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First Pap smear, complaining of irregular periods. - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.

Consult - History and Phy.

First Pap smear.

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

Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night.

Consult - History and Phy.

Feet & Hand Cramping

HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to "pop into place." He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 130/70

Severe tonsillitis, palatal cellulitis, and inability to swallow.

Consult - History and Phy.

Exudative Tonsillitis

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

Left flank pain and unable to urinate.

Consult - History and Phy.

Flank Pain - Consult

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

This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.

Consult - History and Phy.

Essential Tremor & Torticollis

REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade. She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam. She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better. She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity. Since around 6 to 7 years, she has had a head tremor, which is mainly "no- no" and occasional voice tremor also. Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart. She also has some stress incontinence. Last MRI brain was done in 2001 reportedly normal.,CURRENT MEDICATIONS:,1. Klonopin 0.5 mg twice a day.,2. Primidone 100 mg b.i.d.,3. Propranolol long-acting 80 mg once in the morning.,PAST MEDICAL HISTORY: , Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,PAST SURGICAL HISTORY: , L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,FAMILY HISTORY: , Both parents have ET and hypertension. Maternal cousin with lupus.,SOCIAL HISTORY: , Denies any smoking or alcohol. She is married since 44 years, has 3 children. She used to work as a labor and delivery nurse up until early 2001 when she retired.,REVIEW OF SYSTEMS: , No fever, chills, nausea or vomiting. No visual complaints. She complains of hearing decreased on the left. No chest pain or shortness of breath. No constipation. She does give a history of urge incontinence. No rashes. No depressive symptoms.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg. HEENT: PERRLA. EOMI. CARDIOVASCULAR: S1 and S2 normal. Regular rate and rhythm. She does have a rash over the right ankle with a prior basal cell carcinoma was resected. NEUROLOGIC: Alert and oriented x4. Speech shows a voice tremor occasionally. Language is intact. Cranial nerves II through XII intact. Motor examination showed 5/5 power in all extremities with minimal increased tone. Sensory examination was intact to light touch. Reflexes were brisk bilaterally, but they were equal and both toes were downgoing. Her coordination showed minimal intentional component to bilateral finger-to-nose. Gait was intact. Lot of swing on Romberg's. The patient did have a tremor both upper extremities, right more than left. She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,ASSESSMENT AND PLAN: , This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. The patient did not wish to change any of her medication doses at this point. We will go ahead and check MRI brain, and we will get the films later. We will see her back in 3 months. Also, the patient declined any possible Botox for the mild torticollis she has at this point.

Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.

Consult - History and Phy.

Epidural Hematoma

CC:, Fall with questionable associated loss of consciousness.,HX: ,This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.,MEDS:, Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, "Ginsana" (Ginseng) 100mg bid.,PMH: ,1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.,FHX:, Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.,SHX:, Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2,MS: A&O to person, place, time. Speech fluent and without dysarthria.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: not mentioned in chart.,Reflexes: symmetric. Plantar responses were flexor, bilaterally.,Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.,HEENT: abrasion over the right forehead.,Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.,COURSE:, 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.

This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.

Consult - History and Phy.

ER Report - Rib Cage Pain

HISTORY:, The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today. He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had "rib cage pain" for the last few days. He denies any history of trauma. He does have increased pain with laughing. Per the patient, he also claims to have an elevated temperature yesterday of 101. Apparently, the patient did go to the emergency room at ABCD yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to Children's.,PAST MEDICAL HISTORY: , The patient has a medical history significant for "Staphylococcus infection" that was being treated with antibiotics for 10 days.,CURRENT MEDICATIONS: , He states that he is currently taking no medications.,ALLERGIES: ,He is not allergic to any medication.,PAST SURGICAL HISTORY: , He denies any past surgical history.,SOCIAL HISTORY: , The patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago. He also has a history of marijuana used approximately 1 year ago. He currently states that he is in a rehab program.,FAMILY HISTORY:, Unknown by the patient.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,GENERAL: He is alert and appeared to be in no acute distress. He had normal hydration.,HEENT: His pupils were equal, round, reactive. Extraocular muscles intact. He had no erythema or exudate noted in his posterior oropharynx.,NECK: Supple with full range of motion. No lymphadenopathy noted.,RESPIRATORY: He had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,CARDIOVASCULAR: Regular rate and rhythm. Positive S1, S2. No murmurs, rubs, or gallops noted.,GI: Nontender, nondistended with normoactive bowel sounds. No masses noted.,SKIN: Appeared normal except on the left anterior tibial area where the patient had a healing skin lesion. There were no vesicles, erythema or induration noted.,MUSCULOSKELETAL: Nontender with normal range of motion.,NEURO/PSYCHE: The patient was alert and oriented x3 with nonfocal neurological exam.,ASSESSMENT: , This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,PLAN: , Due to the fact that this patient is an adult male, we will transfer him to XYZ Medical Center for further evaluation. I have spoken with XYZ Medical Center Dr. X who has accepted the patient for transfer. He was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress. Dr. X was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork. The plan was explained in detail to the patient who stated that he understood and would comply. The appropriate paperwork was created and one copy was given to the patient.,CONDITION ON DISCHARGE: , At the time of discharge, he was stable, vital signs stable, in no acute distress.

Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.

Consult - History and Phy.

End Stage Renal Disease - Consult

REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:, This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. He took some nitroglycerin tablets at home with no relief. He came to the ER. He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock. This is a late entry dictation. Presently lying in bed, but he feels fine. Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1. Coronary artery disease, status post stent placement two years ago.,2. Diabetes mellitus for the last 12 years.,3. Hypertension.,4. End-stage renal disease.,5. History of TIA in the past.,PAST SURGICAL HISTORY:,1. As mentioned above.,2. Cholecystectomy.,3. Appendectomy.,4. Right IJ PermaCath placement.,5. AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:, He smoked 2 to 3 packets per day for at least last 10 years. He quit smoking roughly about 20 years ago. Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES: ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL: He is alert, seems to be in no apparent distress.,VITAL SIGNS: Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT: Atraumatic and normocephalic.,NECK: No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS: Clear to auscultation. Air entry bilateral equal.,HEART: S1 and S2. No pericardial rub.,ABDOMEN: Soft and nontender. Normal bowel sounds.,EXTREMITIES: No edema.,NEUROLOGIC: The patient is alert without focal deficit.,LABORATORY DATA:, Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1. End-stage renal disease, plan for dialysis today.,2. Diabetes mellitus.,3. Chest pain for coronary angiogram today.,4. Hypertension, blood pressure stable.,PLAN: , Currently follow the patient. Dr. Z is going to assume the care.

Encephalopathy related to normal-pressure hydrocephalus.

Consult - History and Phy.

Encephalopathy - Rehab Consult

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

Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.

Consult - History and Phy.

Elevated PSA - H&P

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

Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.

Consult - History and Phy.

ENT Consult - 1

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

Elevated BNP. Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.

Consult - History and Phy.

Elevated BNP - Consult

REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:, The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested. The patient denies any chest pain or shortness of breath. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, At this time, he is on:,1. Atrovent and albuterol nebulizers.,2. Azithromycin.,3. Potassium chloride 10 mEq p.o. daily.,4. Furosemide 20 mg IV daily.,5. Enoxaparin 40 mg daily.,6. Lisinopril 10 mg p.o. daily.,7. Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:, History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke. Drinks occasionally.,FAMILY HISTORY: ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea. He has cough. No fever. No abdominal pain. No syncope, near-syncope, or palpitation. All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable, not in distress.,VITAL SIGNS: His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT: Atraumatic, normocephalic. Eyes PERRLA.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Clear.,HEART: S1 and S2, regular. No S3. No S4. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,DIAGNOSTIC DATA:, EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay. CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe. Loculated pleural effusion in the left upper lobe. No PE. Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05. White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1. Pneumonia.,2. Diastolic heart failure, not contributing to his present problem.,3. Hypertension, controlled.,4. History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics. No further cardiac workup at this time.

13 years old complaining about severe ear pain - Chronic otitis media.

Consult - History and Phy.

Ear pain - Pediatric Consult

PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain. He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS: ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team. Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms. Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:, Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks. Vaginal delivery was uneventful with a normal perinatal course. Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months. His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years). He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team. Mom reports that he has several friends, but she is concerned about the time required for the wrestling team. Patient is in 8th grade this year and an A/B student. Both siblings are healthy. His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications. Mom is healthy and has asthma.,PAST MEDICAL HISTORY: ,Patient has been seen in the clinic yearly for well child exams. He has had no major illnesses or hospitalizations. He had one emergency room visit 2 years ago for a knee laceration. Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections. He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems. Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn. Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food. He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days. He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch. Mom or his sister cooks supper in the evening. The family goes out to eat once or twice a week and he only gets "fast food" once or twice a week according to his Mom. He says he eats "a lot" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight: Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile). He is following the growth pattern he established in infancy.,Vital signs: BP 110/60, T 99.2, HR 70, R 16.,General: Alert, cooperative but a bit shy.,Neuro: DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact. He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT: Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal. TMs deep red, dull, landmarks obscured, full bilaterally. Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs: CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac: S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen: Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat. Bowel sounds active in all quadrants. No hepatosplenomegaly or tenderness. No CVA tenderness.,Musculoskeletal: Full range of motion, all extremities. Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital: Normal male, Tanner stage 4. Rectal exam - small amount of soft stool, no fissures or masses.,LABS: ,Stool negative for blood and H. pylori antigen. Normal CBC and urinalysis. A barium swallow and upper GI was scheduled for the following week. It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case. It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment). It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE., There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely. Trauma. Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD., The history of "heartburn" relieved by his father's medication was striking. The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:, Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks. Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it. The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication. He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks. At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication. A 6-month follow up appointment was scheduled.

Abnormal cardiac enzyme profile. The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile.

Consult - History and Phy.

Elevated Cardiac Enzymes

REASON FOR CONSULTATION:, Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. This is a consultation for evaluation of the same. The patient is unable to give history. History obtained through the family members. As per the patient's son, he does not have history of cardiac disease. He lives in Utah, presently spending few months in Arizona. As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far. No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1. Vitamin supplementation.,2. Prednisone.,3. Cyclobenzaprine.,4. Losartan 50 mg daily.,5. Nifedipine 90 mg daily.,6. Lasix.,7. Potassium supplementation.,ALLERGIES:, SULFA.,PERSONAL HISTORY:, He is an ex-smoker. Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same. Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation. No prior cardiac history. Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat.,LUNGS: Air entry bilaterally clear, rales are scattered.,HEART: PMI displaced. S1, S2 regular. Systolic murmur, grade 2/6.,ABDOMEN: Soft, nontender.,EXTREMITIES: Chronic skin changes, markings in the lower extremities noted. Pulses found palpable. Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex. Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11. Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423. Chest x-ray, no acute changes.,IMPRESSION:,1. The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2. Septicemia, septic shock secondary to cellulitis of the leg.,3. Acute renal shutdown.,4. Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1. Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2. Aggressive medical management including dialysis.,3. From cardiac standpoint, conservative treatment at this juncture. His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4. Explained to patient's family in detail regarding condition which is critical which they are aware of.

A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.

Consult - History and Phy.

Dog Bite

CHIEF COMPLAINT:, Dog bite to his right lower leg.,HISTORY OF PRESENT ILLNESS:, This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.,PAST MEDICAL HISTORY: ,Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.,ALLERGIES: ,There are no known allergies.,MEDICATIONS:, Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin.,FAMILY HISTORY: , Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has diabetes.,SOCIAL HISTORY:, He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD.,REVIEW OF SYSTEMS:, He denies any chest pain. He does admit to exertional shortness of breath. He denies any GI or GU problems. He denies any bleeding disorders.,PHYSICAL EXAMINATION,GENERAL: Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress.,HEENT: Unremarkable.,NECK: Supple. There is no mass, adenopathy or bruit.,CHEST: Normal excursion.,LUNGS: Clear to auscultation and percussion.,COR: Regular. There is no S3 or S4 gallop. There is no obvious murmur.,ABDOMEN: Soft. It is nontender. Bowel sounds are present. There is no tenderness.,SKIN: He does have like a Chevron incisional scar across his lower chest and upper abdomen. It appears to be well healed and unremarkable.,GENITALIA: Deferred.,RECTAL: Deferred.,EXTREMITIES: He has about 1+ pitting edema to both legs and they have been present since the surgery. In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap. The wound is spread apart about may be a centimeter all along that area and it is relatively clean. There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate. There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc. The flap appeared to be viable.,NEUROLOGIC: Without focal deficits. The patient is alert and oriented.,IMPRESSION:, A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago. He is on multiple medications and he is on chronic Bactrim. We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult. We will see him back in the office early next week to reassess his wound. He is to keep the wound clean with the moist dressing right now. He may shower several times a day.

Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes.

Consult - History and Phy.

Dizziness - Recurrent

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

Patient with episode of lightheadedness and suddenly experienced vertigo.

Consult - History and Phy.

Dural AVM

CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The "vascular blush" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.

Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis

Consult - History and Phy.

Dysphagia & Hematemesis

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

A 12-year-old with discoid lupus on the control with optimal regimen.

Consult - History and Phy.

