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Tiger Research 69

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

CHIEF COMPLAINT: Left wrist pain. HISTORY OF PRESENT PROBLEM:

Write a clinical note about a patient with the following chief complaint: Well-child check.

CHIEF COMPLAINT: Well-child check. HISTORY OF PRESENT ILLNESS: This is a 12-month-old female here with her mother for a well-child check. Mother states she has been doing well. She is concerned about drainage from her left eye. Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning. She states it is worse when the child gets a cold. She has been using massaging when she can remember to do so. The patient is drinking whole milk without problems. She is using solid foods three times a day. She sleeps well without problems. Her bowel movements are regular without problems. She does not attend daycare. DEVELOPMENTAL ASSESSMENT: Social: She can feed herself with fingers. She is comforted by parent’s touch. She is able to separate and explore. Fine motor: She scribbles. She has a pincer grasp. She can drink from a cup. Language: She says dada. She says one to two other words and she indicates her wants. Gross motor: She can stand alone. She cruises. She walks alone. She stoops and recovers. PHYSICAL EXAMINATION: General: She is alert, in no distress. Vital signs: Weight: 25th percentile. Height: 25th percentile. Head circumference: 50th percentile. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Left eye with watery secretions and crusted lashes. Conjunctiva is clear. TMs are clear bilaterally. Nares are patent. Mild nasal congestion present. Oropharynx is clear. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular. No murmur. Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly. GU: Female external genitalia. Extremities: Symmetrical. Femoral pulses are 2+ bilaterally. Full range of motion of all extremities. Neurologic: Grossly intact. Skin: Normal turgor. Testing: Hearing and vision assessments grossly normal. ASSESSMENT: 1. Well child. 2. Left lacrimal duct stenosis. PLAN: MMR #1 and Varivax #1 today. VIS statements given to Mother after discussion. Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct. Anticipatory guidance for age. She is to return to the office in three months.

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

CHIEF COMPLAINT: Urinary retention. HISTORY OF PRESENT ILLNESS: This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time. Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably secondary to dehydration. He was seen by urology again at this visit for urinary retention. He had been seen by urology during a previous hospitalization and he passed his voiding trial at the time of his stent removal on 01/22/08. Cystoscopy showed at that time obstructive BPH. He was started on Flomax at the time of discharge from the hospital. During the most recent readmission on 02/04/08, he went back into urinary retention and he had had a Foley placed at the outside hospital. REVIEW OF SYSTEMS: Positive for blurred vision, nasal congestion, and occasional constipation. Denies chest pain, shortness of breath or any rashes or lesions. All other systems were reviewed and found to be negative. PAST MEDICAL HISTORY: 1. End-stage renal disease, now status post deceased donor kidney transplant in 12/07. 2. Hypertension. 3. History of nephrolithiasis. 4. Gout. 5. BPH. 6. DJD. PAST SURGICAL HISTORY: 1. Deceased donor kidney transplant in 12/07. 2. Left forearm and left upper arm fistula placements. FAMILY HISTORY: Significant for mother with an unknown type of cancer, possibly colon cancer or lung and prostate problems on his father side of the family. He does not know whether his father side of the family had any history of prostate cancer. HOME MEDICATIONS: 1. Norvasc. 2. Toprol 50 mg. 3. Clonidine 0.2 mg. 4. Hydralazine. 5. Flomax. 6. Allopurinol. 7. Sodium bicarbonate. 8. Oxybutynin. 9. Coumadin. 10. Aspirin. 11. Insulin 70/30. 12. Omeprazole. 13. Rapamune. 14. CellCept. 15. Prednisone. 16. Ganciclovir. 17. Nystatin swish and swallow. 18. Dapsone. 19. Finasteride. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: GENERAL: This is a well-developed, well-nourished male, in no acute distress. VITAL SIGNS: Temperature 98, blood pressure 129/72, pulse 96, and weight 175.4 pounds. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm with a 3/6 systolic murmur. ABDOMEN: Right lower quadrant incision site scar well healed. Nontender to palpation. Liver and spleen not enlarged. No hernias appreciated. PENIS: Normal male genitalia. No lesions appreciated on the penis. Previous DRE showed the prostate of approximately 40 grams and no nodules. Foley in place and draining clear urine. The patient underwent fill and pull study, in which his bladder tolerated 120 ml of sterile water passively filling his bladder. He spontaneously voided without the Foley 110 mL. ASSESSMENT AND PLAN: This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since the kidney transplant in 12/07. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again. We discussed with Mr. Barker that he has a urologist closer to his home and he lives approximately 3 hours away; however, he desires to continue follow up with the urology clinic at MCG and has been set up for followup in 6 weeks. He was also given a prescription for 6 months of Flomax and Proscar. He did not have a PSA drawn today as he had a catheter in place, therefore his PSA could be falsely elevated. He will have PSA level drawn either just before his visit for followup.

Write a clinical note about a patient with the following chief complaint: Right distal ureteral calculus.

CHIEF COMPLAINT: Right distal ureteral calculus. HISTORY OF PRESENT ILLNESS: The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement. PAST MEDICAL HISTORY: 1. Prostatism. 2. Coronary artery disease. PAST SURGICAL HISTORY: 1. Right spermatocelectomy. 2. Left total knee replacement in 1987. 3. Right knee in 2005. MEDICATIONS: 1. Coumadin 3 mg daily. 2. Fosamax. 3. Viagra p.r.n. ALLERGIES: NONE. REVIEW OF SYSTEMS: CARDIOPULMONARY: No shortness of breath or chest pain. GI: No nausea, vomiting, diarrhea or constipation. GU: Voids well. MUSCULOSKELETAL: No weakness or strokes. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL APPEARANCE: An alert male in no distress. HEENT: Grossly normal. NECK: Supple. LUNGS: Clear. HEART: Normal sinus rhythm. No murmur or gallop. ABDOMEN: Soft. No masses. GENITALIA: Normal penis. Testicles descended bilaterally. RECTAL: Examination benign. EXTREMITIES: No edema. IMPRESSION: Right distal ureteral calculus. PLAN: Right ureteroscopy, ureteral lithotripsy. Risks and complications discussed with the patient. He signed a true informed consent. No guarantees or warrantees were given.

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

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

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

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

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

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

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

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

Write a clinical note about a patient with the following chief complaint: 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: Well-child check and school physical.

CHIEF COMPLAINT: Well-child check and school physical. HISTORY OF PRESENT ILLNESS: This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially writing, but he is receiving help with that and math. He continues to eat well. He could do better with milk intake, but Mother states he does eat cheese and yogurt. He brushes his teeth daily. He has regular dental visits every six months. Bowel movements are without problems. He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors. DEVELOPMENTAL ASSESSMENT: Social: He has a sense of humor. He knows his rules. He does home chores. Fine motor: He is as mentioned before. He can draw a person with six parts. Language: He can tell time. He knows the days of the week. He reads for pleasure. Gross motor: He plays active games. He can ride a bicycle. REVIEW OF SYSTEMS: He has had no fever and no vision problems. He had an eye exam recently with Dr. Crum. He has had some headaches which precipitated his vision exam. No earache or sore throat. No cough, shortness of breath or wheezing. No stomachache, vomiting or diarrhea. No dysuria, urgency or frequency. No excessive bleeding or bruising. MEDICATIONS: No daily medications. ALLERGIES: Cefzil. IMMUNIZATIONS: His immunizations are up to date. PHYSICAL EXAMINATION: General: He is alert and in no distress, afebrile. HEENT: Normocephalic, atraumatic. Pupils equal, round and react to light. TMs are clear bilaterally. Nares: Patent. Oropharynx is clear. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular. No murmur. Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly. GU: Tanner III. Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities. Back: No scoliosis. Neurological: Grossly intact. Skin: Normal turgor. No rashes. Hearing: Grossly normal. ASSESSMENT: Well child. PLAN: Anticipatory guidance for age. He is to return to the office in one year.

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: Severe back pain and sleepiness. The patient is not a good historian and history was obtained from the patient's husband at bedside.

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

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

CHIEF COMPLAINT: Right shoulder pain. HISTORY OF PRESENT PROBLEM:

Write a clinical note about a patient with the following chief complaint: Well-child check sports physical.

