, any neck pain at this time even though he did get hit in the head. He has no chest or abdominal pain. Apparently, no knives or guns were involved. PAST MEDICAL HISTORY: He has had toe problems and left knee pain in the past. REVIEW OF SYSTEMS: No coughing, sputum production, dyspnea or chest pain. No vomiting or abdominal pain. No visual changes. No neurologic deficits other than some numbness in his left hand. SOCIAL HISTORY: He is in Juvenile Hall for about 25 more days. He is a nonsmoker. ALLERGIES: MORPHINE. CURRENT MEDICATIONS: Abilify. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. HEENT: PERRLA. EOMI. Conjunctivae anicteric. Skull is normocephalic. He is not complaining of bruising. HEENT: TMs and canals are normal. There is no Battle sign. NECK: Supple. He has good range of motion. Spinal processes are normal to palpation. LUNGS: Clear. CARDIAC: Regular rate. No murmurs or rubs. EXTREMITIES: Left elbow is tender. He does not wish to move it at all. Shoulder and clavicle are within normal limits. Wrist is normal to inspection. He does have some pain to palpation. Hand has good capillary refill. He seems to have decreased sensation in all three dermatomes. He has moderately good abduction of all fingers. He has moderate opponens strength with his thumb. He has very good extension of all of his fingers with good strength. We did an x-ray of his elbow. He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length. The proximal part looks like it is in good position. The distal part has about 6 mm of displacement. There is no significant angulation. The joint itself appears to be intact. The fracture line ends where it appears above the joint. I do not see any extra blood in the joint. I do not see any anterior or posterior Siegert sign. I spoke with Dr. X. He suggests we go ahead and splint him up and he will follow the patient up. At this point, it does not seem like there needs to be any surgical revision. The chance of a compartment syndrome seems very low at this time. Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow. He had much better comfort once this was applied. There was good color to his fingers and again, much better comfort. Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass. We then gave him a sling. We gave him #2 Vicodin p.o. and #4 to go. Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime. I gave him the name and telephone number of Dr. X whom they can follow up with. They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems. DIAGNOSES: 1. Fracture of the humerus, spiral. 2. Possible nerve injuries to the radial and median nerve, possibly neurapraxia. 3. Psychiatric disorder, unspecified. DISPOSITION: The patient will follow up as mentioned above. They can return here anytime as needed.

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: Cough and abdominal pain for two days.

CHIEF COMPLAINT: Cough and abdominal pain for two days. HISTORY OF PRESENT ILLNESS: This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated that the abdominal pain was only associated with coughing. The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home. PAST MEDICAL HISTORY: Significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis. PAST SURGICAL HISTORY: The patient had bilateral cataract extractions in 2007, appendectomy as a child, and three D&Cs in the past secondary to miscarriages. MEDICATIONS: On presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily. The patient also takes multivitamin and Lutein over-the-counter for macular degeneration. ALLERGIES: THE PATIENT HAS NO KNOWN DRUG ALLERGIES. FAMILY HISTORY: Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old. SOCIAL HISTORY: The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years. Denies any alcohol use. Denies any IV drug use. PHYSICAL EXAMINATION: GENERAL: This is a 76-year-old female, well nourished. VITAL SIGNS: On presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20. HEENT: Anicteric sclerae. Conjunctivae pink. Throat was clear. Mucosal membranes were dry. CHEST: Coarse breath sounds bilaterally at the bases. CARDIAC: S1 and S2. No murmurs, rubs or gallops. No evidence of carotid bruits. ABDOMEN: Positive bowel sounds, presence of soreness on examination in the abdomen on palpation. There is no rebound or guarding. EXTREMITIES: No clubbing, cyanosis or edema. HOSPITAL COURSE: The patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes. There is no evidence of effusion or consolidation. Degenerative changes were seen in the shoulder. The patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern. Urinalysis showed no evidence of infection as well as her influenza A&B were negative. Preliminary blood cultures have been with no growth to date status post 48 hours. The patient was started on cefepime 1 g IV q.12h. and given IV hydration. She has also been on Xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol. In terms of prophylactic measures, she received Lovenox subcutaneously for DVT prophylaxis. Currently today, she feels much improved with still only a mild cough. The patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18. Her white count on presentation was 13.6 and yesterday's white count was 10.3. FINAL DIAGNOSIS: Bronchitis. DISPOSITION: The patient will be going home. MEDICATIONS: Hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily. Also, Avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily. DIET: To follow a low-salt diet. ACTIVITY: As tolerated. FOLLOWUP: To follow up with Dr. ABC in two weeks.

Write a clinical note about a patient with the following chief complaint: Detox from heroin.

CHIEF COMPLAINT: Detox from heroin. HISTORY OF PRESENT ILLNESS: This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse. PAST MEDICAL HISTORY: Remarkable for chronic pain. He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain. He has previously been followed by ABC but has not seen him for several years. REVIEW OF SYSTEMS: The patient states that he did use heroin as well as cocaine earlier today and feels under the influence. Denies any headache or visual complaints. No hallucinations. No chest pain, shortness of breath, abdominal pain or back pain. Denies any abscesses. SOCIAL HISTORY: The patient is a smoker. Admits to heroin use, alcohol abuse as well. Also admits today using cocaine. FAMILY HISTORY: Noncontributory. MEDICATIONS: He has previously been on analgesics and pain medications chronically. Apparently, he just recently got out of prison. He has previously also been on Klonopin and lithium. He was previously on codeine for this pain. ALLERGIES: NONE. PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile. He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard. His respiratory rate is normal at 18. GENERAL: The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation. HEENT: Unremarkable. Pupils are actually moderately dilated about 4 to 5 mm, but reactive. Extraoculars are intact. His oropharynx is clear. NECK: Supple. His trachea is midline. LUNGS: Clear. He has good breath sounds and no wheezing. No rales or rhonchi. Good air movement and no cough. CARDIAC: Without murmur. ABDOMEN: Soft and nontender. He has multiple track marks, multiple tattoos, but no abscesses. NEUROLOGIC: Nonfocal. IMPRESSION: MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN. ASSESSMENT AND PLAN: At this time, I think the patient can be followed up at XYZ. I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy. I do not think he needs any further workup at this time. He is discharged otherwise in stable condition.

Write a clinical note about a patient with the following chief complaint: Cut on foot.

CHIEF COMPLAINT: Cut on foot. HISTORY OF PRESENT ILLNESS: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints. PAST MEDICAL HISTORY: Asthma. CURRENT MEDICATION: Albuterol. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient is a smoker. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16. 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 and 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 conjunctiva and cornea bilaterally. NECK: Supple with full range of motion. CARDIOVASCULAR: Peripheral pulse is +2 to the right foot. Capillary refills less than two seconds to all the digits of the right foot. RESPIRATIONS: No shortness of breath. MUSCULOSKELETAL: The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot. There is no palpable foreign body, no foreign body is visualized. There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels. It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home. The patient does not have any tenderness to the foot. The patient has full range of motion to all the joints, all the toes, as well as the ankles. The patient ambulates well without any difficulty or discomfort. There are no other injuries noted to the rest of the body. SKIN: The 4-mm partial thickness laceration to the right foot as previously described. No other injuries are noted. NEUROLOGIC: Motor is 5/5 to all the muscle groups of the right lower extremity. Sensory is intact to light touch to all the dermatomes of the right foot. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No active bleeding is occurring at this time. No evidence of bruising is noted to the body. EMERGENCY DEPARTMENT COURSE: The patient had antibiotic ointment and a bandage applied to his foot. DIAGNOSES: 1. A 4-MM LACERATION TO THE RIGHT FOOT. 2. ACUTE RIGHT FOOT PAIN, NOW RESOLVED. CONDITION UPON DISPOSITION: Stable. DISPOSITION: To home. The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection. The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.

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: Followup diabetes mellitus, type 1. ,

CHIEF COMPLAINT: Followup diabetes mellitus, type 1. ,SUBJECTIVE: Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago. Reports that his blood sugar dropped too low which caused the accident. Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer. ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time. Reports that he had some indications of kidney damage when first diagnosed. His urine microalbumin today is 100. His last hemoglobin A1C drawn at the end of December is 11.9. Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7. His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker. Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today. Patient also has a history of gastroparesis and impotence. Patient requests Nexium and Viagra, neither of which are covered under the Health Plan. , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head. Was not wearing a helmet. Reports that he did not go to the emergency room and had a headache for several days after this incident. Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room. Patient did not comply. Reports that the headache has resolved. Denies any dizziness, nausea, vomiting, or other neurological abnormalities. ,PHYSICAL EXAMINATION: WD, WN. Slender, 34-year-old white male. VITAL SIGNS: Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16. Microalbumin 100. SKIN: There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long. No signs of infection. Wound is closed with new granulation tissue. Appears to be healing well. HEENT: Normocephalic. PERRLA. EOMI. TMs pearly gray with landmarks present. Nares patent. Throat with no redness or swelling. Nontender sinuses. NECK: Supple. Full ROM. No LAD. CARDIAC:

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

CHIEF COMPLAINT: Vomiting and nausea. HPI: The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe. She states she has it at least once a day. It can be any time, but can also be postprandial. She states she will vomit up some dark brown-to-green fluid. There has been no hematemesis. She states because of the nausea and vomiting, she has not been able to take much in the way of PO intake over the past week. She states her appetite is poor. The patient has lost 40 pounds of weight over the past 16 months. She states for the past few days, she has been getting severe heartburn. She used Tums over-the-counter and that did not help. She denies having any dysphagia or odynophagia. She is not having any abdominal pain. She has no diarrhea, rectal bleeding, or melena. She has had in the past, which was remote. She did have some small amounts of rectal bleeding on the toilet tissue only if she passed a harder stool. She has a history of chronic constipation for most of her life but she definitely has a bowel movement every 3 to 4 days and this is unchanged. The patient states she has never had any endoscopy or barium studies of the GI tract. The patient is anemic and her hemoglobin is 5.7 and she is thrombocytopenic with the platelet count of 34. She states she has had these abnormalities since she has been diagnosed with breast cancer. She states that she has metastatic breast cancer and that is in her rib cage and spine and she is getting hormonal chemotherapy for this and she is currently under the care of an oncologist. The patient also has acute renal failure at this point. The patient said she had a PET scan done about a week ago. PAST MEDICAL HISTORY: Metastatic breast cancer to her rib cage and spine, hypothyroidism, anemia, thrombocytopenia, hypertension, Bells palsy, depression, uterine fibroids, hysterectomy, cholecystectomy, breast lumpectomy, and thyroidectomy. ALLERGIES: No known drug allergies. MEDICINES: She is on Zofran, Protonix, fentanyl patch, Synthroid, Ativan, and Ambien. SOCIAL HISTORY: The patient is divorced and is a homemaker. No smoking or alcohol. FAMILY HISTORY: Negative for any colon cancer or polyps. Her father died of mesothelioma, mother died of Hodgkin lymphoma. SYSTEMS REVIEW: No fevers, chills or sweats. She has no chest pain, palpitations, coughing or wheezing. She does get shortness of breath, no hematuria, dysuria, arthralgias, myalgias, rashes, jaundice, bleeding or clotting disorders. The rest of the system review is negative as per the HPI. PHYSICAL EXAM: Temperature 98.4, blood pressure 95/63, heart rate 84, respiratory rate of 18, and weight is 108 kg. GENERAL APPEARANCE: The patient was comfortable in bed. Skin exam is negative for any rashes or jaundice. LYMPHATICS: There is no palpable lymphadenopathy of the cervical or the supraclavicular area. HEENT: She has some mild ptosis of the right eye. There is no icterus. The patient's conjunctivae and sclerae are normal. Pupils are equal, round, and reactive to light and accommodation. No lesions of the oral mucosa or mucosa of the pharynx. NECK: Supple. Carotids are 2+. No thyromegaly, masses or adenopathy. HEART: Has regular rhythm. Normal S1 and S2. She has a 2/6 systolic ejection murmur. No rubs or gallops. Lungs are clear to percussion and auscultation. Abdomen is obese, it may be mildly distended. There is no increased tympany. The patient does have hepatosplenomegaly. There is no obvious evidence of ascites. The abdomen is nontender, bowel sounds are present. The extremities show some swelling and edema of the ankle regions bilaterally. Legs are in SCDs. No cyanosis or clubbing. For the rectal exam, it shows brown stool that is very trace heme positive at most. For the neuro exam, she is awake, alert, and oriented x3. Memory intact. No focal deficits. Insight and judgment are intact. X-RAY AND LABORATORY DATA: She came in, white count 9.2, hemoglobin 7.2, hematocrit 22.2, MCV of 87, platelet count is 47,000. Calcium is 8.1, sodium 134, potassium 5.3, chloride 102, bicarbonate 17, BUN of 69, creatinine of 5.2, albumin 2.2, ALT 28, bilirubin is 2.2, alkaline phosphatase is 359, AST is 96, and lipase is 30. Today, her hemoglobin is 5.7, TSH is 1.1, platelet count is 34,000, alkaline phosphatase is 303, and bilirubin of 1.7. IMPRESSION,1. The patient has one week of nausea and vomiting with decreased p.o. intake as well as dehydration. This could be on the basis of her renal failure. She may have a viral gastritis. The patient does have a lot of gastroesophageal reflux disease symptoms recently. She could have peptic mucosal inflammation or peptic ulcer disease. 2. The patient does have hepatosplenomegaly. There is a possibility she could have liver metastasis from the breast cancer. 3. She has anemia as well as thrombocytopenia. The patient states this is chronic. 4. A 40-pound weight loss. 5. Metastatic breast cancer. 6. Increased liver function tests. Given her bone metastasis, the elevated alkaline phosphatase may be from this as opposed to underlying liver disease. 7. Chronic constipation. 8. Acute renal failure. PLAN: The patient will be on a clear liquid diet. She will continue on the Zofran. She will be on IV Protonix. The patient is going to be transfused packed red blood cells and her hemoglobin and hematocrit will be monitored. I obtained the result of the abdominal x-rays she had done through the ER. The patient has a consult pending with the oncologist to see what her PET scan show. There is a renal consult pending. I am going to have her get a total abdominal ultrasound to see if there is any evidence of liver metastasis and also to assess her kidneys. Her laboratory studies will be followed. Based upon the patient's medical condition and including her laboratory studies including a platelet count, we talked about EGD versus upper GI workup per upper GI symptoms. I discussed informed consent for EGD. I discussed the indications, risks, benefits, and alternatives. The risks reviewed included, but were not limited to an allergic reaction or side effect to medicines, cardiopulmonary complications, bleeding, infection, perforation, and needing to get admitted for antibiotics or blood transfusion or surgery. The patient voices her understanding of the above. She wants to think about what she wants to do. Overall, this is a very ill patient with multiorgan involvement.

Write a clinical note about a patient with the following chief complaint: A 2-month-old female with 1-week history of congestion and fever x2 days.

