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3,200 | This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills. | General Medicine | Viral Syndrome - ER Visit | SUBJECTIVE: ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT: Denies any severe headache or sore throat.,CHEST: No true p... | general medicine, sputum, short of breath, fever, chills, copd, emphysema, viral respiratory illness, green and grayish sputum, viral syndrome, respiratory rate, cough syrup, cough, antibiotics, inhaler, |
3,201 | Sore throat - Upper respiratory infection. | General Medicine | URI - SOAP | SUBJECTIVE:, Mom brings patient in today because of sore throat starting last night. Eyes have been very puffy. He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday. He has had low-grade fever and just felt very run down, appearing very tired. He is still eating and... | general medicine, soap, uri, upper respiratory infection, water's view, congestion, light reflex, sore throat, respiratory, strep, infection, |
3,202 | Patient with morbid obesity. | General Medicine | Weight Loss Evaluation | REASON FOR VISIT:, Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:, | general medicine, medifast, obesity, weight loss, morbid obesity, weight loss evaluation, weight |
3,203 | Patient with worsening shortness of breath and cough. | General Medicine | 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... | null |
3,204 | 3-Dimensional Simulation. This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. | Hematology - Oncology | 3-Dimensional Simulation | 3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. This optimizes the chance of controlling tumor while diminishing the acute and long-term side... | hematology - oncology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose onl... |
3,205 | History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days. | General Medicine | Trouble Breathing - H&P | CHIEF COMPLAINT: , "I have had trouble breathing for the past 3 days",HISTORY: , 69-year-old Caucasian male complaining of difficulty breathing for 3 days. He also states that he has been coughing accompanying with low-grade type fever. He also admits to having intermittent headaches and bilateral chest pain that doe... | null |
3,206 | Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days.. | General Medicine | Toothache - ER Visit | CHIEF COMPLAINT:, Toothache.,HISTORY OF PRESENT ILLNESS: ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left s... | general medicine, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental, |
3,207 | A 54-year-old patient, here for evaluation of new-onset swelling of the tongue. | General Medicine | Tongue Swelling | REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1. Diabetes type II.,2. High blood pressure.,3. High cholesterol.,4. Acid reflux disease.,5. Chronic back pain.,PAST SURGICAL HISTORY:,1. Lap-Band done today.,2. Right foot surgery.,MEDIC... | null |
3,208 | Patient with immune thrombocytopenia | General Medicine | Thrombocytopenia - SOAP Note | SUBJECTIVE: , I am following the patient today for immune thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day. Repeat on 01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I have spoken with her hematolo... | general medicine, platelets, platelet count, thrombocytopenia, prednisone, |
3,209 | Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure. | General Medicine | Sleepiness - Consult | CHIEF COMPLAINT: , Severe back pain and sleepiness.,The patient is not a good historian and history was obtained from the patient's husband at bedside.,HISTORY OF PRESENT ILLNESS: ,The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinen... | null |
3,210 | Sepsis. The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. | General Medicine | Sepsis - Consult | REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet ... | null |
3,211 | The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. | General Medicine | Shortness Of Breath - Progress Note | She was evaluated this a.m. and was without any significant clinical change. Her white count has been improving and down to 12,000. A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change. There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has b... | general medicine, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcri... |
3,212 | Chronic snoring in children | General Medicine | Snoring | CHRONIC SNORING,Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome. Both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardi... | general medicine, snoring, chronic snoring, behavior difficulty, fatigue, hyperactivity, obstructive sleep apnea, oxygen, oxygen desaturation, polysomnogram, poor sleep quality, right ventricular hypertrophy, school performance, sleep fragmentation, somnolence, systemic hypertension, upper airway, upper airway resistan... |
3,213 | He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. | General Medicine | SOAP - Substance Abuse | SUBJECTIVE: , This patient presents to the office today with his mom for checkup. He used to live in the city. He used to go to college down in the city. He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. He has a history of doing heroin... | general medicine, addicted to drugs, substance abuse, abuse, heroin, methadone |
3,214 | Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction. | General Medicine | Sleep Apnea | REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to ... | general medicine, daytime stamina, fiberoptic ent exam, moderate to severe, smart card, sleep apnea, cpap, apnea, sleep, |
3,215 | Right hand laceration x3, repaired. | General Medicine | Right Hand Laceration | HISTORY: , The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation. He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand. He has three lacerations on his right hand. His wound w... | general medicine, accutane, hand laceration, laceration, hand, |
3,216 | Consultation for evaluation of thrombocytopenia. | General Medicine | Thrombocytopenia - Consult | REASON FOR CONSULTATION:, Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:, Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks. She has been referred for the further evaluation of her thrombocytopenia. This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006. He... | null |
3,217 | Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial. | General Medicine | Sleep Study Followup | REASON FOR VISIT:, This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,HISTORY OF PRESENT ILLNESS: , The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion. At that time, she was evaluated and found to ... | null |
