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" HISTORY OF PRESENT ILLNESS: The patient is a 49 -year-old white male with a history of urinary frequency, burning, and recent fever. His urine was loaded with white cells in the office, and he is being admitted for intravenous antibiotics. Last night, he presented to the ER and had a temperature to 102.5 degrees, then subsequently developed worsening fever. His fever ultimately broke about 2:30 in the morning with a temperature that ended at approximately 103 degrees. PAST MEDICAL HISTORY: Significant for o ral agent diabetes mellitus and hypertension. REGULAR MEDICATIONS: Include: (1) Glucovance. (2) Avandia. (3) Zantac. (4) Tricor. (5) Zestril. ALLERGIES: PENICILLIN (he is unsure of the reaction - he thinks it has something to do with swelling). FAMILY HISTORY: Significant for a father who died of myocardial infarction and mother died of a stroke. He has had a previous urinary tract infection, Escherichia coli type, in 1998, with admission to the hospital then. He has not had any other hospitalizations. SOCIAL HISTORY: He is a truck driver. He is not an abuser of alcohol or tobacco. REVIEW OF SYSTEMS: Significant for dysuria; PSA score of only 3. PHYSICAL EXAMINATION: VITAL SIGNS: Recorded in nursing notes: Temperature maximum of 101.5 degrees. He is slightly hypertensive at 145/75. His pulse oximetry is normal. His pulse rate is in the low 90s. His respiratory rate is 16. GENERAL APPEARANCE: His mood and affect are normal. He is alert and oriented x 3. He is an excellent historian. HEAD, EYES, EARS, NOSE, AND THROAT: Examination reveals he is normocephalic, atraumatic. Extraocular movements are intact. NECK: Supple without jugular venous distention or thyromegaly. CHEST: Grossly clear. HEART: Rate is regular. Peripheral pulses appear to be normal. LYMPHATICS: He has no abnormal adenopathy in the axillary, supraclavicular, cervical, or inguinal lymph node regions. ABDOMINAL EXAMINATION: Soft, nontender, slightly protuberant. No evidence of inguinal, umbilical, or other fascial hernias are noted. GENITOURINARY: The testes and phallus are normal. Prostate is about 20 g in size and significantly tender on the right hand side. LABORATORY DATA: Indicative of a white blood cell count of 13.7. Hemoglobin and platelet count are well within normal limits. Compreh ensive metabolic panel reveals a normal creatinine. Urinalysis reveals white cells present. Urine culture has been sent. DIAGNOSTIC IMPRESSION: 1. Probable prostatitis. 2. Urinary tract infection. PLAN: Admission. Will do non-contrast CT scan to evaluate him for possible stone. No apparent prostate abscess is present and he will be treated with intravenous
M. she was on Demadex 100 mg one-half tablet daily. LUNGS: On the ventilator.D. Model # 5346. The pacemaker was subsequently reprogrammed with immediate resolution of that tachycardia. hypertensive heart disease. LABORATORY DATA: Cardiac enzymes reveal: Mild troponin level bump is noted at 0. Myoglobin assay 92. She also had.0.5 mg daily. calcium carbonate one tablet daily.. and prednisone 10 mg daily. Diltiazem XR 240 mg daily.8. BUN 33. CK-MB 4.m. she is somewhat combative. Toprol XL 50 mg daily. this will be a thing of the past. hopefully. I suspect this whole scenario is related to tachyarrhythmia and that currently. NECK: Jugular venous pressure appears to be normal. Creatinine 1. is 42. at that time. Also.7. Amaryl 2 mg daily. Thanks so much for allowing us to share in her management. Coumadin daily. potassium 20 mEq daily.1). CONSULTING PHYSICIAN: Abraham Lincoln. F. It is unclear as to why she was taken off of her Plavix. EXTREMITIES: No edema. there are severe other medical problems including the chronic obstructive pulmonary disease. VITAL SIGNS: Blood pressure 140/60. Tegretol 200 mg t. daily. PHYSICAL EXAMINATION: Currently: GENERAL APPEARANCE: When awake. HEART: Demonstrates S1 less than S2. Glucose 317.o. Magnesium 4..000. with the reprogramming. ASSESSMENT: The cardiac status at this point appears to be more