Discoid Lupus

HISTORY: ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit. She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus. A has been doing well with just Plaquenil alone and mother said that during the summer, the rash gets brighter, but now that it is getting darker and she is at school, the rash is starting to become lighter again. She has been using her cream, which is hydrocortisone at night and applying it with no problems. She denies any hair losses, denies any decrease in appetite, actually, she has been gaining some weight. She denies any ulcerations in her mouth, eye problems, or any lumps in her body. She denies any fevers or any problems with the urine.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Today temperature is 100.1, weight is 73.5 kg, blood pressure is 121/61, height is 158, and pulse is 84.,GENERAL: She is alert, active, and oriented in no distress.,HEENT: She had a head full of hair with no bald spots. She has a macular rash on her cheeks bilaterally with hyperpigmented circles. No scales, no excoriations, and no palpable erythema. Oral mucosa is clear with no ulcerations.,NECK: Soft with no masses. She does have acanthosis nigricans on the base of the neck.,CHEST: Clear to auscultation.,HEART: Regular rhythm with no murmur.,ABDOMEN: Soft and nontender with no visceromegaly.,MUSCULOSKELETAL: Shows no limitation, swelling, or tenderness in any of her joints.,SKIN: Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size, but most of them are about 1 cm in diameter, which are hyperpigmented. No erythema, no purpura, no petechiae, and no raised borders. They look more like cigarette points. She has this in her upper extremities especially in the forearms and also on her lower extremities, on the legs, but just very few lesions and very light. She has some periungual erythema, as well as some palmar erythema, but this is minimal.,LABORATORY DATA:, Laboratories today done, we have a CBC with a white blood cell count of 7.9, hemoglobin is 14.3, platelet count is 321,000, sed rate is only 11, and CMP shows no abnormalities. Pending is antinuclear antibody complement level.,ASSESSMENT: , She is 12-year-old with discoid lupus on the control with optimal regimen. We are going to switch her to Protopic at night, especially in the face. Continue on Plaquenil, get some laboratories and wait for the results. Diet evaluation today because of the gaining weight and acanthosis nigricans, and will see her back in about 3 months for follow-up. Future plans will be depending on whether or not she evolves into a full-blown lupus. I discussed the plan with her mother and they had no further questions.

He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again.

Consult - History and Phy.

Diplopia

HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76

A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure. He has noted shortness of breath with exertion and occasional shortness of breath at rest.

Consult - History and Phy.

Dilated Cardiomyopathy - Consult

REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure. He feels in general "OK," but is stressed and fatigued. He works hard running 3 companies. He has noted shortness of breath with exertion and occasional shortness of breath at rest. There has been some PND, but he sleeps on 1 pillow. He has no edema now, but has had some mild leg swelling in the past. There has never been any angina and he denies any palpitations, syncope or near syncope. When he takes his pulse, he notes some irregularity. He follows no special diet. He gets no regular exercise, although he has recently started walking for half an hour a day. Over the course of the past year, these symptoms have been slowly getting worse. He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982. He had trauma to his right thumb. There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife. He has a lot of stress in his life. He does not smoke, but does drink. He has high school education.,On family history, mother is alive at age 89. Father died at 72 of heart attack. He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. His blood pressure is 120/70 in each arm seated. His pulse is 80 beats per minute and regular. He is breathing 1two times per minute and that is unlabored. Eyelids are normal. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. Neck is supple and symmetrical without adenopathy or thyromegaly. Jugular venous pressure is normal. Carotids are brisk without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is regular. The first and second heart sounds are normal. He does have a fourth heart sound and a soft systolic murmur. The precordial impulse is enlarged. Abdomen is soft without hepatosplenomegaly or masses. He has no clubbing, cyanosis or peripheral edema. Distal pulses are normal throughout both arms and both legs. On neurologic examination, his mentation is normal. His mood and affect are normal. He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33. His glucose is 97 and creatinine 0.9. Potassium is 4.3. He is not anemic. Urinalysis was normal.,I reviewed his echocardiogram personally. This shows a dilated cardiomyopathy with EF of 15%. The left ventricular diastolic dimension is 6.8 cm. There are no significant valvular abnormalities.,He had a stress thallium. His heart rate response to stress was appropriate. The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged. The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES: ,1. Dilated cardiomyopathy.,2. Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. In addition, he could benefit from a loop diuretic such as furosemide. I did not start this as he is planning to go back home to San Salvador tomorrow. I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing. There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here. He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:, See the above.

Difficulty with both distance vision and with fine print at near.

Consult - History and Phy.

Difficulty Distance Vision & Fine Print at Near

REASON FOR VISIT: , Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient. He states that he has difficulty with both his distance vision and also with fine print at near.,HISTORY OF PRESENT ILLNESS:, Mr. ABC states that over the last year, he has had increasing difficulty with distance vision particularly when he is driving. He is also having trouble when he is reading. He does occasionally wear over-the-counter reading glasses, which do help with his near vision.,Past ocular history is significant for astigmatism for which he wore glasses since he was 18 years old. However, Mr. ABC mentioned today that he has not worn his glasses for the last few years.,His past medical history is significant for hypertension, low serum testosterone level, hypercholesterolemia, GERD, depression, actinic keratoses, and a history of Pityrosporum folliculitis.,His family history is significant for diabetes in both parents. He states that his mother is seen by Mrs. Goldberg, but he is not aware of her ocular history. He has no known family history of glaucoma, age-related macular degeneration or hereditary blindness.,MEDICATIONS: , Wellbutrin XL 450 mg daily, Ritalin long-acting 60 mg daily, hydrochlorothiazide at an unknown dose, Vytorin at an unknown dose, and aspirin.,ALLERGIES: , No known drug allergies.,FINDINGS:, Visual acuity today without correction was 20/20 -2 pinholing to 20/16 in the right eye, and 20/40 +2 pinholing to 20/16 in the left eye. Near vision unaided was J2 in both eyes.,Manifest refraction today following pharmacological dilation was -0.50, +0.50 times 155 in the right eye revealing a vision of 20/16. Manifest refraction was -1.00, +0.25 times 005 revealing a vision of 20/16 in the left eye. The add was +2 in both eyes. Visual fields are full to finger counting in both eyes.,Extraocular movements were within normal limits. Intraocular pressure by applanation was 16 mmHg in the right eye and 18 mmHg in the left eye measured at 11.30 in the morning.,Examination of the anterior segment was unremarkable in both eyes except for mild nuclear sclerotic opacities in both eyes.,Dilated fundus examination of the right eye revealed a sharp and pink optic disc with a healthy rim and cup-to-disc ratio of 0.7; however, there was central excavation of the disc, but no disc hemorrhages were noted. On examination of the macula, there were drusen scattered temporally. Examination of the vasculature was normal. Peripheral retinal examination was entirely normal.,On funduscopic examination of the left eye, there was a sharp and pink disc with a healthy rim, but with central excavation and a cup-to-disc ratio of 0.6. Of note, there were no disc hemorrhages. On examination of the macula, there was scattered tiny drusen centrally and superiorly. Examination of the vasculature was entirely normal. Peripheral fundus examination was unremarkable.,ASSESSMENT:,1. Age-related macular degeneration category three (right greater than sign left).,2. Glaucoma suspect based on disc appearance (increased cup-to-disc ratio and disc asymmetry).,3. Presbyopia and astigmatism.,4. Non-visually significant cataracts bilaterally.,PLANS:,1. The above diagnoses and management plans each were discussed with the patient who expressed understanding.,2. Commence Ocuvite PreserVision capulets one tablet twice a day by mouth for age-related macular degeneration.,3. Humphrey visual field and disc photographs today for baseline documentation in view of glaucoma suspicion.,4. Followup in Glaucoma Clinic arranged in 4 months' time with repeat Humphrey visual fields at this time for reevaluation and comparison.,5. Follow up with Mrs. Braithwaite in the Comprehensive Eye Service Clinic for undilated refraction.,6. We will follow up this gentleman in our clinic in 12 months' time; however, I have asked him to return to us soon should he develop any worsening ocular symptoms in the interim.

Dietary consultation for weight reduction secondary to diabetes.

Consult - History and Phy.

Dietary Consultation - 2

SUBJECTIVE:, This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes. She did attend diabetes education classes at Abc Clinic. She comes however, wanting to really work at weight reduction. She indicates that she has been on the Atkins' diet for about two years and lost about ten pounds. She is now following a veggie diet which she learned about in Poland originally. She has been on it for three weeks and intends to follow it for another three weeks. This does not allow any fruits or grains or starchy vegetables or meats. She does eat nuts for protein. She is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet. She also wants to know that if she gets skinny enough, if the diabetes will go away. Her problem time, blood sugar wise, is in the morning. She states that if she eats too much in the evening that her blood sugars are always higher the next morning.,OBJECTIVE:, Weight: 189 pounds. Reported height: 5 feet 5 inches. BMI is approximately 31-1/2. Diabetes medications include metformin 500 mg daily. Lab from 5/12/04: Hemoglobin A1C was 6.4%.,A diet history was obtained. I instructed the patient on dietary guidelines for weight reduction. A 1200-calorie meal plan was recommended.,ASSESSMENT:, Patient's diet history reflects that she is highly restricting carbohydrates in her food intake. She does not have blood sugar records with her for me to review, but we discussed strategies for improving blood sugar control in the morning. This primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts. She is doing some physical activity two to three times a week. This includes aerobic walking with weights on her arms and her ankles. She is likely going to need to increase frequency in this area to help support weight reduction. Her basal metabolic rate was estimated at 1415 calories a day. Her total calorie requirements for weight maintenance are estimated at 1881 calories a day. A 1200-calorie meal plan should support a weight loss of at least one pound a week.,PLAN:, Recommend patient increase the frequency of her walking to five days a week. Encouraged a 30-minute duration. Also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations. And lastly, I encouraged caloric intake of just under 1200 calories daily. Recommend keeping food records and tracking caloric intake. It is unlikely that her blood sugars would drop significantly low on the current dose of Glucophage. However, I encouraged her to be careful not to reduce calories below 1000 calories daily. She may want to consider a multivitamin as well. This was a one-hour consultation.

Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.

Consult - History and Phy.

Disseminated Intravascular Coagulation

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.

Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.

Consult - History and Phy.

Dietary Consult - Weight Reduction

SUBJECTIVE:, This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendations to assist both of them in healthier eating. The two of them live alone now, and she is used to cooking for large portions. She is having a hard time adjusting to preparing food for the two of them. She would like to do less food preparation, in fact. She is starting a new job this week.,OBJECTIVE:, Her reported height is 5 feet 4 inches. Today’s weight was 170 pounds. BMI is approximately 29. A diet history was obtained. I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well. Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:, The patient’s basal energy expenditure is estimated at 1361 calories a day. Her total calorie requirement for weight maintenance is estimated at 1759 calories a day. Her diet history reflects that she is making some very healthy food choices on a regular basis. She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals. She also is emphasizing lower fat selections. Her physical activity level is moderate at this time. She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend. We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction. We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well. We discussed menu selection, as well as food preparation techniques. The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that. I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:, Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk. Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week. This translates into a 1200-calorie meal plan. I encouraged the patient to keep food records in order to better track calories consumed. I recommended low fat selections and especially those that are lower in saturated fats. Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well. This was a one-hour consultation. I provided my name and number should additional needs arise.

Dietary consultation for gestational diabetes.

Consult - History and Phy.

Dietary Consult - Gestational Diabetes

SUBJECTIVE:, This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historically however, she likes to eat out with a high frequency. She enjoys eating rice as part of her meals. She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home. She sleeps two to four hours at a time throughout the day. She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:, Today's weight: 155.5 pounds. Weight from 10/07/04 was 156.7 pounds. A diet history was obtained. Blood sugar records for the last three days reveal the following: fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88. I instructed the patient on dietary guidelines for gestational diabetes. The Lily Guide for Meal Planning was provided and reviewed. Additional information on gestational diabetes was applied. A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:, Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day. Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day. Her diet history reveals that she has somewhat irregular eating patterns. In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m. We discussed the need for small frequent eating. We identified carbohydrate as the food source that contributes to the blood glucose response. We identified carbohydrate sources in the food supply, recognizing that they are all good for her. The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars. In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice. We discussed the need for moderating the portion of carbohydrates consumed at one given time. Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake. Her weight loss was discouraged. Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:, The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan. The meal plan was devised to distribute her carbohydrates more evenly throughout the day. The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time. The meal plan is as follows: breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings. Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep. Encouraged adequate rest. Also recommend adequate calories to sustain weight gain of one-half to one pound per week. If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly. This was a one-hour consultation. I provided my name and number should additional needs arise.

Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia.

Consult - History and Phy.

Dietary Consultation - 1

SUBJECTIVE:, This is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia. The patient reports that she has resumed food record keeping which she feels like it has given her greater control. Her physical activity level has remained high. Her struggle times are in the mid-afternoon if she has not had enough food to eat, as well as in the evening after dinner.,OBJECTIVE:, Vital Signs: Weight is 189-1/2 pounds. Food records were reviewed,ASSESSMENT:, The patient has experienced a weight loss of 1-1/2 pounds in the last month. She is commended for these efforts. We have reviewed food records identifying that she has done a nice job keeping a calorie count for the last two or three weeks. We discussed the value of this and how it was very difficulty to resume it, however, after she suspended the record keeping. We also discussed its reflection that she is not getting very many fruits and vegetables on a regular basis. We identified some ways of preventing her from feeling sluggish and having problems with low blood sugar in the middle of the afternoon by routinely planning an afternoon snack that can prevent these symptoms. This will likely be around 2:30 or 3 p.m. for her. We also discussed strategies for evening snacking to help put some definition and boundaries to the snacking.,PLAN:, I recommended the patient routinely include an afternoon snack around 2:30 to 3 p.m. It will be helpful if this snack includes some protein such as nuts or low-fat cheese. She is also encouraged to continue with her record keeping for food choices and calorie points. I also recommended she maintain her high level of physical activity. Will plan to follow the patient in one month for ongoing support. This was a 30-minute consultation.

Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

Consult - History and Phy.

Dietary Consult - Hyperlipidemia

SUBJECTIVE:, This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome. The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it. She is not sure that she was following it accurately. She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well. Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off. However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:, Weight is 275 pounds. Food records were reviewed.,ASSESSMENT:, The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago. I did carefully review her food records and evaluated calories consumed. While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected. Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well. She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates. While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction. We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:, A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat. This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack. This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack. We have eliminated the morning snack. The patient will now track the grams of fat in her meats as well as added fats. Her goal for total fats over the course of the day is no more than 42 grams of fat per day. This was a half hour consultation. We will plan to see the patient back in one month for support.

Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.

Consult - History and Phy.

Dietary Consult - Diabetes - 2

SUBJECTIVE:, The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds. She was diagnosed with type 2 diabetes in 1983. She is not allergic to any medicines.,DIABETES MEDICATIONS:, Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper. Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:, The patient and her daughter completed both days of diabetes education in a group setting. Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician. Fasting blood sugars are 127, 80, and 80. Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63. Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109. Assessment of her knowledge is completed at the end of the counseling session. She demonstrated increased knowledge in all areas and had no further questions. She also completed an evaluation of the class.,The patient's feet were examined during the education session. She had flat feet bilaterally. Skin color was pink, temperature warm. Pedal pulses 2+. Her right second and third toes lay on each other. Also, the same on her left foot. However, there was no skin breakdown. She had large bunions, medial aspect of the ball of both feet. She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care. First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels. Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control. Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control. Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:, Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness. She is to followup with Dr. XYZ for possible reduction in her insulin doses.

The patient is brought in by an assistant with some of his food diary sheets.

Consult - History and Phy.

Dietary Consult - 3

SUBJECTIVE:, The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.,OBJECTIVE:, The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop. I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:, The patient is losing weight at an acceptable rate. He needs to continue keeping a food diary and his regular physical activity.,PLAN:, The patient plans to see Dr. XYZ at the end of May 2005. I recommended that they ask Dr. XYZ what weight he would like for the patient to be at. Follow up will be with me June 13, 2005.

The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.

Consult - History and Phy.

Dietary Consult - 2

SUBJECTIVE:, The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.,OBJECTIVE:, Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food diary. I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern. I encouraged her to continue all of this.,ASSESSMENT:, The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. She needs to continue all this.,PLAN:, Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.

Dietary consultation for diabetes during pregnancy.

Consult - History and Phy.

Dietary Consult - Diabetes - 1

SUBJECTIVE:, This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. Patient reports that she had gestational diabetes with her first pregnancy. She did use insulin at that time as well. She does not fully understand what ketones are. She walks her daughter to school and back home each day which takes 20 minutes each way. She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:, Weight is 238.3 pounds. Weight from last week’s visit was 238.9 pounds. Prepregnancy weight is reported at 235 pounds. Height is 62-3/4 inches. Prepregnancy BMI is approximately 42-1/2. Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time. Blood sugar records for the last week reveal the following: Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116. Overall average is 140. A diet history was obtained. Expected date of confinement is May 1, 2005. Instructed the patient on dietary guidelines for gestational diabetes. A 2300 meal plan was provided and reviewed. The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:, Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day. Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day. Her diet history reveals that she is eating three meals a day and three snacks. The snacks were just added last week following presence of ketones in her urine. We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most. We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget. We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy. We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars. While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day. Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis. At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:, Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate. Breakfast: Three carbohydrate servings. Morning snack: One carbohydrate serving. Lunch: Four carbohydrate servings. Afternoon snack: One carbohydrate serving. Supper: Four carbohydrate servings. Bedtime snack: One carbohydrate serving. Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack. Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy. Recommend patient include a fruit or a vegetable with most of her meals. Also recommend including solid protein with each meal as well as with the bedtime snack. Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment: Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units. Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial. Provided my name and number should there be additional dietary questions.

One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.

Consult - History and Phy.

Decreased Vision Consult

She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003. She also has a history of glaucoma diagnosed in 1990 and macular degeneration. She has been followed in her home country and is here visiting family. She had the above-mentioned observation and was brought in on an urgent basis today.,Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,Her medications include V-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% OU three times a day. She took both the drops this morning. She also takes Eltroxin which is for hypothyroidism, Plendil for blood pressure, and pravastatin.,She is allergic to Cosopt.,She has a family history of blindness in her brother as well as glaucoma and hypertension.,Her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye. Manifest refraction showed no improvement in either eye. The intraocular pressures by applanation were 7 on the right and 18 in the left eye. Gonioscopy showed grade 4 open angles in both eyes. Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes. The lids were normal OU. She has mild dry eye OU. The corneas are clear OU. The anterior chamber is deep and quiet OU. Irides appear normal. The lenses show well centered posterior chamber intraocular lenses OU.,Dilated fundus exam shows clear vitreous OU. The optic nerves are normal in size. They both appear to have mild pallor. The optic cups in both eyes are shallow. The cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye. In the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,The macula on the right shows drusen with focal areas of RPE atrophy. I do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage. She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye. In the left eye, she has also several high-risk drusen, but no evidence of neovascularization. The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild. I do not see any dense or focal areas of frank RPE atrophy or hypertrophy.,The peripheral retinas are attached in both eyes.,Ms. ABC has pseudophakia OU which is stable and she is doing well in this regard. She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye. The intraocular pressure in the mid-to-high teens in the left eye is probably high for her. She has allergic reaction to Cosopt. I will recommend starting Xalatan OS nightly. I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD. She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan.,Regarding the macular degeneration, she has had high-risk changes in both eyes. The vision in the right eye is good, but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye. I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.

Counting calorie points, exercising pretty regularly, seems to be doing well

Consult - History and Phy.

Dietary Consult - 4

SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. The patient requests information on diabetic exchanges. She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs: The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004. I praised her weight loss and her regular exercising. I looked at her food journal. I praised her record keeping. I gave her a list of the diabetic exchanges and explained them. I also gave her a food dairy sheet so that she could record exchanges. I encouraged her to continue.,ASSESSMENT:, The patient seems happy with her progress and she seems to be doing well. She needs to continue.,PLAN:, Followup is on a p.r.n. basis. She is always welcome to call or return.

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.

Consult - History and Phy.

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.

Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.

Consult - History and Phy.

CVA Consult - ER Visit

ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. This occurred at 2:30 a.m. His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room. He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning. Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache. He underwent workup including a CT, which was negative and his symptoms slowly began to resolve. He was initially admitted, placed on Plavix and aspirin. However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech. Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted. He also underwent an echo, carotid ultrasound, and lab work in the emergency room. Wife is at the bedside and denies he had any other symptoms previous to this. He denied any chest pain or palpitations. She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES: ,He has no known drug allergies.,CURRENT MEDICATIONS:,1. Multivitamin.,2. Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1. Nasopharyngeal cancer. Occurred in 1991. Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2. Lumbar disk disease.,3. Status post diskectomy.,4. Chronic neck pain secondary to XRT.,5. History of thalassemia.,6. Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer.,FAMILY HISTORY: ,Pertinent for father who died of an inoperable brain tumour. Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS: ,He reports he was in his usual state of health up until he awoke this morning. He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right. He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS: Stable. His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL: He is alert, pleasant, and in no acute distress at this time. He answers questions appropriately.,HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Sclerae are clear. TMs clear. Oropharynx is clear.,NECK: Supple with full range of motion. He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR: Regular rate and rhythm without murmur.,LUNGS: Clear bilaterally.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Show no clubbing, cyanosis or edema.,NEUROLOGIC: He does have a minimally slurred speech at present. He does have a slight facial droop. He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left. Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA: ,His initial blood work, PT was 11 and PTT 27. CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1. Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG. CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT. Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal. He underwent an echocardiogram in the emergency room, which was essentially normal. He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1. Cerebrovascular accident, in progress.

A 10 years of age carries a diagnosis of cystic fibrosis

Consult - History and Phy.

Cystic Fibrosis

INTERVAL HISTORY:, ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit. He was accompanied by his adopted mother. He is attending the fourth grade and has not missed significant days for illness. He has a chronic cough that has been slightly increased for the prior 4 days. Sputum is not produced. Sinuses are described as clear. He is an eager eater, eating a regular diet of increased calorie and protein. He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half. Belly complaints are denied. He has 2 to 3 bowel movements per day. He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks, A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS: Respiratory rate 20 and pulse 91. Temperature is 100.0 per tympanic membrane. Oximetry is 98% on room air. Height is 128 cm, which is an increase of 1.0 cm from prior visit. Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL: He is a cooperative school-aged boy in no apparent distress.,HEENT: Tympanic membranes clear, throat with minimal postnasal drip.,CHEST: Significant for 1+ hyperinflation. Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC: Regular sinus rhythm without murmur.,ABDOMEN: Palpated as soft, without hepatosplenomegaly.,EXTREMITIES: Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN. Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION: PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons. He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis. This situation will be looked into with the hope of restarting soon. Other than that the patient seems to be doing well. A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well. Reinforcement of current medication regime was supplied. No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family. Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues. At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines. This is despite the fact that he has an excellent appetite. Mom reports he is taking his enzymes consistently as well as vitamins. He does have problems meeting his goal for resource drinks per day. Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely. A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital. The patient is doing well in school. With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1. Cystic fibrosis.,2. Poor nutritional status.,PLAN: ,1. Give flu vaccine 0.5 mg IM now, this was done.,2. Continue all other medications and treatment.,3. Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4. Needs to augment current high-calorie diet to give more nutrition. To follow advice by a dietician.,5. Continue all the medication treatments before.,6. To continue off and ongoing psychosocial nutritional counseling as necessary.

A male referred to Wheelchair Clinic for evaluation for a new wheelchair.

Consult - History and Phy.

Consult for New Wheelchair

HISTORY OF PRESENT ILLNESS:, This 42-year-old male was referred to Wheelchair Clinic for evaluation for a new wheelchair. The client has a power wheelchair at home and it is two years old. However, he is unable to transfer throughout the community. The client does have two teenage children for which he does need to keep up with. He has a quickie revolution manual wheelchair that is greater than seven years old and in a complete state of repair. His past medical history includes TIA, complete spinal cord injury resulting from a gunshot wound in 1995, diabetes mellitus, right forearm fracture, bilateral hip fracture, right fifth tendon repair, left great toe surgery, and spinal surgery.,SOCIAL HISTORY: , The patient lives with his wife and two children, ages 15 and 16 in a single floor apartment with rear entry. The client does not work; however, he does fix some type of computers as his hobby. His wife transports him in an oversized four-door vehicle.,FUNCTIONAL STATUS:, The patient is modified and independent for all transfers utilizing the lateral technique. However, he does require a sideboard for tub transfers as well as car transfers. He is independent with his bed mobility. He is unable to ambulate due to his level of injury. At home, he does have an extended tub bench for showering. His wheelchair mobility has succeeded to modified independent level as well as wheelchair management and pressure release. He is dependent for community mobility with his manual wheelchair. The patient is unable to function, propel with ultra lightweight manual wheelchair throughout the community therefore putting him at the dependent level for this activity.,ACTIVITY OF DAILY LIVING: , The patient is independent with his self care, completing this from the bed or chair level. He self casts every four to six hours a day independently and as previously mentioned completes this from the chair. Instrumental ADLs completed with assistance from his wife. He stays indoors 12 plus hours. His cognition is alert and oriented x 4.,PHYSICAL EXAMINATION:,EXTREMITIES: Upper extremity range of motion is within functional limits, has 4-5 strength proximally and 5/5 distally. He is right hand dominant. Sitting posture reveals sacral sitting with a partially flexible posterior pelvic tilt. When taken out of his posterior tilt the client has loosed his trunk control. He has decreased postural control as he is unable to elevate his upper extremities greater than 90 degrees in unsupported sit.,His skin integrity is currently intact. His vision is within normal limits. Lower extremity range of motion is within normal limits with 0-5 strength throughout.,EQUIPMENT RECOMMENDATION: , The patient was seen at clinic for evaluation for a new sitting system. He is unable to ambulate due to his level of injury. He is able to propel in ultra lightweight manual wheelchair. However, he does have difficulty propelling throughout the community when trying to maintain his level of activities with two teenage children. Therefore the following ultra lightweight wheelchair with powered six wheels is recommended.,1. Invacare Crossfire T6. As previously mentioned the client is unable to ambulate secondary to spinal cord injury. He does require manual wheelchair for all forms of mobility. He is very active in his wheelchair. He completes his self care as well as his __________ from the chair. He has two teenage children and he participates in community activities with. The patient also fixes computers at the wheelchair level.,2. Emotion power six wheels. The client has a history of right forearm fracture as well as fifth tendon repair. He has 4/5 shoulder strength bilaterally. He is an active computer user making it extremely difficult for him to propel his wheelchair over the varied terrain. Due to the patient's young age, he has many years that he will be depending on his upper extremities for all transfers and wheelchair mobility. It is important to be proactive in order to minimize the wear and tear on the joint as he already has upper extremity pain from repetitively propelling.,3. Flat-free inserts. The patient is at risk for flats due to his level of activity. He does require maintenance free wheelchair as he is unable to ambulate.,4. Removable covers. This is required for increased apprehension specifically in the winter.,5. Extra battery pack. This will allow the client to always have available power for these wheels. This is required as he is an extremely active user.,6. V-front end. This set up will keep his lower extremities close and prohibit external rotation and abduction of his lower extremities.,7. Frog leg suspension. This is required in order to absorb the shock in order to prevent his lower extremity from displacing from the foot plate.,8. Ergonomic seat with a tapered front end. This style will support the client at his widest point which is his pelvis/thigh/back of the knee.,9. Adjustable height push handles. This will accommodate various heights of the caregivers when pushed or bend up and down the stairs.,10. Soft roll caster. The client needs the extra width of a caster in order for use of community mobility rolling over the cracks as well as the stone in the community.,11. Plastic coated hand ends. This is required for increased __________ with propulsion.,12. Frame protector. This will protect his skin, specifically his lateral shins.,13. Positioning strap. This is required for pelvic positioning and safety.,14. Folding side guards. These will protect the clothing, however, may also be folded it in order to be moved out of the way for transfers.,15. Anti-tipper. These will prevent posterior tipping with all ramp and threshold use.,16. 3 inch locking Star cushion. The client is currently utilizing an air cushion without skin issues. The locking mechanism is required for stability with all of his transfers.,The above chair was decided upon after a safe and independent trial. This report will serve as the letter of medical necessity. We have staff who will follow up with the vendor and the patient to ensure that he has an appropriate effective manual wheelchair with power assist wheels. This request for consultation is greatly appreciated.,

A female with unknown gestational age who presents to the ED after a suicide attempt.