CHIEF COMPLAINT: Well-child check sports physical. HISTORY OF PRESENT ILLNESS: This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. He is here with his mother for a well-child check. Mother states he has been doing well with regard to his asthma and allergies. He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed. His last exacerbation was 04/04. He has been very competitive in his sports this spring and summer and has had no issues since that time. He eats well from all food groups. He has very good calcium intake. He will be attending Maize High School in the ninth grade. He has same-sex and opposite-sex friends. He has had a girlfriend in the past. He denies any sexual activity. No use of alcohol, cigarettes or other drugs. His bowel movements are without problems. His immunizations are up to date. His last tetanus booster was in 07/03. CURRENT MEDICATIONS: As above. ALLERGIES: He has no known medication allergies. REVIEW OF SYSTEMS: Constitutional: He has had no fever. HEENT: No vision problems. No eye redness, itching or drainage. No earache. No sore throat or congestion. Cardiovascular: No chest pain. Respiratory: No cough, shortness of breath or wheezing. GI: No stomachache, vomiting or diarrhea. GU: No dysuria, urgency or frequency. Hematological: No excessive bruising or bleeding. He did have a minor concussion in 06/04 while playing baseball. PHYSICAL EXAMINATION: General: He is alert and in no distress. Vital signs: He is afebrile. His weight is at the 75th percentile. His height is about the 80th percentile. HEENT: Normocephalic. Atraumatic. Pupils are equal, round and reactive to light. TMs are clear bilaterally. Nares patent. Nasal mucosa is mildly edematous and pink. No secretions. Oropharynx is clear. Neck: Supple. Lungs: Good air exchange bilaterally. Heart: Regular. No murmur. Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly. GU: Male. Testes descended bilaterally. Tanner IV. No hernia appreciated. Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities. Back: No scoliosis. Neurological: Grossly intact. Skin: Normal turgor. Minor sunburn on upper back. Neurological: Grossly intact. ASSESSMENT: 1. Well child. 2. Asthma with good control. 3. Allergic rhinitis, stable. PLAN: Hearing and vision assessment today are both within normal limits. Will check an H&H today. Continue all medications as directed. Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue. Anticipatory guidance for age. He is to return to the office in one year or sooner if needed.

Write a clinical note about a patient with the following history of present illness: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has existed for 2 weeks. He indicates the problem location is the right hand and left hand. Patient indicates no modifying factors. Severity of condition is slowly worsening. Onset was unknown.

CHIEF COMPLAINT: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has existed for 2 weeks. He indicates the problem location is the right hand and left hand. Patient indicates no modifying factors. Severity of condition is slowly worsening. Onset was unknown. ALLERGIES: Patient admits allergies to aspirin resulting in GI upset, disorientation. MEDICATION HISTORY: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD. PAST MEDICAL HISTORY: Past medical history is unremarkable. PAST SURGICAL HISTORY: Patient admits past surgical history of (+) appendectomy in 1989. FAMILY HISTORY: Patient admits a family history of rheumatoid arthritis associated with maternal grandmother. SOCIAL HISTORY: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. REVIEW OF SYSTEMS: Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) numbness,Musculoskeletal: (-) back pain (chronic) (-) decreased ROM (-) episodic weakness,Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms (-) sleep apnea,PHYSICAL EXAM: BP Standing: 120/84 HR: 79 Temp: 98.6 Height: 5 ft. 8 in. Weight: 168 lbs. Patient is a 26 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Palpation of skin shows no abnormalities. HEENT: Inspection of head and face shows no abnormalities. Hair growth and distribution is normal. Examination of scalp shows no abnormalities. Conjunctiva and lids reveal no signs or symptoms of infection. Pupil exam reveals round and reactive pupils without afferent pupillary defect. Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Bilateral retinas reveal normal color, contour, and cupping. Inspection of ears reveals no abnormalities. Otoscopic examination reveals no abnormalities. Examination of oropharynx reveals no abnormalities and tissues pink and moist. ENT: Inspection of ears reveals no abnormalities. Examination of larynx reveals no abnormalities. Inspection of nose reveals no abnormalities. Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable. Thyroid examination reveals no abnormalities and smooth and symmetric gland with no enlargement, tenderness or masses noted. Lymphatic: Neck lymph nodes are normal. Respiratory: Assessment of respiratory effort reveals even respirations without use of accessory muscles and no intercostal retractions noted. Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion. Auscultation of lungs reveals clear lung fields and no rubs noted. Cardiovascular: Heart auscultation reveals normal S1 and S2 and no murmurs, gallop, rubs or clicks. Examination of peripheral vascular system reveals full to palpation, varicosities absent, extremities warm to touch and no edema. Abdomen: Abdominal contour is slightly rounded. Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities. Palpation of spleen reveals no abnormalities. Musculoskeletal: Gait and station examination reveals normal arm swing, with normal heel-toe and tandem walking. Inspection and palpation of bones, joints and muscles is unremarkable. Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Neurologic/Psychiatric: Psychiatric: Oriented to person, place and time. Mood and affect normal and appropriate to situation. Testing of cranial nerves reveals no deficits. Coordination is good. Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal. TEST & X-RAY RESULTS: Rheumatoid factor: 52 U/ml. Sed rate: 31 mm/hr. C4 complement: 19 mg/dl. IMPRESSION: Rheumatoid arthritis. PLAN: ESR ordered; automated. Ordered RBC. Ordered quantitative rheumatoid factor. Return to clinic in 2 week (s). PRESCRIPTIONS: Vioxx Dosage: 12.5 mg tablet Sig: BID Dispense: 30 Refills: 2 Allow Generic: No

Write a clinical note about a patient with the following history of present illness: This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. Patient relates pain on a scale from 0 to 10 as 5/10. Severity: The severity has worsened over the past 3 months. Timing (onset/frequency): Onset was gradual and after pitching a baseball game. Modifying Factors: Patient's condition is aggravated by throwing. He participates with difficulty in basketball. Past conservative treatments include NSAID and muscle relaxant medications.

CHIEF COMPLAINT: This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. Patient relates pain on a scale from 0 to 10 as 5/10. Severity: The severity has worsened over the past 3 months. Timing (onset/frequency): Onset was gradual and after pitching a baseball game. Modifying Factors: Patient's condition is aggravated by throwing. He participates with difficulty in basketball. Past conservative treatments include NSAID and muscle relaxant medications. ALLERGIES: No known medical allergies. MEDICATION HISTORY: None. PAST MEDICAL HISTORY: Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY: No previous surgeries. FAMILY HISTORY: Patient admits a family history of arthritis associated with mother. SOCIAL HISTORY: Patient denies smoking, alcohol abuse, illicit drug use and STDs. REVIEW OF SYSTEMS: Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM. Psychiatric: (-) psychiatric or emotional difficulties. Eyes: (-) visual disturbance or change. Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms. Allergic / Immunologic: (-) allergic or immunologic symptoms. Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat. Gastrointestinal: (-) GI symptoms. Genitourinary: (-) GU symptoms. Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness. Cardiovascular: (-) cardiovascular problems or chest symptoms. Respiratory: (-)breathing difficulties, respiratory symptoms. Physical Exam: BP Standing: 116/68 Resp: 16 HR: 68 Temp: 98.1 Height: 5 ft. 11 in. Weight: 165 lbs. Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Oriented to person, place and time. Right shoulder shows evidence of swelling and tenderness. Radial pulses are 2 /4, bilateral. Brachial pulses are 2 /4, bilateral. Appearance: Normal. Tenderness: Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right. Range of Motion: Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation. L shoulder normal. Strength: External rotation - fair. Internal rotation - poor right. AC Joint: Pain with ABD and cross-chest - mild right. Rotator Cuff: Impingement - moderate. Painful arc - moderate right. Instability: None. TEST & X-RAY RESULTS: X-rays of the shoulder were performed. X-ray of right shoulder reveals cuff arthropathy present. IMPRESSION: Rotator cuff syndrome, right. PLAN: Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed. I noted that this is a very common condition resulting in significant difficulties with use of the arm. Several treatment options and their potential benefits were described. Nonsteroidal anti-inflammatories can be helpful but typically are slow acting. Cortisone shots can be very effective and are quite safe. Often more than one injection may be required. Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength. If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear. Injected shoulder joint and with Celestone Soluspan 1.0 cc . Ordered x-rays of shoulder right. PRESCRIPTIONS: Vioxx Dosage: 25 mg tablet Sig: TID Dispense: 60 Refills: 0 Allow Generic: Yes,PATIENT INSTRUCTIONS: Patient was instructed to restrict activity. Patient was given instructions on RICE therapy.