CHIEF COMPLAINT: A 2-month-old female with 1-week history of congestion and fever x2 days. HISTORY OF PRESENT ILLNESS: The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions. The mother states that the cough is at times paroxysmal and associated with posttussive emesis. The patient has had short respiratory pauses following the coughing events. The patient's temperature has ranged between 102 and 104. She has had a decreased oral intake and decreased wet diapers. The brother is also sick with URI symptoms, and the patient has had no diarrhea. The mother reports that she has begun to regurgitate after her feedings. She did not do this previously. MEDICATIONS: None. SMOKING EXPOSURE: None. IMMUNIZATIONS: None. DIET: Similac 4 ounces every 2 to 3 hours. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: The patient delivered at term. Birth weight was 6 pounds 1 ounce. Postnatal complications: Neonatal Jaundice. The patient remained in the hospital for 3 days. The in utero ultrasounds were reported to be normal. PRIOR HOSPITALIZATIONS: None. FAMILY/SOCIAL HISTORY: Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family. DEVELOPMENT: Normal. The patient tests normal on the newborn hearing screen. REVIEW OF SYSTEMS: GENERAL: The patient has had fever, there have been no chills. SKIN: No rashes. HEENT: Mild congestion x1 week. Cough, at times paroxysmal, no cyanosis. The patient turns red in the face during coughing episodes, posttussive emesis. CARDIOVASCULAR: No cyanosis. GI: Posttussive emesis, decreased oral intake. GU: Decreased urinary output. ORTHO: No current issues. NEUROLOGIC: No change in mental status. ENDOCRINE: There is no history of weight loss. DEVELOPMENT: No loss of developmental milestones. PHYSICAL EXAMINATION: VITAL SIGNS: Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%. GENERAL: This is a well-appearing infant in no acute distress. HEENT: Shows anterior fontanelle to be open and flat. Pupils are equal and reactive to light with red reflex. Nares are patent. Oral mucosa is moist. Posterior pharynx is clear. Hard palate is intact. Normal gingiva. HEART: Regular rate and rhythm without murmur. LUNGS: A few faint rales. No retractions. No stridor. No wheezing on examination. Mild tachypnea. EXTREMITIES: Warm, good perfusion. No hip clicks. NEUROLOGIC: The patient is alert. Normal tone throughout. Deep tendon reflexes are 2+/4. No clonus. SKIN: Normal. LABORATORY DATA: CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. Electrolytes were within normal limits. C-reactive protein 0.3. Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. UA shows 10 to 25 bacteria. ASSESSMENT/PLAN: This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. The patient is currently stable in the emergency room. We will admit the patient to the pediatric floor. We will send out pertussis PCR. We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.

Write a clinical note about a patient with the following chief complaint: Multiple problems, main one is chest pain at night.

CHIEF COMPLAINT: Multiple problems, main one is chest pain at night. HISTORY OF PRESENT ILLNESS: This is a 60-year-old female with multiple problems as numbered below: 1. She reports that she has chest pain at night. This happened last year exactly the same. She went to see Dr. Murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month. She wakes in the middle of the night and reports that she has a pressure. It is mild-to-moderate in the middle of her chest and will stay there as long she lies down. If she gets up, it goes away within 15 minutes. It is currently been gone on for the last week. She denies any fast heartbeats or irregular heartbeats at this time. 2. She has been having stomach pains that started about a month ago. This occurs during the daytime. It has no relationship to foods. It is mild in nature, located in the mid epigastric area. It has been better for one week as well. 3. She continues to have reflux, has noticed that if she stops taking Aciphex, then she has symptoms. If she takes her Aciphex, she seems that she has the reflux belching, burping, and heartburn under control. 4. She has right flank pain when she lies down. She has had this off and on for four months. It is a dull achy pain. It is mild in nature. 5. She has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past. It is not painful. 6. She has had spots in her armpits initially on the right side and then going to the left side. They are not itchy. 7. She is having problems with urgency of urine. When she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking. She is wearing a pad now. 8. She is requesting a colonoscopy for screening as well. She is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer. 9. She has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months. There has been no swelling or redness or trauma to these areas. REVIEW OF SYSTEMS: She has recently been to the eye doctor. She has noticed some hearing loss gradually. She denies any problems with swallowing. She denies episodes of shortness of breath, although she has had a little bit of chronic cough. She has had normal bowel movements. Denies any black or bloody stools, diarrhea, or constipation. Denies seeing blood in her urine and has had no urinary problems other than what is stated above. She has had no problems with edema or lower extremity numbness or tingling. SOCIAL HISTORY: She works at nursing home. She is a nonsmoker. She is currently trying to lose weight. She is on the diet and has lost several pounds in the last several months. She quit smoking in 1972. FAMILY HISTORY: Her father has type I diabetes and heart disease. She has a brother who had heart attack at the age of 52. He is a smoker. PAST MEDICAL HISTORY: Episodic leukopenia and mild irritable bowel syndrome. CURRENT MEDICATIONS: Aciphex 20 mg q.d. and aspirin 81 mg q.d. ALLERGIES: No known medical allergies. OBJECTIVE: Vital Signs: Weight: 142 pounds. Blood pressure: 132/78. Pulse: 72. General: This is a well-developed adult female who is awake, alert, and in no acute distress. HEENT: Her pupils are equally round and reactive to light. Conjunctivae are white. TMs look normal bilaterally. Oropharynx appears to be normal. Dentition is excellent. Neck: Supple without lymphadenopathy or thyromegaly. Lungs: Clear with normal respiratory effort. Heart: Regular rhythm and rate without murmur. Radial pulses are normal bilaterally. Abdomen: Soft, nontender, and nondistended without organomegaly. Extremities: Examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the PIP joint and DIP joint. Her armpits are examined. She has what appears to be a tinea versicolor rash present in the armpits bilaterally. She has a lesion on her left shoulder, which is 6 mm in diameter. It has diffuse borders and is slightly red. It has two brown spots in it. In her lower extremities, there is no cyanosis or edema. Pulses at the radial and posterior tibial pulses are normal bilaterally. Her gait is normal. Psychiatric: Her affect is pleasant and positive. Neurological: She is grossly intact. Her speech seems to be clear. Her coordination of upper and lower extremities is normal. ASSESSMENT/PLAN: 1. Chest pain. At this point, because of Dr. Murphy’s evaluation last year and the symptoms exactly the same, I think this is noncardiac. My intonation is that this is reflux. I am going have her double her Aciphex or increase it to b.i.d. and I am going to have her see Dr. XYZ for possible EGD if he thinks that would be appropriate. She is to let me know if her symptoms are getting worse or if she is having any severe episodes. 2. Stomach pain, uncertain at this point, but I feel like this is probably related as well to chest pain. 3. Suspicious lesions on the left shoulder. We will do a punch biopsy and set her up for an appointment for that. 4. Tinea versicolor in the axillary area. I have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days. 5. Cystocele. We will have her see Dr. XYZ for further discussion of repair due to her urinary incontinence. 6. History of leukopenia. We will check a CBC. 7. Pain in the thumbs, probably arthritic in nature, observe for now. 8. Screening. We will have her see Dr. XYZ for discussion of colon cancer screening. 9. Gastroesophageal reflux disease. I have increased Aciphex to b.i.d. for now.

Write a clinical note about a patient with the following chief complaint: Congestion and cough.

CHIEF COMPLAINT: Congestion and cough. HISTORY OF PRESENT ILLNESS: The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion. ALLERGIES: She has no known drug allergies. MEDICATIONS: None except the Amoxil and Aldex started on Monday. PAST MEDICAL HISTORY: Negative. SOCIAL HISTORY: She lives with mom, sister, and her grandparent. BIRTH HISTORY: She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth. IMMUNIZATIONS: Also up-to-date. PAST SURGICAL HISTORY: Negative. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Her respiratory rate was approximately 60 to 65. GENERAL: She was very congested and she looked miserable. She had no retractions at this time. HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact. NECK: Supple. Full range of motion. CARDIOVASCULAR EXAM: She was tachycardic without murmur. LUNGS: Revealed diffuse expiratory wheezing. ABDOMEN: Soft, nontender, and nondistended. EXTREMITIES: Showed no clubbing, cyanosis or edema. LABORATORY DATA: Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending. IMPRESSION AND PLAN: RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.

Write a clinical note about a patient with the following chief complaint: Congestion, tactile temperature.

CHIEF COMPLAINT: Congestion, tactile temperature. HISTORY OF PRESENT ILLNESS: The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol. Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature. The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea. EMERGENCY ROOM COURSE: In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each. REVIEW OF SYSTEMS: See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative. BIRTH/PAST MEDICAL HISTORY: The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far. PAST SURGICAL HISTORY: Circumcision. ALLERGIES: No known drug allergies. MEDICATIONS: Tylenol. IMMUNIZATIONS: None of the family members this year have received a flu vaccine. SOCIAL HISTORY: At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom. FAMILY HISTORY: Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age. PHYSICAL EXAMINATION: VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg. GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken. HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea. CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds. LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes. ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge. GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge. HIPS: Negative Barlow or Ortolani maneuvers. SKIN: Positive facial erythema toxicum. LABORATORY DATA: CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3. A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66. A cath urinalysis was negative. A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms. ASSESSMENT: A 21-day-old with: 1. Rule out sepsis. 2. Possible upper respiratory infection. Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count). Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient. PLAN: 1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours. 2. We will follow up with his blood, urine, and CSF cultures.

Write a clinical note about a patient with the following chief complaint: Lump in the chest wall.

CHIEF COMPLAINT: Lump in the chest wall. HISTORY OF PRESENT ILLNESS: This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. It is tender on palpation and also he feels like, when he takes a deep breath also, it hurts. CHRONIC/INACTIVE CONDITIONS,1. Hypertension. 2. Hyperlipidemia. 3. Glucose intolerance. 4. Chronic obstructive pulmonary disease?,5. Tobacco abuse. 6. History of anal fistula. ILLNESSES: See above. PREVIOUS OPERATIONS: Anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery. PREVIOUS INJURIES: He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. He told me that he hit a moose once, but he does not remember hitting his chest. ALLERGIES: TO BACTRIM, SIMVASTATIN, AND CIPRO. CURRENT MEDICATIONS,1. Lisinopril. 2. Metoprolol. 3. Vitamin B12. 4. Baby aspirin. 5. Gemfibrozil. 6. Felodipine. 7. Levitra. 8. Pravastatin. FAMILY HISTORY: Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke. SOCIAL HISTORY: The patient is married. He works as a truck driver and he drives in town. He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs. REVIEW OF SYSTEMS,CONSTITUTIONAL: Denies weight loss/gain, fever or chills. ENMT: Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision. CV: See history of present illness. Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains. RESPIRATORY: He has a chronic cough. Denies shortness of breath, wheezing, sputum production or bloody sputum. GI: Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation. GU: Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain. MS: Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness. NEURO: Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis. PSYCH: Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts. INTEGUMENTARY: Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration. PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds. The patient is well developed, well nourished, and with fair attention to grooming. The patient is moderately overweight. NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses. RESPIRATION: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs. There is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum. CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click, or rub. Carotid pulses 2+ without bruits. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 2+ bilaterally, without audible bruits. Extremities show no edema or varicosities.

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: Buttock abscess.

CHIEF COMPLAINT: Buttock abscess. HISTORY OF PRESENT ILLNESS: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation. PAST MEDICAL HISTORY: Diabetes type II, poorly controlled, high cholesterol. PAST SURGICAL HISTORY: C-section and D&C. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Insulin, metformin, Glucotrol, and Lipitor. FAMILY HISTORY: Diabetes, hypertension, stroke, Parkinson disease, and heart disease. REVIEW OF SYSTEMS: Significant for pain in the buttock. Otherwise negative. PHYSICAL EXAMINATION: GENERAL: This is an overweight African-American female not in any distress. VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range. HEENT: Normal to inspection. NECK: No bruits or adenopathy. LUNGS: Clear to auscultation. CV: Regular rate and rhythm. ABDOMEN: Protuberant, soft, and nontender. EXTREMITIES: No clubbing, cyanosis or edema. RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema. ASSESSMENT AND PLAN: Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details.

Write a clinical note about a patient with the following chief complaint: Blood in urine.

CHIEF COMPLAINT: Blood in urine. HISTORY OF PRESENT ILLNESS: This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine. The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool. The patient has not had any fever. There is no abdominal pain and the patient is still able to pass urine. The patient has not had any melena or hematochezia. There is no nausea or vomiting. The patient has already completed chemotherapy and is beyond treatment for his cancer at this time. The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer. The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever or chills. The patient does report generalized fatigue and weakness over the past several days. HEENT: No headache, no neck pain, no rhinorrhea, no sore throat. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days. GASTROINTESTINAL: The patient denies any abdominal pain. No nausea or vomiting. No changes in the bowel movement. No melena or hematochezia. GENITOURINARY: A gross hematuria since yesterday as previously described. The patient is still able to pass urine without difficulty. The patient denies any groin pain. The patient denies any other changes to the genital region. MUSCULOSKELETAL: The chronic lower back pain which has not changed over these past few days. The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either. SKIN: No rashes or lesions. No easy bruising. NEUROLOGIC: No focal weakness or numbness. No incontinence of urine or stool. No saddle paresthesia. No dizziness, syncope or near-syncope. ENDOCRINE: No polyuria or polydipsia. No heat or cold intolerance. HEMATOLOGIC/LYMPHATIC: The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria. PAST MEDICAL HISTORY: Prostate cancer with metastatic disease as previously described. PAST SURGICAL HISTORY: TURP. CURRENT MEDICATIONS: Morphine, Darvocet, Flomax, Avodart and ibuprofen. ALLERGIES: VICODIN. SOCIAL HISTORY: The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be pale, but otherwise looks well. The patient is calm, comfortable. The patient is pleasant and cooperative. HEENT: Eyes normal with clear conjunctivae and corneas. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx normal without any sign of infection. Mucous membranes are moist. NECK: Supple. Full range of motion. No JVD. CARDIOVASCULAR: Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop. Peripheral pulses are +2. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruit. No masses or pulsatile masses. GENITOURINARY: The patient has normal male genitalia, uncircumcised. There is no active bleeding from the penis at this time. There is no swelling of the testicles. There are no masses palpated to the testicles, scrotum or the penis. There are no lesions or rashes noted. There is no inguinal lymphadenopathy. Normal male exam. MUSCULOSKELETAL: Back is normal and nontender. There are no abnormalities noted to the arms or legs. The patient has normal use of the extremities. SKIN: The patient appears to be pale, but otherwise the skin is normal. There are no rashes or lesions. NEUROLOGIC: Motor and sensory are intact to the extremities. The patient has normal speech. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: There is no evidence of bruising noted to the body. No lymphadenitis is palpated. EMERGENCY DEPARTMENT TESTING: CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6. Neutrophils were 81%. The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable. Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable. Alkaline phosphatase was 770 and albumin was 2.4. Rest of the values all are within normal limits of the LFTs. Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's. The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen. Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3. EMERGENCY DEPARTMENT COURSE: The patient was given normal saline 2 liters over 1 hour without any adverse effect. The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect. The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department. The patient did not have an adverse reaction to these medicines either. Phenergan resolved his nausea and morphine did relieve his pain and make him pain free. I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion. It was all a matter of what the patient wished to do given the advanced stage of his cancer. Dr. X was willing to assist in any way the patient wished him to. I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion. The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight. The patient's son felt comfortable with his father's choice. This was done. The patient was transfused 2 units of packed red blood cells after appropriately typed and match. The patient did not have any adverse reaction at any point with his transfusion. There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength. Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction. Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder. The patient was given a leg bag and the Foley catheter was left in place. DIAGNOSES,1. HEMATURIA. 2. PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE. 3. SIGNIFICANT ANEMIA. 4. URINARY OBSTRUCTION. CONDITION ON DISPOSITION: Fair, but improved. DISPOSITION: To home with his son. PLAN: We will have the patient follow up with Dr. X in his office in 2 days for reevaluation. The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight. The patient was encouraged to drink extra water. The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.

