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Write a clinical note about a patient with the following diagnoses: 1. Disseminated intravascular coagulation. 2. Streptococcal pneumonia with sepsis. | DIAGNOSES: 1. Disseminated intravascular coagulation. 2. Streptococcal pneumonia with sepsis. CHIEF COMPLAINT: Unobtainable as the patient is intubated for respiratory failure. CURRENT HISTORY OF PRESENT ILLNESS: This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and resp... | |
Write a clinical note about a patient with the following chief complaint: Dental pain. | CHIEF COMPLAINT: Dental pain. HISTORY OF PRESENT ILLNESS: This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation. PAST MEDICAL HISTORY: Remarkable for chronic back pain,... | |
Write a clinical note about a patient with the following chief complaint: "I want my colostomy reversed.", | CHIEF COMPLAINT: "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital with ... | |
Write a clinical note about a patient with the following chief complaint: Vomiting and nausea. | CHIEF COMPLAINT: Vomiting and nausea. HPI: The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe. She states she has it at least once a day. It can be any time, but can also be postprandial. She states she will vomit up some dark brown-to-green fluid. The... | |
Write a clinical note about a patient with the following chief complaint: Detox from heroin. | CHIEF COMPLAINT: Detox from heroin. HISTORY OF PRESENT ILLNESS: This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostl... | |
Write a clinical note about a patient with the following chief complaint: Cut on foot. | CHIEF COMPLAINT: Cut on foot. HISTORY OF PRESENT ILLNESS: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has norm... | |
Write a clinical note about a patient with the following chief complaint: Cough and abdominal pain for two days. | CHIEF COMPLAINT: Cough and abdominal pain for two days. HISTORY OF PRESENT ILLNESS: This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated... | |
Write a clinical note about a patient with the following chief complaint: Worsening seizures. | CHIEF COMPLAINT: Worsening seizures. HISTORY OF PRESENT ILLNESS: A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. The patient stated she was in ... | |
Write a clinical note about a patient with the following chief complaint: I need refills. | CHIEF COMPLAINT: I need refills. HISTORY OF PRESENT ILLNESS: The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause ... | |
Write a clinical note about a patient with the following chief complaint: Right hydronephrosis. | CHIEF COMPLAINT: Right hydronephrosis. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axil... | |
Write a clinical note about a patient with the following chief complaint: Left knee pain. | CHIEF COMPLAINT: Left knee pain. SUBJECTIVE: This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she ... | |
Write a clinical note about a patient with the following chief complaint: Multiple problems, main one is chest pain at night. | CHIEF COMPLAINT: Multiple problems, main one is chest pain at night. HISTORY OF PRESENT ILLNESS: This is a 60-year-old female with multiple problems as numbered below: 1. She reports that she has chest pain at night. This happened last year exactly the same. She went to see Dr. Murphy, and he did a treadmill and an... | |
Write a clinical note about a patient with the following chief complaint: Left breast cancer. | CHIEF COMPLAINT: Left breast cancer. HISTORY: The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center. On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomed... | |
Write a clinical note about a patient with the following chief complaint: Congestion and cough. | CHIEF COMPLAINT: Congestion and cough. HISTORY OF PRESENT ILLNESS: The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was des... | |
Write a clinical note about a patient with the following chief complaint: A 2-month-old female with 1-week history of congestion and fever x2 days. | CHIEF COMPLAINT: A 2-month-old female with 1-week history of congestion and fever x2 days. HISTORY OF PRESENT ILLNESS: The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid br... | |
Write a clinical note about a patient with the following chief complaint: Congestion, tactile temperature. | CHIEF COMPLAINT: Congestion, tactile temperature. HISTORY OF PRESENT ILLNESS: The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any pe... | |
Write a clinical note about a patient with the following chief complaint: Chronic otitis media. | CHIEF COMPLAINT: Chronic otitis media. HISTORY OF PRESENT ILLNESS: This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perf... | |
Write a clinical note about a patient with the following chief complaint: Lump in the chest wall. | CHIEF COMPLAINT: Lump in the chest wall. HISTORY OF PRESENT ILLNESS: This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. It is tender on palpation and also he feels like, when he takes ... | |
Write a clinical note about a patient with the following chief complaint: Palpitations. CHEST PAIN / | CHIEF COMPLAINT: Palpitations. CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY: The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyo... | |
Write a clinical note about a patient with the following chief complaint: Buttock abscess. | CHIEF COMPLAINT: Buttock abscess. HISTORY OF PRESENT ILLNESS: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patie... | |
Write a clinical note about a patient with the following chief complaint: Burn, right arm. | CHIEF COMPLAINT: Burn, right arm. HISTORY OF PRESENT ILLNESS: This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with h... | |
Write a clinical note about a patient with the following chief complaint: Blood in urine. | CHIEF COMPLAINT: Blood in urine. HISTORY OF PRESENT ILLNESS: This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted... | |
Write a clinical note about a patient with the following chief complaint: Recurrent bladder tumor. | CHIEF COMPLAINT: Recurrent bladder tumor. HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient unde... | |
Write a clinical note about a patient with the following chief complaint: Blood in toilet. | CHIEF COMPLAINT: Blood in toilet. HISTORY: Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acut... | |