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 history of present illness: Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years. He denies any gasping, choking, or coughing episodes while asleep at night. His bedtime is between 10 to 11 p.m. has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed. He has two to three episodes of nocturia per night. He denies any morning symptoms. He has mild excess daytime sleepiness manifested by dozing off during boring activities.

CHIEF COMPLAINT: Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years. He denies any gasping, choking, or coughing episodes while asleep at night. His bedtime is between 10 to 11 p.m. has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed. He has two to three episodes of nocturia per night. He denies any morning symptoms. He has mild excess daytime sleepiness manifested by dozing off during boring activities. PAST MEDICAL HISTORY: Hypertension, gastritis, and low back pain. PAST SURGICAL HISTORY: TURP. MEDICATIONS: Hytrin, Motrin, Lotensin, and Zantac. ALLERGIES: None. FAMILY HISTORY: Hypertension. SOCIAL HISTORY: Significant for about a 20-pack-year tobacco use, quit in 1991. No ethanol use or illicit drug use. He is married. He has one dog at home. He used to be employed at Budd Automotors as a die setter for about 37 to 40 years. REVIEW OF SYSTEMS: His weight has been steady over the years. Neck collar size is 17½". He denies any chest pain, cough, or shortness of breath. Last chest x-ray within the past year, per his report, was normal. PHYSICAL EXAM: A pleasant, obese, African-American male in no apparent respiratory distress. T: 98. P: 90. RR: 20. BP: 156/90. O2 saturation: 97% on room air. Ht: 5' 5". Wt: 198 lb. HEENT: A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD. CARDIAC: Regular rate and rhythm without any adventitious sounds. CHEST: Clear lungs bilaterally. ABDOMEN: An obese abdomen with active bowel sounds. EXTREMITIES: No cyanosis, clubbing, or edema. NEUROLOGIC: Non-focal. IMPRESSION: 1. Probable obstructive sleep apnea syndrome. 2. Hypertension. 3. Obesity. 4. History of tobacco use. PLAN: 1. We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome. 2. Encouraged weight loss. 3. Check TSH. 4. Asked not to drive and engage in any activity that could endanger himself or others while sleepy. 5. Asked to return to the clinic one week after sleep the study is done.

Write a clinical note about a patient with the following identifying data: The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.

IDENTIFYING DATA: The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. CHIEF COMPLAINT: "I am not sure." The patient has poor insight into hospitalization and need for treatment. HISTORY OF PRESENT ILLNESS: The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas. According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks. The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle. The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail. The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold). PAST PSYCHIATRIC HISTORY: History of schizophrenia, chronic paranoid. The patient as noted has been treated in Houston but has not had recent treatment or medications. PAST MEDICAL HISTORY: No acute medical problems noted. CURRENT MEDICATIONS: None. The patient was most recently treated with Invega and Abilify according to his records. FAMILY SOCIAL HISTORY: The patient resides with his father in Houston. The patient has no known history of substances abuse. The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold. FAMILY PSYCHIATRIC HISTORY: Need to increase database. MENTAL STATUS EXAMINATION: Attitude: Calm and cooperative. Appearance: Shows poor hygiene and grooming. Psychomotor: Behavior is within normal limits without agitation or retardation. No EPS or TDS noted. Affect: Is suspicious. Mood: Anxious but cooperative. Speech: Shows normal rate and rhythm. Thoughts: Disorganized,Thought Content: Remarkable for paranoia "they want to hurt me.",Psychosis: The patient endorses paranoid delusions as above. The patient denies auditory hallucinations. Suicidal/Homicidal Ideation: The patient denies on admission. Cognitive Assessment: Grossly intact. The patient is alert and oriented x 3. Judgment: Poor, shown by noncompliance with treatment. Assets: Include stable physical status. Limitations: Include recurrent psychosis. FORMULATION: The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment. INITIAL IMPRESSION: AXIS I: Schizophrenia, chronic paranoid. AXIS II: None. AXIS III: None. AXIS IV: Severe. AXIS V: 10. ESTIMATED LENGTH OF STAY: 12 days. PLAN: The patient will be restarted on Invega and Abilify for psychosis. The patient will also be continued on Cogentin for EPS. Increased database will be obtained.

Write a clinical note about a patient with the following identifying data: The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner.

IDENTIFYING DATA: The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner. CHIEF COMPLAINT: "I'm in jail because I was wrongly arrested." The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability. HISTORY OF PRESENT ILLNESS: The patient has minimal insight into the circumstances that resulted in this admission. He reports being diagnosed with AIDS and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition. Prior to admission, the patient was brought to Emergency Room after he attempted to shoplift from a local department store, during which he apparently slapped his partner. The patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability. On the interview, the patient is still disorganized and confused. He believes that he has been arrested and is in jail. Reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary. I was able to contact his partner by telephone. His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers. His partner estimates the patient spends about 20% of the year in episodes of worse symptoms. His partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons. He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night. He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently. He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home. He reports that the patient has been eating regularly with no recent weight loss. He states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months. His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening. He reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine. He also reports that the patient has expressed the belief in the past that he does not suffer from either condition. PAST PSYCHIATRIC HISTORY: The patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown. The patient was last enrolled in an outpatient mental health treatment in mid 2009. He dropped out of care about six months ago when he moved with his partner. His partner reports the patient was most recently prescribed Seroquel, which, though the patient denied benefiting from, his partner felt was "useful, but not dosed high enough." Past medication trials that the patient reports include Haldol and lithium, neither of which he found to be particularly helpful. MEDICAL HISTORY: The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis. He is currently followed at Clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year. The patient is fairly vague on his history of AIDS related conditions, but does identify the following: Thrush, skin lesions, and lung infections; additional details of these problems are not currently known. CURRENT MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL AND DEVELOPMENTAL HISTORY: The patient lives with his partner. He is unemployed. Details of his educational and occupational history are not currently known. His source of finances is also unknown, though social security disability is presumed. SUBSTANCE AND ALCOHOL HISTORY: The patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month. His partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently. The patient reports smoking marijuana a few times in his life, but not recently. Denies other illicit substance use. LEGAL HISTORY: Unknown. GENETIC PSYCHIATRIC HISTORY: Also unknown. MENTAL STATUS EXAM: Attitude: The patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions. His appearance is cachectic. The patient is poorly groomed. Psychomotor: There is no psychomotor agitation or retardation. No other observed extrapyramidal symptoms or tardive dyskinesia. Affect: His affect is fairly detached. Mood: Describes his mood is "okay.",Speech: His speech is normal rate and volume. Tone, his volume was decreased initially, but this improved during the course of the interview. Thought Process: His thought processes are markedly tangential. Thought content: The patient is fairly scattered. He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time. He denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline. Paranoid delusions are elicited. Homicidal/Suicidal Ideation: He denies suicidal or homicidal ideation. Denies previous suicide attempts. Cognitive Assessment: Cognitively, he is alert and oriented to person and year only. His memory is intact to names of his Madison Clinic providers. Insight/Judgment: His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses. His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions. Assets: His assets include his housing and his history of supportive relationship with his partner over many years. Limitations: His limitations include his AIDS and his history of poor compliance with treatment. FORMULATION: The patient is a 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months. It is unclear to me how much his presentation is a direct expression of an AIDS-related condition, though I suspect the impact of his HIV status is likely to be substantial. DIAGNOSES: AXIS I: Schizophrenia by history. Rule out AIDS-induced psychosis. Rule out AIDS-related cognitive disorder. AXIS II: Deferred. AXIS III: AIDS (stable by his report). Anemia. AXIS IV: Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and HIV-related providers. AXIS V: Global Assessment Functioning is currently 15. PLAN: I will attempt to increase the database, will specifically request records from the last mental health providers. The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis. With the patient's permission, I will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past. I anticipate titrating further for effect during the course of his admission.

Write a clinical note about a patient with the following reason for consult: Anxiety.