Consult - History and Phy.

Consult/ER Report - OB/GYN

The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period. She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus. She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus. However, she states she did not know that she was pregnant at this time. She denies any abdominal pain or vaginal bleeding. She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY: Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1. Gastric bypass.,2. Bilateral carpal tunnel release.,3. Laparoscopic cholecystectomy.,4. Hernia repair after gastric bypass surgery.,5. Thoracotomy.,6. Knee surgery.,MEDICATIONS:,1. Lexapro 10 mg daily.,2. Tramadol 50 mg tablets two by mouth four times a day.,3. Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES: AMOXICILLIN CAUSES THROAT SWELLING. AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY: The patient denies tobacco, ethanol, or drug use. She is currently separated from her partner who is the father of her 21-month-old daughter. She currently lives with her parents in Greenville. However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY: The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY: Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery. Gravida 2 is current.,REVIEW OF SYSTEMS: The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 134/45, pulse 130, respirations 28. Oxygen saturation 100%.,GENERAL: Patient lying quietly on a stretcher. No acute distress.,HEENT: Normocephalic, atraumatic. Slightly dry mucous membranes.,CARDIOVASCULAR EXAM: Regular rate and rhythm with tachycardia.,CHEST: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. No rebound or guarding.,SKIN: Normal turgor. No jaundice. No rashes noted.,EXTREMITIES: No clubbing, cyanosis, or edema.,NEUROLOGIC: Cranial nerves II through XII grossly intact.,PSYCHIATRIC: Flat affect. Normal verbal response.,ASSESSMENT AND PLAN: A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1. Given the substances taken, medications are unlikely to affect the development of the fetus. There have been no reported human anomalies associated with Ambien or tramadol use. There is, however, a 4% risk of congenital anomalies in the general population.,2. Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3. Recommend prenatal vitamins.,4. The patient to follow up as an outpatient for routine prenatal care.,

A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.

Consult - History and Phy.

Consult - Vomiting & 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.

A gentleman with a long history of heroin abuse, 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.

Consult - History and Phy.

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.

Elevated cholesterol and is on medication to lower it.

Consult - History and Phy.

Dietary Consult - 1

SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.,OBJECTIVE:, Height: 6 foot 2 inches. Weight: 204 pounds on 03/07/05. Ideal body weight: 190 pounds, plus or minus ten percent. He is 107 percent standard of midpoint ideal body weight. BMI: 26.189. A 48-year-old male. Lab on 03/15/05: Cholesterol: 251. LDL: 166. VLDL: 17. HDL: 68. Triglycerides: 87. I explained to the patient the dietary guidelines to help improve his lipids. I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight. I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read. I encouraged him to continue as he is doing.,ASSESSMENT:, Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories. His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake. He needs to continue as he is doing. He verbalized understanding and seemed receptive.,PLAN:, The patient plans to recheck his lipids through Dr. XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet.

Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care.

Consult - History and Phy.

Cut on Foot - ER Visit

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.

Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.

Consult - History and Phy.

Cough & Abdominal Pain

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.

Cerebral palsy, worsening seizures. 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.

Consult - History and Phy.

Consult - Seizures - 1

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.

Nonhealing right ankle stasis ulcer. A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery.

Consult - History and Phy.

Consult - Stasis Ulcer

REASON FOR THE CONSULT:, Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer. There is a concern that the patient had a low-grade fever of 100.2 early this morning. The patient otherwise feels well. He was not even aware of the fever. He does have some ankle pain, worse on the right than the left. Old medical records were reviewed. He has multiple hospitalizations for leg cellulitis. Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past. Klebsiella and Enterobacter have also grown in the few wound cultures at some point. The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No malaise. Positive recent low-grade fevers. No chills.,HEENT: No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion. No sore throat.,CARDIAC: No chest pain or cough.,GASTROINTESTINAL: No nausea, vomiting or diarrhea.,All other systems were reviewed and were negative.,PAST MEDICAL HISTORY: ,Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,SOCIAL HISTORY: , The patient admits to heavy alcohol drinking in the past, quit several years ago. He is also a former cigarette smoker, quit several years ago.,ALLERGIES:, None known.,CURRENT MEDICATIONS:, Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS: Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,GENERAL APPEARANCE: The patient is awake, alert, and not in cardiorespiratory distress. Height 6 feet 1.5 inches, body weight 125.26 kilos.,EYES: Pink conjunctivae, anicteric sclerae. Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions.,NECK: No palpable neck masses. Thyroid is not enlarged on inspection.,RESPIRATORY: Regular inspiratory effort. No crackles or wheezes.,CARDIOVASCULAR: Regular cardiac rhythm. No thrills or rubs.,GASTROINTESTINAL: Normoactive bowel sounds. Soft. No guarding or rigidity.,LYMPHATIC: No cervical lymphadenopathy.,MUSCULOSKELETAL: Good range of motion of upper and lower extremities.,SKIN: There is hyperpigmentation involving the distal calf of both legs. There is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage. Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg. There is warmth, but minimal tenderness on palpation of this area. There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm. Wound edges are poorly defined.,PSYCHIATRIC: Appropriate mood and affect, oriented x3. Fair judgment and insight.,LABORATORY RESULTS: , White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000. BUN and creatinine 9.2/0.52. Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6. One wound culture from right leg wound culture from 01/27/09 noted with young growth. Left leg wound culture from 01/27/09 also with young growth.,RADIOLOGY:, Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus. No absolute findings.,IMPRESSION:,1. Fevers.,2. Right leg/ankle cellulitis.,3. Chronic recurrent bilateral ankle venous ulcers.,4. Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.,5. Hypertension.,RECOMMENDATIONS:,1. We have ordered 2 sets of blood cultures.,2. Agree with daptomycin and Primaxin IV.,3. Follow up result of wound cultures.,4. I will order an MRI of the right ankle to check for underlying osteomyelitis.,Additional ID recommendations as appropriate upon followup.

Patient was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.

Consult - History and Phy.

Consult - Syncope

REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS: ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. No palpitation. Presently, he is comfortable, lying in the bed. As per the patient, no prior cardiac history.,CORONARY RISK FACTORS: , History of hypertension. No history of diabetes mellitus. Nonsmoker. Cholesterol status is borderline elevated. No history of established coronary artery disease. Family history noncontributory.,PAST MEDICAL HISTORY: ,Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation.,PAST SURGICAL HISTORY: ,Back surgery, shoulder surgery, and appendicectomy.,FAMILY HISTORY: , Nonsignificant.,MEDICATIONS:,1. Pain medications.,2. Thyroid supplementation.,3. Lovastatin 20 mg daily.,4. Propranolol 20 b.i.d.,5. Protonix.,6. Flomax.,ALLERGIES:, None.,PERSONAL HISTORY:, He is married. Nonsmoker. Does not consume alcohol. No history of recreational drug use.,REVIEW OF SYSTEMS,CONSTITUTIONAL: No weakness, fatigue, or tiredness.,HEENT: No history of cataract or glaucoma.,CARDIOVASCULAR: No congestive heart failure. No arrhythmias.,RESPIRATORY: No history of pneumonia or valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Arthritis and muscle weakness.,SKIN: Nonsignificant.,NEUROLOGIC: No TIA or CVA. No seizure disorder.,ENDOCRINE/HEMATOLOGIC: Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins are flat. No significant carotid bruits.,LUNGS: Air entry is bilaterally decreased.,HEART: PMI is displaced. S1 and S2 are regular.,ABDOMEN: Soft and nontender. Bowel sounds are present.,EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis. The patient is moving all extremities; however, the patient has tremors.,RADIOLOGICAL DATA: , EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors.,LABORATORY DATA: , H&H stable. White count of 14. BUN and creatinine are within normal limits. Cardiac enzyme profile is negative. Ammonia level is elevated at 69. CT angiogram of the chest, no evidence of pulmonary embolism. Chest x-ray is negative for acute changes. CT of the head, unremarkable, chronic skin changes. Liver enzymes are within normal limits.,IMPRESSION:,1. The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.

Consultation - an 87-year-old white female with weakness and a history of polymyositis.

Consult - History and Phy.

Consult - Weankness & Polymyositis

REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you.

Sepsis, possible SBP. A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month.

Consult - History and Phy.

Consult - Sepsis

REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. He ran out of prescription medications 1 month ago. In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24. White blood cell count was slightly low at 4 and platelet count was only 22,000. Abdominal ultrasound showed mild-to-moderate ascites. He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night. Dr. X was called early this morning due to hypotension, SBP in the 70s. He then changed antibiotic regiment to vancomycin and doripenem.,PAST MEDICAL HISTORY: , Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy.,SOCIAL HISTORY: , The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago.,ALLERGIES:, None known.,CURRENT MEDICATIONS: , Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n., magnesium p.r.n., Zofran. p.r.n., norepinephrine drip, and vitamin K.,REVIEW OF SYSTEMS: , Not obtainable as the patient is drowsy and confused.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS: Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula.,GENERAL APPEARANCE: The patient is drowsy. Morbidly obese. Height 5 feet 8 inches, body weight 182 kilos.,EYES: Slightly pale conjunctivae, icteric sclerae. Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions.,NECK: No palpable neck masses. Thyroid is not enlarged on inspection.,RESPIRATORY: Regular inspiratory effort. No crackles or wheezes.,CARDIOVASCULAR: Regular cardiac rhythm. No rales or rubs. Positive bipedal edema, 2+, right worse than left.,GASTROINTESTINAL: Globular abdomen. Soft. No guarding, no rigidity. Tender on palpation of n right upper quadrant and epigastric area. Mildly tender on palpation of right upper quadrant and epigastric area.,LYMPHATIC: No cervical lymphadenopathy.,SKIN: Positive diffuse jaundice. No palpable subcutaneous nodules.,PSYCHIATRIC: Poor judgment and insight.,LABORATORY DATA: , White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000. INR 3.84, PTT more than 240. BUN and creatinine 26.8/1.2. AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85. Total CK 1198.6, LDH 873.2. Troponin 0.09, myoglobin 2792. Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria. Two sets of blood cultures from 01/07/09 still pending.,RADIOLOGY:, Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures. Left knee x-rays on 01/07/09 showed advanced osteoarthritis. Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid. Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein. Appendix was not clearly seen, but there was no evidence of pericecal inflammation.,IMPRESSION:,1. Septic shock.,2. Possible urinary tract infection.,3. Ascites, rule out spontaneous bacterial peritenonitis.,4. Hyperbilirubinemia, consider cholangitis.,5. Alcoholic liver disease.,6. Thrombocytopenia.,7. Hepatitis C.,8. Cryoglobulinemia.,RECOMMENDATIONS:,1. Continue with vancomycin and doripenem at this point.,2. Agree with paracentesis.,3. Send ascitic fluid for cell count, differential and cultures.,4. Follow up with result of blood cultures.,5. We will get urine culture from the specimen on admission.,6. The patient needs hepatitis A vaccination.,Additional ID recommendations as appropriate upon followup.

Patient referred for evaluation of her left temporal lobe epilepsy.

Consult - History and Phy.

Consult - Seizures

REASON FOR CONSULTATION: ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:, This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002. At that time, she had one generalized tonic-clonic seizure. Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds. She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop. She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep. She also had an MRI done on September 05, 2002, with and without contrast that was negative. Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy. She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then. She reports no seizures in the past several years. She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures. There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father. Her mother died in a motor vehicle accident.,SOCIAL HISTORY: ,She works running a day care at home. She has three children. She is married. She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart. Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS: ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination: Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart. Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally. There is no drift and there are no abnormalities to orbit. Sensory examination, light touch, and temperature intact at all distal extremities. Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair. She has normal step, stride, arm swing, toe, heel, and tandem. Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago. CT of the head was performed, which I reviewed, dated September 07, 2006. The findings were within the range of normal variation. There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1. Continue lamotrigine 150 mg p.o. b.i.d.,2. I discussed with the patient the option of a trial of medications. We need to repeat her EEG as well as her MRI prior to weaning her medications. The patient wants to continue her lamotrigine at this time. I concur.,3. The patient will be following up with me in six months.,

Consult for prostate cancer

Consult - History and Phy.

Consult - Prostate Cancer

CONSULT FOR PROSTATE CANCER,The patient returned for consultation for his newly diagnosed prostate cancer. The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding, infection, rectal injury, impotence, and incontinence. These were discussed at length. Alternative therapies including radiation therapy; either radioactive seed placement, conformal radiation therapy, or the HDR radiation treatments were discussed with the risks of bladder, bowel, and rectal injury and possible impotence were discussed also. There is a risk of rectal fistula. Hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis, gynecomastia, hot flashes and impotency. Potency may not recover after the hormone therapy has been completed. Cryosurgery was discussed with the risks of urinary retention, stricture formation, incontinence and impotency. There is a risk of rectal fistula. He would need to have a suprapubic catheter for about two weeks and may need to learn self-intermittent catheterization if he cannot void adequately. Prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence. Observation therapy was discussed with him in addition. I answered all questions that were put to me and I think he understands the options that are available. I spoke with the patient for over 60 minutes concerning these options.

Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.

Consult - History and Phy.