stable with the rhythm potentially improving her pulmonary status. and 25 units p. MEDICATIONS: The patient had been on some amiodarone in the nursing home at 200 mg b. The patient has had a recent history of a non-Q wave myocardial infarction with subsequent balloon intervention to the ramus branch with stenting and good results. Total CPK. ABDOMINAL EXAMINATION: Obese and fine to examination.000. The patient was treated with Solu-Medrol in the emergency room and was given Lasix 40 mg intravenously and was placed on a low dose of dopamine at 3 mcg/kg per minute and 5 mcg of intravenous nitroglycerin..Medical Transcription Consultation Report Sample DATE OF CONSULTATION: REASON FOR CONSULTATION: Cardiology.m.i. Humulin 70/30 insulin mixture at 30 units in the a. but she was to continue on the Plavix in light of her recent stent placement. isosorbidemononitrate 30 mg daily. a sick sinus conduction system disease with paroxysmal arrhythmia and tachycardia/bradycardia type symptom atology with ultimately the placement of a permanent pacemaker.C. however.D. Platelet count 290.A. Meanwhile. She is currently sedated on Diprivan. Recheck seemed to stay in the range of 110 -140. Altace 2. REFERRING PHYSICIAN: George Washington.d. Hemoglobin and hematocrit are 11 and 34. Potassium 4.C. . Will follow as needed. The patient did well in the nursing home until the day when she presented to the emergency room with pulmonary edema. the lungs demonstrate to be fairly clear. It was a sequential type Integrity AFXDR. HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old female who was admitted from the nursing home with respiratory failure. These will be stabilized.20. aspirin 325 mg p.7. She was intubated and was subsequently stabilized.5 (normal less than 4. The initial rhythm of her heart was 139 which is clearly a pacemaker mediated tachycardia. M. the diabetes mellitus. White blood cell count 13. No S3 is noted.i.2. Phosphorus 4.d.
CLINICAL IMPRESSION: Colic.d. SOCIAL HISTORY: Negative.CHIEF COMPLAINT: Colic. HEART: Shows a regular rhythm without murmurs. PLAN: Gaviscon. The fontanel is soft and ballotable. changing the formula. The rest of the review of systems is negative. I might add. HEENT: The pharynx is wet. She had some flatus several times.9. Both parents are present and appropriately concerned. . PAST SURGICAL HISTORY: Negative. She is not constipated. and see their doctor in 1 days.Respirations 52. symptoms is negat ive. ABDOMEN: Somewhat distended. SKIN: She has no skin lesions. and then it diminishes. or jaundice. no iron. t which shows no obstruction. There is no induration of the throat and there is no adenopathy. REVIEW OF SYSTEMS: The complete review of systems is essentially negative except for colicky abdominal pain and increased flatus. at least. It is totally nontender. HISTORY OF PRESENT ILLNESS: This 6-week-old enters with colicky pain and increasing flatus and crampy abdominal pain that she gets mostly at night. (4) They should follow up with their own doctor. GENERAL APPEARANCE: She is alert and is moving all extremities. (3) To increase the Gaviscon to 3 drops q. Has been on Gaviscon but has gotten only one dose a night apparently. Pulse oximetry is 96% on room air. FAMILY HISTORY: Negative. NEUROLOGIC: Intact for age including a positive Moro. and the pulses are 2+ and equal. The tympanic membranes are normal.i. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98. LUNGS: Clear. Pulse 130. She has had no blood in her stool and normal urine and normal intake and no nausea or vomiting. PAST MEDICAL HISTORY: Other than the above. DISCUSSION: I think this is colic. The patient is on formula with iron and does not use a gas decreasing bottle system. -7 CONDITION ON DISCHARGE: Good. (2) To use soy based formula. There is no dyspnea. DATABASE: X-rays: Upright abdominal and chest combination is normal excep for gas in the bowel. She has good tone. I have suggested the following: (1) To change to formula without iron. She has not had any fever. icterus. NECK: Supple.
