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,Skin: Without abnormalities. | [
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":",
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"abnormalities",
"."
] | [
{
"end": 29,
"label": "KEYPHRASE",
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"start": 16
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.397252" | null |
,Breasts: Normal symmetrical breasts without dimpling or retraction. | [
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"without",
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"or",
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.397529" | null |
No nipple discharge. | [
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"No",
"nipple",
"discharge",
"."
] | [
{
"end": 20,
"label": "KEYPHRASE",
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.397787" | null |
No masses or lesions to palpation. | [
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{
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"label": "KEYPHRASE",
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.398057" | null |
No axillary masses or lymphadenopathy. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.398329" | null |
,Genitourinary: Normal external genitalia. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.398606" | null |
The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. | [
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} | Default | "2022-12-07T10:15:39.398919" | null |
Cervix is visualized without lesion. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.399243" | null |
She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.399603" | null |
No cervical motion tenderness. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.399892" | null |
No adnexal tenderness or fullness. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.400166" | null |
She is just using her Proventil inhaler but is using it daily. | [
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} | Default | "2022-12-07T10:15:39.401104" | null |
May need to increase the dose. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.401804" | null |
She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary. | [
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} | Default | "2022-12-07T10:15:39.402140" | null |
If her shortness of breath worsens she is to call me or go into the emergency department. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.402924" | null |
Allergic rhinitis. | [
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} | Default | "2022-12-07T10:15:39.403619" | null |
We will plan on restarting Allegra and Flonase daily for the time being. | [
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} | Default | "2022-12-07T10:15:39.403910" | null |
Premenstrual dysphoric disorder. | [
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} | Default | "2022-12-07T10:15:39.404369" | null |
She may have some perimenopausal symptoms. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.404639" | null |
Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing. | [
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} | Default | "2022-12-07T10:15:39.405820" | null |
She does have some frequent dysuria but is not having it currently. | [
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} | Default | "2022-12-07T10:15:39.406127" | null |
Cervical dysplasia. | [
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] | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.406584" | null |
Pap smear is taken. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.406834" | null |
If normal we will go back to yearly Pap smear. | [
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} | Default | "2022-12-07T10:15:39.407342" | null |
She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.407669" | null |
Recommend she get 1200 mg of calcium and 400 U of vitamin D a day. | [
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} | Default | "2022-12-07T10:15:39.407988" | null |
CHIEF COMPLAINT: , This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." | [
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Mother states he has been wheezing and coughing. | [
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} | Default | "2022-12-07T10:15:39.411338" | null |
He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic. | [
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} | Default | "2022-12-07T10:15:39.411779" | null |
He has had some vomiting and some abdominal pain. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.412186" | null |
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. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.412491" | null |
,PAST MEDICAL HISTORY:, Asthma with his last admission in 07/2007. | [
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Also inclusive of frequent pneumonia by report. | [
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} | Default | "2022-12-07T10:15:39.412934" | null |
,MEDICATIONS: ,Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol. | [
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} | Default | "2022-12-07T10:15:39.413456" | null |
,SOCIAL HISTORY: , Lives at home, here in the ED with the mother and there is no smoking in the home. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.413871" | null |
,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.414599" | null |
Oxygen saturation low at 91% on room air. | [
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} | Default | "2022-12-07T10:15:39.414825" | null |
,GENERAL: This is a well-developed male who is cooperative, alert, active with oxygen by facemask. | [
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{
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"start": 36
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{
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"score": 0,
"start": 68
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{
"end": 86,
"label": "KEYPHRASE",
"score": 0,
"start": 80
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.415084" | null |
,HEENT: Head is atraumatic and normocephalic. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.415304" | null |
Pupils are equal, round, and reactive to light. | [
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{
"end": 38,
"label": "KEYPHRASE",
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"start": 30
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.415517" | null |
Extraocular motions are intact and conjugate. | [
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] | [
{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.415715" | null |
Clear TMs, nose, and oropharynx. | [
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{
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"start": 22
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.415910" | null |
Full painless nontender range of motion. | [
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{
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{
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"start": 25
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.416241" | null |
,CHEST: Tight wheezing and retractions heard bilaterally. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.416440" | null |
,ABDOMEN: Soft, nontender. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.416778" | null |
No masses. | [
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] | [
{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.416947" | null |
No hepatosplenomegaly. | [
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] | [
{
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"label": "KEYPHRASE",
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"start": 4
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.417116" | null |