REASON FOR CONSULT: Anxiety. CHIEF COMPLAINT: "I felt anxious yesterday.",HPI: A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath. The patient was consulted by Psychiatry for anxiety. I know this patient from a previous consult. During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with "syncopal episodes." She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours. The patient was seen by Abc, MD, and Def, Ph.D. The laboratories were reviewed and were positive for UTI, and anemia is also present. The TSH level was within normal limits. She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety. A low dose of Klonopin was also helpful for sedation. PAST MEDICAL HISTORY: Metastatic breast cancer to bone. The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis. PAST PSYCHIATRIC HISTORY: The patient has a history of depression and anxiety. She was taking Remeron 15 mg q.h.s. Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home. FAMILY HISTORY: There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family. SOCIAL HISTORY: The patient is married and lives at home with her husband. She has a history of smoking one pack per day for 18 years. The patient quit in 1967. According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day. MEDICATIONS: 1. Klonopin 0.25 mg p.o. every evening. 2. Fluconazole 200 mg p.o. daily. 3. Synthroid 125 mcg p.o. everyday. 4. Remeron 15 mg p.o. at bedtime. 5. Ceftriaxone IV 1 g in 1/2 NS every 24 hours. P.R.N. MEDICATIONS: 1. Tylenol 650 mg p.o. every 4 hours. 2. Klonopin 0.5 mg p.o. every 8 hours. 3. Promethazine 12.5 mg every 4 hours. 4. Ambien 5 mg p.o. at bedtime. ALLERGIES: No known drug allergies,LABORATORY DATA: These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90. White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000. TSH level 0.88. The urinalysis was positive for UTI. MENTAL STATUS EXAMINATION: GENERAL APPEARANCE: The patient is dressed in a hospital gown. She is lying in bed during the interview. She is well groomed with good hygiene. MOTOR ACTIVITY: No psychomotor retardation or agitation noted. Good eye contact. ATTITUDE: Pleasant and cooperative. ATTENTION AND CONCENTRATION: Normal. The patient does not appear to be distracted during the interview. MOOD: Okay. AFFECT: Mood congruent normal affect. THOUGHT PROCESS: Logical and goal directed. THOUGHT CONTENT: No delusions noted. PERCEPTION: Did not assess. MEMORY: Not tested. SENSORIUM: Alert. JUDGMENT: Good. INSIGHT: Good. IMPRESSION: 1. AXIS I: Possibly major depression or generalized anxiety disorder. 2. AXIS II: Deferred. 3. AXIS III: Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism. 4. AXIS IV: Interpersonal stressors.

Write a clinical note about a patient with the following chief complaint: Penile cellulitis status post circumcision.

CHIEF COMPLAINT: Penile cellulitis status post circumcision. HISTORY OF PRESENT ILLNESS: The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin. He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago. The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103. He was seen at Hospital, transferred to Children's Hospital for further care. Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant. He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother. I was requested a consultation by Dr. X because of the appearance of penis. The patient has been voiding without difficulty throughout. PAST MEDICAL HISTORY: The patient has no known allergies. He was a term delivery via vaginal delivery. Surgeries; he has had 2 circumcisions. No other hospitalizations. He has had no heart murmurs, seizures, asthma, or bronchitis. REVIEW OF SYSTEMS: A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned. He also had an ear infection about 1 to 2 weeks before his circumcision. SOCIAL HISTORY: The patient lives with both parents and no siblings. There are smokers at home. MEDICATIONS: Clindamycin and bacitracin ointment. Also Bactrim. PHYSICAL EXAMINATION: VITAL SIGNS: Weight is 14.9 kg. GENERAL: The patient was sleepy but easily arousable. HEAD AND NECK: Grossly normal. His neck and chest are without masses. NARES: He had some crusted nares; otherwise, no other discharge. LUNGS: Clear. CARDIAC: Without murmurs or gallops. ABDOMEN: Soft without masses or tenderness. GU: He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema. There was some induration around the penis; however, there were no signs of active infection. He has a buried appearance of the penis after recent circumcision with a normal appearing glans. The tissue itself, however, was quite dull and is soft or readily retractable at this time. The scrotum was normal, and there was no erythema, there was no tenderness. Both testes were descended without hydroceles. EXTREMITIES: He has full range of motion of all 4 extremities. SKIN: Warm, pink, and dry. NEUROLOGIC: Grossly intact. BACK: Normal. IMPRESSION/PLAN: The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis. This is being treated, but it is most likely Staph and pending sensitivities. I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad. I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day. I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely. Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so. He has a scheduled followup appointment with his urologist and he should keep that appointment or followup sooner if there is any other problem arising.

Write a clinical note about a patient with the following chief complaint: Penile discharge, infected-looking glans.

CHIEF COMPLAINT: Penile discharge, infected-looking glans. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for wet gangrene. The patient was transferred to Nursing Home and presents today from the nursing home with complaints of bleeding from the right AKA stump and penile discharge. As per the patient during his hospitalizations over here, he had indwelling Foley catheter for a few days and when he was discharged at the nursing home he was discharged without the catheter. However, the patient was brought back to the ED today when he suffered fall yesterday and started bleeding from his stump. While placing the catheter in the ED on retraction of foreskin purulent discharge was seen from the penis and the glans appeared infected, so urology consult was placed. REVIEW OF SYSTEMS: Negative except as in the HPI. PAST MEDICAL HISTORY: Significant for end-stage renal disease on dialysis, hypertension, peripheral vascular disease, coronary artery disease, congestive heart failure, diabetes, and hyperlipidemia. PAST SURGICAL HISTORY: Right AKA,MEDICATIONS: Novolin, Afrin, Nephro-Vite, Neurontin, lisinopril, furosemide, Tums, labetolol, Plavix, nitroglycerin, Aricept, omeprazole, oxycodone, Norvasc, Renagel, and morphine. ALLERGIES: PENICILLIN and ADHESIVE TAPE. FAMILY HISTORY: Significant for hypertension, hyperlipidemia, diabetes, chronic renal insufficiency, and myocardial infarction. SOCIAL HISTORY: The patient lives alone. He is unemployed, disabled. He has history of tobacco use in the past. He denies alcohol or drug abuse. PHYSICAL EXAMINATION: GENERAL: A well-appearing African-American male lying comfortably in bed, in acute distress. NECK: Supple. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: S1 and S2, normal. ABDOMEN: Soft, nondistended, and nontender. GENITOURINARY: Penis is not circumcised. Currently, indwelling Foley catheter in place. On retraction of the foreskin, pale-looking glans tip with areas of yellow-white tissue. The proximal glans appeared pink. The patient currently has indwelling Foley catheter and glans slightly tender to touch. However, no purulent discharge was seen on compression of the glans. Otherwise on palpation, no other deformity noticed. Bilateral testes descended. No palpable abnormality. No evidence of infection in his perineal area. EXTREMITIES: Right AKA. NEUROLOGIC: Awake, alert, and oriented. No sensory or motor deficit. LABORATORY DATA: I independently reviewed the lab work done on the patient. The patient had a UA done in the ED which showed few bacteria, white blood cells 6 to 12, and a few epithelial cells which were negative. His basic metabolic panel with creatinine of 7.2 and potassium of 5, otherwise normal. CBC with a white blood cell count of 11.5, hemoglobin of 9.5, and INR of 1.13. IMPRESSION: A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. I think it is due to chronic ischemic changes. RECOMMENDATIONS: Our recommendation would be: 1. To remove the Foley catheter. 2. Local hygiene. 3. Local application of bacitracin ointment. 4. Antibiotic for urinary tract infection. 5. Follow up as needed. Of note, it was explained to the patient that the appearance of this glans may improve or may get worsened but at this point, there is no indication to operate on him. If increased purulent discharge, the patient was asked to call us sooner, otherwise follow up as scheduled.

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 low back, left buttock and leg pain.

CHIEF COMPLAINT: Chronic low back, left buttock and leg pain. HISTORY OF PRESENT ILLNESS: This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005. Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain. Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain. He states that approximately 75% of his pain is in his buttock and leg and 25% in his back. He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back. He rated his pain today as 6/10, describing it is shooting, sharp and aching. It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication. It is constant but variable in degree. It continues to affect activities and sleep at night as well as mood at times. He is currently not satisfied completely with his level of pain relief. MEDICATIONS: Kadian 30 mg b.i.d. Zanaflex one-half to one tablet p.r.n. spasm, and Advil p.r.n. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: Complete multisystem review was noted and signed in the chart. SOCIAL HISTORY: Unchanged from prior visit. PHYSICAL EXAMINATION: Blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs. He is a well-developed obese male in no acute distress. He is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression. He ambulates with normal gait and has normal station. He is able to heel and toe walk. He denies any sensory changes. ASSESSMENT & PLAN: This is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. We discussed treatment options at length and he is willing to undergo a trial of Lyrica. He is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime. We discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him. We also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him. He will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.