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: Blood in toilet.

CHIEF COMPLAINT: Blood in toilet. HISTORY: Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants. PAST MEDICAL HISTORY: Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past. PAST SURGICAL HISTORY: Unknown. SOCIAL HISTORY: No tobacco or alcohol. MEDICATIONS: Listed in the medical records. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress. HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact. NECK: No lymphadenopathy or JVD. HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi. ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted. GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region. EXTREMITIES: No significant abnormalities. WORKUP: CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization. ER COURSE: Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood. ASSESSMENT: Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

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

CHIEF COMPLAINT: Nausea. PRESENT ILLNESS: The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum. PAST MEDICAL HISTORY: Significant for hypertension and morbid obesity, now resolved. PAST SURGICAL HISTORY: Gastric bypass surgery in December 2007. MEDICATIONS: Multivitamins and calcium. ALLERGIES: None known. FAMILY HISTORY: Positive for diabetes mellitus in his father, who is now deceased. SOCIAL HISTORY: He denies tobacco or alcohol. He has what sounds like a data entry computer job. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84. He is drowsy, but easily arousable and appropriate with conversation. He is oriented to person, place, and situation. He is normocephalic, atraumatic. His sclerae are anicteric. His mucous membranes are somewhat tacky. His neck is supple and symmetric. His respirations are unlabored and clear. He has a regular rate and rhythm. His abdomen is soft. He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. He otherwise has no organomegaly, masses, or abdominal hernias evident. His extremities are symmetrical with no edema. His posterior tibial pulses are palpable and symmetric. He is grossly nonfocal neurologically. STUDIES: His white blood cell count is 8.4 with 79 segs. His hematocrit is 41. His electrolytes are normal. His bilirubin is 2.8. His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239. ASSESSMENT: Choledocholithiasis, ? cholecystitis. PLAN: He will be admitted and placed on IV antibiotics. We will get an ultrasound this morning. He will need his gallbladder out, probably with intraoperative cholangiogram. Hopefully, the stone will pass this way. Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted. Dr. X will see him later this morning and discuss the plan further. The patient understands.

Write a clinical note about a patient with the following chief complaint: Possible exposure to ant bait.

CHIEF COMPLAINT: Possible exposure to ant bait. HISTORY OF PRESENT ILLNESS: This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type. PAST MEDICAL HISTORY: Negative. Generally very healthy. REVIEW OF SYSTEMS: The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not see anything her mouth. MEDICATIONS: None. ALLERGIES: NONE. PHYSICAL EXAMINATION: VITAL SIGNS: The patient was afebrile. Stable vital signs and normal pulse oximetry. GENERAL: The child is very active, cheerful youngster, in no distress whatsoever. HEENT: Unremarkable. Oral mucosa is clear, moist, and well hydrated. I do not see any evidence of any sort of liquid on the face. Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso. Apparently, she had some on her hands that has been wiped off. EMERGENCY DEPARTMENT COURSE: I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case. IMPRESSION: Exposure to ant bait. PLAN: At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely. She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation. So, the patient is discharged in stable condition.

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 a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss. PAST MEDICAL HISTORY: Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement. PAST SURGICAL HISTORY: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted. ALLERGIES: SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN. SOCIAL HISTORY: She does not drink or smoke. REVIEW OF SYSTEMS: Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath. PHYSICAL EXAMINATION: GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress. VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits. HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected. NECK: Supple. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness. PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse. EXTREMITIES: Grossly and neurovascularly intact. LABORATORY VALUES: White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7. DIAGNOSTIC STUDIES: EKG shows normal sinus rhythm. IMPRESSION AND PLAN: A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.

Write a clinical note about a patient with the following chief complaint: Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.

CHIEF COMPLAINT: Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting. HISTORY OF PRESENT ILLNESS: AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements. He has not eaten anything, and has vomited 8 times. AF reports 10/10 pain in the LLQ. PAST MEDICAL HISTORY: AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain. Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain" ,PAST SURGICAL HISTORY: AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS: None. ALLERGIES: Iodine, IV contrast (anaphylaxis), and seafood/shellfish. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: AF was born and raised in San Francisco. His father was an alcoholic. He currently lives with his sister, and does not work; he collects a pension. HEALTH-RELATED BEHAVIORS: AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day. REVIEW OF SYSTEMS: Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia. PHYSICAL EXAM: Vital Signs: T: 37.1

Write a clinical note about a patient with the following chief complaint: Nausea and abdominal pain after eating.

CHIEF COMPLAINT: Nausea and abdominal pain after eating. GALL BLADDER HISTORY: The patient is a 36 year old white female. Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC. PAST MEDICAL HISTORY: No significant past medical problems. PAST SURGICAL HISTORY: Diagnostic laparoscopic exam for pelvic pain/adhesions. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: No current medications. OCCUPATIONAL /SOCIAL HISTORY: Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs. FAMILY MEDICAL HISTORY: There is no significant, contributory family medical history. OB GYN HISTORY: LMP: 5/15/1999. Gravida: 1. Para: 1. Date of last pap smear: 1/15/1998. REVIEW OF SYSTEMS: Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax. Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment. Neurological: Patient admits to symptoms of seizures and ataxia. Skin: Denies scaling, rashes, blisters, photosensitivity. PHYSICAL EXAMINATION: Appearance: Healthy appearing. Moderately overweight. HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions. Neck: Neck mobile. Trachea is midline. Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy. Breast: Normal appearing breasts bilaterally, nipples everted. No nipple discharge, skin changes. Chest: Normal breath sounds heard bilaterally without rales or rhonchi. No pleural rubs. No scars. Cardiovascular: Regular heart rate and rhythm without murmur or gallop. Abdominal: Bowel sounds are high pitched. Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal. Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions. IMPRESSION DIAGNOSIS: Gall Bladder Disease. Abdominal Pain. DISCUSSION: Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure. PLAN: We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram. MEDICATIONS PRESCRIBED:

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

CHIEF COMPLAINT: GI bleed. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue. CBC revealed microcytic anemia with hemoglobin of 8.9. Stool dark brown, strongly OB positive. The patient denied any shortness of breath. No chest pain. No GI complaints. The patient was admitted to ABCD for further evaluation. PAST MEDICAL HISTORY: Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism. PHYSICAL EXAMINATION: GENERAL: The patient is in no acute distress. VITAL SIGNS: Stable. HEENT: Benign. NECK: Supple. No adenopathy. LUNGS: Clear with good air movement. HEART: Irregularly regular. No gallops. ABDOMEN: Positive bowel sounds, soft, and nontender. No masses or organomegaly. EXTREMITIES: 1+ lower extremity edema bilaterally. HOSPITAL COURSE: The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis. Colonoscopy did reveal diverticulosis as well as polyp, which was resected. The patient tolerated the procedure well. She was transfused, and prior to discharge hemoglobin was stable at 10.7. The patient was without further GI complaints. Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume. The patient was discharged with outpatient PMD, GI, and Cardiology followup. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Anemia. 3. Atrial fibrillation. 4. Non-insulin-dependent diabetes mellitus. 5. Hypertension. 6. Hypothyroidism. 7. Asthma. CONDITION UPON DISCHARGE: Stable. MEDICATIONS: Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d. KCl 20 mEq daily, Lasix 40 mg b.i.d. atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily. ALLERGIES: None. DIET: 1800-calorie ADA. ACTIVITY: As tolerated. FOLLOWUP: The patient to hold Coumadin through weekend. Followup CBC and INR were ordered. Outpatient followup as arranged.

Write a clinical note about a patient with the following chief complaint: Foul-smelling urine and stomach pain after meals.

CHIEF COMPLAINT: Foul-smelling urine and stomach pain after meals. HISTORY OF PRESENT ILLNESS: Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time. She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI. This visit was in July 2010. REVIEW OF SYSTEMS: HEENT: No headaches. No visual disturbances, no eye irritation. No nose drainage or allergic symptoms. No sore throat or masses. Respiratory: No shortness of breath. No cough or wheeze. No pain. Cardiac: No palpitations or pain. Gastrointestinal: Pain and cramping. Denies nausea, vomiting, or diarrhea. Has some regurgitation with gas after meals. Genitourinary: "Smelly" urine. Musculoskeletal: No swelling, pain, or numbness. MEDICATION ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: General: Unremarkable. HEENT: PERRLA. Gaze conjugate. Neck: No nodes. No thyromegaly. No masses. Lungs: Clear. Heart: Regular rate without murmur. Abdomen: Soft, without organomegaly, without guarding or tenderness. Back: Straight. No paraspinal spasm. Extremities: Full range of motion. No edema. Neurologic: Cranial nerves II-XII intact. Deep tendon reflexes 2+ bilaterally. Skin: Unremarkable. LABORATORY STUDIES: Urinalysis was done, which showed blood due to her period and moderate leukocytes. ASSESSMENT: 1. UTI. 2. GERD. 3. Dysphagia. 4. Contraception consult. PLAN: 1. Cipro 500 mg b.i.d. x five days. Ordered BMP, CBC, and urinalysis with microscopy. 2. Omeprazole 20 mg daily and famotidine 20 mg b.i.d. 3. Prescriptions same as #2. Also referred her for a barium swallow series to rule out a stricture. 4. Ortho Tri-Cyclen Lo.

Write a clinical note about a patient with the following chief complaint: Stomach pain for 2 weeks.

CHIEF COMPLAINT: Stomach pain for 2 weeks. HISTORY OF PRESENT ILLNESS: The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts. PAST MEDICAL HISTORY: Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence. PAST SURGICAL HISTORY: Left femoral neck fracture with prosthesis secondary to a fall 4 years ago. FAMILY HISTORY: Mother with diabetes. No history of liver disease. No malignancies. SOCIAL HISTORY: The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior. ALLERGIES: NKDA. MEDICATIONS: Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days. REVIEW OF SYSTEMS: No headache, vision changes. No shortness of breath. No chest pain or palpitations. PHYSICAL EXAMINATION: Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress. HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist. Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses. CHEST: Clear to auscultation bilaterally. CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops. Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly. Rectal: Stool was brown and guaiac negative. Ext: No cyanosis/clubbing/edema. Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit. Skin: No jaundice. No skin rashes or lesions. IMAGING DATA: CT Abdomen with contrast ( 11/29/03 ): There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections. HOSPITAL COURSE: The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.

Write a clinical note about a patient with the following chief complaint: Dysphagia and hematemesis while vomiting.

CHIEF COMPLAINT: Dysphagia and hematemesis while vomiting. HISTORY OF PRESENT ILLNESS: This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal. The back and chest pain is 8/10, no radiation and is constant. She denied fever, abdominal pain, or dysphagia before current event eating bones or fish. This is the first episode of hematemesis and feeling of globus pallidus. In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain. CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified. REVIEW OF SYSTEMS: The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event. Denied any exertional chest pain or shortness of breath. No headache, limb weakness. No joint pain or muscle ache. No dysuria. PAST MEDICAL HISTORY: Remarkable for: 1. Asthma. 2. Hepatitis C - 1995. 3. HIV, known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09. The patient does not take HIV medications against medical advice. 4. Hypertension, known since 2008. 5. Negative PPD test, 10/08. PAST SURGICAL HISTORY: Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005. FAMILY HISTORY: Mother deceased at age 68 of cirrhosis. She had history of alcohol abuse. Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension. ALLERGIES: Not known allergies. MEDICATIONS AT HOME: Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily. The patient does not take her HIV medications for the last 2 to 3 months. Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily. SOCIAL HISTORY: She is single, lives with her 21-year-old daughter, works as CNA, smokes one pack per day for the last 8 years. She had periods when she quit smoking and started again 2-1/2 years ago. She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago. PHYSICAL EXAMINATION: Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air. African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort. Oriented x3, mildly drowsy, calm and cooperative. Eyes, EOMI, PERRLA. Tympanic membranes normal appearance bilaterally. External canal, no erythema or discharge. Nose, no erythema or discharge. Throat, dry mucous, no exudates. No ulcers in oral area. Full upper denture and extensive decayed lower teeth. No cervical lymphadenopathy, no carotid bruits bilaterally. Heart: RRR, S1 and S2 appreciated. No additional sounds or murmurs were auscultated. Lung: Good air entrance bilaterally. No rales or rhonchi. Abdomen: Soft, nontender, nondistended. No masses or organomegaly were palpated. Legs: No signs of DVT, peripheral pulses full, posterior dorsalis pedis 2+. Skin: No rashes or other lesions, warm and well perfused. Nails: No clubbing. No other signs of skin infection. Neurological exam: Cranial nerves II through XII grossly intact. No motor or sensory deficit was found. CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10. Impression: Cardiomegaly, normal aorta, large distention of esophagus containing food. Chest x-ray: Cardiomegaly, no evidence of CHF or pneumonia. EKG: Normal sinus rhythm, no signs of ischemia. LABORATORY DATA: Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197. Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8. Urine: Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+. Troponin 0.040. BNP 1328. PLAN: 1. Diffuse esophageal dilatation/hematemesis. We will put her n.p.o. we will give IV fluid, half normal saline D5 100 mL per hour. I discussed the case with Dr. Y, gastroenterologist. The patient planned for EGD starting today. Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis. We will treat according to the EGD findings. We will give IV Nexium 40 mg daily for GI prophylaxis. We will hold all p.o. medication. 2. CHF. Cardiomegaly on x-ray. She is clinically stable. Lungs are clear. No radiological sign of CHF exacerbation. We will restart lisinopril and metoprolol after EGD study will be completed. 3. HIV - follow up by Dr. X, (ABCD Medical Center). The last visit was on 08/08. The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load. We will check CD4 number and viral load. We will contact Dr. X (ID specialist in ABCD Med). 4. Hypertension. We will control blood pressor with Lopressor 5 mg IV p.r.n. If blood pressure more than 160/90, we will hold metoprolol and lisinopril. 5. Hepatitis C, known since 1995. The patient does not take any treatment. 6. Tobacco abuse. The patient refused nicotine patch. 7. GI prophylaxis as stated above; and DVT prophylaxis, compression socks. We will restrain from using heparin or Lovenox. ADDENDUM: The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus. There is no evidence of leakage of the oral contrast. There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time. There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach. After procedure, the patient had profuse vomiting with bloody content and spiked fever 102. The patient felt relieved after vomiting. The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours. ID consult was called and thoracic surgeon consult was ordered.

