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

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

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

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

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

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

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

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

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

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

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

CHIEF COMPLAINT: Cut on foot. HISTORY OF PRESENT ILLNESS: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints. PAST MEDICAL HISTORY: Asthma. CURRENT MEDICATION: Albuterol. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient is a smoker. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16. Oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well-nourished, well-developed, the patient appears to be healthy. The patient is calm and comfortable in no acute distress and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear conjunctiva and cornea bilaterally. NECK: Supple with full range of motion. CARDIOVASCULAR: Peripheral pulse is +2 to the right foot. Capillary refills less than two seconds to all the digits of the right foot. RESPIRATIONS: No shortness of breath. MUSCULOSKELETAL: The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot. There is no palpable foreign body, no foreign body is visualized. There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels. It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home. The patient does not have any tenderness to the foot. The patient has full range of motion to all the joints, all the toes, as well as the ankles. The patient ambulates well without any difficulty or discomfort. There are no other injuries noted to the rest of the body. SKIN: The 4-mm partial thickness laceration to the right foot as previously described. No other injuries are noted. NEUROLOGIC: Motor is 5/5 to all the muscle groups of the right lower extremity. Sensory is intact to light touch to all the dermatomes of the right foot. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No active bleeding is occurring at this time. No evidence of bruising is noted to the body. EMERGENCY DEPARTMENT COURSE: The patient had antibiotic ointment and a bandage applied to his foot. DIAGNOSES: 1. A 4-MM LACERATION TO THE RIGHT FOOT. 2. ACUTE RIGHT FOOT PAIN, NOW RESOLVED. CONDITION UPON DISPOSITION: Stable. DISPOSITION: To home. The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection. The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.

Write a clinical note about a patient with the following chief complaint: Cough and abdominal pain for two days.

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

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

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

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

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

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

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

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

CHIEF COMPLAINT: Left knee pain. SUBJECTIVE: This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension. Rates her pain in her knee as a 10/10. She does alternate ice and heat. She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief. ALLERGIES,1. PENICILLIN. 2. KEFLEX. 3. BACTRIM. 4. SULFA. 5. ACE BANDAGES. MEDICATIONS,1. Toprol. 2. Xanax. 3. Advair. 4. Ventolin. 5. Tylenol No. 3. 6. Advil. REVIEW OF SYSTEMS: Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first. Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below. PHYSICAL EXAMINATION,VITAL SIGNS: Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches. GENERAL: This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect. She is well developed, well nourished, appears her stated age. EXTREMITIES: Orthopedic evaluation of the left knee reveals there to be well-healed portholes. She does have some medial joint line swelling. Negative ballottement. She has significant pain to palpation of the medial joint line, none of the lateral joint line. She has no pain to palpation on the popliteal fossa. Range of motion is approximately -5 degrees to 95 degrees of flexion. It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right. She has a click with McMurray. Negative anterior-posterior drawer. No varus or valgus instability noted. Positive patellar grind test. Calf is soft and nontender. Gait is stable and antalgic on the left. ASSESSMENT,1. Osteochondral defect, torn meniscus, left knee. 2. Obesity. PLAN: I have encouraged the patient to work on weight reduction, as this will only benefit her knee. I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction. She questions whether she needs a total knee; I don't believe she needs total knee replacement. She may, however, at some point need an arthroscopy. I have encouraged her to start formal physical therapy and a home exercise program. Will use ice or heat p.r.n. I have given her refills on Tylenol No. 3, Flector patch, and Relafen not to be taken with any other anti-inflammatory. She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily. She will follow up in our office in four weeks. If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy. The patient shows a good understanding of this treatment plan and agrees.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Write a clinical note about a patient with the following chief complaint: Palpitations. CHEST PAIN /

CHIEF COMPLAINT: Palpitations. CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY: The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs. PALPITATIONS HISTORY: Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal. VALVULAR DISEASE HISTORY: Patient has documented mitral valve prolapse on echocardiography in 1992. PAST MEDICAL HISTORY: No significant past medical problems. Mitral Valve Prolapse. FAMILY MEDICAL HISTORY: CAD. OB-GYN HISTORY: The patients last child birth was 1997. Para 3. Gravida 3. SOCIAL HISTORY: Denies using caffeinated beverages, alcohol or the use of any tobacco products. ALLERGIES: No known drug allergies/Intolerances. CURRENT MEDICATIONS: Inderal 20 prn. REVIEW OF SYSTEMS: Generally healthy. The patient is a good historian. ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision. ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms. ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc. ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia. ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence. ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc. ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system. ROS Extremities: The patient denies any extremities complaints. ROS Cardiovascular: As per HPI. EXAMINATION: Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal. Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal. There is no cyanosis, clubbing or edema. General: Healthy appearing, well developed,. The patient is in no acute distress. Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic. Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected. Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple. Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles. Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs. IMPRESSION / DIAGNOSIS: Mitral Valve Prolapse. Palpitations. TESTS ORDERED: Cardiac tests: Echocardiogram. MEDICATION PRESCRIBED: ,Cardizem 30-60 qid prn.