Consult - Rectal Bleeding

PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. The patient states that he had his first colonoscopy 6 years ago and it was negative. His mother was diagnosed with colon cancer probably in her 50s, but she died of cancer of the esophagus at age 86. The patient does have hemorrhoidal bleed about once a week. Otherwise, he denies any change in bowel habits, abdominal pain, or weight loss. He gets heartburn mainly with certain food such as raw onions and he has had it for years. It will typically occur every couple of weeks. He has had no dysphagia. He has never had an upper endoscopy.,MEDICAL HISTORY: , Remarkable for hypertension, adult-onset diabetes mellitus, hyperlipidemia, and restless legs syndrome.,SURGICAL HISTORY: , Appendectomy as a child and cholecystectomy in 2003.,MEDICATIONS: ,His medications are lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice a day, Januvia 100 mg daily, clonazepam 10 mg at bedtime for restless legs syndrome, Crestor 10 mg nightly, and Flomax 0.4 mg daily.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient is retired. He is married. He had 4 children. He quite smoking 25 years ago after a 35-year history of smoking. He does not drink alcohol.,FAMILY HISTORY: , Mother had colon cancer in her 50s, esophageal cancer in her 80s. Her mother smoked and drank. Father got a mesothelioma at age 65. There is a brother of 65 with hypertension.,REVIEW OF SYSTEMS: , He has had prostatitis with benign prostatic hypertrophy. He has some increased urinary frequency from a history of prostatitis. He has the heartburn, which is diet dependent and the frequent rectal bleeding. He also has restless legs syndrome at night. No cardio or pulmonary complaints. No weight loss.,PHYSICAL EXAMINATION: , Reveals a well-developed, well-nourished man in no acute distress. BP 112/70. Pulse 80 and regular. Respirations non-labored. Height 5 feet 7-1/2 inches. Weight 209 pounds. HEENT exam: Sclerae are anicteric. Pupils equal, conjunctivae clear. No gross oropharyngeal lesions. Neck is supple without lymphadenopathy, thyromegaly, or JVD. Lungs are clear to percussion and auscultation. Heart sounds are regular without murmur, gallop, or rub. The abdomen is soft and nontender. There are no masses. There is no hepatosplenomegaly. The bowel sounds are normal. Rectal examination: Deferred. Extremities have no clubbing, cyanosis or edema. Skin is warm and dry. The patient is alert and oriented with a pleasant affect and no gross motor deficits.,IMPRESSION:,1. Family history of colon cancer.,2. Rectal bleeding.,3. Heartburn and a family history of esophageal cancer.,PLAN:, I agree with the indications for repeat colonoscopy, which should be done at least every 5 years. Also, discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable. I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett's esophagus. If he does not have it now then it should not be a significant risk in the future. The indications and benefits of EGD, colonoscopy, and IRC were discussed. The risks including sedation, bleeding, infection, and perforation were discussed. The importance of a good bowel prep so as to minimize missing any lesions was discussed. His questions were answered and informed consent obtained. It was a pleasure to care for this nice patient.

Chronic headaches and pulsatile tinnitus.

Consult - History and Phy.

Consult - Pulsatile Tinnitus

HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus. The patient reports she has been having daily headaches since 02/25/2008. She has been getting pulsations in the head with heartbeat sounds. Headaches are now averaging about three times per week. They are generally on the very top of the head according to the patient. Interestingly, she denies any previous significant history of headaches prior to this. There has been no nausea associated with the headaches. The patient does note that when she speaks on the phone, the left ear has "weird sounds." She feels a general fullness in the left ear. She does note pulsation sounds within that left ear only. This began on February 17th according to the patient. The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family. The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks. Interestingly, there has been no significant drop or change in her hearing. She does report she has had dizzy episodes in the past with nausea, being off balance at times. It is not associated with the pulsations in the ear. She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear. She is denying any vision changes. The headaches are listed as moderate to severe in intensity on average about three to four times per week. She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: , ,ALLERGY/IMMUNOLOGIC: Negative.,CARDIOVASCULAR: Hypercholesterolemia.,PULMONARY: Negative.,GASTROINTESTINAL: Pertinent for nausea.,GENITOURINARY: The patient is noted to be a living kidney donor and has only one kidney.,NEUROLOGIC: History of dizziness and the headaches as listed above.,VISUAL: Negative.,DERMATOLOGIC: History of itching. She has also had a previous history of skin cancer on the arm and back.,ENDOCRINE: Negative.,MUSCULOSKELETAL: Negative.,CONSTITUTIONAL: She has had an increased weight gain and fatigue over the past year.,PAST SURGICAL HISTORY:, She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.,FAMILY HISTORY:, Father, history of cancer, hypertension, and heart disease.,CURRENT MEDICATIONS: , Tylenol, Excedrin, and she is on multivitamin and probiotic's.,ALLERGIES: , She is allergic to codeine and penicillin.,SOCIAL HISTORY: , She is married. She works at Eye Center as a receptionist. She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,PHYSICAL EXAMINATION: , VITAL SIGNS: Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,GENERAL: The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: There is an old mastoidectomy scar, left ear. The ear canals are clean and dry. Drums intact and mobile. Weber exam is midline. Grossly hearing is intact. Please note audiologist not available at today's visit for further audiologic evaluation.,NASAL: Reveals clear drainage. Deviated nasal septum to the left, listed as mild to moderate. Ostiomeatal complexes are patent and turbinates are healthy. There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy. See fiberoptic nasopharyngoscopy separate exam.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,IMPRESSION: ,1. Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology. Consider, also normal pressure hydrocephalus.,2. Recurrent headaches.,3. Deviated nasal septum.,4. Dizziness, again also consider possible Meniere disease.,RECOMMENDATIONS: , I did recommend the patient begin a 2 g or less sodium diet. I have also ordered a carotid ultrasound study as part of the workup and evaluation. She has had a recent CAT scan of the brain though this was without contrast. It did reveal previous mastoidectomy, left temporal bone, but no other mass noted. I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related. Hearing protection devices should be used at all times as well. I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues. I am going to recheck her in three weeks. If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office. She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.

The patient needs refills on her Xanax

Consult - History and Phy.

Consult - Smoking Cessation

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.

Patient comes for discussion of a screening colonoscopy.

Consult - History and Phy.

Consult - Screening Colonoscopy

HISTORY:, A is a 55-year-old who I know well because I have been taking care of her husband. She comes for discussion of a screening colonoscopy. Her last colonoscopy was in 2002, and at that time she was told it was essentially normal. Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy. I told her that the interval was appropriate and that it made sense to do so. She denies any significant weight change that she cannot explain. She has had no hematochezia. She denies any melena. She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:, On today's visit we reviewed her entire health history. Surgically she has had a stomach operation for ulcer disease back in 1974, she says. She does not know exactly what was done. It was done at a hospital in California which she says no longer exists. This makes it difficult to find out exactly what she had done. She also had her gallbladder and appendix taken out in the 1970s at the same hospital. Medically she has no significant problems and no true medical illnesses. She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day. She was counseled to quit. She occasionally uses alcohol. She has never used illicit drugs. She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL: A is a healthy appearing female in no apparent distress.,VITAL SIGNS: Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT: No cervical bruits, thyromegaly, or masses. She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS: Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART: Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO: No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy. We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers. She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well. I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.

The patient admitted with palpitations and presyncope.

Consult - History and Phy.

Consult - Palpitations & Presyncope

HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable pattern. She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. While working on a computer, she had a spell. Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse. She does have a couple of sodas and at least one to two coffees daily. She is a nonsmoker. She is a mother of two. There is no family history of congenital heart disease. She has had no history of thoracic trauma. No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia. Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals. No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable. No evidence of myocardial injury. Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period. Outpatient workup would be appropriate. Event recorder should be obtained and the patient can be seen again in the office upon completion of that study. Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation. We will be happy to follow her both during this hospitalization and following discharge. Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5. CT scan showed no evidence of pulmonary embolus. Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,

Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.

Consult - History and Phy.

Consult - Jaw Pain

HISTORY: ,The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain. This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue. This numbness has been present for approximately two months. It seems to be there "all the time." He was seen by his dentist and after dental evaluation was noted to be "okay." He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time. He has been taking cough drops and trying to increase his fluids. He has recently stopped tobacco. He has been chewing tobacco for about 30 years. Again, there is concern regarding the numbness he has been having. He has had a loss of sensation of taste as well. Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip. He does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity. He has had no trauma to the face. He does note a history of headaches. These are occasional and he gets these within the neck area when they do flare up. The headaches are noted to be less than one or two times per month. The patient does note he has a history of anxiety disorder as well. He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time. He denies any fever or chills. He is not having any dental pain with biting down. He has had no jaw popping and no trismus noted. The patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.,REVIEW OF SYSTEMS: , Other than those listed above were otherwise negative.,PAST SURGICAL HISTORY: , Pertinent for hernia repair.,FAMILY HISTORY: , Pertinent for hypertension.,CURRENT MEDICATIONS:, Tylenol. He is on Nicorette gum.,ALLERGIES: ,He is allergic to codeine, unknown reaction.,SOCIAL HISTORY: ,The patient is single, self-employed carpenter. He chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.,GENERAL: The patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: Both ears, external ears are normal. The ear canals are clean and dry. The drums are intact and mobile. He does have moderate tympanosclerosis noted, no erythema. Weber exam is midline. Hearing is grossly intact and normal.,NASAL: Reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: He does have slightly decreased sensation to the left jaw. He is able to feel pressure on touch. This extends also on to the left lateral tongue and the left intrabuccal mucosa.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,PROCEDURE: , A fiberoptic nasopharyngoscopy was also performed. See separate operative report in chart. This does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.,IMPRESSION: ,1. Persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.,2. History of tobacco use.,3. Hypogeusia with loss of taste.,4. Headaches.,5. Xerostomia.,RECOMMENDATIONS:, I have ordered a CT of the head. This includes sinuses and mandible. This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had. On the mucosal surface, I do not see any evidence of malignancy and no visible or palpable masses were noted. I did recommend he increase his fluid intake. He is to remain off the tobacco. I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time.

Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.

Consult - History and Phy.

Consult - ICU Management

REASON FOR CONSULTATION: , ICU management.,HISTORY OF PRESENT ILLNESS: , The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. The patient was transferred to the ABCD Hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting. The patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a CT scan. Repeat CT scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen. The patient was taken emergently to the operating room last night by the General Surgery Service where proximal half of the jejunum was noted to be liquified with 3 perforations. This section of small bowel was resected, and a wound VAC placed for damage control. Plan was to return the patient to the Operating Room tomorrow for further exploration and possible re-anastomosis of the bowel. The patient is currently intubated, sedated, and on pressors for septic shock and in the down ICU.,PAST MEDICAL HISTORY:, Prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and GERD.,PAST SURGICAL HISTORY:, Included a cardiac cath with no interventions taken.,HOME MEDICATIONS:, Include Lantus insulin as well as oral hypoglycemics.,CURRENT MEDS:, Include Levophed, Ativan, fentanyl drips, cefepime, Flagyl, fluconazole, and vancomycin. Nexium, Synthroid, hydrocortisone, and Angiomax, which is currently on hold.,REVIEW OF SYSTEMS:, Unable to be obtained secondary to the patient's intubated and sedated status.,ALLERGIES: , None.,FAMILY HISTORY:, Includes diabetes on his father side of the family. No other information is provided.,SOCIAL HISTORY:, Includes tobacco use as well as alcohol use.,PHYSICAL EXAMINATION:,GENERAL: The patient is currently intubated and sedated on Levophed drip.,VITAL SIGNS: Temperature is 100.6, systolic is 110/60 with MAP of 80, and heart rate is 120, sinus rhythm.,NEUROLOGIC: Neurologically, he is sedated, on Ativan with fentanyl drip as well. He does arouse with suctioning, but is unable to open his eyes to commands.,HEAD AND NECK EXAMINATION: His pupils are equal, round, reactive, and constricted. He has no scleral icterus. His mucous membranes are pink, but dry. He has an EG tube, which is currently 24-cm at the lip. He has a left-sided subclavian vein catheter, triple lumen.,NECK: His neck is without masses or lymphadenopathy or JVD.,CHEST: Chest has diminished breath sounds bilaterally.,ABDOMEN: Abdomen is soft, but distended with a wound VAC in place. Groins demonstrate a left-sided femoral outline.,EXTREMITIES: His bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left. His toes are cool, and pulses are not palpable.,LABORATORY EXAMINATION: , Laboratory examination reveals an ABG of 7.34, CO2 of 30, O2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, CO2 18, BUN 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22. After stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively. LFTs are all normal. Amylase and lipase are normal. Triglycerides are 73, INR is 2.2, PTT is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211. UA was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria. Chest x-rays performed and show the tip of the EG tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles. Tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted.,ASSESSMENT AND PLAN:, This is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion. He is status post small bowel resection. We plan to go back to operating room tomorrow for further debridement and possible closure. Neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands. I did not suspect any sort of pathologic abnormality of his neurologic status as he has further CT scan of his brain, which was normal. Currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator. We will form daily sedation holidays to assess his neurologic status and avoid over sedating with Ativan.,1. Cardiovascular. The patient currently is in septic shock requiring vasopressors maintained on MAP greater than 70. We will continue to try to wean the vasopressin after continued volume loading, also place SvO2 catheter to assess his oxygen delivery and consumption given his state of shock. Currently, his rhythm is of sinus tachycardia, I do not suspect AFib or any other arrhythmia at this time. If he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function. Once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.,2. Pulmonology. Currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, PEEP of 6, and FiO2 of 60. We will wean his FiO2 as tolerated to keep his saturation greater than 90% and wean his PEEP as tolerated to reduce preload compromise. We will keep the head of bed elevated and start chlorhexidine as swish and swallow for VAP prevention.,3. Gastrointestinal. The patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the SMV. He is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum. We will maintain NG tube as he has a blind stump there, and we will preclude any further administration of any meds through this NG tube. I will keep him on GI prophylaxis as he is intubated. We will currently hold his TPN as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes. He will have a long-term TPN after this acute episode. His LFTs are all normal currently. Once he is postop tomorrow, we will restart the Angiomax for his venous occlusion.,4. Renal. The patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium. His critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail. He currently is started to make more urine since being volume resuscitated with Hespan as well as bicarb drip. Hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis. We will re-consult Nephrology at this time.,5. Endocrine. The patient has adrenal insufficiency based on lack of stem to cosyntropin. We will start hydrocortisone 50 q.6h.,6. Infectious Disease. Currently, the patient is on broad-spectrum antibiotic prophylaxis imperially. Given his bowel ischemia, we will continue these, and appreciate ID service's input.,7. Hematology. Hematologically, the patient has a hypercoagulable syndrome, also had HIT secondary to his heparin administration. We will restart the Angiomax once he is back from the OR tomorrow. Currently, his INR is 2.2. Therefore, he should be covered at the moment. Appreciate the Hematology's input in this matter.,Please note the total critical care time spent at the bedside excluding central line placement was 1 hour.