Write a clinical note about a patient with the following chief complaint: "I want my colostomy reversed.",

CHIEF COMPLAINT: "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a "bag." According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch. The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic. The patient also complains of the development of an incisional hernia since his surgery in November. He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X. Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort. He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort. PAST MEDICAL AND SURGICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Question of hypertension. 3. Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional. 4. Status post cholecystectomy. 7. Status post unknown foot surgery. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives in Greensboro. He smokes one pack of cigarettes a day and has done so for 15 years. He denies any IV drug use and has an occasional alcohol. FAMILY HISTORY: Positive for diabetes, hypertension, and coronary artery disease. REVIEW OF SYSTEMS: Please see history of present illness; otherwise, the review of systems is negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds. GENERAL: This is a pleasant African-American male appearing his stated age in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Moist mucous membranes. Extraocular movements intact. NECK: Supple, no JVD, and no lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, and nondistended with a left lower quadrant stoma. The stoma is pink, protuberant, and productive. The patient also has a midline incisional hernia approximately 6 cm in diameter. It is reducible. Otherwise, there are no further hernias or masses noted. EXTREMITIES: No clubbing, cyanosis or edema. ASSESSMENT AND PLAN: This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis. The patient presents for reversal of his colostomy as well as repair of his incisional hernia. I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery. He stated that he would try and do this and bring the records to our clinic on his next appointment. I have also set him up for a barium enema to study the rectal stump. He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point. This was discussed with the patient as well as his sister and significant other in the clinic today. They were in agreement with this plan. We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag. To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.

Write a clinical note about a patient with the following chief complaint: Colostomy failure. ,

CHIEF COMPLAINT: Colostomy failure. ,HISTORY OF PRESENT ILLNESS: This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of "heartburn." He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY: As above. Also, hypertension. ,ALLERGIES: "Fleet enema." ,MEDICATIONS: Accupril and vitamins. ,REVIEW OF SYSTEMS: SYSTEMIC: The patient denies fever or chills. HEENT: The patient denies blurred vision, headache, or change in hearing. NECK: The patient denies dysphagia, dysphonia, or neck pain. RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis. CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain. GASTROINTESTINAL: See above. MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling. NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis. GENITOURINARY: The patient denies dysuria, flank pain, or hematuria. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING: Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION: Bowel obstruction, status post colostomy. ,DISPOSITION: Admission to observation. The patient's condition is good. He is hemodynamically stable.

Write a clinical note about a patient with the following chief complaint: Bright red blood per rectum ,

CHIEF COMPLAINT: Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY: Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: Celecoxib (rash). SOCIAL HISTORY: Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY: Non-contributory. PHYSICAL EXAM: Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: CBC: WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism.

Write a clinical note about a patient with the following chief complaint: Blood in toilet.

CHIEF COMPLAINT: Blood in toilet. HISTORY: Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants. PAST MEDICAL HISTORY: Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past. PAST SURGICAL HISTORY: Unknown. SOCIAL HISTORY: No tobacco or alcohol. MEDICATIONS: Listed in the medical records. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress. HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact. NECK: No lymphadenopathy or JVD. HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi. ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted. GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region. EXTREMITIES: No significant abnormalities. WORKUP: CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization. ER COURSE: Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood. ASSESSMENT: Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

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 a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss. PAST MEDICAL HISTORY: Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement. PAST SURGICAL HISTORY: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted. ALLERGIES: SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN. SOCIAL HISTORY: She does not drink or smoke. REVIEW OF SYSTEMS: Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath. PHYSICAL EXAMINATION: GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress. VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits. HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected. NECK: Supple. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness. PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse. EXTREMITIES: Grossly and neurovascularly intact. LABORATORY VALUES: White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7. DIAGNOSTIC STUDIES: EKG shows normal sinus rhythm. IMPRESSION AND PLAN: A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.

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

CHIEF COMPLAINT: Nausea. PRESENT ILLNESS: The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum. PAST MEDICAL HISTORY: Significant for hypertension and morbid obesity, now resolved. PAST SURGICAL HISTORY: Gastric bypass surgery in December 2007. MEDICATIONS: Multivitamins and calcium. ALLERGIES: None known. FAMILY HISTORY: Positive for diabetes mellitus in his father, who is now deceased. SOCIAL HISTORY: He denies tobacco or alcohol. He has what sounds like a data entry computer job. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84. He is drowsy, but easily arousable and appropriate with conversation. He is oriented to person, place, and situation. He is normocephalic, atraumatic. His sclerae are anicteric. His mucous membranes are somewhat tacky. His neck is supple and symmetric. His respirations are unlabored and clear. He has a regular rate and rhythm. His abdomen is soft. He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. He otherwise has no organomegaly, masses, or abdominal hernias evident. His extremities are symmetrical with no edema. His posterior tibial pulses are palpable and symmetric. He is grossly nonfocal neurologically. STUDIES: His white blood cell count is 8.4 with 79 segs. His hematocrit is 41. His electrolytes are normal. His bilirubin is 2.8. His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239. ASSESSMENT: Choledocholithiasis, ? cholecystitis. PLAN: He will be admitted and placed on IV antibiotics. We will get an ultrasound this morning. He will need his gallbladder out, probably with intraoperative cholangiogram. Hopefully, the stone will pass this way. Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted. Dr. X will see him later this morning and discuss the plan further. The patient understands.

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

CHIEF COMPLAINT: Sinus problems. SINUSITIS HISTORY: The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning. REVIEW OF SYSTEMS: ROS General: General health is good. ROS ENT: As noted in history of present Illness listed above. ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc. ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements. ROS Respiratory: Complaints include coughing. ROS Neurological: Patient complains of headaches. All other systems are negative. PAST SURGICAL HISTORY: Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY: Negative. PAST SOCIAL HISTORY: Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home. FAMILY MEDICAL HISTORY: Family history of allergies and hypertension. CURRENT MEDICATIONS: Claritin. Dilantin. PREVIOUS MEDICATIONS UTILIZED: Rhinocort Nasal Spray. EXAM: Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation. Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus. Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic. Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles. Exam Facial: There is bilateral maxillary sinus tenderness to palpation. X-RAY / LAB FINDINGS: Water's view x-ray reveals bilateral maxillary mucosal thickening. IMPRESSION: Acute maxillary sinusitis (461.0). Snoring (786.09). MEDICATION: Augmentin. 875 mg bid. MucoFen 800 mg bid. PLAN:

Write a clinical note about a patient with the following chief complaint: Recurrent nasal obstruction.

CHIEF COMPLAINT: Recurrent nasal obstruction. HISTORY OF PRESENT ILLNESS: The patient is a 5-year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea. Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis. All of his symptoms had resolved when he had seen Dr. F, so no surgical plan was made and no further followup was needed. However, the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes. Again, the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature. It sounds like he is snoring loudly and does have some nasal obstruction at nighttime. He also is sniffing a lot through his nose. He has been tried on some nasal steroids but they only use this on a p.r.n. basis about one or two days every month and we are unsure if that has even helped at all, probably not. The child is not having any problems with his ears including ear infections or hearing. He is also not having any problems with strep throat. PAST MEDICAL HISTORY: Eczema. PAST SURGICAL HISTORY: None. MEDICATIONS: None. ALLERGIES: No known drug allergies. FAMILY HISTORY: No family history of bleeding diathesis or anesthesia difficulties. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 43 pounds, height 37 inches, temperature 97.4, pulse 65, and blood pressure 104/48. GENERAL: The patient is a well-nourished male in no acute distress. Listening to his voice today in the clinic, he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation. NOSE: Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea. EARS: The patient tympanic membranes are clear and intact bilaterally. There is no middle ear effusion. ORAL CAVITY: The patient has 2+ tonsils bilaterally. There are clearly nonobstructive. His uvula is midline. NECK: No lymphadenopathy appreciated. ASSESSMENT AND PLAN: This is a 5-year-old male, who presents for repeat evaluation of a possible nasal obstruction, questionable sleep apnea. Again, the mother gives a confusing sleep history but it does not really sound like he is having apneic events. They deny any actual gasping events. It sounds like true obstructive events. He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis. I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately. I have given them prescription for Nasacort Aqua one spray to each nostril twice a day. I instructed them on correct way to use this and the importance to use it on a daily basis. They may not see any benefit for several weeks. I would like to evaluate him in six weeks to see how we are progressing. If he continues to have problems, I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child. He may also need an allergy evaluation at that point if he continues to have problems. However, I would like to be fairly conservative in this child. Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen (I did instruct her call us if it worsens), we may even need to pursue a sleep study just to settle that issue once and for all. We will see him back in six weeks.

Write a clinical note about a patient with the following chief complaint: This 3-year-old female presents today for evaluation of chronic ear infections bilateral.

CHIEF COMPLAINT: This 3-year-old female presents today for evaluation of chronic ear infections bilateral. ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: Associated signs and symptoms include: cough, fever, irritability and speech and language delay. Duration (ENT): Duration of symptom: 12 rounds of antibiotics for otitis media. Quality of ear problems: Quality of the pain is throbbing. ALLERGIES: No known medical allergies. MEDICATIONS: None currently. PMH: Past medical history is unremarkable. PSH: No previous surgeries. SOCIAL HISTORY: Parent admits child is in a large daycare. FAMILY HISTORY: Parent admits a family history of Alzheimer's disease associated with paternal grandmother. ROS: Unremarkable with exception of chief complaint. PHYSICAL EXAM: Temp: 99.6 Weight: 38 lbs. Patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus. The child is accompanied by her mother who communicates well in English. Head & Face: Inspection of head and face shows no abnormalities. Examination of salivary glands shows no abnormalities. Facial strength is normal. Eyes: Pupil exam reveals PERRLA. ENT: Otoscopic examination reveals otitis media bilateral. Hearing exam using tuning fork shows hearing to be diminished bilateral. Inspection of left ear reveals drainage of a small amount. Inspection of nasal mucosa, septum and turbinates reveals no abnormalities. Frontal and maxillary sinuses all transilluminate well bilaterally. Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals no abnormalities. Examination of nasopharynx reveals adenoid hypertrophy. Neck: Neck exam reveals no abnormalities. Lymphatic: No neck or supraclavicular lymphadenopathy noted. Respiratory: Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion. Auscultation of lungs reveal clear lung fields and no rubs noted. Cardiovascular: Heart auscultation reveals no murmurs, gallop, rubs or clicks. Neurological/Psychiatric: Testing of cranial nerves reveals no deficits. Mood and affect normal and appropriate to situation. TEST RESULTS: Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram. IMPRESSION: OM, suppurative without spontaneous rupture. Adenoid hyperplasia bilateral. PLAN: Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003. Surgery will be performed at Children's Hospital. Pre-operative consent form read and signed by parent. Common risks and side effects of the procedure and anesthesia were mentioned. Parent questions elicited and answered satisfactorily regarding planned procedure. ,EDUCATIONAL MATERIAL PROVIDED: Hospital preregistration, middle ear infection and myringtomy and tubes surgery. PRESCRIPTIONS: Augmentin Dosage: 400 mg-57 mg/5 ml powder for reconstitution Sig: One PO Q8h Dispense: 1 Refills: 0 Allow Generic: No

Write a clinical note about a patient with the following chief complaint: Chronic otitis media, adenoid hypertrophy.

CHIEF COMPLAINT: Chronic otitis media, adenoid hypertrophy. HISTORY OF PRESENT ILLNESS: The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions. He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy. He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes. ALLERGIES: None. MEDICATIONS: Antibiotics p.r.n. FAMILY HISTORY: Diabetes, heart disease, hearing loss, allergy and cancer. MEDICAL HISTORY: Unremarkable. SURGICAL HISTORY: None. SOCIAL HISTORY: Some minor second-hand tobacco exposure. There are no pets in the home. PHYSICAL EXAMINATION: Ears are well retracted, immobile. Tympanic membranes with effusions present bilaterally. No severe congestions, thick mucoid secretions, no airflow. Oral cavity: Oropharynx 2 to 3+ tonsils. No exudates. Floor of mouth and tongue are normal. Larynx and pharynx not examined. Neck: No nodes, masses or thyromegaly. Lungs: Reveal rare rhonchi, otherwise, clear. Cardiac exam: Regular rate and rhythm. No murmurs. Abdomen: Soft, nontender. Positive bowel sounds. Neurologic exam: Nonfocal. IMPRESSION: Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy. PLAN: The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes.

Write a clinical note about a patient with the following chief complaint: Severe tonsillitis, palatal cellulitis, and inability to swallow.

CHIEF COMPLAINT: Severe tonsillitis, palatal cellulitis, and inability to swallow. HISTORY OF PRESENT ILLNESS: This patient started having sore throat approximately one week ago; however, yesterday it became much worse. He was unable to swallow. He complained to his parent. He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar. He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis. A CT scan at ER did not show abscess. He has not had airway compromise, but he has had difficulty swallowing. He may have had a low-grade fever, but nothing marked at home. His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis. He had a negative monospot and negative strep screen. PAST MEDICAL HISTORY: The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight. He is a sophomore at High School. FAMILY HISTORY: Noncontributory to this illness. SURGERIES: None. HABITS: Nonsmoker, nondrinker. Denies illicit drug use. REVIEW OF SYSTEMS: ENT: The patient other than having dysphagia, the patient denies other associated ENT symptomatology. GU: Denies dysuria. Orthopedic: Denies joint pain, difficulty walking, etc. Neuro: Denies headache, blurry vision, etc. Eyes: Says vision is intact. Lungs: Denies shortness of breath, cough, etc. Skin: He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care. Mildly itchy. Mother has penicillin allergy. Endocrine: The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism. Physical Exam: General: This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4. Voice is normal. He is handling his secretions. There is no stridor. Vital Signs: See vital signs in nurses notes. Ears: TM and EACs are normal. External, normal. Nose: Opening clear. External nose is normal. Mouth: Has bilateral marked exudates, tonsillitis, right greater than left. Uvula is midline. Tonsils are touching. There is some redness of the right palatal area, but is not consistent with peritonsillar abscess. Tongue is normal. Dentition intact. No mucosal lesions other than as noted. Neck: No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes. Chest: Clear to auscultation. Heart: No murmurs, rubs, or gallops. Abdomen: Obese. Complete exam deferred. Skin: Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction. Neuro: Cranial nerves II through XII are intact. Eyes, pupils are equal, round, and reactive to light and accommodation, full range. IMPRESSION: Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection. No significant prior history of tonsillitis. Possible rash to PENICILLIN. RECOMMENDATIONS: I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral. I do not insist that this patient will need surgical intervention since there is no evidence of abscess. This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient. The patient's parents in the room had expressed good understanding, have a chance to ask questions. At this time, I will see the patient back on an as needed basis.

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

CHIEF COMPLAINT: Right ear pain with drainage. HISTORY OF PRESENT ILLNESS: This is a 12-year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has been draining for several days and it has a foul smell to it. He has had some low-grade fever. The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever. The patient was evaluated for Strep throat which was negative and just had been doing supportive care. He did have a recent airplane ride a couple of weeks ago also. There has been no cough, shortness of breath or wheezing. No vomiting or diarrhea. PHYSICAL EXAM: General: He is alert in no distress. Vital Signs: Temperature: 99.1 degrees. HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. The left TM is clear. The right TM is poorly visualized secondary to purulent secretions in the right ear canal. There is no erythema of the ear canals. Nares is patent. Oropharynx is clear. The patient does wear braces. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular. No murmur. ASSESSMENT: 1. Right otitis media. 2. Right otorrhea. PLAN: Ceftin 250 mg by mouth twice a day for 10 days. Ciprodex four drops to the right ear twice a day. The patient is to return to the office in two weeks for followup.