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

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

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

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

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

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

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

CHIEF COMPLAINT: Recurrent bladder tumor. HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006. This was followed by bladder instillation of BCG. At this time, the patient denies any voiding symptoms or hematuria. The patient opting for TUR and electrofulguration of the recurrent tumors. ALLERGIES: None known. MEDICATIONS: Atenolol 5 mg daily. OPERATIONS: Status post bilateral knee replacements and status post TUR of bladder tumors. REVIEW OF SYSTEMS: Other than some mild hypertension, the patient is in very, very good health. No history of diabetes, shortness of breath or chest pain. PHYSICAL EXAMINATION: Well-developed and well-nourished woman, alert and oriented. Her lungs are clear. Heart, regular sinus rhythm. Back, no CVA tenderness. Abdomen, soft and nontender. No palpable masses. IMPRESSION: Recurrent bladder tumors. PLAN: The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.

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

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

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

CHIEF COMPLAINT: Bladder cancer. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall. Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan. This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement. All of this workup was found to be grossly negative. Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis. The patient presents today for evaluation by Dr. Y. PAST MEDICAL HISTORY: Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication. The patient denies coronary artery disease. PAST SURGICAL HISTORY: Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2. The patient denies any bowel resection or GU injury at that time; however, he is unsure. CURRENT MEDICATIONS: 1. Metoprolol 100 mg b.i.d. 2. Diltiazem 120 mg daily. 3. Hydrocodone 10/500 mg p.r.n. 4. Pravastatin 40 mg daily. 5. Lisinopril 20 mg daily. 6. Hydrochlorothiazide 25 mg daily. FAMILY HISTORY: Negative for any GU cancer, stones or other complaints. The patient states he has one uncle who died of lung cancer. He denies any other family history. SOCIAL HISTORY: The patient smokes approximately 2 packs per day times greater than 40 years. He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month. He denies any drug use. He is a retired liquor store owner. PHYSICAL EXAMINATION: GENERAL: He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age. VITAL SIGNS: Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds. HEAD AND NECK: Normocephalic atraumatic. LUNGS: Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. The liver and spleen are not palpably enlarged. There is a large midline defect covered by skin, of which the fascia has numerous holes poking through. These small hernias are of approximately 2 cm in diameter at the largest and are nontender. GU: The penis is circumcised and there are no lesions, plaques, masses or deformities. There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place. Testes are bilaterally descended and there are no masses or tenderness. There is bilateral mild atrophy. Epididymidis are grossly within normal limits bilaterally. Spermatic cords are grossly within normal limits. There are no palpable inguinal hernias. RECTAL: The prostate is mildly enlarged with a small focal firm area in the midline near the apex. There is however no other focal nodules. The prostate is grossly approximately 35 to 40 g and is globally firm. Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault. EXTREMITIES: Demonstrate no cyanosis, clubbing or edema. There is dark red urine in the Foley bag collection. LABORATORY EXAM: Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42. Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup. CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam. There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted. IMPRESSION: Bladder cancer. PLAN: The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery. Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop. The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia. The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging. The patient understands these instructions and also agrees to quit smoking prior to his next visit. This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.

Write a clinical note about a patient with the following chief complaint: The patient comes for bladder instillation for chronic interstitial cystitis.

CHIEF COMPLAINT: The patient comes for bladder instillation for chronic interstitial cystitis. SUBJECTIVE: The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not think she can take any more pain. She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help. They seem to be intensifying her pain. She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine. So, she has to have somebody come with her and that is kind of troublesome to her. We discussed this at length. I did suggest that it was completely appropriate for her to decide. She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality. She had Hysterectomy in the past. MEDICATIONS: Premarin 1.25 mg daily, Elmiron 100 mg t.i.d. Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily. ALLERGIES: Compazine and Allegra. OBJECTIVE: Vital Signs: Weight: 140 pounds. Blood pressure: 132/90. Pulse: 102. Respirations: 18. Age: 27. PLAN: We discussed going for another evaluation by Dr. XYZ and seeking his opinion. She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete. The instillations give that a full trial and then he would be willing to see her back. As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her. She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend. I thought that was reasonable and agreed that that would work out. PROCEDURE: : She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine. We waited about 20 minutes. The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed. The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder. She seemed to tolerate it moderately well. She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it. If not, she will cancel and will start over next week or she will see Dr. Friesen.