Write a clinical note about a patient with the following chief complaint: Back pain and right leg pain. The patient has a three-year history of small cell lung cancer with metastases.

CHIEF COMPLAINT: Back pain and right leg pain. The patient has a three-year history of small cell lung cancer with metastases. HISTORY OF PRESENT ILLNESS: The patient is on my schedule today to explore treatment of the above complaints. She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis. She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count. She says she has just finished a series of 10 radiation treatments for pain relief. She states she continues to have significant pain symptoms. Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee. She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times. She complains of some diffuse, mid back pain. She describes the pain as sharp, dull, and aching in nature. She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain. She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking. She is on significant doses of narcotics. She has had multiple CT scans looking for metastasis. PAST MEDICAL HISTORY: Significant for cancer as above. She also has a depression. PAST SURGICAL HISTORY: Significant for a chest port placement. CURRENT MEDICATIONS: Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet. She does not know of what strength up to eight daily. She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent. She is on Neurontin 300 mg three times daily. HABITS: She smokes one pack a day for last 30 years. She drinks beer approximately twice daily. She denies use of recreational drugs. SOCIAL HISTORY: She is married. She lives with her spouse. FAMILY HISTORY: Significant for two brothers and father who have cancer. REVIEW OF SYSTEMS: Significant mainly for her pain complaints. For other review of systems the patient seems stable. PHYSICAL EXAMINATION: General: Reveals a pleasant somewhat emaciated Caucasian female. Vital Signs: Height is 5 feet 2 inches. Weight is 130 pounds. She is afebrile. HEENT: Benign. Neck: Shows functional range of movements with a negative Spurling's. Chest: Clear to auscultation. Heart: Regular rate and rhythm. Abdomen: Soft, regular bowel sounds. Musculoskeletal: Examination shows functional range of joint movements. No focal muscle weakness. She is deconditioned. Neurologic: She is alert and oriented with appropriate mood and affect. The patient has normal tone and coordination. Reflexes are 2+ in both knees and absent at both ankles. Sensations are decreased distally in the left foot, otherwise intact to pinprick. Spine: Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement. The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints. FUNCTIONAL EXAMINATION: Gait has a normal stance and swing phase with no antalgic component to it. INVESTIGATION: She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally. She has had increased uptake in the sacroiliac joint regions bilaterally. CT of the chest showed no evidence of recurrent metastatic disease. CT of the abdomen showed no evidence of metastatic disease. MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs. CT of the pelvis showed a trabecular pattern with healed metastases. CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan. MR of the brain showed no acute intracranial abnormalities and no significant interval changes. IMPRESSION: 1. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs. 2. Symptomatic facet and sacroiliac joint syndrome on the right. 3. Chronic pain syndrome. RECOMMENDATIONS: Dr. XYZ and I discussed with the patient her pathology. Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right. Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today. I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed. She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this. We have asked for stat protime today. She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications. She is on significant dose of narcotics already, however, she continues to have pain symptoms. Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed. I will plan on evaluating her in the Clinic on Tuesday. I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead. She voiced understanding and is in agreement with this plan. I have also asked her to get an x-ray of the lumbar spine for further evaluation. Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings. Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.

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: Neck and lower back pain.

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

Write a clinical note about a patient with the following chief complaint: Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.

CHIEF COMPLAINT: Neck pain, thoracalgia, low back pain, bilateral lower extremity pain. HISTORY OF PRESENT ILLNESS: Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse. She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week. She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism. She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s. In 2000, she developed "sciatica" mostly in her right lower extremity. She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004. Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages. Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes. The patient has essentially three major pain complaints. Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms. She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches. She has been told by Dr. Megahed in the past that she is not considered a surgical candidate. She has done physical therapy twice as recently as three years ago for treatment of her symptoms. She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling. Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution. Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing. There is no associated shortness of breath. She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly. She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production. Her weight has been stable without any type of constitutional symptoms. Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day. She complains of occasional subjective weakness to the right lower extremity. Her pain is worse with sitting, standing and is essentially worse in the supine position. Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution. She has noted some subjective atrophy as well of the right calf. She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls. She has treated her back symptoms with physical therapy as well. She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications. She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis. Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain. Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying. Alleviating factors including sitting, applying heat and ice. PAST MEDICAL HISTORY: As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis. PAST SURGICAL HISTORY: Cholecystectomy, eye surgery, D&C. MEDICATIONS: Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin. ALLERGIES: Multiple. All over-the-counter medications. Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin. FAMILY HISTORY: Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis. SOCIAL HISTORY: The patient is retired. She is married with three grown children. Has a high school level education. Does not smoke, drink, or utilize any illicit substances. OSWESTRY PAIN INVENTORY: Significant impact on every aspect of her quality of life. She would like to become more functional. REVIEW OF SYSTEMS: A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological. Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins. Pulmonary review of systems negative. GI review of systems is positive for irritable bowel and acid reflux symptoms. Genitourinary, occasional stress urinary incontinence and history of remote hematuria. She is postmenopausal and on hormone replacement. Endocrine is positive for a low libido and thyroid disorder. Integument: Dry skin, itching and occasional rashes. Immunologic is essentially negative. Musculoskeletal: As per HPI. HEENT: Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache. Neurological: As per history of present illness. Constitutional: As history of present illness. PHYSICAL EXAMINATION: Weight 180 pounds, temp 97.6, pulse 56, BP 136/72. The patient walks with a normal gait pattern. There is no antalgia, spasticity, or ataxia. She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty. She can flex her lumbar spine and touch the floor with her fingertips. Lumbar extension and ipsilateral bending provoke her axial back pain. There is tenderness over the PSIS on the right and no particular pelvic asymmetry. Head is normocephalic and atraumatic. Cranial nerves II through XII are grossly intact. Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation. The neck is supple. The trachea is midline. The thyroid is not particularly enlarged. Lungs are clear to auscultation. Heart has regular rate and rhythm with normal S1, S2. No murmurs, rubs, or gallops. The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses. Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema. I can radial, dorsalis pedis and posterior tibial pulses. The nailbeds on her feet have trophic changes. Brisk capillary refill is evident over both upper extremities. Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity. She has chronic osteoarthritic changes evident over both hands. There is mild restriction of range of motion of the right shoulder, but no active impingement signs. Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders. Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline. There is no midline spinous process tenderness over the cervicothoracic regions. Palpation of the articular pillars is met with mild provocation of pain. Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness. There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally. The xiphoid process is not particularly tender. There is no dermatomal sensory abnormality in the thoracic spine appreciated. Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala. Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally. I cannot elicit S1 reflexes. There are no long tract signs. Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski. Motor examination of the upper, as well as lower extremities appears to be intact throughout. I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made. SUMMARY OF DIAGNOSTIC IMAGING: As per above. IMPRESSION: 1. Osteoarthritis. 2. Cervical spinal stenosis. 3. Lumbar spinal stenosis. 4. Lumbar radiculopathy, mostly likely at the right L5-S1 levels. 5. History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction. 6. Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes. PLAN: The natural history and course of the disease was discussed in detail with Mr. XYZ. Greater than 80 minutes were spent facet-to-face at this visit. I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures. I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed. Pending the results of her preliminary studies, this should be ruled out. I will see her in followup in about two weeks with the results of her scans.

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

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

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

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

Write a clinical note about a patient with the following chief complaint: Mental status changes after a fall.