syncopal episode. History of gastroesophageal reflux disease. Barlow s and Ortolani s Tests (signs) Test done on infants/newborns: (Sometimes dictated on Discharge Summaries) Barlow's test identifies unstable hip that lies in the reduced position but can be passively dislocated (and hence unstable). The patient underwent a dual isotope stress test. Lipitor 10 mg every day.o. The patient had a Holter monitor placed but the report is not available at this time. Ortolani s sign is the palpable sensation of the gliding of the femoral head in and out of the acetabulum. HISTORY OF PRESENT ILLNESS: This is a 51-year-old female admitted through the emergency room with syncopal episode with chest pain and also noted to have epigastric discomfort. 2. . 4. History of hyperlipidemia. Premarin 0. The patient had serial cardiac enzymes and ruled out for myocardial infarction. 3. 4. There was no evidence of reversible ischemia on the Cardiolite scan. 2. 3. workup in progress. The patienthasremainedhemodynamicallystable. DIAGNOSTIC IMPRESSION: 1. HOSPITAL COURSE AND TREATMENT: The patient was admitted and started on Lovenox and nitroglycerin paste. DISCHARGE MEDICATIONS: Include: 1. Chest pain. Enteric-coated aspirin 325 mg every day. every day.625 mg every day. The patient has been ambulated. Syncope. Will discharge. ruled out myocardial infarction. FURTHER PLAN: Will discharge. Prevacid 30 mg p.REASON FOR ADMISSION: Chest pain.
He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour. MEDICATIONS: Aspirin 81 milligrams QDay. He admits some shortness of breath & diaphoresis. The patient is diabetic and has a prior history of coronary artery disease. He states that he has had nausea & 3 episodes of vomiting tonight. COURSE IN EMERGENCY DEPARTMENT: The patient's chest pain improved after the sublingual nitroglycerine and completely resolved with the Nitroglycerin Drip at 30 ug/Minute. ABC. He is alert. ins ulin 50 units in a. The severity of the pain has progressively increased. There is no evidence of respiratory distress. The patient ranks his present pain a 4 on a scale of 1-10. Chest: No chest wall tenderness to palpation. Pupils are 2. no rash noted. No calf/ thigh tenderness or swelling. no erythema. and oriented to person place and circumstance. No tenderness noted. There is free range of motion & no tenderness. H e tolerated the TPA well. No CVAT. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. equal round and react to light bilaterally. Extra-ocular muscles are intact bilaterally. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. Heart: i rregularlyirregular rate and rhythm no murmurs gallops or rubs. He was transferred to the CCU in a stable condition PROCEDURES: . He states the pain is somewhat worse with walking and seems to be relieved with rest. He denies any fever or chills.5 mm. He appears in moderate discomfort but there is no evidence of distress. General: The patient is moderately obese but he is otherwise well developed & well nouri shed. atrial fibrillation. Humulin N.Works as a banker. diaphoretic.Acute Inferior Myocardial Infarction Description: Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction. (Medical TranscriptionSampleReport) CHIEF COMPLAINT: Chest pain.m. Extremities: No gross visible deformity. The patient ambulates without gait abnormality or difficulty. HCTZ 50 mg QDay. Neck is supple. FAMILY HISTORY: Positive for coronary artery disease (father & brother). External auditory canals are clear bilaterally. There is no change in pain with positioning. HEENT: Normocephalic/atraumatic head. PHYSICAL EXAM: The patient is a 40-year-old white male. REVIEW OF SYSTEMS: All other systems reviewed & are negative. He ranks the pain a 7 on a scale of 1 -10. which he states has partially relieved his pain. coronary artery disease. hypertension. Tympanic membranes are clear and intact bilaterally. free range of motion. The most recent episode of pain has lasted one-hour. head trauma. exudates or tonsillar enlargement. Normal PMI Abdomen: Soft. The patient denies any history of recent surgery. Smokes 2 packs of cigarettes per day. status po st PTCA in 1995 by Dr.Nitroglycerin 1/150 sublingually PRN chest pain. PAST MEDICAL HISTORY: Diabetes mellitus type II. recent stroke. Neck: No JVD. Skin: Warm. Pharynx: Clear. No edema or cyanosis. abnormal bleeding such as blood in urine or stool or nosebleed. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old white male who presents with a chief complaint of "chest pain". mucous membranes moist. He admits prior episodes of similar pain prior to his PTCA in 1995. Lungs: Clear to auscultation bilaterally. normal turgor. thyromegaly or lymphadenopathy noted. SOCIAL HISTORY: Denies alcohol or drugs. ALLERGIES: Penicillin. non-distended.