The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.

Consult - History and Phy.

Consult - Migraine

HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. Neurology consult was called to evaluate the patient in view of the current symptomatology. The headaches were refractory to the treatment. The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY: ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY: ,No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:, Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT: Head, normocephalic, atraumatic. Neck supple. Throat clear. No discharge from the ears or nose. No discoloration of conjunctivae and sclerae. No bruits auscultated over temple, orbits, or the neck.,LUNGS: Clear to auscultation.,CARDIOVASCULAR: Normal heart sounds.,ABDOMEN: Benign.,EXTREMITIES: No edema, clubbing or cyanosis.,SKIN: No rash. No neurocutaneous disorder.,MENTAL STATUS: The patient is awake, alert and oriented to place and person. Speech is fluent. No language deficits. Mood normal. Affect is clear. Memory and insight is normal. No abnormality with thought processing and thought content. Cranial nerve examination intact II through XII. Motor examination: Normal bulk, tone and power. Deep tendon reflexes symmetrical. Downgoing toes. No sign of any myelopathy. Cortical sensation intact. Peripheral sensation grossly intact. Vibratory sense not tested. Gait not tested. Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines. Complicated migraines by clinical criteria. Rule out sinusitis. Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today. Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially. The patient already had MRI of the brain and the cervical spine. MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache. Plan and followup discussed with the patient in detail.

Marked right hydronephrosis without hydruria.

Consult - History and Phy.

Consult - 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.

The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.

Consult - History and Phy.

Consult - Facial Twitching

REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. She reports she is still having right posterior head pressure like sensations approximately one time per week. These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair. This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve. Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television. She states that she feels fatigued all the time and does not get good sleep. She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours. Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom. She thinks she may snore, but she is not sure. She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY: ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS: ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination: Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds. Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION: ,As before is nonfocal. Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance. The nature of this lesion is unclear. Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1. Left facial twitching-appears to be improving. Most likely, this is a peripheral nerve injury related to her abscess as previously described. In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2. Posterior pressure like headache, also appears to be improving. The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3. Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep. There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study. For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep. She is on vacation next week and is going to try to see if this will help. We also discussed as before weight loss and exercise, which could be helpful.,4. Right clivus and petrous lesion of unknown etiology. We will repeat the MRI at four months to see for interval change.,5. The patient voiced understanding of these plans and will be following up with me in five months.

Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet.

Consult - History and Phy.

Consult - 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.

Patient with a past medical history of hypertension for 15 years.

Consult - History and Phy.

Consult - Hypertension

HISTORY OF PRESENT ILLNESS:, The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension. According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril. In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s. Her lisinopril was increased to 40 mg daily. She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure. Denies any physical complaints at the present time. Denies having any renal problems in the past.,PAST MEDICAL HISTORY:, As above plus history of anemia treated with Procrit. No smoking or alcohol use and lives alone.,FAMILY HISTORY:, Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular: No chest pain. No palpitations. Pulmonary: No shortness of breath, cough, or wheezing. Gastrointestinal: No nausea, vomiting, or diarrhea. GU: No nocturia. Denies having gross hematuria. Salt intake is minimal. Neurological: Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78. Examination of the head is unremarkable. Neck is supple with no JVD. Lungs are clear. There is no abdominal bruit. Extremities 1+ edema bilaterally.,LABORATORY DATA:, Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital. The creatinine is 0.8. Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney. MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:, Accelerated hypertension. No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA. I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension. She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension. At this point, I would not pursue a diagnosis of renal artery stenosis. Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor. I will continue HCTZ at 24 mg daily. The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure. The patient was told to be stick with her salt intake. She will report to me in 10 days with the result of her blood pressure. She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.

Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.

Consult - History and Phy.

Consult - Coronary Artery Disease

REASON FOR CONSULTATION:, Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness. No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker. Cholesterol elevated. History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1. Metformin.,2. Prilosec.,3. Folic acid.,4. Flomax.,5. Metoprolol.,6. Crestor.,7. Claritin.,ALLERGIES:, DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:, Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer. Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors.,HEENT: No history of cataract or glaucoma.,CARDIOVASCULAR: As above.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena.,UROLOGICAL: Frequency, urgency.,MUSCULOSKELETAL: No muscle weakness.,SKIN: None significant.,NEUROLOGICAL: No TIA or CVA. No seizure disorder.,PSYCHOLOGICAL: No anxiety or depression.,ENDOCRINE: As above.,HEMATOLOGICAL: None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic, normocephalic.,NECK: Veins flat. No significant carotid bruits.,LUNGS: Air entry bilaterally fair.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft, nontender. Bowel sounds present.,EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis.,CNS: Benign.,EKG:

Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.

Consult - History and Phy.

Consult - Congestive Heart Failure

REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure. Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation. Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS: ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:, Married, active smoker, does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above. The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: History of blurry vision and hearing impaired. No glaucoma.,CARDIOVASCULAR: Shortness of breath, congestive heart failure, and arrhythmia. Prior history of chest pain.,RESPIRATORY: Bronchitis and pneumonia. No valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,SKIN: Non-significant.,NEUROLOGICAL: No TIA. No CVA or seizure disorder.,ENDOCRINE: Non-significant.,HEMATOLOGICAL: Non-significant.,PSYCHOLOGICAL: Anxiety. No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat.,LUNGS: Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART: PMI displaced. S1 and S2, regular. Systolic murmur.,ABDOMEN: Soft and nontender.,EXTREMITIES: Trace edema of the ankle. Pulses are feebly palpable. Clubbing plus. No cyanosis.,CNS: Grossly intact.,MUSCULOSKELETAL: Arthritic changes.,PSYCHOLOGICAL: Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect. Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7. INR 1.8. BUN and creatinine within normal limits. Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for:

Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.

Consult - History and Phy.

Consult - Enlarged Tonsils

HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils. The patient has been having difficult time with having two to three bouts of tonsillitis this year. She does average about four bouts of tonsillitis per year for the past several years. She notes that throat pain and fever with the actual infections. She is having no difficulty with swallowing. She does have loud snoring, though there have been no witnessed observed sleep apnea episodes. She is a mouth breather at nighttime, however. The patient does feel that she has a cold at today's visit. She has had tonsil problems again for many years. She does note a history of intermittent hoarseness as well. This is particularly prominent with the current cold that she has had. She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home. For the two tonsillitis, she is on antibiotics again on an average about four times per year. They do seem to help with the infections, but they tend to continue to recur. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC: Negative.,CARDIOVASCULAR: Negative.,PULMONARY: Negative.,GASTROINTESTINAL: Negative.,GENITOURINARY: Negative.,NEUROLOGIC: Negative.,VISUAL: Negative.,DERMATOLOGIC: Negative.,ENDOCRINE: Negative.,MUSCULOSKELETAL: Negative.,CONSTITUTIONAL: Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:, No family history of bleeding disorder. She does have a sister with a current ear infection. There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single. She is a student. Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL: The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: The external ears are normal. The ear canals are clean and dry. The drums are intact and mobile. Hearing is grossly normal. Tuning fork examination with normal speech reception thresholds noted.,NASAL: She has clear drainage, large inferior turbinates, no erythema.,ORAL: Her tongue, lip, floor of mouth are noted to be normal. Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic. Mirror examination of the larynx reveals some mild edema of the larynx at this time. The nasopharynx could not be visualized on mirror exam today.,NECK: Obese, supple. Trachea is midline. Thyroid is nonpalpable.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,IMPRESSION: , ,1. Chronic adenotonsillitis with adenotonsillar hypertrophy.,2. Upper respiratory tract infection with mild acute laryngitis.,3. Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy. All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family. This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc. The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks. We will make further recommendations afterwards.

A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors.

Consult - History and Phy.

Consult - Chest Pain - 1

REASON FOR CONSULTATION:, Chest pain.,HISTORY OF PRESENT ILLNESS: , The patient is a 37-year-old gentleman admitted through emergency room. He presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors. His history is significant as mentioned below. His workup so far has been negative.,CORONARY RISK FACTORS:, No history of hypertension or diabetes mellitus. Active smoker. Cholesterol status, borderline elevated. No history of established coronary artery disease. Family history positive.,FAMILY HISTORY: , His father died of coronary artery disease.,SURGICAL HISTORY: , No major surgery except for prior cardiac catheterization.,MEDICATIONS AT HOME:, Includes pravastatin, Paxil, and BuSpar.,ALLERGIES:, None.,SOCIAL HISTORY: , Active smoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hyperlipidemia, smoking history, and chest pain. He has been, in October of last year, hospitalized. Subsequently underwent cardiac catheterization. The left system was normal. There was a question of a right coronary artery lesion, which was thought to be spasm. Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed. No relation to exertional activity.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills.,HEENT: No history of cataract, blurring vision, or glaucoma.,CARDIOVASCULAR: As above.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,CNS: No TIA. No CVA. No seizure disorder.,ENDOCRINE: Nonsignificant.,HEMATOLOGICAL: Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute.,HEENT: Head is atraumatic and normocephalic. Neck veins flat.,LUNGS: Clear.,HEART: S1 and S2, regular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.,CNS: Benign.,PSYCHOLOGICAL: Normal.,MUSCULOSKELETAL: Within normal limits.,DIAGNOSTIC DATA: , EKG, normal sinus rhythm. Chest x-ray unremarkable.,LABORATORY DATA: , First set of cardiac enzyme profile negative. H&H stable. BUN and creatinine within normal limits.,IMPRESSION:,1. Chest pain in a 37-year-old gentleman with negative cardiac workup as mentioned above, questionably right coronary spasm.,2. Hyperlipidemia.,3. Negative EKG and cardiac enzyme profile.,RECOMMENDATIONS:

Patient with multiple problems, main one is chest pain at night.

Consult - History and Phy.

Consult - Chest Pain

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.

The patient has been suffering from intractable back and leg pain.

Consult - History and Phy.

Consult - Back & Leg Pain

Her axial back pain is greatly improved, but not completely eradicated. There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:, Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:, Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired. Denies tobacco or ethanol use.,FAMILY HISTORY:, Father died of mesothelioma. Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia. Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:, Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN: ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome. Her lumbar facet joints were denervated approximately 6 months ago. The denervation procedure helped her axial back pain approximately 40% when standing. With extension and rotation it helped her axial back pain approximately 70%. She is now able to swing a golf club. She was unable to swing a golf club due to the rotational movements before her rhizotomy. She is currently playing golf. Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d. We will follow her up in 1 month's time.,

Patient presents with complaint of lump in the upper outer quadrant of the right breast

Consult - History and Phy.

Consult - Breast Cancer

CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:, Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.

Patient with a history of right upper pons and right cerebral peduncle infarction.

Consult - History and Phy.

Consult - Cerebral Peduncle Infarction

FAMILY HISTORY AND SOCIAL HISTORY:, Reviewed and remained unchanged.,MEDICATIONS:, List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:, She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS: ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain. Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs: Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General: She was a pleasant person in no acute distress.,HEENT: Normocephalic and atraumatic. No dry mouth. No palpable cervical lymph nodes. Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:, Remained unchanged.,Mental Status: Normal.,Cranial Nerves: Mild decrease in the left nasolabial fold.,Motor: There was mild increased tone in the left upper extremity. Deltoids showed 5-/5. The rest showed full strength. Hip flexion again was 5-/5 on the left. The rest showed full strength.,Reflexes: Reflexes were hypoactive and symmetrical.,Gait: She was mildly abnormal. No ataxia noted. Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement. She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes. She will continue to follow with endocrinology for diabetes and thyroid problems. I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery. I will see her back in about four months or sooner if needed.

The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.

Consult - History and Phy.

Consult - Breast Cancer - 1

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.

Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.

Consult - History and Phy.

Consult - Alzheimer disease

The patient states that she has been doing fairly well at home. She balances her own checkbook. She does not do her own taxes, but she has never done so in the past. She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving. She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home. She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren. She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression. There is unfortunately no one available to us to corroborate how well she is doing at home. She lives alone and takes care of herself and does not communicate very much with her brother and sister. She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren. She denied any sort of personality change, paranoid ideas or hallucinations. She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it. When these headaches are very severe, she goes to the emergency room to get a single shot. She is unclear if this is some sort of a migraine medication or just a primary pain medication. She takes Fiorinal for these headaches and she states that this helps greatly. She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia. She also denies any sort of movement disorders, tremors, rigidities or clonus. Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness. She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago. The patient was not sure of exactly when it was diagnosed. This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations. The mesothelioma is in her abdomen. She does not know of any history of having lung mesothelioma. She states that she has never gotten chemotherapy or radiation for her mesothelioma. Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable. She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position. These have all occurred over the past five years. She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation. This diagnosis was given in March 2006.,MEDICATIONS:, Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:, Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer. Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg. She is alert and well nourished in no apparent distress. She occasionally fumbles with questions of orientation, missing the day and the date. She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in. She lost three points for recall. Even with prompting, she could not remember the objects that she was given to remember. Her Mini Mental Score was 22/30. There were no naming problems or problems with repetition. There were also no signs of dysarthria. Her pupils were bilaterally reactive to light and accommodation. Her extraocular movements were intact. Her visual fields were full to confrontation. Her sensations of her face, arm, and leg were normal. There were no signs of neglect with double simultaneous stimulation. Tongue was midline. Her palate was symmetric. Her face was symmetric as well. Strength was approximately 5/5. She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain. Her reflexes were symmetric and +2 except for her toes, which were +1 to trace. Her plantar reflexes were mute. Her sensation was normal for pain, temperature, and vibration. There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia. Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:, Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type. We tactfully discussed the patient's diagnosis with her, and she felt reassured. We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept. She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept. The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV. It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment. She will follow up with us in the next six months and will call us if she has any problems with the Aricept. She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day. We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.,

Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.