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

CHIEF COMPLAINT: Septal irritation. HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation. The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a "stretching" like pressure. She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose. She has no other complaints at this time. PHYSICAL EXAM: GENERAL: This is a pleasant African-American female resting in the examination room chair in no apparent distress. ENT: External auditory canals are clear. Tympanic membrane shows no perforation, is intact. NOSE: The patient has a slightly deviated right septum. Septum has a large perforation in the anterior 2/3rd of the septum. This appears to be well healed. There is no sign of crusting in the nose. ORAL CAVITY: No lesions or sores. Tonsils show no exudate or erythema. NECK: No cervical lymphadenopathy. VITAL SIGNS: Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73. ASSESSMENT AND PLAN: The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation. At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis. At this time, I counseled the patient on the risks and benefits of surgery. She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip. We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.

Write a clinical note about a patient with the following chief complaint: Chronic otitis media.

CHIEF COMPLAINT: Chronic otitis media. HISTORY OF PRESENT ILLNESS: This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection. He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia. ALLERGIES: None. MEDICATIONS: None. FAMILY HISTORY: Noncontributory. MEDICAL HISTORY: Mild reflux. PREVIOUS SURGERIES: None. SOCIAL HISTORY: The patient is not in daycare. There are no pets in the home. There is no secondhand tobacco exposure. PHYSICAL EXAMINATION: Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present. Left ear is still little bit black. Nose, moderate inferior turbinate hypertrophy. No polyps or purulence. Oral cavity, oropharynx 2+ tonsils. No exudates. Neck, no nodes, masses or thyromegaly. Lungs are clear to A&P. Cardiac exam, regular rate and rhythm. No murmurs. Abdomen is soft and nontender. Positive bowel sounds. IMPRESSION: Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation. PLAN: The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.

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: Followup diabetes mellitus, type 1. ,

CHIEF COMPLAINT: Followup diabetes mellitus, type 1. ,SUBJECTIVE: Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago. Reports that his blood sugar dropped too low which caused the accident. Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer. ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time. Reports that he had some indications of kidney damage when first diagnosed. His urine microalbumin today is 100. His last hemoglobin A1C drawn at the end of December is 11.9. Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7. His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker. Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today. Patient also has a history of gastroparesis and impotence. Patient requests Nexium and Viagra, neither of which are covered under the Health Plan. , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head. Was not wearing a helmet. Reports that he did not go to the emergency room and had a headache for several days after this incident. Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room. Patient did not comply. Reports that the headache has resolved. Denies any dizziness, nausea, vomiting, or other neurological abnormalities. ,PHYSICAL EXAMINATION: WD, WN. Slender, 34-year-old white male. VITAL SIGNS: Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16. Microalbumin 100. SKIN: There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long. No signs of infection. Wound is closed with new granulation tissue. Appears to be healing well. HEENT: Normocephalic. PERRLA. EOMI. TMs pearly gray with landmarks present. Nares patent. Throat with no redness or swelling. Nontender sinuses. NECK: Supple. Full ROM. No LAD. CARDIAC:

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: Testicular pain.

CHIEF COMPLAINT: Testicular pain. HISTORY OF PRESENT ILLNESS: The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning. He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it. Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful. He had no voiding or stooling problems. No nausea, vomiting or fever. Family denies trauma or dysuria. At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved. He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning. He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation. He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago. He is on no medications and he is here for evaluation. PAST MEDICAL HISTORY: The patient has no known allergies. He is term delivery via spontaneous vaginal delivery. He has had no problems or hospitalizations with circumcision. PAST SURGICAL HISTORY: He has had no previous surgeries. REVIEW OF SYSTEMS: All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago. IMMUNIZATIONS: Up-to-date. FAMILY HISTORY: The patient lives at home with both parents who are Spanish speaking. He is not in school. MEDICATIONS: He is on no medications. PHYSICAL EXAMINATION: VITAL SIGNS: On physical exam, weight is 15.9 kg. GENERAL: The patient is a cooperative little boy. HEENT: Normal head and neck exam. No oral or nasal discharge. NECK: Without masses. CHEST: Without masses. LUNGS: Clear. CARDIAC: Without murmurs or gallops. ABDOMEN: Soft. No masses or tenderness. His scrotum did not have any swelling at the present time. There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted. No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only. His left testis was slightly harder than the right, but this was not very significant. EXTREMITIES: He had full range of motion in all 4 extremities. SKIN: Warm, pink, and dry. NEUROLOGIC: Grossly intact. LABORATORY DATA: Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left. This is personally reviewed by me. The right was normal. No masses were appreciated. There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study. ASSESSMENT/PLAN: The patient has a possibly torsion detorsion versus other acute testicular problem. If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found. I discussed the pre and postsurgical care with the parents. Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure. The parents understand and wished to proceed. We will schedule this later today emergently.

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: 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: 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: 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: "Bloody bump on penis.",

CHIEF COMPLAINT: "Bloody bump on penis.",HISTORY OF PRESENT ILLNESS: This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis. The patient states that he has had a large bump on the end of his penis for approximately a year and a half. He states that it has never bled before. It has never caused him any pain or has never been itchy. The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years. He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice. The patient does state that last night he was "trying to get some," meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis. The patient said that there is a large amount of blood from this injury. This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding. The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed. The patient denies any drainage or discharge from his penis. He denies fevers or chills recently. He also denies nausea or vomiting. The patient has not had any discharge from his penis. He has not had any other skin lesions on his penis that are new to him. He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years. The patient has never had these checked out. He denies fevers, chills, or night sweats. He denies unintentional weight gain or loss. He denies any other bumps, rashes, or lesions throughout the skin on his body. PAST MEDICAL HISTORY: No significant medical problems. PAST SURGICAL HISTORY: Surgery for excision of a bullet after being shot in the back. SOCIAL HABITS: The patient denies illicit drug usage. He occasionally smokes tobacco and drinks alcohol. MEDICATIONS: None. ALLERGIES: No known medical allergies. PHYSICAL EXAMINATION: GENERAL: This is an African-American male who appears his stated age of 29 years. He is well nourished, well developed, in no acute distress. The patient is pleasant. He is sitting on a Emergency Department gurney. VITAL SIGNS: Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air. HEART: Regular rate and rhythm. Clear S1, S2. No murmur, rub, or gallop is appreciated. LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. ABDOMEN: Soft, nontender, nondistended, and positive bowel sounds throughout. GENITOURINARY: The patient's external genitalia is markedly abnormal. There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus. This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter. The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well. There are no open lesions at this point. There is a small tear of the skin where the mass attaches to the glans near the urethral meatus. Bleeding is currently stanch, and there is no sign of secondary infection at this time. Bilateral testicles are descended and normal without pain or mass bilaterally. There is no inguinal adenopathy. EXTREMITIES: No edema. SKIN: Warm, dry, and intact. No rash or lesion. DIAGNOSTIC STUDIES: Non-emergency department courses. It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass. ASSESSMENT AND PLAN: Penile mass. The patient does have a large pedunculated penile mass. He will be referred to the urologist who is on-call today. The patient will need this mass excised and biopsied. The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.

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 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: 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: Head injury.

CHIEF COMPLAINT: Head injury. HISTORY: This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizzy. She complained of a headache. She was able to walk. She continued to participate in her flag practice. She got dizzier. She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation. PAST MEDICAL HISTORY: Hypertension. ALLERGIES: DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH. CURRENT MEDICATIONS: Enalapril. PAST SURGICAL HISTORY: She had some kind of an abdominal obstruction as an infant. SOCIAL HISTORY: She is here with mother and father who lives at home. There is no smoking at home. There is second-hand smoke exposure. FAMILY HISTORY: No noted family history of infectious disease exposure. IMMUNIZATIONS: She is up-to-date on her shots, otherwise negative. REVIEW OF SYSTEMS: On the 10-plus systems reviewed with the section of those noted on the template. PHYSICAL EXAMINATION: VITAL SIGNS: Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg. GENERAL: She is supine awake, alert, cooperative, and active child. HEENT: Head atraumatic, normocephalic. Pupils equal, round, reactive to light. Extraocular motions intact and conjugate. Clear TMs, nose and oropharynx. Moist oral mucosa without noted lesions. NECK: Supple, full painless nontender range motion. CHEST: Clear to auscultation, equal, stable to palpation. HEART: Regular without rubs or murmurs. ABDOMEN: No abdominal bruits are heard. EXTREMITIES: Equal femoral pulses are appreciated. Equal radial and dorsalis pedis pulses are appreciated. He moves all extremities without difficulty. Nontender. No deformity. No swelling. SKIN: There was no significant bruising, lesions or rash about her abdomen. No significant bruising, lesions or rash. NEUROLOGIC: Symmetric face and extremity motion. Ambulates without difficulty. She is awake, alert, and appropriate. MEDICAL DECISION MAKING: The differential entertained includes head injury, anxiety, and hypertensive emergency. She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s. Her laboratory data shows a mildly elevated creatinine of 1.3. Urine is within normal. Urinalysis showing no signs of infection. Head CT read by staff has no significant intracranial pathology. No mass shift, bleed or fracture per Dr. X. A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90. No significant ST-T wave changes. No significant change from previous 09/2007 EKG. Her headache has resolved. She is feeling better. I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home. Follow up with her regular doctor. Blood pressures have normalized for her. She should return to emergency department on concern. They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.

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

CHIEF COMPLAINT: Foot pain. HISTORY OF PRESENT ILLNESS: This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an hour prior to this injury. Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care. He is able to bear weight; however, complains of pain in his toes. The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot. According to the patient, he was at his baseline state of health prior to this acute event. PAST MEDICAL HISTORY: Significant for attention deficit hyperactivity disorder. PAST SURGICAL HISTORY: Positive for wisdom tooth extraction. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He does not use alcohol, tobacco or illicit drugs. He plays water polo for the school team. IMMUNIZATION HISTORY: All immunizations are up-to-date for age. REVIEW OF SYSTEMS: The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative. PRESENT MEDICATIONS: Provigil, Accutane and Rozerem. ALLERGIES: None. PHYSICAL EXAMINATION: GENERAL: This is a pleasant white male in no acute distress. VITAL SIGNS: He is afebrile. Vitals are stable and within normal limits. HEENT: Negative for acute evidence of trauma, injury or infection. LUNGS: Clear. HEART: Regular rate and rhythm with S1 and S2. ABDOMEN: Soft. EXTREMITIES: There are some abrasions across the dorsum of the right foot including the second, third and fourth toes. There is some mild tenderness to palpation. However, there are no clinical fractures. Distal pulses are intact. The left foot notes superficial avulsion lacerations to the third and fourth digit. There are no subungual hematomas. Range of motion is decreased secondary to pain. No obvious fractures identified. BACK EXAM: Nontender. NEUROLOGIC EXAM: He is alert, awake and appropriate without deficit. RADIOLOGY: AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries. On reevaluation, the patient was resting comfortably. He was informed of the x-ray findings. The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair. DISCHARGE MEDICATIONS: Darvocet. The patient's condition at discharge was stable. All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge. The patient/family understood the instructions and was discharged without further incident.

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: 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: Questionable foreign body, right nose. Belly and back pain. ,

CHIEF COMPLAINT: Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper. PAST MEDICAL HISTORY: Otherwise negative. ALLERGIES: No allergies. MEDICATIONS: No medications other than recent amoxicillin. SOCIAL HISTORY: Parents do smoke around the house. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. He is afebrile. GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance. HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative. NECK: Without lymphadenopathy. No other findings. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted. BACK: Without any findings. Diaper area normal. GU: No rash or infections. Skin is intact. ED COURSE: He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings. ASSESSMENT: 1. Infected foreign body, right naris. 2. Mild constipation. PLAN: As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode.

Write a clinical note about a patient with the following chief complaint: Stomach pain for 2 weeks.

CHIEF COMPLAINT: Stomach pain for 2 weeks. HISTORY OF PRESENT ILLNESS: The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts. PAST MEDICAL HISTORY: Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence. PAST SURGICAL HISTORY: Left femoral neck fracture with prosthesis secondary to a fall 4 years ago. FAMILY HISTORY: Mother with diabetes. No history of liver disease. No malignancies. SOCIAL HISTORY: The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior. ALLERGIES: NKDA. MEDICATIONS: Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days. REVIEW OF SYSTEMS: No headache, vision changes. No shortness of breath. No chest pain or palpitations. PHYSICAL EXAMINATION: Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress. HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist. Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses. CHEST: Clear to auscultation bilaterally. CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops. Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly. Rectal: Stool was brown and guaiac negative. Ext: No cyanosis/clubbing/edema. Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit. Skin: No jaundice. No skin rashes or lesions. IMAGING DATA: CT Abdomen with contrast ( 11/29/03 ): There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections. HOSPITAL COURSE: The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.

Write a clinical note about a patient with the following chief complaint: "I took Ecstasy.",

CHIEF COMPLAINT: "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets. The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis. Mother called the EMS service when the patient vomited. On arrival here, the patient states that she no longer has any nausea and that she feels just fine. The patient states she feels wired but has no other problems or complaints. The patient denies any pain. The patient does not have any auditory of visual hallucinations. The patient denies any depression or suicidal ideation. The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself. The patient denies any homicidal ideation. The patient denies any recent illness or recent injuries. The mother states that the daughter appears to be back to her usual self now. REVIEW OF SYSTEMS: CONSTITUTIONAL: No recent illness. No fever or chills. HEENT: No headache. No neck pain. No vision change or hearing change. No eye or ear pain. No rhinorrhea. No sore throat. CARDIOVASCULAR: No chest pain. No palpitations or racing heart. RESPIRATIONS: No shortness of breath. No cough. GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then. The patient denies any abdominal pain. No change in bowel movements. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No dizziness, syncope, or near syncope. PSYCHIATRIC: The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations. ENDOCRINE: No heat or cold intolerance. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Appendectomy when she was 9 years old. CURRENT MEDICATIONS: Birth control pills. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient denies smoking cigarettes. The patient does drink alcohol and also uses illicit drugs. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal. CONSTITUTIONAL: The patient is well nourished, and well developed, appears to be healthy. The patient is calm and 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 cornea and conjunctiva bilaterally. The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally. No evidence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Nose is normal without rhinorrhea or audible congestion. Ears are normal without any sign of infection. Mouth and oropharynx are normal without any signs of infection. Mucous membranes are moist. NECK: Supple and nontender. Full range of motion. There is no JVD. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +3 and bounding. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, normal and benign. MUSCULOSKELETAL: No abnormalities noted in back, arms, or legs. The patient is normal use of her extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact in all extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. The patient does not have any smell of alcohol and does not exhibit any clinical intoxication. The patient is quite pleasant, fully cooperative. HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted. No bruising is noted. DIAGNOSES: 1. ECSTASY INGESTION. 2. ALCOHOL INGESTION. 3. VOMITING SECONDARY TO STIMULANT ABUSE. CONDITION UPON DISPOSITION: Stable disposition to home with her mother. PLAN: I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation. The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal. The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.