CHIEF COMPLAINT: Mental status changes after a fall. HISTORY: Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes. She was very confused, incomprehensible speech, and was not responding appropriately. She was transported here stable, with no significant changes. She ultimately upon arrival here was unchanged in that she was not responding appropriately. She would have garbled speech, somewhat inappropriate at times, and unable to follow commands. No other history was able to be obtained. All pertinent history is documented within the records. Physical examination also documented in the records, essentially as above. PHYSICAL EXAMINATION: HEENT: Without any obvious signs of trauma. Pupils are equal and reactive. Extraocular movements are difficult to assess with her eyes closed, but she will open to voice. TMs, canals are normal without any signs of hemotympanum. Nasal mucosa and oropharynx are normal. NECK: Nontender, full range of motion, was not examined initially, a collar was placed. HEART: Regular. LUNGS: Clear. CHEST/BACK/ABDOMEN: Without trauma. SKIN: With multiple excoriations from scratching and itching. NEUROLOGIC: Otherwise she has good sensation, withdrawals to pain. When lifting the arm, she will hold them up and draw, let them down slowly. With movement of the legs, she did straighten them back out slowly. DTRs were intact and equal bilaterally. Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change. LABORATORY DATA: CT scan of the head was negative as was cervical spine. She has a history of being on Coumadin. Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands. CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3. ASSESSMENT AND PLAN: Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved. It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved. At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation. I have discussed this with her son, he agrees. Otherwise, she has improved significantly. The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.

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

CHIEF COMPLAINT: Marginal zone lymphoma. HISTORY OF PRESENT ILLNESS: This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass. On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma). Overall, she is doing well. She has a good energy level and her ECOG performance status is 0. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. She has normal bowel and bladder habits. No melena or hematochezia. CURRENT MEDICATIONS: Macrobid 100 mg q.d. ALLERGIES: Sulfa, causes nausea and vomiting. REVIEW OF SYSTEMS: As per the HPI, otherwise negative. PAST MEDICAL HISTORY: 1. She is status post a left partial nephrectomy as a new born. 2. In 2008 she had a right ankle fracture. SOCIAL HISTORY: She has a 20-pack year history of tobacco use. She has rare alcohol use. She has no illicit drug use. She is in the process of getting divorced. She has a 24-year-old son in the area and 22-year-old daughter. FAMILY HISTORY: Her mother had uterine cancer. Her father had liver cancer. PHYSICAL EXAM: VIT:

Write a clinical note about a patient with the following identifying data: Mr. T is a 45-year-old white male.

IDENTIFYING DATA: Mr. T is a 45-year-old white male. CHIEF COMPLAINT: Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests. He has had suicidal ideation, but this is currently in remission. Furthermore, he continues to have hopeless thoughts and crying spells. Mr. T stated these symptoms appeared approximately two months ago. HISTORY OF PRESENT ILLNESS: On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee." This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him "bitch." Mr. T then retaliated, and went to hit the other employee. Due to this event, Mr. T was fired. It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to "deal with it.",There are no other apparent stressors in Mr. T's life at this time or in recent months. Mr. T stated that work was his entire life and he based his entire identity on his work ethic. It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years. PAST PSYCHIATRIC HISTORY: There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time. Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003. PAST PSYCHIATRIC REVIEW OF SYSTEMS: Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders. He denied any suicide attempts, or profound suicidal or homicidal ideation. Mr. T furthermore stated that his family psychiatric history is unremarkable. SUBSTANCE ABUSE HISTORY: Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years. No other substance abuse was noted. LEGAL HISTORY: Currently, charges are pending over the above described incident. MEDICAL HISTORY: Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia. PERSONAL AND SOCIAL HISTORY: Mr. T was born in Dwyne, Missouri, with no complications associated with his birth. Originally, he was raised by both parents, but they separated at an early age. When he was about seven years old, he was raised by his mother and stepfather. He did not sustain a relationship with his biological father from that time on. He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education. Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old. He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company. He then became a homemaker while his wife worked for Chrysler for approximately two years. Mr. T was married for eleven years, and divorced in 1993. He has a son who is currently 20 years old. After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer. Mental Status Exam: Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense. At times he showed some involuntary movements that would be more akin to a resting tremor. There was no psychomotor retardation, but there was some mild psychomotor excitement. His speech was clear, concise, but pressured. His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger. There was no evidence of euphoria or diurnal mood variation. His affective expression was restricted range, but there was no evidence of lability. At times, his affective tone and facial expressions were inappropriate to the interview. There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations. There was no evidence of illusions, depersonalizations, or derealizations. Mr. T presented with a sequential and goal directed stream of thought. There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking. There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts. There was evidence of concreteness for similarities and proverbs. His intelligence was average. His concentration was mildly impaired, and there was no evidence of distractibility. He was oriented to time, place, person and situation. There was no evidence of clouded consciousness or dissociation. His memory was intact for immediate, recent, and remote events. He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence. There was a moderate preoccupation with his physical health pertaining to his headaches. His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans. Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem. His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments. He has a well-developed empathy for others and capacity for affection. There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation. His credibility seemed good. There was no evidence for potential self-injury, suicide, or violence. The reliability and completeness of information was very good, and there were no barriers to communication. The information gathered was based on the patient's self-report and objective testing and observation. His attitude toward the examiner was neutral and his attitude toward the examination process was neutral. There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder. IMPRESSIONS: Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy. At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment. Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year. As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning. Furthermore, it only appears logical that this would precipitate a major depressive episode.

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

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

Write a clinical note about a patient with the following history of present illness: Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms. HPI -

CHIEF COMPLAINT: Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms. HPI - LUMBAR SPINE: The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset. PAST SPINE HISTORY: Unremarkable. PRESENT LUMBAR SYMPTOMS: Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset. PRESENT RIGHT LEG SYMPTOMS: Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset. PRESENT LEFT LEG SYMPTOMS: None. NEUROLOGIC SIGNS/SYMPTOMS: The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.

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: 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: Left knee pain and stiffness.

CHIEF COMPLAINT: Left knee pain and stiffness. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are negotiated 1 at a time. His problems with bilateral knee DJD have been well documented. He had arthroscopy in the 1991/199two time frame for both of these. He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. Significant pain is handled by narcotic medication. His attending physician is Dr. X. PAST MEDICAL HISTORY: Hypertension. PRIOR SURGERIES: 1. Inguinal hernia on the left. 2. Baker's cyst. 3. Colon cancer removal. 4. Bilateral knee scopes. 5. Right groin hernia. 6. Low back surgery for spinal stenosis. 7. Status post colon cancer second surgery. MEDICATIONS: 1. Ambien 12.5 mg nightly. 2. Methadone 10 mg b.i.d. 3. Lisinopril 10 mg daily. IV MEDICATIONS FOR PAIN: Demerol appears to work the best. ALLERGIES: Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction. REVIEW OF SYSTEMS: He does have paresthesias down into his thighs secondary to spinal stenosis. SOCIAL HISTORY: Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees. HABITS: No tobacco or alcohol. Chewed until 2003. RECREATIONAL PURSUITS: Golfs, gardens, woodworks. FAMILY HISTORY: 1. Cancer. 2. Coronary artery disease. PHYSICAL EXAMINATION: GENERAL APPEARANCE: A pleasant, cooperative 57-year-old white male. VITAL SIGNS: Height 5' 9", weight 167. Blood pressure 148/86. Pulse 78 per minute and regular. HEENT: Unremarkable. Extraocular movements are full. Cranial nerves II-XII intact. NECK: Supple. CHEST: Clear. CARDIOVASCULAR: Regular rhythm. Normal S1 and 2. ABDOMEN: No organomegaly. No tenderness. Normal bowel sounds. NEUROLOGIC: Intact. MUSCULOSKELETAL: Left knee reveals a range of -10 degrees extension, 126 flexion. His extensor mechanism is intact. There is mild varus. He has good stability at 30 degrees of flexion. Lachman's and posterior drawer are negative. He has good muscle turgor. Dorsalis pedis pulse 2+. DIAGNOSTICS: X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right. IMPRESSION: 1. Bilateral knee degenerative joint disease. 2. Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.

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: 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: Intractable epilepsy, here for video EEG.

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

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

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

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

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

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

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

Write a clinical note about a patient with the following chief complaint: Not gaining weight.