Consult - History and Phy.

Consult - Atrial Fibrillation

REASON FOR CONSULTATION:, Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke. She was found to have confusion while in her facility. She then came to the emergency room and found to have a right sided acute stroke. 12-lead EKG performed on August 10, 2009, found to have atrial fibrillation. Telemetry also revealed atrial fibrillation with rapid ventricular response. Currently, the telemetry is normal sinus rhythm. Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian. She did not recall why she is in the hospital, she said she had a stroke. She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1. Coronary artery disease status post bypass grafting surgery. Unable to obtain the place, location, anatomy, and the year it was performed.,2. Carotid artery stenosis status post right carotid artery stenting. Again, the time was unknown.,3. Diabetes.,4. Hypertension.,5. Hyperlipidemia.,6. History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, The patient is a resident of Lake Harris Port Square. She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air. Temperature 99, respiratory rate 16.,GENERAL: The patient is sitting in the chair at bedside. Appears comfortable. Left facial droop. Left side hemiplegia.,HEAD AND NECK: No JVP seen. Right side carotid bruit heard.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI not displaced, regular rhythm. Normal S1 and S2. Positive S4. There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN: Soft.,EXTREMITIES: Not edematous.,DATA:, A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute. Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7. The patient's hemoglobin was 8.2 a few days ago before blood transfusion. Chemistry-7 within normal limits. Lipid profile: Triglycerides 64, total cholesterol 106, HDL 26, LDL 17. Liver function tests are within normal limits. INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%. Mild apical hypokinesis. Mild dilated left atrium. Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. No intracardiac masses or thrombus were noted. The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1. Paroxysmal atrial fibrillation. It is unknown if this is a new onset versus a paroxysmal atrial fibrillation. Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated. However, given the patient's current neurologic status, the safety of falling is unclear. We need to further discuss with the patient's primary care physician, probably rehab physician. If the patient's risk of falling is low, then Coumadin is indicated. However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended. Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management. Therefore, I will not recommend transesophageal echocardiogram at this point. Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2. Carotid artery stenosis. The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery. It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting. If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency. However, given the patient's current acute stroke, revascularization is not indicated at this time.,3. Coronary artery disease. Clinically stable. No further test is indicated at this time.

Atrial fibrillation and shortness of breath. The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.

Consult - History and Phy.

Consult - Atrial Fibrillation - 1

REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman. The patient had shortness of breath over the last few days, progressively worse. Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea. Coronary artery disease workup many years ago. He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:, Married, ex-smoker, and does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness. The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: Weakness, fatigue, tiredness.,HEENT: No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR: Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL: Some frequency, urgency, no hematuria.,MUSCULOSKELETAL: Arthritis, muscle weakness.,SKIN: Chronic skin changes.,CNS: History of TIA. No CVA, no seizure disorder.,ENDOCRINE: Nonsignificant.,HEMATOLOGICAL: Nonsignificant.,PSYCHOLOGICAL: No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins flat. No significant carotid bruits.,LUNGS: Air entry bilaterally fair, decreased in basal areas. No rales or wheezes.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft and nontender. Bowel sounds present.,EXTREMITIES: Chronic skin changes. Pulses are palpable. No clubbing or cyanosis.,CNS: Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits. First set of cardiac enzymes profile negative. BNP 4810.,Chest x-ray confirms unremarkable findings. EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:

A 5-month-old infant with 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.

Consult - History and Phy.

Congestion & Cough - 5-month-Old

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.

She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.

Consult - History and Phy.

Connective Tissue Disorder

Her past medical history includes a presumed diagnosis of connective tissue disorder. She has otherwise, good health. She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically. She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye. Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD. She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS. Intraocular pressures are 13 OU and by applanation. Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes. Gonioscopy showed normal anterior segment angle morphology in both eyes. She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes. Conjunctivae were quite, OU. Cornea were clear in both eyes. The anterior chamber is deep and quiet, OU. She has clear lenses, which are in good position, OU. Dilated fundus exam shows moderately optically clear vitreous, OU. The optic nerves are normal in size. The cup-to-disc ratios were approximately 0.4, OU. The nerve fiber layers are excellent, OU. The macula, vessels, and periphery were normal in both eyes. No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous. She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur. Otherwise, I can see her in 1 to 2 years.

A 2-month-old female with 1-week history of congestion and fever x2 days.

Consult - History and Phy.

Congestion & Fever - 2-month-old

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.

Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.

Consult - History and Phy.

Consult - Abnormal EKG

REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female. From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena. The patient relates to have some low-grade fever. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. As per the medications, they are not very clear. Husband has gone out to brief her medications. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.,CORONARY RISK FACTORS: , No hypertension or diabetes mellitus. Nonsmoker. Cholesterol status is normal. Questionable history of coronary artery disease. Family history noncontributory.,FAMILY HISTORY:, Nonsignificant.,PAST SURGICAL HISTORY: , Questionable coronary artery bypass surgery versus valve replacement.,MEDICATIONS: , Unclear at this time, but she does take Coumadin.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY: , She is married, nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: No history of cataract, history of blurry vision and hearing impairment.,CARDIOVASCULAR: Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,RESPIRATORY: Shortness of breath, questionable pneumonia. No valley fever.,GASTROINTESTINAL: No nausea, no vomiting, hematemesis or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Arthritis, muscle weakness.,CNS: No TIA. No CVA. No seizure disorder.,SKIN: Nonsignificant.,PSYCHOLOGIC: Anxiety and depression.,ALLERGIES: Nonsignificant except as mentioned above for medications.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,HEENT AND NECK: Neck is supple. Atraumatic and normocephalic. Neck veins are flat. No thyromegaly.,LUNGS: Air entry bilaterally fair. Decreased breath sounds especially in the right basilar areas. Few crackles.,HEART: Normal S1 and S2, irregular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulse is palpable. No clubbing or cyanosis.,CNS: Grossly intact.,MUSCULOSKELETAL: Arthritic changes.,PSYCHOLOGICAL: None significant.,DIAGNOSTIC DATA: , EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes. INR of 4.5, H and H 10 and 30. BUN and creatinine are within normal limits. Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,IMPRESSION:,1. The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2. Symptoms as above.,RECOMMENDATIONS:,1. We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia. Once, if she is stable, we will consider further cardiac workup.,2. We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.

Routine colorectal cancer screening. He occasionally gets some loose stools.

Consult - History and Phy.

Colon Cancer Screening

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation.

Congestion, tactile temperature.

Consult - History and Phy.

Congestion - 21-day-old

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.

Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.

Consult - History and Phy.

Colon Cancer Consult

REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:, The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy. Unfortunately, she had miscarriage at about seven weeks. She again had abdominal cramping, severe, in late March 2007. She underwent colonoscopy on 04/30/2007 by Dr. Y. Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure. She was not able to have the scope passed past this lesion. Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday. The surgery was laparoscopic assisted with anastomosis. At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis. There was no angiolymphatic invasion noted. Radial margin was 0.1 mm. Other margins were 5 and 6 mm. Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis. This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs. The degenerative changes were noted at L5-S1. The ovaries were normal. An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:, She has otherwise been feeling well. She has not had fevers, night sweats, or noticed lymphadenopathy. She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber. She was eating well up until the time of her surgery. She is up-to-date on mammography, which will be due again in June. She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:, None.,PAST MEDICAL HISTORY: , No significant medical problem. She has had three miscarriages, all of them at about seven weeks. She has no prior surgeries.,SOCIAL HISTORY: ,She smoked cigarettes socially while in her 20s. A pack of cigarettes would last for more than a week. She does not smoke now. She has two glasses of wine per day, both red and white wine. She is married and has no children. An IUD was recently placed. She works as an esthetician.,FAMILY HISTORY: ,Father died of stage IV colon cancer at age 45. This occurred when the patient was young and she is not sure of the rest of the paternal family history. She does believe that aunts and uncles on that side may have died early. Her brother died of pancreas cancer at age 44. Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago. Otherwise, he has no medical problem. Mother is aged 82 and healthy. She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL: She is in no acute distress.,VITAL SIGNS: The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN: Warm and dry. She has no jaundice.,LYMPHATICS: No cervical or supraclavicular lymph nodes are palpable.,LUNGS: There is no respiratory distress.,CARDIAC: Regular rate.,ABDOMEN: Soft and mildly tender. Dressings are clean and dry.,EXTREMITIES: No peripheral edema is noted. Sequential compression devices (SCDs) are in place.,LABORATORY DATA:, White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6. Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133. Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis. Firstly, she has a good prognosis for being cured without adjuvant therapy. I would consider her borderline for chemotherapy given her young age. Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit. Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects. We did not review all that information today.,She has a family history of early colon cancer. Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can. Tumor is being tested for microsatellite instability and we will discuss this when those results are available. She has one sibling and he is up-to-date on colonoscopy. She does report multiple tubes of blood were drawn prior to her admission. I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed. If not, those can be drawn tomorrow.

Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.

Consult - History and Phy.

Cholestasis Of Pregnancy

FINAL DIAGNOSES:, Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. The patient underwent a 2-day induction. On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress. During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration. Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication. There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery. It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay. The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit. The maternal tachycardia resolved within a day. The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns. The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%. It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively. Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state. An alert and oriented patient who is desirous at discharge. Full range of motion, all extremities; fully ambulatory. Pulse is regular and strong. Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus. The incision is beautiful and soft and nontender. There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet. Follow up with me in 1 to 2 weeks. Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No. 3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.

Clogged AV shunt. The patient complains of fatigue, nausea, vomiting and fever.

Consult - History and Phy.

Clogged AV Shunt - Consult

REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint. The patient complains of fatigue, nausea, vomiting and fever. The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement. The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked. The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem. At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed. As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read "did not work". The patient has had dialysis since January secondary to hypertension-induced renal failure. He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center. He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago. The patient's history at this point is a little sketchy; however, he states that he left AMA. All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years. No alcohol, occasional marijuana, and no IV drug use. He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs: In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air. General: This is an alert and oriented African-American male x3 and in no acute distress. The patient is extremely lethargic and had to be aroused multiple times to answer questions. Mucous membranes are moist. HEENT: Head is normocephalic and atraumatic. There is no scleral icterus noted. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Cardiovascular: Shows a heart rate that is regular with a laterally displaced point of maximum intensity. There is no murmur, gallop, or rub noted. Lungs: Clear to auscultation bilaterally. No wheeze, rhonchi or rales. Abdomen: Soft, nontender and nondistended. Bowel sounds are present. Extremities: Show left forearm with an incision that is well healed from a left AV fistula. There is a distal thrill palpable and there is some tenderness over the incisional area. There is no erythema or pus noted. Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131. Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1. Nonfunctional AV fistula.,2. End-stage renal disease.,3. Hypertension.,4. Status post MI.,5. Clogged PermCath.,PLAN:,1. Give the patient TPA to the shunt, PermCath in both feet.,2. To board for Tuesday for shunt repair if needed.,3. To dialyze as soon as possible.,4. To review previous operative report.,5. The patient will be contacted in the morning and told whether to go to dialysis or not.

A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.

Consult - History and Phy.

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.

Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.

Consult - History and Phy.

Cholangiocarcinoma Consult

REASON FOR CONSULTATION:, Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY: ,Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES: ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS: ,The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:

Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor.

Consult - History and Phy.

Chest Wall Lump - Consult

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.

A routine return appointment for a 71-year-old woman with chronic atrial fibrillation. Chief complaint today is shortness of breath.

Consult - History and Phy.

Chronic Atrial Fibrillation

REASON FOR VISIT:, This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:, I last saw her in 09/2008. Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode. She was found to have a fast heart rate in the atrial fibrillation. She was also found to be in heart failure and so they diuresed her. They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise. My plan advent is to control her heart rate. This has been a bit difficult with her retaining fluid. We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation. She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights. I think these are manifestations of heart failure. She has peripheral edema. She is short of breath when she tries to walk a city block. I believe she takes her medications as directed, but I am never sure she actually is taking them correctly. In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute. There is a nonspecific IVCD. This is unchanged from her last visit except that her heart rate is faster. In addition, I reviewed her echocardiogram done at XYZ. Her ejection fraction is 50% and she has paradoxical septal motion. Her right ventricular systolic pressure is normal. There are no significant valvular abnormalities.,MEDICATIONS: ,1. Fosamax - 70 mg weekly.,2. Lisinopril - 20 mg daily.,3. Metformin - 850 mg daily.,4. Amlodipine - 5 mg daily.,5. Metoprolol - 150 mg twice daily.,6. Warfarin - 5 mg daily.,7. Furosemide - none.,8. Potassium - none.,9. Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, she again looks the same which is in heart failure. Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular. She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit. She is breathing 1two times per minute and it is unlabored. Eyelids are normal. She has vitiligo. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. She has marked keloid formation on both sides of her neck, the left being worse than the right. The jugular venous pressure is elevated. Carotids are brisk are without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is irregularly irregular. She has a variable first and second heart sounds. No murmurs today. Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux. She has no clubbing or cyanosis, but does have 1+ peripheral edema. Distal pulses are good. On neurological examination, her mentation is normal. Her mood and affect are normal. She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES: ,1. Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2. Heart failure and she needs more diuretic.,3. High blood pressure controlled.,4. Hyperlipidemia.,5. Diabetes mellitus type 2.,6. Nonspecific intraventricular conduction delay.,7. History of alcohol abuse.,8. Osteoporosis.,9. Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic. There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily. If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.

Patient with palpitations and rcent worsening of chronic chest discomfort.

Consult - History and Phy.

Chest discomfort & palpitations - Consult.

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.

Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.

Consult - History and Phy.