3,218 | Request for consultation to evaluate stomatitis, possibly methotrexate related. | General Medicine | Request For Consultation | REASON FOR CONSULTATION:, Please evaluate stomatitis, possibly methotrexate related.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days. The patient has a long his... | general medicine, stomatitis, nsaid, blistering, blisters, buccal mucosa, dermatitis, erosive stomatitis, gastrointestinal, methotrexate, mouth, rheumatoid arthritis, stomatitis conditions, superficial erosions, upper respiratory infection, illness, medication |
3,219 | A 40-year-old male seen today for a 90-day revocation admission. Noncompliant with medications, refusing oral or IM medications, became agitated. History of hyperlipidemia with elevated triglycerides. | General Medicine | Revocation Admission | IDENTIFYING DATA:, This is a 40-year-old male seen today for a 90-day revocation admission. He had been reported by his case manager as being noncompliant with medications, refusing oral or IM medications, became agitated, had to be taken to ABCD for evaluation, admitted at that time to auditory hallucinations and co... | null |
3,220 | Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used. | General Medicine | Recurrent Abscesses - Consult | REASON FOR CONSULTATION: , Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.,HISTORY OF PRESENT ILLNESS:, A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas. She would usually have pustular type of lesion tha... | null |
3,221 | Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency. | General Medicine | Renal Insufficiency - Consult | REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of... | null |
3,222 | Symptomatic thyroid goiter. Total thyroidectomy. | General Medicine | Post Thyroidectomy - Discharge Summary | ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS: ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY: ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. ... | general medicine, nodular, symptomatic thyroid goiter, thyroidectomy, goiter, |
3,223 | Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. | General Medicine | Pneumoconiosis | HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. The patient also has a positive history of smoking in the past. At the present time, he is admitted for continued,manag... | null |
3,224 | Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression. | General Medicine | Refractory Hypertension - Followup | PROBLEM LIST:,1. Refractory hypertension, much improved.,2. History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3. History of GI bleed in 1995.,4. History of depression.,HISTORY OF PRESENT ILLNESS:, This is a return visit to the renal clinic for this patient. She is an 85-year-old woman ... | general medicine, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia |
3,225 | Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. | General Medicine | Perioperative Elevated Blood Pressure | REASON FOR CONSULTATION:, Perioperative elevated blood pressure.,PAST MEDICAL HISTORY:,1. Graves disease.,2. Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.,3. Diverticulosis.,4. GERD.,5. High blood pressure.,6. Prostatic hypertrophy, status post transurethral ... | null |
3,226 | Pressure decubitus, right hip | General Medicine | Pressure decubitus | CHIEF COMPLAINT:, Pressure decubitus, right hip.,HISTORY OF PRESENT ILLNESS:, This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spendin... | general medicine, pressure decubitus, acticoat, sequelae, breast reduction, decubitus, hysterectomy, ischial area, pressure, spina bifida, trochanter, wheelchair, bifida, |
3,227 | Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. | General Medicine | Pneumonia - Discharge Summary | ADMISSION DIAGNOSES:,1. Pneumonia, failed outpatient treatment.,2. Hypoxia.,3. Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1. Atypical pneumonia, suspected viral.,2. Hypoxia.,3. Rheumatoid arthritis.,4. Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had s... | general medicine, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia, |
3,228 | Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year. | General Medicine | Pyelonephritis - Discharge Summary | ADMISSION DIAGNOSES:,1. Pyelonephritis.,2. History of uterine cancer and ileal conduit urinary diversion.,3. Hypertension.,4. Renal insufficiency.,5. Anemia.,DISCHARGE DIAGNOSES:,1. Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2. Hypertension.,3. Mild renal insuff... | general medicine, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit |
3,229 | Patient in emergency room due to high potassium value. | General Medicine | Patient with High Potassium | CHIEF COMPLAINT:, "My potassium is high",HISTORY OF PRESENT ILLNESS:, A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs d... | general medicine, potassium is high, chest x-ray, chest ct scan, abdominal ct scan, testicular ultrasound, lymph node, ct scan, blood pressure, abdominal, multiple, subcarinal, epididymis, potassium, lymphadenopathy, |
3,230 | Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study. | General Medicine | Obesity Hypoventilation Syndrome | HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. ... | general medicine, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity, |
3,231 | A 47-year-old white female presents with concern about possible spider bite to the left side of her neck. | General Medicine | Possible Spider Bite | SUBJECTIVE:, This 47-year-old white female presents with concern about possible spider bite to the left side of her neck. She is not aware of any specific injury. She noticed a little tenderness and redness on her left posterior shoulder about two days ago. It seems to be getting a little bit larger in size, and sh... | general medicine, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite, |
3,232 | This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. | General Medicine | Pain from Hernia - ER Consult | HISTORY OF PRESENT ILLNESS: ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. At the time of my exam, he states that his left lower extremity pain has impro... | general medicine, blood in stool, nausea, capillary refill, angiogram, hernia, extremity, |
3,233 | A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern. | General Medicine | Not Feeling Well - ER Visit | CHIEF COMPLAINT: ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:, This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well. The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generaliz... | null |