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

CHIEF COMPLAINT: Dental pain. HISTORY OF PRESENT ILLNESS: This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation. PAST MEDICAL HISTORY: Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease. She has chronic pain in general and is followed by Dr. X. REVIEW OF SYSTEMS: Otherwise, unremarkable. Has not noted any fever or chills. However she, as mentioned, does note the dental discomfort with increasing swelling and pain. Otherwise, unremarkable except as noted. CURRENT MEDICATIONS: Please see list. ALLERGIES: IODINE, FISH OIL, FLEXERIL, BETADINE. PHYSICAL EXAMINATION: VITAL SIGNS: The patient was afebrile, has stable and normal vital signs. The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain. HEENT: Unremarkable. I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region. There is no neck adenopathy. Oral mucosa is moist and well hydrated. Dentition looks to be in reasonable condition. However, she definitely is tender to percussion on the left lower first premolar. I do not see any huge cavity or anything like that. No real significant gingival swelling and there is no drainage noted. None of the teeth are tender to percussion. PROCEDURE: Dental nerve block. Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia. I have then written a prescription for penicillin and Vicodin for pain. IMPRESSION: ACUTE DENTAL ABSCESS. ASSESSMENT AND PLAN: The patient needs to follow up with the dentist for definitive treatment and care. She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics. However, outpatient followup should be adequate. She is discharged in stable condition.

Write a clinical note about a patient with the following chief complaint: The patient complains of chest pain. ,

CHIEF COMPLAINT: The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY: The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES: None. ,CURRENT MEDICATIONS: Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS: The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: FINAL DIAGNOSIS: 1. Evaluation of chest pain. ,2. Possible esophageal reflux.

Write a clinical note about a patient with the following chief complaint: Chest pain and fever.

CHIEF COMPLAINT: Chest pain and fever. HISTORY OF PRESENT ILLNESS: This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating. The patient does have a past medical history of diabetes and hypertension. In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well. The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits. She has not had any musculoskeletal or neurological deficits. She denies any rashes or skin lesions. PAST MEDICAL HISTORY: Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes. PAST SURGICAL HISTORY: Cholecystectomy, appendectomy, oophorectomy. FAMILY HISTORY: Positive for coronary artery disease in her father and brother in their 40s. SOCIAL HISTORY: She is married and does not smoke or drink nor did she ever. PHYSICAL EXAMINATION: On admission, temperature 99.4 degrees F. blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort. In general, she is well developed, well nourished, oriented, and alert and in no apparent distress. Head, ears, eyes, nose, and throat are unremarkable. Neck is supple. No neck vein distention is noted. No bruits are heard. Chest is clear to percussion and auscultation. Heart has a regular rhythm and rate without murmurs or rubs or gallops. Abdomen is soft, obese, and nontender. Musculoskeletal is intact without deformity. However, the patient did develop severe cramp behind her left knee during her treadmill testing. Neurologic: Cranial nerves are intact and she is nonfocal. Skin is warm and dry without rash or lesions noted. LABORATORY FINDINGS: Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2. Liver function panel is normal. CK was 82. MB fraction was 1.0. Troponin was less than 0.1 on three occasions. White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000. Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods. Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0. EKG was normal. DIAGNOSES ON ADMISSION: 1. Urinary tract infection. 2. Chest pain of unclear etiology, rule out myocardial infarction. 3. Neck and back pain of unclear etiology with a negative spinal tap. 4. Hypertension. 5. Diabetes type II, not treated with insulin. 6. Hyperlipidemia treated with TriCor but not statins. 7. Arthritis. ADDITIONAL LABORATORY STUDIES: B-natriuretic peptide was 26. Urine smear and culture negative on 24 and 48 hours. Chest x-ray was negative. Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81. COURSE IN THE HOSPITAL: The patient was placed on home medications. This will be listed at the end of the discharge summary. She was put on rule out acute myocardial infarction routine, and she did in fact rule out. She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70. She has a strong family history of early myocardial disease in the men in their 40s. DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 81 mg one daily. This is new, as the patient was not taking aspirin at home. 2. TriCor 48 mg one daily. 3. Zantac 40 mg one daily. 4. Lisinopril 20 mg one daily. 5. Mobic 75 mg one daily for arthritis. 6. Metformin 500 mg one daily. 7. Macrodantin one two times a day for several more days. 8. Zocor 20 mg one daily, which is a new addition. 9. Effexor XR 37.5 mg one daily. DIET: ADA 1800-calorie diet. ACTIVITY: As tolerated. Continue water exercise five days a week. DISPOSITION: Recheck at Hospital with a regular physician there in 1 week. Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.

Write a clinical note about a patient with the following chief complaint: The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath.

CHIEF COMPLAINT: The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multiple visits in the past. Today, the patient presents himself in severe respiratory distress. His wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath. Today, his symptoms worsened and she brought him to the emergency room. To the best of her knowledge, there has been no fever. He has persistent chronic cough, as always. More complete history cannot be taken because of the patient’s acute respiratory decompensation. PAST MEDICAL HISTORY: Hypertension and emphysema. MEDICATIONS: Lotensin and some water pill as well as, presumably, an Atrovent inhaler. ALLERGIES: None are known. HABITS: The patient is unable to cooperate with the history. SOCIAL HISTORY: The patient lives in the local area with his wife. REVIEW OF BODY SYSTEMS: Unable, secondary to the patient’s condition. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96 degrees, axillary. Pulse 128. Respirations 48. Blood pressure 156/100. Initial oxygen saturations on room air are 80. GENERAL: Reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing. HEENT: Head is normocephalic and atraumatic. NECK: The neck is supple without obvious jugular venous distention. LUNGS: Auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales. HEART: Cardiac examination reveals sinus tachycardia, without pronounced murmur. ABDOMEN: Soft to palpation. Extremities: Without edema. DIAGNOSTIC DATA: White blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. Chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, CO2 44, BUN 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. Troponin is 0.11. Urinalysis reveals yellow clear urine. Specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. No white cells and 0-2 red cells. Chest x-ray suboptimal in quality, but without obvious infiltrates, consolidation or pneumothorax. CRITICAL CARE NOTE: Critical care one hour. Shortly after the patient’s initial assessment, the patient apparently began to complain of chest pain and appeared to the nurse to have mounting exhaustion and respiratory distress. Although O2 had been placed, elevating his oxygen saturations to the mid to upper 90s, he continued to complain of symptoms, as noted above. He became progressively more rapidly obtunded. The patient did receive one gram of magnesium sulfate shortly after his arrival, and the BiPAP apparatus was being readied for his use. However, the patient, at this point, became unresponsive, unable to answer questions, and preparations were begun for intubation. The BiPAP apparatus was briefly placed while supplies and medications were assembled for intubation. It was noted that even with the BiPAP apparatus, in the duration of time which was required for transfer of oxygen tubing to the BiPAP mask, the patient’s O2 saturations rapidly dropped to the upper 60 range. All preparations for intubation having been undertaken, Succinylcholine was ordered, but was apparently unavailable in the department. As the patient was quite obtunded, and while the Dacuronium was being sought, an initial trial of intubation was carried out using a straight blade and a cupped 7.9 endotracheal tube. However, the patient had enough residual muscle tension to make this impractical and further efforts were held pending administration of Dacuronium 10 mg. After approximately two minutes, another attempt at intubation was successful. The cords were noted to be covered with purulent exudates at the time of intubation. The endotracheal tube, having been placed atraumatically, the patient was initially then nebulated on 100% oxygen, and his O2 saturations rapidly rose to the 90-100% range. Chest x-ray demonstrated proper placement of the tube. The patient was given 1 mg of Versed, with decrease of his pulse from the 140-180 range to the 120 range, with satisfactory maintenance of his blood pressure. Because of a complaint of chest pain, which I myself did not hear, during the patient’s initial triage elevation, a trial of Tridil was begun. As the patient’s pressures held in the slightly elevated range, it was possible to push this to 30 mcg per minute. However, after administration of the Dacuronium and Versed, the patient’s blood pressure fell somewhat, and this medication was discontinued when the systolic pressure briefly reached 98. Because of concern regarding pneumonia or sepsis, the patient received one gram of Rocephin intravenously shortly after the intubation. A nasogastric and Foley were placed, and an arterial blood gas was drawn by respiratory therapy. Dr. X was contacted at this point regarding further orders as the patient was transferred to the Intensive Care Unit to be placed on the ventilator there. The doctor’s call was transferred to the Intensive Care Unit so he could leave appropriate orders for the patient in addition to my initial orders, which included Albuterol or Atrovent q. 2h. and Levaquin 500 mg IV, as well as Solu-Medrol. Critical care note terminates at this time. EMERGENCY DEPARTMENT COURSE: See the critical care note. MEDICAL DECISION MAKING (DIFFERENTIAL DIAGNOSIS): This patient has an acute severe decompensation with respiratory failure. Given the patient’s white count and recent history of pneumonia, the possibility of recurrence of pneumonia is certainly there. Similarly, it would be difficult to rule out sepsis. Myocardial infarction cannot be excluded. COORDINATION OF CARE: Dr. X was contacted from the emergency room and asked to assume the patient’s care in the Intensive Care Unit. FINAL DIAGNOSIS: Respiratory failure secondary to severe chronic obstructive pulmonary disease. DISCHARGE INSTRUCTIONS: The patient is to be transferred to the Intensive Care Unit for further management.

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

CHIEF COMPLAINT: Dental pain. HISTORY OF PRESENT ILLNESS: This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw. The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured. The patient states that the pain in her left lower teeth kept her up last night. The patient did go to Clinic but arrived there later than 7 a.m. so she was not able to be seen there will call line for dental care. The patient states that the pain continues to be very severe at 9/10. She states that this is like a throbbing heart beat in her left jaw. The patient denies fevers or chills. She denies purulent drainage from her gum line. The patient does believe that there may be an area of pus accumulating in her gum line however. The patient denies nausea or vomiting. She denies recent dental trauma to her knowledge. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Hypothyroidism. PAST SURGICAL HISTORY: Coronary artery stent insertion. SOCIAL HABITS: The patient denies alcohol or illicit drug usage. Currently she does have a history of tobacco abuse. MEDICATIONS: 1. Plavix. 2. Metoprolol. 3. Synthroid. 4. Potassium chloride. ALLERGIES: 1. Penicillin. 2. Sulfa. PHYSICAL EXAMINATION: GENERAL: This is a Caucasian female who appears of stated age of 45 years. She is well-nourished, well-developed, in no acute distress. The patient is pleasant but does appear to be uncomfortable. VITAL SIGNS: Afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air. HEENT: Head is normocephalic. Pupils are equal, round and reactive to light and accommodation. Sclerae are anicteric and noninjected. Nares are patent and free of mucoid discharge. Mucous membranes are moist and free of exudate or lesion. Bilateral tympanic membranes are visualized and free of infection or trauma. Dentition shows significant decay throughout the dentition. The patient has had extraction of teeth 17, 18, and 19. The patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site. There is no pus draining from the socket of the tooth. No other acute abnormality to the other dentition is visualized. DIAGNOSTIC STUDIES: None. PROCEDURE NOTE: The patient does receive an injection of 1.5 mL of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth. The patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two Vicodin here in the Emergency Department and a dose of Keflex for treatment of her dental infection. ASSESSMENT: Dental pain with likely dental abscess. ,PLAN: The patient was given a prescription for Vicodin. She is also given prescription for Keflex, as she is penicillin allergic. She has tolerated a dose of Keflex here in the Emergency Department well without hypersensitivity. The patient is strongly encouraged to follow up with Dental Clinic on Monday, and she states that she will do so. The patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the ER.

Write a clinical note about a patient with the following chief complaint: Bright red blood per rectum ,

CHIEF COMPLAINT: Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY: Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: Celecoxib (rash). SOCIAL HISTORY: Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY: Non-contributory. PHYSICAL EXAM: Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: CBC: WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism.

Write a clinical note about a patient with the following chief complaint: Cut on foot.

CHIEF COMPLAINT: Cut on foot. HISTORY OF PRESENT ILLNESS: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints. PAST MEDICAL HISTORY: Asthma. CURRENT MEDICATION: Albuterol. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient is a smoker. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16. 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 and 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 conjunctiva and cornea bilaterally. NECK: Supple with full range of motion. CARDIOVASCULAR: Peripheral pulse is +2 to the right foot. Capillary refills less than two seconds to all the digits of the right foot. RESPIRATIONS: No shortness of breath. MUSCULOSKELETAL: The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot. There is no palpable foreign body, no foreign body is visualized. There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels. It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home. The patient does not have any tenderness to the foot. The patient has full range of motion to all the joints, all the toes, as well as the ankles. The patient ambulates well without any difficulty or discomfort. There are no other injuries noted to the rest of the body. SKIN: The 4-mm partial thickness laceration to the right foot as previously described. No other injuries are noted. NEUROLOGIC: Motor is 5/5 to all the muscle groups of the right lower extremity. Sensory is intact to light touch to all the dermatomes of the right foot. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No active bleeding is occurring at this time. No evidence of bruising is noted to the body. EMERGENCY DEPARTMENT COURSE: The patient had antibiotic ointment and a bandage applied to his foot. DIAGNOSES: 1. A 4-MM LACERATION TO THE RIGHT FOOT. 2. ACUTE RIGHT FOOT PAIN, NOW RESOLVED. CONDITION UPON DISPOSITION: Stable. DISPOSITION: To home. The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection. The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.

Write a clinical note about a patient with the following chief complaint: Status post motor vehicle accident.

CHIEF COMPLAINT: Status post motor vehicle accident. HISTORY OF PRESENT ILLNESS: The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle. He denies loss of consciousness, although the EMT people report that he did have loss of consciousness. The patient was stable en route. Upon arrival, he complained of headache. PAST MEDICAL HISTORY: Medical: None. Surgical: None. REVIEW OF SYSTEMS: CARDIAC: No history. PULMONARY: Some morning cough. (Patient is a smoker.),MEDICATIONS: None. ALLERGIES: ALLERGIC TO PENICILLIN, CAUSES SKIN RASH. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/80, pulse 82, respirations 20, temperature 36.8°. HEENT: Contusion over right occipital area. Tympanic membranes benign. NECK: Nontender. CHEST: Atraumatic, nontender. LUNGS: Clear to auscultation and percussion. ABDOMEN: Flat, soft, and nontender. BACK: Atraumatic, nontender. PELVIS: Stable,EXTREMITIES: Contusion over right forearm. No bone deformity or crepitus. RECTAL: Normal sphincter tone; guaiac negative. NEUROLOGIC: Glasgow coma scale 15. Pupils equal, round, reactive to light. Patient moves all 4 extremities without focal deficit. LABORATORY DATA: Serial hematocrits 42.4, and 40.4. White blood count 6.3. Ethanol: None. Amylase 66. Urinalysis normal. PT 12.6, PTT 29. Chem-7 panel within normal limits. X-rays of cervical spine and lumbosacral spine within normal limits. X-rays of pelvis and chest within normal limits. ASSESSMENT: 1. Closed head injury. 2. Rule out intra-abdominal injury. PLAN: The patient will be admitted to the trauma surgery service for continued evaluation and treatment for closed head injury as well as possible intra-abdominal injury.