Write a clinical note about a patient with the following identifying data: The patient is a 35-year-old Caucasian female who speaks English.

IDENTIFYING DATA: The patient is a 35-year-old Caucasian female who speaks English. CHIEF COMPLAINT: The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband. She then turned on the oven and put her head in the oven and then tried to climb over the second storied balcony. All of these behaviors were interrupted by her husband who called 911. He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period. HISTORY OF PRESENT ILLNESS: The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked. After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium. Her husband states that he restrained her from jumping, "so she would not kill herself," and this was taken as a statement in his affidavit. The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital. She arrives here and is today pacing on the unit and in and out of the large TV room area. She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner. She is highly tangential, delusional, and disorganized. She refused to sign all admit papers and a considerable part of her immediate history is unknown. PAST PSYCHIATRIC HISTORY: The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009. Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present. She is currently treated by Dr. Y. She has been involuntarily detained at least 7 times and revoked at least 6 times. She was on XYZ Inpatient in 2001 and in 01/2009. She states that she "feels invincible" when she becomes manic and this is also the description given by her husband. MEDICAL HISTORY: The patient has a history of a herniated disc in 1999. MEDICATIONS: Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o. AM and 600 mg p.o. q.p.m. Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard. She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc. Of note, she also has a history of abusing Vicodin. ALLERGIES: Said to be PENICILLIN, LAMICTAL, and ZYPREXA. SOCIAL AND DEVELOPMENTAL HISTORY: The patient lives with her husband. There are no children. She reportedly has a college education and has 2 brothers. SUBSTANCE AND ALCOHOL HISTORY: Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin. The X Hospital tox screen of last night was positive for opiates. Her lithium level per last night at X Hospital was 0.42 mEq/L. She smokes nicotine, the amount is not known although she has asked and received Nicorette gum. LEGAL HISTORY: She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated. MENTAL STATUS EXAM: ATTITUDE: The patient's attitude is agitated when asked questions, loud and evasive. APPEARANCE: Disheveled and moderately well nourished. PSYCHOMOTOR: Restless with erratic sudden movements. EPS: None. AFFECT: Hyperactive, hostile, and labile. MOOD: Her mood is agitated, suspicious, and angry. SPEECH: Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real. THOUGHT CONTENT: Delusional, disorganized, psychotic, and paranoid. Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt. COGNITIVE ASSESSMENT: The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital. Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing. JUDGMENT AND INSIGHT: Nil. When asked, are there situations when you lose control, she refuses to answer. When asked, are meds helpful, she refuses to answer. She refuses to give her family information nor release of information to contact them. ASSETS: The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications. LIMITATIONS: The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner. FORMULATION,: The patient has bipolar affective disorder in a manic state at present. She also may be depressed and is struggling with marital issues. DIAGNOSES:

Write a clinical note about a patient with the following identifying data: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",

IDENTIFYING DATA: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan. PRESENT ILLNESS: The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital. PAST PSYCHIATRIC HISTORY: Listed extensively in his admission note and will not be repeated. MEDICAL HISTORY: Includes migraine headaches and a history of concussion. He describes "allergy" to Haldol medication. OUTPATIENT CARE: The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X. DISCHARGE MEDICATIONS: The patient is discharged with: 1. Klonopin 1 mg t.i.d. p.r.n. 2. Extended-release lithium 450 mg b.i.d. 3. Depakote 1000 mg b.i.d. 4. Seroquel 1000 mg per day. SOCIAL HISTORY: The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together. SUBSTANCE ABUSE: The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment. MENTAL STATUS EXAM: Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications. FORMULATION: The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds. DIAGNOSES: AXIS I: 1. Bipolar disorder. 2. Major depression with anxiety and panic attacks. 3. Polysubstance abuse, benzodiazepines, and others street meds. 4. ADHD. AXIS II: Deferred at present, but consider personality disorder traits. AXIS III: History of migraine headaches and past history of concussion. AXIS IV: Stressors are moderate. AXIS V: GAF is 40. PLAN: The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan.

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

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

Write a clinical note about a patient with the following identification: The patient is a 15-year-old female.