Write a clinical note about a patient with the following chief complaint: Bladder cancer. | CHIEF COMPLAINT: Bladder cancer. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. CT scan was performed, which demonstrated no hydronephrosis o... | |
Write a clinical note about a patient with the following chief complaint: The patient comes for bladder instillation for chronic interstitial cystitis. | CHIEF COMPLAINT: The patient comes for bladder instillation for chronic interstitial cystitis. SUBJECTIVE: The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not think ... | |
Write a clinical note about a patient with the following identifying data: The patient is a 35-year-old Caucasian female who speaks English. | IDENTIFYING DATA: The patient is a 35-year-old Caucasian female who speaks English. CHIEF COMPLAINT: The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. Last night, she tried to turn on the garb... | |
Write a clinical note about a patient with the following identifying data: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approxima... | IDENTIFYING DATA: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he... | |
Write a clinical note about a patient with the following chief complaint: Possible exposure to ant bait. | CHIEF COMPLAINT: Possible exposure to ant bait. HISTORY OF PRESENT ILLNESS: This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure ... | |
Write a clinical note about a patient with the following identification: The patient is a 15-year-old female. | IDENTIFICATION: The patient is a 15-year-old female. CHIEF COMPLAINT: Right ankle pain. HISTORY OF PRESENT ILLNESS: The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician ... | |
Write a clinical note about a patient with the following chief complaint: Right ankle sprain. | CHIEF COMPLAINT: Right ankle sprain. HISTORY OF PRESENT ILLNESS: This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other ... | |
Write a clinical note about a patient with the following diagnosis: Refractory anemia that is transfusion dependent. | DIAGNOSIS: Refractory anemia that is transfusion dependent. CHIEF COMPLAINT: I needed a blood transfusion. HISTORY: The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, strok... | |
Write a clinical note about a patient with the following chief complaint: Nausea. | CHIEF COMPLAINT: Nausea. PRESENT ILLNESS: The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped aro... | |
Write a clinical note about a patient with the following chief complaint: Chest pain. | CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old white male who presents with a chief complaint of "chest pain". The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has be... | |
Write a clinical note about a patient with the following chief complaint: A 5-month-old boy with cough. | CHIEF COMPLAINT: A 5-month-old boy with cough. HISTORY OF PRESENT ILLNESS: A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he... | |
Write a clinical note about a patient with the following chief complaint: Neck pain, thoracalgia, low back pain, bilateral lower extremity pain. | CHIEF COMPLAINT: Neck pain, thoracalgia, low back pain, bilateral lower extremity pain. HISTORY OF PRESENT ILLNESS: Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse. She has previou... | |
Write a clinical note about a patient with the following chief complaint: Left foot pain. | CHIEF COMPLAINT: Left foot pain. HISTORY: XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to contin... | |
Write a clinical note about a patient with the following chief complaint: Abdominal pain. | CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluat... | |
Write a clinical note about a patient with the following chief complaint: Left wrist pain. | CHIEF COMPLAINT: Left wrist pain. HISTORY OF PRESENT PROBLEM: | |
Write a clinical note about a patient with the following chief complaint: Aching and mid back pain. | DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is... | |
Write a clinical note about a patient with the following chief complaint: "Trouble breathing.", | CHIEF COMPLAINT: "Trouble breathing.",HISTORY OF PRESENT ILLNESS: A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smok... | |
Write a clinical note about a patient with the following chief complaint: Hip pain. | CHIEF COMPLAINT: Hip pain. HISTORY OF PRESENTING ILLNESS: The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management... | |
Write a clinical note about a patient with the following history of present illness: Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of lo... | CHIEF COMPLAINT: Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the ... | |
Write a clinical note about a patient with the following history of present illness: Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement... | CHIEF COMPLAINT: Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter. HISTORY OF PRESENT ILLNESS: The patient was... | |
Write a clinical note about a patient with the following chief complaint: The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath. | CHIEF COMPLAINT: The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multipl... | |
Write a clinical note about a patient with the following chief complaint: The patient complains of chest pain. , | CHIEF COMPLAINT: The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; howev... | |
Write a clinical note about a patient with the following chief complaint: Palpitations. CHEST PAIN / | CHIEF COMPLAINT: Palpitations. CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY: The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyo... | |
Write a clinical note about a patient with the following chief complaint: Increased work of breathing. | CHIEF COMPLAINT: Increased work of breathing. HISTORY OF PRESENT ILLNESS: The patient is a 2-month-old female with a 9-day history of illness. Per mom's report, the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night, whi... | |
Write a clinical note about a patient with the following chief complaint: Chest pain. | CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old white male who presents with a chief complaint of "chest pain". The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has be... | |
Write a clinical note about a patient with the following history of present illness: This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, give... | CHIEF COMPLAINT: This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma,... |
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