Write a clinical note about a patient with the following chief complaint: Increased work of breathing.

CHIEF COMPLAINT: Increased work of breathing. HISTORY OF PRESENT ILLNESS: The patient is a 2-month-old female with a 9-day history of illness. Per mom's report, the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night, which she feels to have helped. The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough. At that time, the patient also had significant increasing congestion. Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms. On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings. The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated. A chest x-ray was obtained and was noted to be normal. The patient's saturations were noted to be normal and the patient was discharged home. Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity. The patient had a 101 temperature on Wednesday evening, but has had no true fevers. The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation. REVIEW OF SYSTEMS: The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: As above. IMMUNIZATIONS: None. PAST MEDICAL HISTORY: No hospitalizations. No surgeries. BIRTH HISTORY: The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery. Birth weight 6 pounds 12 ounces. Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery. The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy. FAMILY HISTORY: Brother, mother, and father all have asthma. Mom was noted to have gestational diabetes. SOCIAL HISTORY: The patient lives with mother, father, and a brother. There is one bird. There are smokers in the household. There are sick contacts. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 97.7 and pulse is 181, but the patient is fussy. Respiratory rate ranged between 36 and 44. The patient is saturating 100% on one-half liter and 89% on room air. GENERAL APPEARANCE: Nontoxic child, but with increased work of breathing. No respiratory distress. HEENT: Head is normocephalic and atraumatic. Anterior fontanelle flat. Pupils are equal, round, and reactive to light bilaterally. Tympanic membranes are clear bilaterally. Nares are congested. Mucous membranes are moist without erythema. NECK: Supple. No lymphadenopathy. CHEST: Exhibits symmetric expansion and retractions. LUNGS: The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi. CARDIOVASCULAR: Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder. ABDOMEN: Soft, nondistended, and nondistended. Good bowel sounds noted in all 4 quadrants. GU: Normal female. No discharge or erythema. BACK: Normal with a normal curvature. EXTREMITIES: A 2+ pulses in the bilateral upper lower extremities. No evidence of clubbing, cyanosis, or edema. Capillary refill less than 3 seconds. LABORATORY DATA: Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes. A urinalysis obtained in the emergency room was noted to be negative. CRP was noted to be 2.0. The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening. ASSESSMENT AND PLAN: This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis. At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed. Currently, at this time, I feel no respiratory treatments are indicated in this patient. I hear no evidence of wheezing or reactive airway disease. We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.

Write a clinical note about a patient with the following chief complaint: Colostomy failure. ,

CHIEF COMPLAINT: Colostomy failure. ,HISTORY OF PRESENT ILLNESS: This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of "heartburn." He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY: As above. Also, hypertension. ,ALLERGIES: "Fleet enema." ,MEDICATIONS: Accupril and vitamins. ,REVIEW OF SYSTEMS: SYSTEMIC: The patient denies fever or chills. HEENT: The patient denies blurred vision, headache, or change in hearing. NECK: The patient denies dysphagia, dysphonia, or neck pain. RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis. CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain. GASTROINTESTINAL: See above. MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling. NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis. GENITOURINARY: The patient denies dysuria, flank pain, or hematuria. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING: Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION: Bowel obstruction, status post colostomy. ,DISPOSITION: Admission to observation. The patient's condition is good. He is hemodynamically stable.

Write a clinical note about a patient with the following chief complaint: Blood in toilet.

CHIEF COMPLAINT: Blood in toilet. HISTORY: Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants. PAST MEDICAL HISTORY: Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past. PAST SURGICAL HISTORY: Unknown. SOCIAL HISTORY: No tobacco or alcohol. MEDICATIONS: Listed in the medical records. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress. HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact. NECK: No lymphadenopathy or JVD. HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi. ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted. GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region. EXTREMITIES: No significant abnormalities. WORKUP: CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization. ER COURSE: Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood. ASSESSMENT: Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

Write a clinical note about a patient with the following history of present illness: This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic. They told to go to the ER if he got worse. He has had some vomiting and some abdominal pain. His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.

CHIEF COMPLAINT: This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic. They told to go to the ER if he got worse. He has had some vomiting and some abdominal pain. His peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day. PAST MEDICAL HISTORY: Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia by report. IMMUNIZATIONS: Up-to-date. ALLERGIES: Denied. MEDICATIONS: Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol. PAST SURGICAL HISTORY: Denied. SOCIAL HISTORY: Lives at home, here in the ED with the mother and there is no smoking in the home. FAMILY HISTORY: No noted exposures. REVIEW OF SYSTEMS: Documented on the template. Systems reviewed on the template. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg. Oxygen saturation low at 91% on room air. GENERAL: This is a well-developed male who is cooperative, alert, active with oxygen by facemask. HEENT: Head is atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular motions are intact and conjugate. Clear TMs, nose, and oropharynx. NECK: Supple. Full painless nontender range of motion. CHEST: Tight wheezing and retractions heard bilaterally. HEART: Regular without rubs or murmurs. ABDOMEN: Soft, nontender. No masses. No hepatosplenomegaly. GENITALIA: Male genitalia is present on a visual examination. SKIN: No significant bruising, lesions or rash. EXTREMITIES: Moves all extremities without difficulty, nontender. No deformity. NEUROLOGIC: Symmetric face, cooperative, and age appropriate. MEDICAL DECISION MAKING: The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia. He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation. Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate. She is further treated in the emergency department with continued breathing treatments. At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells. Based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.

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

CHIEF COMPLAINT: Ankle pain. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts to move or bear weight. No other injuries noted. He does not think he has had injuries to his ankle in the past. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: He does not drink or smoke. ALLERGIES: Unknown. MEDICATIONS: Adderall and Accutane. REVIEW OF SYSTEMS: As above. Ten systems reviewed and are negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air. GENERAL:

Write a clinical note about a patient with the following chief complaint: Blood in urine.

CHIEF COMPLAINT: Blood in urine. HISTORY OF PRESENT ILLNESS: This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine. The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool. The patient has not had any fever. There is no abdominal pain and the patient is still able to pass urine. The patient has not had any melena or hematochezia. There is no nausea or vomiting. The patient has already completed chemotherapy and is beyond treatment for his cancer at this time. The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer. The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever or chills. The patient does report generalized fatigue and weakness over the past several days. HEENT: No headache, no neck pain, no rhinorrhea, no sore throat. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days. GASTROINTESTINAL: The patient denies any abdominal pain. No nausea or vomiting. No changes in the bowel movement. No melena or hematochezia. GENITOURINARY: A gross hematuria since yesterday as previously described. The patient is still able to pass urine without difficulty. The patient denies any groin pain. The patient denies any other changes to the genital region. MUSCULOSKELETAL: The chronic lower back pain which has not changed over these past few days. The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either. SKIN: No rashes or lesions. No easy bruising. NEUROLOGIC: No focal weakness or numbness. No incontinence of urine or stool. No saddle paresthesia. No dizziness, syncope or near-syncope. ENDOCRINE: No polyuria or polydipsia. No heat or cold intolerance. HEMATOLOGIC/LYMPHATIC: The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria. PAST MEDICAL HISTORY: Prostate cancer with metastatic disease as previously described. PAST SURGICAL HISTORY: TURP. CURRENT MEDICATIONS: Morphine, Darvocet, Flomax, Avodart and ibuprofen. ALLERGIES: VICODIN. SOCIAL HISTORY: The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be pale, but otherwise looks well. The patient is calm, comfortable. The patient is pleasant and cooperative. HEENT: Eyes normal with clear conjunctivae and corneas. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx normal without any sign of infection. Mucous membranes are moist. NECK: Supple. Full range of motion. No JVD. CARDIOVASCULAR: Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop. Peripheral pulses are +2. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruit. No masses or pulsatile masses. GENITOURINARY: The patient has normal male genitalia, uncircumcised. There is no active bleeding from the penis at this time. There is no swelling of the testicles. There are no masses palpated to the testicles, scrotum or the penis. There are no lesions or rashes noted. There is no inguinal lymphadenopathy. Normal male exam. MUSCULOSKELETAL: Back is normal and nontender. There are no abnormalities noted to the arms or legs. The patient has normal use of the extremities. SKIN: The patient appears to be pale, but otherwise the skin is normal. There are no rashes or lesions. NEUROLOGIC: Motor and sensory are intact to the extremities. The patient has normal speech. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: There is no evidence of bruising noted to the body. No lymphadenitis is palpated. EMERGENCY DEPARTMENT TESTING: CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6. Neutrophils were 81%. The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable. Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable. Alkaline phosphatase was 770 and albumin was 2.4. Rest of the values all are within normal limits of the LFTs. Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's. The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen. Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3. EMERGENCY DEPARTMENT COURSE: The patient was given normal saline 2 liters over 1 hour without any adverse effect. The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect. The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department. The patient did not have an adverse reaction to these medicines either. Phenergan resolved his nausea and morphine did relieve his pain and make him pain free. I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion. It was all a matter of what the patient wished to do given the advanced stage of his cancer. Dr. X was willing to assist in any way the patient wished him to. I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion. The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight. The patient's son felt comfortable with his father's choice. This was done. The patient was transfused 2 units of packed red blood cells after appropriately typed and match. The patient did not have any adverse reaction at any point with his transfusion. There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength. Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction. Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder. The patient was given a leg bag and the Foley catheter was left in place. DIAGNOSES,1. HEMATURIA. 2. PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE. 3. SIGNIFICANT ANEMIA. 4. URINARY OBSTRUCTION. CONDITION ON DISPOSITION: Fair, but improved. DISPOSITION: To home with his son. PLAN: We will have the patient follow up with Dr. X in his office in 2 days for reevaluation. The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight. The patient was encouraged to drink extra water. The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.

Write a clinical note about a patient with the following chief complaint: Possible exposure to ant bait.

CHIEF COMPLAINT: Possible exposure to ant bait. HISTORY OF PRESENT ILLNESS: This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type. PAST MEDICAL HISTORY: Negative. Generally very healthy. REVIEW OF SYSTEMS: The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not see anything her mouth. MEDICATIONS: None. ALLERGIES: NONE. PHYSICAL EXAMINATION: VITAL SIGNS: The patient was afebrile. Stable vital signs and normal pulse oximetry. GENERAL: The child is very active, cheerful youngster, in no distress whatsoever. HEENT: Unremarkable. Oral mucosa is clear, moist, and well hydrated. I do not see any evidence of any sort of liquid on the face. Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso. Apparently, she had some on her hands that has been wiped off. EMERGENCY DEPARTMENT COURSE: I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case. IMPRESSION: Exposure to ant bait. PLAN: At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely. She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation. So, the patient is discharged in stable condition.

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

CHIEF COMPLAINT: Altered mental status. HISTORY OF PRESENT ILLNESS: This is a 6-year-old white male, who was sent from the Emergency Room with the diagnosis of intracranial bleeding. The patient was found by the 8-year-old sister in the bathroom. He was laying down on one side, and he was crying and moaning. The sibling went and told the parents. The parents rushed to the bathroom, they found him crying, and he was not moving the left side of his body. He was initially alert, but his alertness diminished. They decided to take him to the emergency room in Hospital, where a CT was done on his head, which showed a 4 x 4 x 2.5 cm bleed. The emergency physician called our emergency room, and I decided to involve Neurosurgery, Mr. X, the physician assistant, who is on call for the Neurosurgery Services. Collectively, they have made arrangements with the ICU attendings to have the child transported to our emergency room. For a small stop, I am obtaining an MRI and then admitting to the ICU. History was taken from the parents. He had a history of gastroesophageal reflux disease, otherwise, a healthy child. MEDICATIONS: None. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: He had only tympanostomy tubes placed. FAMILY MEDICAL HISTORY: Unremarkable. PHYSICAL EXAMINATION: GENERAL: He was brought by our transport team. While en route, he was not as alert as he was. He was still oriented. He had to be stimulated via sternal rub to wake up, and saturation went down to the 80s, and he was started on nasal cannula, and code 3 was initiated, and he was rushed to our emergency room. When I saw him, he was lethargic, but arousable. He could recognize where he was, and he could recognize also his parents well. HEENT: Pupils are 4 mm reactive to direct and indirect light. No signs of trauma is seen on the head. Throat is clear. LUNGS: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft. NEUROLOGIC: He has left-sided weakness, but his cranial nerves II through XII are grossly intact. EMERGENCY DEPARTMENT COURSE: In the emergency room, at the time when I saw him, Dr. Y and Dr. Z were from the ICU and Anesthesia Services arrived also, and they evaluated the patient with me and pretty much they took care of the patient. They decided to give him a dose of IV mannitol. I ordered his labs, type and cross. CBC is 15.6 white blood cell count, hemoglobin 12.8. PT/PTT were ordered due to the bleed, which was seen intracerebrally. They were 13.1 and 24.5 respectively. Blood gas, I-STAT pH 7.36, pCO2 is 51. This was a venous specimen. The ICU attendings decided to do a rapid sequence intubation. This was done in our emergency room by Dr. Y and Dr. Z. The patient was sent to the MRI, and from where he was going to be admitted to the ICU in critical condition. DIFFERENTIAL DIAGNOSES: Arteriovenous malformation, stroke, traumatic injury. IMPRESSION: Intracerebral hemorrhage of uncertain etiology to be determined while inpatient. TIME SPENT: I spent 30 minutes critical care time with the patient excluding any procedures.

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

CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old white male who presents with a chief complaint of "chest pain". The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath & diaphoresis. He states that he has had nausea & 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour. The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed. REVIEW OF SYSTEMS: All other systems reviewed & are negative. PAST MEDICAL HISTORY: Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC. SOCIAL HISTORY: Denies alcohol or drugs. Smokes 2 packs of cigarettes per day. Works as a banker. FAMILY HISTORY: Positive for coronary artery disease (father & brother). MEDICATIONS: Aspirin 81 milligrams QDay. Humulin N. insulin 50 units in a.m. HCTZ 50 mg QDay. Nitroglycerin 1/150 sublingually PRN chest pain. ALLERGIES: Penicillin. PHYSICAL EXAM: The patient is a 40-year-old white male. General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates

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 a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss. PAST MEDICAL HISTORY: Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement. PAST SURGICAL HISTORY: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted. ALLERGIES: SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN. SOCIAL HISTORY: She does not drink or smoke. REVIEW OF SYSTEMS: Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath. PHYSICAL EXAMINATION: GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress. VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits. HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected. NECK: Supple. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness. PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse. EXTREMITIES: Grossly and neurovascularly intact. LABORATORY VALUES: White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7. DIAGNOSTIC STUDIES: EKG shows normal sinus rhythm. IMPRESSION AND PLAN: A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.