CHIEF COMPLAINT: Not gaining weight. HISTORY OF PRESENT ILLNESS: The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur. At this point, the Hospitalist Service was contacted for admission. The patient was directly admitted to Children's Hospital Explore Ward. In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure. The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained. PAST MEDICAL/BIRTH HISTORY: The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female. Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking. Birthweight was 7 pounds 4 ounces at Community Hospital. The mother did have a repeat C-section. There is no rupture of membranes or group B strep status. The prenatal care began in the second month of pregnancy and was otherwise uncomplicated. Mother denies any sexual transmitted diseases or other significant illness. The patient was discharged home on day of life #3 without any complications. ALLERGIES: No known drug allergies. DIET: The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours. ELIMINATION: The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day. FAMILY HISTORY/SOCIAL HISTORY: The patient lives with the mother. She has 2 older male siblings. All were reported good health. Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures. REVIEW OF SYSTEMS: GENERAL: The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain. Mother does not report that she sweats whenever she eats or has any episodes of cyanosis. ,HEENT: Denies any significant nasal congestion or cough. ,RESPIRATORY: Denies any difficulty breathing or wheezing. ,CARDIOVASCULAR: As per above. GI: No history of any persistent vomiting or diarrhea. ,GU: Denies any decreased urinary output. ,MUSCULOSKELETAL: Negative. ,NEUROLOGICAL: Negative. ,SKIN: Negative. All other systems reviewed are negative. PHYSICAL EXAMINATION: GENERAL: The patient is examined in her room, our next floor. She is crying very vigorously, especially when I examined but she is consolable. VITAL SIGNS: Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying. HEENT: Normocephalic. The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head. The anterior fontanelle is soft and flat. Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism. There is also some mild posterior rotation of the ears. Oropharynx, mucous membranes are pink and moist. There is a slightly high arched palate. NECK: Significant for possible mild reddening of the neck. LUNGS: Significant for perihilar crackles. Mild tachypnea is noted. O2 saturations are currently 97% on room air. There is mild intercostal retraction. CARDIOVASCULAR: Heart has regular rate and rhythm. Peripheral pulses are only 1+. Capillary refills less than 3-4 seconds. EXTREMITIES: Slightly cool to touch. There is 2-3/6 systolic murmur along the left sternal border. Does radiate to the axilla and to the back. ABDOMEN: Soft, slightly distended, but nontender. The liver edge is palpable 4 cm below right costal margin. The spleen tip is also palpable. GU: Normal female external genitalia is noted. MUSCULOSKELETAL: The patient has poor fat deposits in her extremities. Strength is only 2/4. She had normal number of fingers and toes. SKIN: Significant for slight mottling. There are very poor subcutaneous fat deposits in her skin. LABORATORY DATA: The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4. CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4. Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure. ASSESSMENT: This is an almost 2-month-old presents with: 1. Failure-to-thrive. 2. Significant murmur and patent ductus arteriosus. 3. Congestive heart failure. PLAN: At present, we are going to admit and monitor closely tonight. We will get a chest x-ray and start Lasix at 1 mg/kg twice daily. We will also get a CBC and check a blood culture and further workup as necessary.

Write a clinical note about a patient with the following chief complaint: "A lot has been thrown at me.",The patient is interviewed with husband in room.

CHIEF COMPLAINT: "A lot has been thrown at me.",The patient is interviewed with husband in room. HISTORY OF PRESENT ILLNESS: This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets. She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today. The patient states she had been thinking about suicide for a couple of weeks. Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble. Reports she has been not socializing with her family because of her worsening depression. Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth. They did as they have instructed and husband feels this may have had some factor on her worsening depression. The patient decided to ingest the pills when her husband went to work on Friday. She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened. Her husband left around 7 in the morning and returned around 11 and found her sleeping. About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital. She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene. She does not clearly explain how this has made her suicidality subside. This is the third suicide attempt in the last two months for this patient. About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall. She was taken to Southwest Memorial Hermann Hospital. A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor. Husband locked the gun after that and she was taken to Bellaire Hospital. The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days. She sees Dr. X once or twice weekly. He started seeing her after her first suicide attempt. The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active. Since then she has had worsening of her Huntington symptoms including short-term memory loss. At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath. The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease. The patient's mother passed away 25 years ago from Huntington's. Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's. The patient has told her husband that she does not want to go that way. The patient denies auditory or visual hallucinations, denies paranoid ideation. The husband and the patient deny any history of manic or hypomanic symptoms in the past. PAST PSYCHIATRIC HISTORY: As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression. MEDICATIONS: Her medications on admission, alprazolam 0.5 mg p.o. b.i.d. Artane 2 mg p.o. b.i.d. Haldol 2.5 mg p.o. t.i.d. Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily. Husband has stated that the patient's chorea becomes better when she takes Haldol. Alprazolam helps her with anxiety symptoms. PAST MEDICAL HISTORY: Huntington disease, symptoms of dementia and hypertension. She has an upcoming appointment with the Neurologist. Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y. ALLERGIES: CODEINE AND KEFLEX. FAMILY MEDICAL HISTORY: Strong family history for Huntington disease as per the HPI. Mother and grandmother died of Huntington disease. Two young brothers also had Huntington disease. FAMILY PSYCHIATRIC HISTORY: The patient denies history of depression, bipolar, schizophrenia, or suicide attempts. SOCIAL HISTORY: The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active. MENTAL STATUS EXAM: This is an elderly woman appearing stated age. Alert and oriented x4 with poor eye contact. Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips. She is cooperative. Her speech is of low volume and slow rate and rhythm. Her mood is sad. Her affect is constricted. Her thought process is logical and goal-directed. Her thought content is negative for current suicidal ideation. No homicidal ideation. No auditory or visual hallucinations. No command auditory hallucinations. No paranoia. Insight and judgment are fair and intact. LABORATORY DATA: A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality. U-tox positive for amphetamines and tricyclic antidepressants. Acetaminophen level 206.7, alcohol level 0. The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4. ASSESSMENT: This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. She took 30 tablets of Haldol and 40 tablets of Tylenol. At present, the patient is without suicidal ideation. She reports that her worsening depression has coincided with her worsening Huntington disease. She is more hopeful today, feels that she may be able to get help with her depression. The patient was admitted four days ago to the medical floor and has subsequently been stabilized. Her liver function tests are within normal limits. AXIS I: Major depressive disorder due to Huntington disease, severe. Cognitive disorder, NOS. AXIS II: Deferred. AXIS III: Hypertension, Huntington disease, status post overdose. AXIS IV: Chronic medical illness. AXIS V: 30. PLAN,1. Safety. The patient would be admitted on a voluntary basis to Main-7 North. She will be placed on every 15-minute checks with suicidal precautions. 2. Primary psychiatric issues/medical issues. The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h. Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h. fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d. amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation. 3. Substance abuse. No acute concern for alcohol or benzo withdrawal. 4. Psychosocial. Team will update and involve family as necessary. DISPOSITION: The patient will be admitted for evaluation, observation, treatment. She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy. We will place occupational therapy consult and social work consults.

Write a clinical note about a patient with the following admission diagnosis: Left hip fracture.

ADMISSION DIAGNOSIS: Left hip fracture. CHIEF COMPLAINT: Diminished function, secondary to the above. HISTORY: This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture identified on x-rays at that time. Pain and inability to ambulate brought him in. He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. His medical issues are under good control. The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions. PAST MEDICAL HISTORY: Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties. ALLERGIES: Zyloprim, penicillin, Vioxx, NSAIDs. CURRENT MEDICATIONS,1. Heparin. 2. Albuterol inhaler. 3. Combivent. 4. Aldactone. 5. Doxepin. 6. Xanax. 7. Aspirin. 8. Amiodarone. 9. Tegretol. 10. Synthroid. 11. Colace. SOCIAL HISTORY: Lives in a 1-story home with 1 step down; wife is there. Speech and language pathology following with current swallowing dysfunction. He is minimum assist for activities of daily living, bed mobility. REVIEW OF SYSTEMS: Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain. PHYSICAL EXAMINATION,HEENT: Oropharynx clear. CV: Regular rate and rhythm without murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Nontender, nondistended. Bowel sounds positive. EXTREMITIES: Without clubbing, cyanosis, or edema. NEUROLOGIC: There are no focal motor or sensory losses to the lower extremities. Bulk and tone normal in the lower extremities. Wound site has healed well with staples out. IMPRESSION ,1. Status post left hip fracture and hemiarthroplasty. 2. History of panic attack, anxiety, depression. 3. Myocardial infarction with stent placement. 4. Hypertension. 5. Hypothyroidism. 6. Subdural hematoma. 7. Seizures. 8. History of chronic obstructive pulmonary disease. Recent respiratory insufficiency. 9. Renal insufficiency. 10. Recent pneumonia. 11. O2 requiring. 12. Perioperative anemia. PLAN: Rehab transfer as soon as medically cleared.