IMPRESSION: Acute Inferior Myocardial Infarction. glucose 186 Serum Troponin I: 2. Cardiac monitor. He is to come see patient in the emergency department. BUN 15. ABC. DIAGNOSTIC STUDIES: CBC: WBC 14.5. 10:45 PM risks & benefits of TPA discussed with patient & his family.5 Chest x-ray: Lung fields clear. ST elevation III &aVF (refer to EKG multimedia). hematocrit 33. He agrees with T PA per 90 minute protocol & IV nitroglycerin drip. platelets 316 Chem 7: Na 142. potassium 4. Nitroglycerin drip at 30 micrograms/minute.e. creatinine 1. ABC present in emergency department assisting with patient care. CO2 22. ABC (cardiologist) apprised. 2. TREATMENT: Heparin lock X.5. Heparin IV 5000 unit bolus followed by 1000 units/hour. Nasal cannula oxygen 3 liters/minute.10:40 PM Dr.6. chloride 102. . Acute inferior ischemic changes noted i. PLAN: Patient admitted to Coronary Care Unit under the care of Dr.2. 10:50 PM TPA started. No cardiomegaly or other acute findings EKG: Atrial fibrillation with Ventricular rate of 65. They agree with administration of TPA and are willing to accept the risks.2. TPA 90 minute protocol. Aspirin 5 grains chew & swallow. 11:20 PM Dr. Cardiac monitor: Sinus rhythm-atrial of fibrillation rate 60s -70s.
nasopharyngeal symptoms. He has no constitutional complaints such as fevers. His pain level has improved.2. Cardiovascular: He denies any palpitations. Lungs: Clear. rather than a genuine finding. Gross neurologic examination is normal. 2. and he was seen in our clinic on 04/12/05. I do not have any paperwork authenticating his claim that there is an open claim. nausea or vomiting. affecting both right and left sides. He still localizes it to a band between L4 and the sacrum. with facet involvement at L2-L3. ENT examination reveals normal oropharynx. (Medical TranscriptionSampleReport) HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. PHYSICAL EXAMINATION: Vital signs: Blood pressure 158/86. 4. organ systems.Leg Pain . and tympanic membranes. The patient's MRI dated 10/18/04 showed multi-level degenerative changes. Vicodin. He denies any abnormalities of endocrine. Lower extremity reflexes are symmetric. SOCIOECONOMIC STATUS: Lifting limitations of 5 pounds and limited stooping. There was no neural impingement. as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak. Most recently he was working at Taco Bell. respiration 14. Pulmonary: He denies any dyspnea or respiratory difficulties. GI: The patient has no abdominal pain. Straight leg raises do not elicit any leg complaints on today's visit. hematologic. He attributes this to an incident in which he was injured in 1994. MEDICATIONS: Atenolol. There is no overt muscular spasm. Zestril. alert and oriented and in no acute distress. Neck: Full range of motion with no adenopathy or thyromegaly. HEENT: The patient denies any cephalgia.Progress Note Description: History of right leg pain. Skin is warm and dry. temperature 100. however it was qualified in that it may have been artifact. He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10. The leg pain is no longer present. Leg pain is no longer present. There is no gross hematuria. when he had a recurrence of back pain. He rated pain of approximately 8/10 in severity. bending and twisting. 3. He can continue with physical therapy. Cardiovascular: Regular rate and rhythm. Follow up is within one week. He is sitting upright. nasopharynx. pulse 60. The area of concern was L4-L5. REVIEW OF SYSTEMS: Focal lower paralumbar pain. L3-L4 and L5-S1. ocular. syncope or near-syncope. He has no dysphagia. On examination of the lumbar spine. The patient will take another Medrol Dosepak. PLAN: 1. Musculoskeletal: Denies any recent falls or near-falls. chills or sweats. chest pain. DIAGNOSIS: Low back pain with a history of right leg pain. His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension. His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994. Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities. . ALLERGIES: None. He also had an MR myelogram. which showed severe stenosis at L3-L4. GU: The patient denies any urinary frequency or dysuria. he is minimally tender to palpation. He also continues with the same lifting restrictions. He denies any recent illness. He initially had some right leg pain but states that this is minimal and intermittent at the present time. immunologic.