IDENTIFICATION: The patient is a 15-year-old female. CHIEF COMPLAINT: Right ankle pain. HISTORY OF PRESENT ILLNESS: The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician is Dr. Brown. REVIEW OF SYSTEMS: Otherwise negative except as stated above. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS: None. SOCIAL HISTORY: Mother appears loving and caring. There is no evidence of abuse. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: General: The patient is alert and oriented x4 in mild distress without diaphoresis. She is nonlethargic and nontoxic. Vitals: Within normal limits. The right ankle shows no significant swelling. There is no ecchymosis. There is no significant tenderness to palpation. The ankle has good range of motion. The foot is nontender. Vascular: +2/2 dorsalis pedis pulse. All compartments are soft. Capillary refill less than 2 seconds. DIAGNOSTIC TEST: The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation. MEDICAL DECISION MAKING: Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home. She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain. She may need to see a specialist, but at this time this is a very mild ankle injury. There is no significant physical finding, and I foresee no complications. I will give her 1 week off of PE. MORBIDITY/MORTALITY: I expect no acute complications. A full medical screening exam was done and no emergency medical condition exists upon discharge. COMPLEXITY: Moderate. The differential includes fracture, contusion, abrasion, laceration, and sprain. ASSESSMENT: Right ankle sprain. PLAN: Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist. She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.

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

CHIEF COMPLAINT: Right ankle sprain. HISTORY OF PRESENT ILLNESS: This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time. PAST MEDICAL HISTORY: Hypertension and anxiety. PAST SURGICAL HISTORY: None. MEDICATIONS: She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Pulm: No cough, No wheezing, No shortness of breath,CV: No chest pain or palpitations,GI: No abdominal pain. No nausea, vomiting, or diarrhea. PHYSICAL EXAM: GENERAL APPEARANCE: No acute distress,VITAL SIGNS: Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A. NECK: Supple. No lymphadenopathy. No thyromegaly. CHEST: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. No murmurs. ABDOMEN: Non-distended, nontender, normal active bowel sounds. EXTREMITIES: No Clubbing, No Cyanosis, No edema. MUSCULOSKELETAL: The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle. DIAGNOSTIC DATA: X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending. ,IMPRESSION: Right ankle sprain. PLAN: 1. Motrin 800 mg t.i.d. 2. Tylenol 1 gm q.i.d. as needed. 3. Walking cast is prescribed. 4. I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.

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

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

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

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

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

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

Write a clinical note about a patient with the following chief complaint: A 5-month-old boy with cough.

CHIEF COMPLAINT: A 5-month-old boy with cough. HISTORY OF PRESENT ILLNESS: A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever. Mother did not measure it. REVIEW OF SYSTEMS: No vomiting. No diarrhea. He had runny nose started with the cough two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding, he is bottle-fed 2 ounces every 2 hours. Mother states he urinates like 5 to 6 times a day, stools 1 time a day. He is still feeding good to mom. IMMUNIZATIONS: He received first set of shot and due for the second set on 01/17/2008. BIRTH HISTORY: He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said. Mother had good prenatal care at 4 weeks for more than 12 visits. No complications during pregnancy. Rupture of membranes happened two days before the labor. Mother received the antibiotics, but she is not sure, if she received steroids also or not. FAMILY HISTORY: No history of asthma or lung disease. SOCIAL HISTORY: Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales. They have animals, but outside the house and father smokes outside house. No sick contacts as the mother said. PAST MEDICAL HISTORY: No hospitalizations. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: No medications. History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg. GENERAL: In no acute distress. HEAD: Normocephalic and atraumatic. Open, soft, and flat anterior fontanelle. NECK: Supple. NOSE: Dry secretions. EAR: Right ear full of yellowish material most probably pus and necrotic tissue. Tympanic membrane bilaterally visualized. MOUTH: No pharyngitis. No ulcers. Moist mucous membranes. CHEST: Bilateral audible breath sound. No wheezes. No palpitation. HEART: Regular rate and rhythm with no murmur. ABDOMEN: Soft, nontender, and nondistended. GENITOURINARY: Tanner I male with descended testes. EXTREMITIES: Capillary refill less than 2 seconds. LABS: White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6, segments 41, and bands 41. RSV positive. Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis in the right upper lobe and left lung base. ASSESSMENT: A 5-month-old male with 2 days of cough and 1 day of fever. Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive. DIAGNOSES: Respiratory syncytial virus bronchiolitis with right otitis externa. PLAN: Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.

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: 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: Abdominal pain.