Write a clinical note about a patient with the following chief complaint: Decreased ability to perform daily living activities secondary to right knee surgery.

CHIEF COMPLAINT: Decreased ability to perform daily living activities secondary to right knee surgery. HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patient was transfused with 2 units of autologous blood postoperatively. She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings. The remainder of her postoperative course was uneventful. She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation. The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital. She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties. She reports having some right knee pain, which is most intense at a "certain position." The patient is unable to elaborate on which "certain position" causes her the most discomfort. ALLERGIES: NKDA. PAST MEDICAL HISTORY: Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago. MEDICATIONS: On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air. GENERAL: No acute distress at the time of the exam except as mentioned above complains of right knee pain at "certain position.",HEENT: Normocephalic. Sclerae nonicteric. EOMI. Dentition in good repair. Tongue is in midline with no evidence of thrush. NECK: No thyroid enlargement. Trachea is midline. LUNGS: Clear to auscultation. HEART: Regular rate and rhythm. Normal S1 and S2. ABDOMEN: Soft, nontender, and nondistended. No organomegaly. EXTREMITIES: The right knee incision is intact. Steri-Strips are in place. There is some diffuse right knee edema and some limited ecchymosis as well. No calf tenderness bilaterally. Pedal pulses are palpable bilaterally. MENTAL STATUS: The patient appears slightly anxious during the interview and exam, but she was alert and oriented. HOSPITAL COURSE: As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation. She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery. The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours. Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain. She remarked that she had a better degree of flexibility, but she did report an increased need for pain management. Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder. On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen. The patient reported that this rash was itchy. She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively. She was treated with betamethasone cream applied to the rash b.i.d. The patient's therapy had progressed and she continued to make a good progress. At one point, the patient reported some insomnia due to right knee pain. She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain. The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range. The Coumadin was adjusted accordingly according to the INRs during her hospital course. Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally. Initial laboratory data includes a UA on 08/28/2007, which was negative. Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000. Chemistries were within normal limits. Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102. The remainder of chemistries was unremarkable. The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007. DISCHARGE DIAGNOSES: 1. Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007. 2. Anxiety disorder. 3. Insomnia secondary to pain and anxiety postoperatively. 4. Postoperative constipation. 5. Contact dermatitis secondary to preoperative gardening activities. 6. Hypertension. 7. Hypothyroidism. 8. Gastroesophageal reflux disease. 9. Morton neuroma of the feet bilaterally. 10. Distant history of migraine headaches. INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: The patient is advised to continue taking the following medications: Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily. The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926. At the present time, the patient is taking Coumadin 7 mg daily. She will remain on Coumadin for 30 days. An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary. Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office. The patient is encouraged to follow up with her primary care physician, Dr. B. As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation.

Write a clinical note about a patient with the following chief complaint: Decreased ability to perform daily living activity secondary to recent right hip surgery.

CHIEF COMPLAINT: Decreased ability to perform daily living activity secondary to recent right hip surgery. HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively. She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services. Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0. She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery. Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy. MEDICATIONS: Medications taken at home are Paxil, MOBIC, and Klonopin. MEDICATIONS ON TRANSFER: Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker. REVIEW OF SYSTEMS: As mentioned above. She has a history of migraine headaches associated with her menstrual cycle. She wears glasses and has a history of floaters. She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign. The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis. She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery. She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties. First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago. PHYSICAL EXAMINATION: VITAL SIGNS: At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air. GENERAL: No acute distress at the time of exam. HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Dentition is in good repair. NECK: Trachea is at the midline. LUNGS: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Bowel sounds are heard throughout. Soft and nontender. EXTREMITIES: Right hip incision is clean, intact, and no drainage is noted. There is diffuse edema, which extends distally. There is no calf tenderness per se bilaterally and Homans sign is negative. There is no pedal edema. MENTAL STATUS: Alert and oriented x3, pleasant and cooperative during the exam. LABORATORY DATA: Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6. The BUN was normal at 8, creatinine was 0.9, INR was 1.49. CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000. IMPRESSION: 1. Status post right total hip replacement. The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy. 2. Postoperative anemia, Feosol 325 mg one q.d. 3. Pain management. Oxycodone SR 20 mg b.i.d. and oxycodone IR 5 mg one to two tablets q.4h. p.r.n. pain. Additionally, she will utilize ice to help decrease edema. 4. Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s. 5. Osteoarthritis, Celebrex 200 mg b.i.d. 6. GI prophylaxis, Protonix 40 mg b.i.d. Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d. 7. DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR. She will continue on 5 mg every day. 8. Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis. Monitor for any possibility of DVT.

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

CHIEF COMPLAINT: GI bleed. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue. CBC revealed microcytic anemia with hemoglobin of 8.9. Stool dark brown, strongly OB positive. The patient denied any shortness of breath. No chest pain. No GI complaints. The patient was admitted to ABCD for further evaluation. PAST MEDICAL HISTORY: Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism. PHYSICAL EXAMINATION: GENERAL: The patient is in no acute distress. VITAL SIGNS: Stable. HEENT: Benign. NECK: Supple. No adenopathy. LUNGS: Clear with good air movement. HEART: Irregularly regular. No gallops. ABDOMEN: Positive bowel sounds, soft, and nontender. No masses or organomegaly. EXTREMITIES: 1+ lower extremity edema bilaterally. HOSPITAL COURSE: The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis. Colonoscopy did reveal diverticulosis as well as polyp, which was resected. The patient tolerated the procedure well. She was transfused, and prior to discharge hemoglobin was stable at 10.7. The patient was without further GI complaints. Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume. The patient was discharged with outpatient PMD, GI, and Cardiology followup. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Anemia. 3. Atrial fibrillation. 4. Non-insulin-dependent diabetes mellitus. 5. Hypertension. 6. Hypothyroidism. 7. Asthma. CONDITION UPON DISCHARGE: Stable. MEDICATIONS: Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d. KCl 20 mEq daily, Lasix 40 mg b.i.d. atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily. ALLERGIES: None. DIET: 1800-calorie ADA. ACTIVITY: As tolerated. FOLLOWUP: The patient to hold Coumadin through weekend. Followup CBC and INR were ordered. Outpatient followup as arranged.

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 chief complaint: Chest pain and fever.

CHIEF COMPLAINT: Chest pain and fever. HISTORY OF PRESENT ILLNESS: This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating. The patient does have a past medical history of diabetes and hypertension. In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well. The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits. She has not had any musculoskeletal or neurological deficits. She denies any rashes or skin lesions. PAST MEDICAL HISTORY: Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes. PAST SURGICAL HISTORY: Cholecystectomy, appendectomy, oophorectomy. FAMILY HISTORY: Positive for coronary artery disease in her father and brother in their 40s. SOCIAL HISTORY: She is married and does not smoke or drink nor did she ever. PHYSICAL EXAMINATION: On admission, temperature 99.4 degrees F. blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort. In general, she is well developed, well nourished, oriented, and alert and in no apparent distress. Head, ears, eyes, nose, and throat are unremarkable. Neck is supple. No neck vein distention is noted. No bruits are heard. Chest is clear to percussion and auscultation. Heart has a regular rhythm and rate without murmurs or rubs or gallops. Abdomen is soft, obese, and nontender. Musculoskeletal is intact without deformity. However, the patient did develop severe cramp behind her left knee during her treadmill testing. Neurologic: Cranial nerves are intact and she is nonfocal. Skin is warm and dry without rash or lesions noted. LABORATORY FINDINGS: Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2. Liver function panel is normal. CK was 82. MB fraction was 1.0. Troponin was less than 0.1 on three occasions. White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000. Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods. Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0. EKG was normal. DIAGNOSES ON ADMISSION: 1. Urinary tract infection. 2. Chest pain of unclear etiology, rule out myocardial infarction. 3. Neck and back pain of unclear etiology with a negative spinal tap. 4. Hypertension. 5. Diabetes type II, not treated with insulin. 6. Hyperlipidemia treated with TriCor but not statins. 7. Arthritis. ADDITIONAL LABORATORY STUDIES: B-natriuretic peptide was 26. Urine smear and culture negative on 24 and 48 hours. Chest x-ray was negative. Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81. COURSE IN THE HOSPITAL: The patient was placed on home medications. This will be listed at the end of the discharge summary. She was put on rule out acute myocardial infarction routine, and she did in fact rule out. She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70. She has a strong family history of early myocardial disease in the men in their 40s. DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 81 mg one daily. This is new, as the patient was not taking aspirin at home. 2. TriCor 48 mg one daily. 3. Zantac 40 mg one daily. 4. Lisinopril 20 mg one daily. 5. Mobic 75 mg one daily for arthritis. 6. Metformin 500 mg one daily. 7. Macrodantin one two times a day for several more days. 8. Zocor 20 mg one daily, which is a new addition. 9. Effexor XR 37.5 mg one daily. DIET: ADA 1800-calorie diet. ACTIVITY: As tolerated. Continue water exercise five days a week. DISPOSITION: Recheck at Hospital with a regular physician there in 1 week. Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.

Write a clinical note about a patient with the following chief complaint: Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.

CHIEF COMPLAINT: Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years. On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright. He was seen at ABCD Hospital Emergency Room, was evaluated and admitted. He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A. It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007. He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes. The patient reports that he has had a " bulging disk" for approximately 1 year. He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative. The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist. ALLERGIES: PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES. Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all. PAST MEDICAL HISTORY: Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is employed in the finance department. He is a nonsmoker. He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends. He denies any IV drug use or abuse. REVIEW OF SYSTEMS: No chills, fever, shakes or tremors. Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis. The patient reports that his last bowel movement was on 08/30/2007. No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties. The patient does report that he has occasional intermittent "numbness and tingling" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome. He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved. PHYSICAL EXAMINATION: VITAL SIGNS: At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air. The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report. GENERAL: The patient appears to be comfortable, in no acute distress. HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Tongue is at midline and no evidence of thrush. NECK: Trachea is at the midline. LYMPHATICS: No cervical or axillary nodes palpable. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. Normal S1 and S2. ABDOMEN: Obese, softly protuberant, and nontender. EXTREMITIES: There is no clubbing, cyanosis or edema. There is no calf tenderness bilaterally. Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity. The right lower extremity is 4-5/5. MENTAL STATUS: He is alert and oriented. He was pleasant and cooperative during the examination. ASSESSMENT: 1. Acute on chronic back pain. The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy. He will be seen in consultation by Physical Therapy and Occupational Therapy. He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain. 2. Status post right orchiectomy secondary to testicular cancer, stable at this time. We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B. 3. Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis. Colace 100 mg b.i.d. lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily. 4. Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well. 5. Obesity. As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.

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 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: 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: Buttock abscess.

CHIEF COMPLAINT: Buttock abscess. HISTORY OF PRESENT ILLNESS: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation. PAST MEDICAL HISTORY: Diabetes type II, poorly controlled, high cholesterol. PAST SURGICAL HISTORY: C-section and D&C. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Insulin, metformin, Glucotrol, and Lipitor. FAMILY HISTORY: Diabetes, hypertension, stroke, Parkinson disease, and heart disease. REVIEW OF SYSTEMS: Significant for pain in the buttock. Otherwise negative. PHYSICAL EXAMINATION: GENERAL: This is an overweight African-American female not in any distress. VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range. HEENT: Normal to inspection. NECK: No bruits or adenopathy. LUNGS: Clear to auscultation. CV: Regular rate and rhythm. ABDOMEN: Protuberant, soft, and nontender. EXTREMITIES: No clubbing, cyanosis or edema. RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema. ASSESSMENT AND PLAN: Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details.

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: Dental pain.

CHIEF COMPLAINT: Dental pain. HISTORY OF PRESENT ILLNESS: This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw. The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured. The patient states that the pain in her left lower teeth kept her up last night. The patient did go to Clinic but arrived there later than 7 a.m. so she was not able to be seen there will call line for dental care. The patient states that the pain continues to be very severe at 9/10. She states that this is like a throbbing heart beat in her left jaw. The patient denies fevers or chills. She denies purulent drainage from her gum line. The patient does believe that there may be an area of pus accumulating in her gum line however. The patient denies nausea or vomiting. She denies recent dental trauma to her knowledge. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Hypothyroidism. PAST SURGICAL HISTORY: Coronary artery stent insertion. SOCIAL HABITS: The patient denies alcohol or illicit drug usage. Currently she does have a history of tobacco abuse. MEDICATIONS: 1. Plavix. 2. Metoprolol. 3. Synthroid. 4. Potassium chloride. ALLERGIES: 1. Penicillin. 2. Sulfa. PHYSICAL EXAMINATION: GENERAL: This is a Caucasian female who appears of stated age of 45 years. She is well-nourished, well-developed, in no acute distress. The patient is pleasant but does appear to be uncomfortable. VITAL SIGNS: Afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air. HEENT: Head is normocephalic. Pupils are equal, round and reactive to light and accommodation. Sclerae are anicteric and noninjected. Nares are patent and free of mucoid discharge. Mucous membranes are moist and free of exudate or lesion. Bilateral tympanic membranes are visualized and free of infection or trauma. Dentition shows significant decay throughout the dentition. The patient has had extraction of teeth 17, 18, and 19. The patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site. There is no pus draining from the socket of the tooth. No other acute abnormality to the other dentition is visualized. DIAGNOSTIC STUDIES: None. PROCEDURE NOTE: The patient does receive an injection of 1.5 mL of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth. The patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two Vicodin here in the Emergency Department and a dose of Keflex for treatment of her dental infection. ASSESSMENT: Dental pain with likely dental abscess. ,PLAN: The patient was given a prescription for Vicodin. She is also given prescription for Keflex, as she is penicillin allergic. She has tolerated a dose of Keflex here in the Emergency Department well without hypersensitivity. The patient is strongly encouraged to follow up with Dental Clinic on Monday, and she states that she will do so. The patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the ER.

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

CHIEF COMPLAINT: Dental pain. HISTORY OF PRESENT ILLNESS: This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation. PAST MEDICAL HISTORY: Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease. She has chronic pain in general and is followed by Dr. X. REVIEW OF SYSTEMS: Otherwise, unremarkable. Has not noted any fever or chills. However she, as mentioned, does note the dental discomfort with increasing swelling and pain. Otherwise, unremarkable except as noted. CURRENT MEDICATIONS: Please see list. ALLERGIES: IODINE, FISH OIL, FLEXERIL, BETADINE. PHYSICAL EXAMINATION: VITAL SIGNS: The patient was afebrile, has stable and normal vital signs. The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain. HEENT: Unremarkable. I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region. There is no neck adenopathy. Oral mucosa is moist and well hydrated. Dentition looks to be in reasonable condition. However, she definitely is tender to percussion on the left lower first premolar. I do not see any huge cavity or anything like that. No real significant gingival swelling and there is no drainage noted. None of the teeth are tender to percussion. PROCEDURE: Dental nerve block. Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia. I have then written a prescription for penicillin and Vicodin for pain. IMPRESSION: ACUTE DENTAL ABSCESS. ASSESSMENT AND PLAN: The patient needs to follow up with the dentist for definitive treatment and care. She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics. However, outpatient followup should be adequate. She is discharged in stable condition.

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: 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.