Write a clinical note about a patient with the following chief complaint: Non-healing surgical wound to the left posterior thigh.

CHIEF COMPLAINT: Non-healing surgical wound to the left posterior thigh. HISTORY OF PRESENT ILLNESS: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control. PAST MEDICAL HISTORY: Essentially negative other than he has had C. difficile in the recent past. ALLERGIES: None. MEDICATIONS: Include Cipro and Flagyl. PAST SURGICAL HISTORY: Significant for his trauma surgery noted above. FAMILY HISTORY: His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father. SOCIAL HISTORY: He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney. REVIEW OF SYSTEMS: CARDIAC: He denies any chest pain or shortness of breath. GI: As noted above. GU: As noted above. ENDOCRINE: He denies any bleeding disorders. PHYSICAL EXAMINATION: GENERAL: He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress. HEENT: Unremarkable. NECK: Supple. There is no mass, adenopathy, or bruit. CHEST: Normal excursion. LUNGS: Clear to auscultation and percussion. COR: Regular. There is no S3, S4, or gallop. There is no murmur. ABDOMEN: Soft. It is nontender. There is no mass or organomegaly. GU: Unremarkable. RECTAL: Deferred. EXTREMITIES: His right lower extremity is unremarkable. Peripheral pulse is good. His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. There is one small area right essentially within the graft site, and there is one small area down lower on the calf area. The patient has an external fixation on that comes out laterally on his left thigh. Those pin sites look clean. NEUROLOGIC: Without focal deficits. The patient is alert and oriented. IMPRESSION: Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. PLAN: Plan would be for chemical cauterization of these areas. Series of treatment with chemical cauterization till these are closed.

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

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

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

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

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

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

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

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

Write a clinical note about a patient with the following chief complaint: Irritable baby with fever for approximately 24 hours.

CHIEF COMPLAINT: Irritable baby with fever for approximately 24 hours. HISTORY OF PRESENT ILLNESS: This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room and a complete septic workup was done, and the child is being treated in a rule out sepsis protocol. PAST MEDICAL HISTORY: This child was born by term pregnancy, spontaneous vaginal delivery, to a mother who was a teenager. He is bottle fed and he has had his hepatitis B vaccine. He lives in a home where there are smokers. This is his first illness. PAST SURGICAL HISTORY: He has had no previous surgeries. MEDICATION (S): He takes no medications on a regular basis. REVIEW OF SYSTEMS: Positive for those things mentioned already in the past medical history and history of present illness. FAMILY HISTORY: The family history is noncontributory. SOCIAL HISTORY: This child lives with his mother and father, both are teenagers, unmarried, who are not well educated. Grandmother is a heavy smoker. PHYSICAL EXAMINATION: VITAL SIGNS: The vital signs are stable, the patient is febrile at 101-degrees. HEAD, EYES, EARS, NOSE, AND THROAT/GENERAL: The anterior fontanelle is not bulging. The rest of the examination is within normal limits. The neck is supple, no nuchal rigidity noted, though this child is irritable and fussy, and whines and cries where ever you make touch him. He has an irritable disposition no matter what you do to him, and whines even while at rest. HEART: The heart rate is rapid, but there was no murmur noted. LUNGS: The lungs are clear. ABDOMEN: The abdomen is without mass, distention, or visceromegaly. GENITOURINARY/RECTAL: Examination within normal limits. EXTREMITIES: The extremities are normal. No Kernig's or Brudzinski sign. NEUROLOGIC: Cranial nerves II through XII are intact, no focal deficits. As I mentioned before, the child is extremely irritable, fussy, and has a great deal of general inconsolability. SKIN: The child, in addition, has a skin pattern of cutis marmorata, which I think is a bit more exaggerated since the child is febrile and has some peripheral vasodilatation. CLINICAL IMPRESSION (S): Likely viral syndrome, viral meningitis, flu syndrome. PLAN: Continue the septic workup protocol, supportive care with IV fluids, and Tylenol as needed for fever, and continue the antibiotics until spinal fluid cultures and blood cultures are negative for 48 hours. In addition, I believe that the rapid heart rate is a sinus tachycardia, and is related to the child's illness, irritability, and his fever. In addition, there were no intracranial bruits noted.

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: Left leg pain.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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: Left foot pain.

CHIEF COMPLAINT: Left foot pain. HISTORY: XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM: He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender. RADIOGRAPHS: Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION: Left Chopart joint sprain. PLAN: I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.

Write a clinical note about a patient with the following chief complaint: This 26-year-old male presents today for a complete eye examination.

CHIEF COMPLAINT: This 26-year-old male presents today for a complete eye examination. ALLERGIES: Patient admits allergies to aspirin resulting in disorientation, GI upset. MEDICATION HISTORY: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID). PMH: Past medical history is unremarkable. PAST SURGICAL HISTORY: Patient admits past surgical history of (+) appendectomy in 1989. SOCIAL HISTORY: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision. Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness. Musculoskeletal: (-) joint or musculoskeletal symptoms. EYE EXAM: Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus. Pupils: Pupil exam reveals round and equally reactive to light and accommodation. Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral. Visual Fields: Confrontation VF exam reveals full to finger confrontation O.U. IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving. Keratometry: OD: K1 35.875K2 35.875,OS: K1 35.875K2 41.875,Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet. Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance. Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber. Lens: Bilateral lenses reveals transparent lens that is in normal position. Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color, contour, and cupping. Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinas reveal normal reflex and color. VISUAL ACUITY: Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15. REFRACTION: Lenses - final: OD: +0.50 +1.50 X 125 Prism 1.75,OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add: OD: +1.00 OS: +1.00,OU: Far VA 20/25,TEST RESULTS: No tests to report at this time. IMPRESSION: Eye and vision exam normal. PLAN: Return to clinic in 12 month (s). PATIENT INSTRUCTIONS:

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: The patient comes for her first Pap smear, complaining of irregular periods.

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

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

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

Write a clinical note about a patient with the following history of present illness: This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. Timing (onset/frequency): Onset was 6 months ago. Patient denies fever and chills and denies flank pain.

CHIEF COMPLAINT: This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. Timing (onset/frequency): Onset was 6 months ago. Patient denies fever and chills and denies flank pain. ALLERGIES: Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia. MEDICATION HISTORY: Patient is not currently taking any medications. PAST MEDICAL HISTORY: Childhood Illnesses: (+) asthma, Cardiovascular Hx: (-) angina, Renal / Urinary Hx: (-) kidney problems. PAST SURGICAL HISTORY: Patient admits past surgical history of appendectomy in 1992. SOCIAL HISTORY: Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use. FAMILY HISTORY: Patient admits a family history of gout attacks associated with father. REVIEW OF SYSTEMS: Unremarkable with exception of chief complaint. PHYSICAL EXAM: BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6,The patient is a pleasant, 61-year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus. Neck: Neck is normal and symmetrical, without swelling or tenderness. Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted. Respiratory: Respirations are even without use of accessory muscles and no intercostal retractions noted. Breathing is not labored, diaphragmatic, or abdominal. Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted. Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks. Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness. Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted. Liver and/or Spleen: no abnormalities, tenderness, or masses noted. Stool specimen not indicated. Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, or tenderness noted. Scrotum: no abnormalities. No lesions, rash, or sebaceous cyst noted. Epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness. Testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted. Urethral Meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted. Penis: no abnormalities; circumcised; no phimosis, Peyronie's, condylomata, or lumps noted. Prostate: size 60 gr, RT>LT and firm. Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted. Sphincter tone: no abnormalities; good tone; without hemorrhoids or masses. Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed. Neurological/Psychiatric: Oriented to person, place and time. Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation. TEST RESULTS: No tests to report at this time. IMPRESSION: Elevated prostate specific antigen (PSA). PLAN: Cystoscopy in the office. DIAGNOSTIC & LAB ORDERS: Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA). Ordered ultrasound of prostate. I have discussed the findings of this follow-up evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP surgical procedure; risks, complications, benefits, and alternative measures discussed. There are no activity restrictions . Instructed Ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. Questions answered. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at 327-8850. PRESCRIPTIONS: Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: No,PATIENT INSTRUCTIONS: Patient completed benign prostatic hypertrophy questionnaire.

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: 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 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: Recurrent dizziness x1 month.

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

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