Chronic Sinusitis

HISTORY:, I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis. As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics. She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left. She currently is not taking any medication for her sinuses. She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness. Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination. She has tried topical nasal corticosteroid therapy without much improvement. She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen. She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears. She denies any previous history of sinus surgery or nasal injury. She believes she has some degree of allergy symptoms.,PAST MEDICAL HISTORY: ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change. She is currently 180 pounds.,PAST SURGICAL HISTORY:, Lower extremity vein stripping, tonsillectomy and adenoidectomy.,FAMILY HISTORY: , Strong for heart disease and alcoholism.,CURRENT MEDICATIONS: , DynaCirc.,ALLERGIES: , Egg-based products cause hives.,SOCIAL HISTORY: ,The patient used to smoke cigarettes for about 20 years, one-half pack a day. She currently does not, which was encouraged to continue. She rarely drinks any alcohol-containing beverages.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally. No nystagmus.,EARS: During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position. No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice. No evidence of any orthostatic hypotension was noted during the exam. Tympanic membranes were noted to be intact. No signs of middle ear effusion or ear canal inflammation.,NOSE: The patient appears congested. Turbinate hypertrophy is noted. There are no signs of any acute sinusitis. Septum is midline, slightly deviated to the left.,THROAT: There is clear postnasal drip. Oral hygiene is good. No masses or lesions noted. Both vocal cords move well to midline.,NECK: The neck is supple with no adenopathy or masses palpated. The trachea is midline. The thyroid gland is of normal size with no nodules.,LUNGS: Clear to auscultation bilaterally. No wheeze noted.,HEART: Regular rate and rhythm. No murmur noted.,NEUROLOGIC: Facial nerve is intact bilaterally. The remaining cranial nerves are intact without focal deficit.,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,IMPRESSION: ,1. Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2. Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3. Inferior turbinate hypertrophy.,4. Nasal septum deformity.,RECOMMENDATIONS:, An ENG was ordered to evaluate vestibular function. She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening. A Medrol Dosepak was prescribed as directed. The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended. After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations. In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,Thank you for allowing me to participate with the care of your patient.

Chest pain, possible syncopal spells. She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.

Consult - History and Phy.

Chest Pain - Cardiac Consult

REASON FOR REFERRAL:, Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy. Since then she just says "things have changed". She just does not want to go out anymore and just does not feel the same. Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband. Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel "like cramps" and sometimes like a dull ache, which will last all day long. She is also tender in the left breast area and gets numbness in her left hand. She has also had three spells of "falling", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes. Twice it happened, when getting up quickly at night and another time in the grocery store. She suffered no trauma. She has no remote history of syncope. Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:, Sulfa.,SOCIAL HISTORY: , She does not smoke or drink. She is married with two children.,REVIEW OF SYSTEMS:, Otherwise unremarkable.,PEX:, BP: 130/70 without orthostatic changes. PR: 72. WT: 206 pounds. She is a healthy young woman. No JVD. No carotid bruit. No thyromegaly. Cardiac: Regular rate and rhythm. There is no significant murmur, gallop, or rub. Chest: Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed). Lungs: Clear. Abdomen: Soft. Moderately overweight. Extremities: No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1. Syncopal spells - These do sound, in fact, to be syncopal. I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good. I have asked her to drink plenty of fluids and to not to get up suddenly at night. I think this should take care of the problem. I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2. Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors. The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1. Reassurance that her cardiac checkup looks excellent, which it does.,2. Drink plenty of fluids and arise slowly from bed.,3. Flexeril 10 mg q 6 p.r.n.,4. I have asked her to return should the syncopal spells continue.

Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe.

Consult - History and Phy.

Cervical Spondylosis - Neuro Consult

REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1. Ocular migraines.,2. Myomectomy.,3. Infertility.,4. Hyperglycemia.,5. Asthma.,6. Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing.,PERTINENT DATA: ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN: ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically.

Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.

Consult - History and Phy.

Cardiomyopathy & Hypotension - Consult

REASON FOR CONSULTATION:, Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:, I am seeing the patient upon the request of Dr. X. The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that. Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient. The patient denies any chest pain or chest pressure. Denies any palpitations. No bleeding difficulty. No dizzy spells.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No fever or chills.,EYES: No visual disturbances.,ENT: No difficulty swallowing.,CARDIOVASCULAR: Basically, no angina or chest pressure. No palpitations.,RESPIRATORY: No wheezes.,GI: No abdominal pain, although she had diarrhea.,GU: No specific symptoms.,MUSCULOSKELETAL: Have sores on the back.,NEUROLOGIC: Have dementia.,All other systems are otherwise unremarkable as far as the patient can give me information.,PAST MEDICAL HISTORY:,1. Positive for coronary artery disease for about two to three years.,2. Hypertension.,3. Anemia.,4. Chronic renal insufficiency.,5. Congestive heart failure with EF of 25% to 30%.,6. Osteoporosis.,7. Compression fractures.,8. Diabetes mellitus.,9. Hypothyroidism.,PAST SURGICAL HISTORY:,1. Coronary artery bypass grafting x3 in 2008.,2. Cholecystectomy.,3. Amputation of the right second toe.,4. ICD implantation.,CURRENT MEDICATIONS AT HOME:,1. Amoxicillin.,2. Clavulanic acid or Augmentin every 12 hours.,3. Clopidogrel 75 mg daily.,4. Simvastatin 20 mg daily.,5. Sodium bicarbonate 650 mg twice daily.,6. Gabapentin 300 mg.,7. Levothyroxine once daily.,8. Digoxin 125 mcg daily.,9. Fenofibrate 145 mg daily.,10. Aspirin 81 mg daily.,11. Raloxifene once daily.,12. Calcium carbonate and alendronate.,13. Metoprolol 25 mg daily.,14. Brimonidine ophthalmic once daily.,ALLERGIES: , She has no known allergies.,FAMILY HISTORY:

The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.

Consult - History and Phy.

Cardiac Consultation - 7

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me. He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation. There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission. He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation. The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1. Type I diabetes mellitus.,2. Hyperlipidemia.,3. Hypertension.,4. Morbid obesity.,5. Sleep apnea syndrome.,6. Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General: Unremarkable.,Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal: Unremarkable.,Genitourinary: See above.,Musculoskeletal: Unremarkable.,Neurologic: Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease. His mother has congestive heart failure.,SOCIAL HISTORY: ,The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1. Clonidine 0.3 mg b.i.d.,2. Atenolol 50 mg daily.,3. Simvastatin 80 mg daily.,4. Furosemide 40 mg daily.,5. Metformin 1000 mg b.i.d.,6. Hydralazine 25 mg t.i.d.,7. Diovan 320 mg daily.,8. Lisinopril 40 mg daily.,9. Amlodipine 10 mg daily.,10. Lantus insulin 50 units q.p.m.,11. KCl 20 mEq daily.,12. NovoLog sliding scale insulin coverage.,13. Warfarin 7.5 mg daily.,14. Levothyroxine 0.2 mg daily.,15. Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General: A well-appearing, obese black male.,Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.,HEENT: Grossly normal.,Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.,Chest: Midline sternotomy scar.,Lungs: Clear.,Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.,Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.

Patient reports a six to eight-week history of balance problems with later fatigue and weakness.

Consult - History and Phy.

Cervical Cord Lesion - Consult

HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was "rebuilt." He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.

Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.

Consult - History and Phy.

Cardiac Consultation - 4

REASON FOR CONSULTATION:, Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout. Patient used to take medicine for hyperlipidemia and then that was stopped. He used to live in Canada and he moved to Houston four months ago. He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side. It lasts around 10-15 minutes at times. It is 5/10 in quality. It is not associated with shortness of breath, nausea, vomiting, or sweating. It is not also associated with food. He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. No palpitations, syncope or presyncope. He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma. No fever, chills, cough, hemoptysis, hematemesis or hematochezia. His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:, Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease. His father died in his 50s with an acute myocardial infarction.,MEDICATION:, Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:, No known allergies.,REVIEW OF SYSTEMS:, As mentioned above,EXAMINATION:, This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt: 238

To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.

Consult - History and Phy.

Cardiac Consultation - 2

CHIEF REASON FOR CONSULTATION:, Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:, This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time, patient felt extremely short of breath and dizzy. Palpitations lasted for about five to ten minutes without any recurrence. Patient also gives history of having tightness in the chest after she walks briskly up to a block. Chest tightness starts in the retrosternal area with radiation across the chest. Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest. Patient gives history of having hypertension for the last two months. Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1. Astelin nasal spray.,2. Evista 60 mg daily.,3. Lopressor 25 mg daily.,4. Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:, The patient underwent right foot surgery and C-section.,FAMILY HISTORY:, The patient is married, has six children who are doing fine. Father died of a stroke many years ago. Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks. ,ALLERGIES:, THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:, Otherwise negative. ,PHYSICAL EXAMINATION: , ,GENERAL: Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.,NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.,CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard. ,CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard.,ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.,EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO: Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes. Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,

Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.

Consult - History and Phy.

Cardiac Consultation - 6

INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old white female with no prior cardiac history. She sustained a mechanical fall with a subsequent left femoral neck fracture. She was transferred to XYZ Hospital for definitive care. In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms. Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL. She also had a left axis deviation. Serial troponins were obtained. She has had four negative troponins since admission. Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1. Mesothelioma.,2. Recurrent urinary tract infections.,3. Gastroesophageal reflux disease/gastritis.,4. Osteopenia.,5. Right sciatica.,6. Hypothyroidism.,7. Peripheral neuropathy.,8. Fibromyalgia.,9. Chart review also suggests she has atherosclerotic heart disease and pneumothorax. The patient denies either of these.,PAST SURGICAL HISTORY:,1. Tonsillectomy.,2. Hysterectomy.,3. Appendectomy.,4. Thyroidectomy.,5. Coccygectomy.,6. Cystoscopies times several.,7. Bladder neck resuspension.,8. Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, At the time of evaluation include, 1. Cefazolin 1 g intravenous (IV). 2. Morphine sulfate. 3. Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1. Robaxin. 2. Detrol 4 mg q.h.s. 3. Neurontin 300 mg p.o. t.i.d. 4. Armour Thyroid 90 mg p.o. daily. 5. Temazepam, dose unknown p.r.n. 6. Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known. She knows nothing of her father's history. She has no siblings. There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband. She is a lifetime nonsmoker, nondrinker. She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL: The patient is able to walk one block or less prior to the onset of significant leg pain. She ever denies any cardiac symptoms with this degree of exertion. She denies any dyspnea on exertion or chest pain with activities of daily living. She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea. She does have chronic lower extremity edema. Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis. She denies any palpitations or tachycardia. She has remote history of presyncope, no true syncope.,HEMATOLOGIC: Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC: Remarkable for past medical history.,PULMONARY: Remarkable for childhood pneumonia times several. No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL: Remarkable for past medical history.,GENITOURINARY: Remarkable for past medical history.,MUSCULOSKELETAL: Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM: Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC: Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman. No recurrence.,PHYSICAL EXAMINATION:,GENERAL: This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS: She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6. Pulse ranges from 123 to 86 beats per minute. Blood pressure ranges from 124/65 to 152/67 mmHg. Oxygen saturation on 2 L nasal cannula was 94%.,HEENT: Exam is benign. Normocephalic and atraumatic. Extraocular motions are intact. Sclerae anicteric. Conjunctivae noninjected. She does have bilateral arcus senilis. Oral mucosa is pink and moist.

Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.

Consult - History and Phy.

Cardiac Consult & Cardioversion

HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged. He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here. Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide. He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia. Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1. Atenolol 25 mg once a day.,2. Altace 2.5 mg once a day.,3. Zocor 20 mg once a day.,4. Flecainide 200 in the morning and 100 in the evening.,5. Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE. HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well. The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine. No use of illicit drugs. He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife. He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish. He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi. There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18. On general exam, he is a pleasant overweight gentleman, in no acute distress. HEENT: Shows cranium is normocephalic and atraumatic. He has moist mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin warm and perfused. Affect appropriate. He is quite oriented and pleasant. No significant kyphoscoliosis on recumbent back exam. Lungs are clear to auscultation anteriorly. No wheezes. No egophony. Cardiac Exam: S1, S2. Regular rate, controlled. No significant murmurs, rubs or gallops. PMI is nondisplaced. Abdomen is soft, nondistended, appears benign. Extremities without significant edema. Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:, Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so. I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of. After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null. The patient expressed understanding of this risk, benefit, and alternative analysis. I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE: ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions. The patient did actively participate in this time-out procedure. After the universal protocol was done, he then received the cardioversion attempt with 50 joules using "lollipop posterior patch" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy. There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22. We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed. I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself. Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.

A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD.

Consult - History and Phy.

Cardiac Consultation

HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. The patient and her husband live in ABC but they have family in XYZ. She came to our office today as she is in the area visiting her family. She complains of having shortness of breath for the past month that has been increasingly getting worse. She developed a frequent nonproductive cough about 2 weeks ago. She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath. She has also gained about 15 pounds in the past few months and has significant peripheral edema. In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY: ,The patient is married. Lives with her husband. They are retired from ABC.,MEDICATIONS:,1. Plavix 75 mg p.o. daily.,2. Aspirin 81 mg p.o. daily.,3. Isosorbide mononitrate 60 mg p.o. daily.,4. Colace 100 mg p.o. b.i.d.,5. Atenolol 50 mg p.o. daily.,6. Lantus insulin 15 units subcutaneously every evening.,7. Protonix 40 mg p.o. daily.,8. Furosemide 40 mg p.o. daily.,9. Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Positive for generalized fatigue and malaise.,HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing.,ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms.,NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC: Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact.,CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs.,EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish.,RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded.,ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated.,GENITOURINARY: Deferred.,MUSCULOSKELETAL: Adequate range of motion along with extremities.,SKIN: Warm and dry. No lesions or ulcerations are noted.,NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits.,PSYCHIATRIC: Normal affect.,IMPRESSION,1. Coronary artery disease.