he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. pulse 70. This may be a fracture based upon his exam. DISPOSITION: Crutches and splint were administered here. X from Orthopedics.Ankle pain Description: Acute foot or ankle sprain. He will be discharged home to follow up with Dr. and pulse oximetry 100% on room air. PAST SURGICAL HISTORY: None. I gave him a prescription for Motrin and some Darvocet if he needs to length his sleep and if he has continued pain to follow up with Dr. No la xity is noted. (Medical TranscriptionSampleReport) CHIEF COMPLAINT: Ankle pain. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. GENERAL: A pleasant gentleman in no acute distress. He was given Motrin here. Return if any worsening problems. presenting with a foot and ankle injury. No pain to palpation over the lateral or medial mall eolus. Capillary refill and sensation normal. ALLERGIES: Unknown. EXTREMITIES: Focused physical examination. MEDICAL DECISION MAKING: This is a pleasant young gentleman with symptoms as above.6. possible small fracture. He also has some pain over the dorsum of the foot as well. He does not think he has had injuries to his ankle in the past. He has had pain over the lateral aspect of the right foot with some ecchymosis and swelling. respirations 16. . He has had no pain over the metatarsals themselves. PAST MEDICAL HISTORY: None. MEDICATIONS: Adderall and Accutane. No other injuries noted. blood pressure 120/63. X. He does want to have me to put him in a splint. SOCIAL HISTORY: He does not drink or smoke. ASSESSMENT: Acute foot or ankle sprain. He had an x-ray of his ankle that showed a small ossicle versus avulsion fracture of the talonavicular joint on the lateral view. Ten systems reviewed and are negative. It hurts to move or bear weight. No pain over the Achilles tendon. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97. he has full range of motion in his right knee. Pulses are intact. Two hours prior to presentation. possible small fracture. REVIEW OF SYSTEMS: As above.
which are i mproved on her Tenormin and her verapamil. Cardiac exam reveals a normal rate and rhythm. PAST SURGICAL HISTORY: Hysterectomy. Her neck veins are not distended. Mitral valve prolapse: No clear evidence of this has been made. Whether this represents any arrhythmia. Abdomen is soft and nontender to palpation without organomegaly.Cardiology Medical Transcription Report HISTORY: The patient is a 48-year-old female with a long history of atypical chest pain and palpitations. Otherwise. Chest pain with atypical features: As it is not associated with exertion and has radiation over to her body. No murmur. She denies diaphoresis or lightheadedness and any history of MI. cough or diabetes mellitus. which did show mitral valve prolapse. In addition. Extremities reveal no clubbing. atypical chest pain and palpitations. TSH. she has undergone an echocardiogram. No clear explanation has been found for this. cyanosis or edema. strokes. Palpitations: The patient had an evaluation for this in the past with limited Holter. The patient also notes a history of palpitations. bladder suspension and appendectomy. No good explanation of her chest pain has been found. GU exam reveals no costovertebral angle tenderness. These occur once a week. SOCIAL HISTORY: Positive for tobacco abuse. They typically will last for five minutes but are not associated with shortness of breath . ten-point review of systems is PHYSICAL EXAMINATION: She is in no acute distress. I have checked a basic metabolic factor such as a C -reactive protein. lipid. IMPRESSION: 1. one baby aspirin a day and Celexa 40 mg a day. 2. They are not associated with exertion. PAST MEDICAL HISTORY: Mitral valve prolapse. which was not helpful. I have recommended getting an event recorder to try to calibrate her symptoms to arrhythmia or ST segment changes. As a part of her evaluation in the past. ELECTROCARDIOGRAM: Sinus rhythm without significant ST segment abnormalities. UA. atypical chest pain and preserved exercise tolerance. verapamil 120 mg a day. evaluation of her gallbladder in view of negative possible cardiac catheterizations to rule out coronary artery disease certainty. Respiratory exam is clear to aus cultation. She describes her episodes of chest pain as burning and tingling in nature. Her neurological examination is nonfocal. rubs. No murmurwasnotedontheexamination. although it has been documented under previous echo. I plan to see her in followup after six weeks. a cardiac or non -cardiac problem is unclear. negative. 3. If she has no clear explanation for this. CURRENT MEDICATIONS: Atenolol 50 mg a day. FAMILY HISTORY: Positive for coronary artery disease. RECOMMENDATIONS: The patient presents with symptoms of palpitation s. REVIEW OF SYSTEMS: She denies fevers. chest pain. clicks are clearly auscultated. depending on what her event recorder shows possible further evaluation may incl ude consideration of an empiric trial for reflux. . and BMP. Normal S1 and S2. CBC. night sweats.
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