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

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

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

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

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

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

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

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

CHIEF COMPLAINT: Hip pain. HISTORY OF PRESENTING ILLNESS: The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office. She reports moderate to severe pain related to a complicated past medical history. In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23. She was given nonsteroidals at that time, which did help with this discomfort. With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital. She was referred for rehabilitation and strengthening. Most of this was focused on her SI joints. At that time, although she had complained of foot discomfort, she was not treated for it. This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996. She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain. She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back. Medications at that time were salicylate and Ultram. When she returned to Portland in 1996, she was then working for Dr. B. She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case. Subsequently, nuclear bone scans revealed osteoarthritis. Orthotics were provided. She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure. During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle. She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since. She currently does not have an established cardiologist having just changed insurance plans. She is establishing care with Dr. S, of Rheumatology for her ongoing care. Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L. Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis. A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation. She then transferred her care to Ab Cd, FNP under the direction of Dr. K. Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens. Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged. PAST MEDICAL HISTORY: 1. Attention deficit disorder. 2. TMJ arthropathy. 3. Migraines. 4. Osteoarthritis as described above. PAST SURGICAL HISTORY: 1. Cystectomies. 2. Sinuses. 3. Left ganglia of the head and subdermally in various locations. 4. TMJ and bruxism. FAMILY HISTORY: The patient's father also suffered from bilateral hip osteoarthritis. MEDICATIONS: 1. Methadone 2.5 mg p.o. t.i.d. 2. Norco 10/325 mg p.o. q.i.d. 3. Tenormin 50 mg q.a.m. 4. Skelaxin 800 mg b.i.d. to t.i.d. p.r.n. 5. Wellbutrin SR 100 mg q.d. 6. Naprosyn 500 mg one to two pills q.d. p.r.n. ALLERGIES: IV morphine causes hives. Sulfa caused blisters and rash. PHYSICAL EXAMINATION: A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior. VITAL SIGNS: Blood pressure 110/72 with a pulse of 68. HEENT: Normocephalic. Atraumatic. Pupils are equal and reactive to light and accommodation. Extraocular motions are intact. No scleral icterus. No nystagmus. Tongue is midline. Mucous membranes are moist without exudate. NECK: Free range of motion without thyromegaly. CHEST: Clear to auscultation without wheeze or rhonchi. HEART: Regular rate and rhythm without murmur, gallop, or rub. ABDOMEN: Soft, nontender. MUSCULOSKELETAL: There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally. Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side. Toe-heel walking is performed without difficulty. Straight leg raises are negative. Romberg's are negative. NEUROLOGIC: Grossly intact. Intact reflexes in all extremities tested. Romberg is negative and downgoing. ASSESSMENT: 1. Osteoarthritis. 2. Chronic sacroiliitis. 3. Lumbar spondylosis. 4. Migraine. 5. TMJ arthropathy secondary to bruxism. 6. Mood disorder secondary to chronic pain. 7. Attention deficit disorder, currently untreated and self diagnosed. RECOMMENDATIONS: 1. Agree with Rheumatology referral and review. I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies. 2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage.

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

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

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

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

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

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

Write a clinical note about a patient with the following chief complaint: Palpitations. CHEST PAIN /

CHIEF COMPLAINT: Palpitations. CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY: The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs. PALPITATIONS HISTORY: Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal. VALVULAR DISEASE HISTORY: Patient has documented mitral valve prolapse on echocardiography in 1992. PAST MEDICAL HISTORY: No significant past medical problems. Mitral Valve Prolapse. FAMILY MEDICAL HISTORY: CAD. OB-GYN HISTORY: The patients last child birth was 1997. Para 3. Gravida 3. SOCIAL HISTORY: Denies using caffeinated beverages, alcohol or the use of any tobacco products. ALLERGIES: No known drug allergies/Intolerances. CURRENT MEDICATIONS: Inderal 20 prn. REVIEW OF SYSTEMS: Generally healthy. The patient is a good historian. ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision. ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms. ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc. ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia. ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence. ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc. ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system. ROS Extremities: The patient denies any extremities complaints. ROS Cardiovascular: As per HPI. EXAMINATION: Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal. Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal. There is no cyanosis, clubbing or edema. General: Healthy appearing, well developed,. The patient is in no acute distress. Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic. Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected. Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple. Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles. Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs. IMPRESSION / DIAGNOSIS: Mitral Valve Prolapse. Palpitations. TESTS ORDERED: Cardiac tests: Echocardiogram. MEDICATION PRESCRIBED: ,Cardizem 30-60 qid prn.

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

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

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

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

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

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