,GENITALIA: Male genitalia is present on a visual examination. | [
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{
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"score": 0,
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}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.417325" | null |
,SKIN: No significant bruising, lesions or rash. | [
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{
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"label": "KEYPHRASE",
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.417536" | null |
,EXTREMITIES: Moves all extremities without difficulty, nontender. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.417752" | null |
No deformity. | [
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] | [
{
"end": 13,
"label": "KEYPHRASE",
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}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.417933" | null |
,MEDICAL DECISION MAKING:, The differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.418364" | null |
He is evaluated in the emergency department with continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.418664" | null |
Chest x-ray reveals bronchial thickening, otherwise no definite infiltrate. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.418934" | null |
She is further treated in the emergency department with continued breathing treatments. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.419164" | null |
At 0048 hours, he has continued tight wheezes with saturations 99%, but ED sats are 92% with coughing spells. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.419434" | null |
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. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.419737" | null |
HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.424100" | null |
Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.424582" | null |
In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection. | [
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"score": 0,
"start": 367
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{
"end": 382,
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"start": 373
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.425197" | null |
In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.425679" | null |
He currently is not taking any medication for allergies. | [
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{
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"start": 47
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.426005" | null |
He is taking atenolol for blood pressure control. | [
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{
"end": 41,
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"score": 0,
"start": 27
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.426312" | null |
No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.426673" | null |
,PAST MEDICAL HISTORY:, History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension. | [
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{
"end": 187,
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"start": 175
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.427110" | null |
,PAST SURGICAL HISTORY:, PermCath insertion times 3 and peritoneal dialysis. | [
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"medical_specialty": " Allergy / Immunology"
} | Default | "2022-12-07T10:15:39.427459" | null |
,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension. | [
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} | Default | "2022-12-07T10:15:39.427853" | null |
,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite. | [
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,ALLERGIES: , Heparin causing thrombocytopenia. | [
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,SOCIAL HISTORY: , Denies tobacco or alcohol use. | [
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} | Default | "2022-12-07T10:15:39.428812" | null |
,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches. | [
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} | Default | "2022-12-07T10:15:39.429239" | null |
,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress. | [
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} | Default | "2022-12-07T10:15:39.429663" | null |
No masses or lesions noted. | [
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} | Default | "2022-12-07T10:15:39.430204" | null |
,FACE: No facial tenderness or asymmetry noted. | [
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} | Default | "2022-12-07T10:15:39.430493" | null |
,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. | [
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Extraocular movements are intact bilaterally. | [
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} | Default | "2022-12-07T10:15:39.431108" | null |
,EARS: The tympanic membranes are intact bilaterally with a good light reflex. | [
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The external auditory canals are clear with no lesions or masses noted. | [
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Weber and Rinne tests are within normal limits. | [
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} | Default | "2022-12-07T10:15:39.432050" | null |
,NOSE: The nasal cavities are patent bilaterally. | [
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} | Default | "2022-12-07T10:15:39.432341" | null |
The nasal septum is midline. | [
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} | Default | "2022-12-07T10:15:39.432616" | null |
There are no nasal discharges. | [
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No masses or lesions noted. | [
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} | Default | "2022-12-07T10:15:39.433154" | null |
,THROAT: The oral mucosa appears healthy. | [
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No oropharyngeal masses or lesions noted. | [
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} | Default | "2022-12-07T10:15:39.433950" | null |
,NECK: The neck is supple with no adenopathy or masses palpated. | [
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} | Default | "2022-12-07T10:15:39.434486" | null |
The trachea is midline. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.434771" | null |
The thyroid gland is of normal size with no nodules. | [
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] | Argilla | null | null | null | {
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} | Default | "2022-12-07T10:15:39.435073" | null |
,NEUROLOGIC: Facial nerve is intact bilaterally. | [
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The remaining cranial nerves are intact without focal deficit. | [
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,HEART: Regular rate and rhythm. | [
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} | Default | "2022-12-07T10:15:39.436538" | null |
No murmur noted. | [
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Acute allergic reaction, etiology uncertain, however, suspicious for Keflex. | [
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Renal failure requiring dialysis. | [
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} | Default | "2022-12-07T10:15:39.437801" | null |
,RECOMMENDATIONS: ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow. | [
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If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions. | [
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At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy. | [
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Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions. | [
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} | Default | "2022-12-07T10:15:39.439984" | null |
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