3,234 | Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies. | General Medicine | Normal ROS Template - 5 | REVIEW OF SYSTEMS,GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: Negative rash, negative jaundice.,HEMATOPOIETIC: Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: Negative ... | general medicine, respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness |
3,235 | Negative for any nausea, vomiting, fevers, chills, or weight loss. | General Medicine | Normal ROS Template - 4 | GENERAL: Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC: Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT: Negative for any head trauma, neck trauma, neck stiffness, photophobi... | general medicine, review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting, |
3,236 | Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill. | General Medicine | Normal Physical Exam Template - 6 | VITAL SIGNS:, Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are... | general medicine, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds, |
3,237 | Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter. | General Medicine | Normal ROS Template - 3 | HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm... | general medicine, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling, |
3,238 | Most commonly used phrases in physical exam. | General Medicine | Normal Physical Exam Template - 7 | EYES: , The conjunctivae are clear. The lids are normal appearing without evidence of chalazion or hordeolum. The pupils are round and reactive. The irides are without any obvious lesions noted. Funduscopic examination shows sharp disk margins. There are no exudates or hemorrhages noted. The vessels are normal ap... | general medicine, ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination, |
3,239 | Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss. | General Medicine | Normal ROS Template | REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:, Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and den... | general medicine, cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss, |
3,240 | Normal physical exam template. Normocephalic. Negative lesions, negative masses. | General Medicine | Normal Physical Exam Template - 4 | GENERAL: ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.,HEAD: , Normocephalic. Negative lesions, negative masses.,EYES: , PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.,ENT:, Negative nasal hemorrhages, negative nasal obstructi... | |
3,241 | Normal physical exam template. Well developed, well nourished, in no acute distress. | General Medicine | Normal Physical Exam Template - 3 | PHYSICAL EXAMINATION,GENERAL APPEARANCE: , Well developed, well nourished, in no acute distress.,VITAL SIGNS:, ***,SKIN: ,Inspection of the skin reveals no rashes, ulcerations or petechiae.,HEENT:, The sclerae were anicteric and conjunctivae were pink and moist. Extraocular movements were intact and pupils were equ... | |
3,242 | There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. | General Medicine | Normal ROS Template - 1 | REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion. The... | general medicine, weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neckNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for refe... |
3,243 | Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies. | General Medicine | Normal ROS Template - 2 | GENERAL:, Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, neg... | general medicine, nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness, |
3,244 | Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress. | General Medicine | Normal Newborn Infant Physical Exam | GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS: ,Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.,HEENT: ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterall... | general medicine, fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant, |
3,245 | An example normal physical exam | General Medicine | Normal Physical Exam Template - 1 | GENERAL: , Vital signs and temperature as documented in nursing notes. The patient appears stated age and is adequately developed.,EYES:, Pupils are equal, round, reactive to light and accommodation. Lids and conjunctivae reveal no gross abnormality.,ENT: ,Hearing appears adequate. No obvious asymmetry or deformit... | general medicine, vital signs, equal, round, reactive, normal physical exam, physical exam, |
3,246 | An example of a physical exam | General Medicine | Normal Physical Exam Template | GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age. Oriented to time, place and person. No recent loss of memory. Affect appropriate for age.,EYES: ,Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact.,EAR, N... | general medicine, mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam, |
3,247 | Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress. | General Medicine | Normal Physical Exam Template - 5 | GENERAL: , Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetric... | general medicine, respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical, |
3,248 | Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact. | General Medicine | Normal Physical Exam Template - 2 | GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit. Height is ?? feet ?? inches. Weight is ?? pounds. This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:, The... | null |
3,249 | Template for History and Physical for a newborn. | General Medicine | Normal Newborn H&P Template | HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **. Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. The baby was vertex presentation. T... | null |
3,250 | An example/template for a routine normal male physical exam. | General Medicine | Normal Male Exam Template - 3 | PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted. ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae ... | null |
3,251 | An example/template for a routine normal male ROS. | General Medicine | Normal Male ROS Template - 1 | REVIEW OF SYSTEMS:,CONSTITUTIONAL: Patient denies fevers, chills, sweats and weight changes.,EYES: Patient denies any visual symptoms.,EARS, NOSE, AND THROAT: No difficulties with hearing. No symptoms of rhinitis or sore throat.,CARDIOVASCULAR: Patient denies chest pains, palpitations, orthopnea and paroxysmal noc... | general medicine, review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary |
3,252 | An example/template for a routine normal male physical exam. | General Medicine | Normal Male Exam Template - 1 | MALE PHYSICAL EXAMINATION,HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally. Oropharynx is clear without erythema or exudate.,NECK: Supple without lymphadenopathy or thyromegaly. Carotids are silent. There is no... | general medicine, male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx |
3,253 | An example/template for a routine normal male physical exam. | General Medicine | Normal Male Exam Template - 2 | MALE PHYSICAL EXAMINATION,Eye: Eyelids normal color, no edema. Conjunctivae with no erythema, foreign body, or lacerations. Sclerae normal white color, no jaundice. Cornea clear without lesions. Pupils equally responsive to light. Iris normal color, no lesions. Anterior chamber clear. Lacrimal ducts normal. Fu... | general medicine, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape, |
3,254 | An example/template for a routine normal male physical exam. | General Medicine | Normal Male Exam Template - 4 | VITAL SIGNS:, Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:, Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. No p... | general medicine, digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue, |
3,255 | Sample/template for a normal male multisystem exam. | General Medicine | Normal Male Exam Template | MULTISYSTEM EXAM,CONSTITUTIONAL: ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.,EYES: ,The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.,EARS, NOSE AND THROAT: ... | general medicine, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue, |
3,256 | Normal child physical exam template. | General Medicine | Normal Child Exam Template | CHILD PHYSICAL EXAMINATION,VITAL SIGNS: Birth weight is ** grams, length **, occipitofrontal circumference **. Character of cry was lusty.,GENERAL APPEARANCE: Well.,BREATHING: Unlabored.,SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample.,HEAD: Normal. Fontanelles are soft and flat. Su... | general medicine, child physical examination, physical, genitalia, child, |
3,257 | Sample/template for a normal female multisystem exam | General Medicine | Normal Female Exam Template | MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.,EYES: , The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.,EARS, NOSE AND THROAT: ,... | |
3,258 | Sample normal ear, nose, mouth, and throat exam. | General Medicine | Normal ENT Exam - 1 | EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympani... | general medicine, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling, |
3,259 | She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission. | General Medicine | Nausea & Vomiting - ER Visit | HISTORY OF PRESENT ILLNESS: , She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,PAST MEDICAL HISTORY:... | general medicine, iv hydration, elevated alt, emergency, nausea, vomiting, |
3,260 | An example/template for a routine normal female physical exam. | General Medicine | Normal Female Exam Template - 1 | PHYSICAL EXAMINATION,GENERAL: ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae a... | null |
3,261 | Normal female review of systems template. Negative for fever, weight change, fatigue, or aching. | General Medicine | Normal Female ROS Template | CONSTITUTIONAL:, Normal; negative for fever, weight change, fatigue, or aching.,HEENT:, Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects. Ears normal; Negative for hearing or balance problems. Nose normal; Negative for runny nose, sinus problems, or nosebleeds... | general medicine, cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint, |
3,262 | Sample normal ear, nose, mouth, and throat exam. | General Medicine | Normal ENT Exam | EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks an... | general medicine, erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sam... |
3,263 | An example/template for a routine normal female physical exam. | General Medicine | Normal Female Exam Template - 2 | VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:, Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions of lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. E... | general medicine, heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue, |
3,264 | MRI Brain, Carbon Monoxide poisoning. | General Medicine | MRI Brain - CO poisoning | CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next rememb... | null |
3,265 | Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia,
and congestive heart failure. | General Medicine | Multiple Medical Problems - Discharge Summary | ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Co... | null |
3,266 | Multiple contusions and abdominal pain, status post motor vehicle collision. | General Medicine | Motor Vehicle Accident | CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance. The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago. The patient states that she was driving he... | null |
3,267 | Nausea and feeling faint. She complains of some nausea. She feels weak. The patient is advised to put salt on her food for the next week. | General Medicine | Nausea - ER Visit | CHIEF COMPLAINT: , Nausea and feeling faint.,HPI: ,The patient is a 74-year-old white female brought in by husband. The patient is a vague historian at times. She reports her appetite has been fair over the last several days. Today, she complains of some nausea. She feels weak. No other specific complaints.,REVIE... | null |
3,268 | Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture. | General Medicine | Jaw Pain - ER Visit | CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS: ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointmen... | general medicine, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema, |
3,269 | Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive ... | General Medicine | Melena - ICU Followup | HISTORY:, Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic ob... | general medicine, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding |
3,270 | A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. | General Medicine | Infantile Spasms | CHIEF COMPLAINT:, Arm and leg jerking.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These mo... | null |
3,271 | Local reaction secondary to insect sting. Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today. | General Medicine | Insect Sting | HISTORY OF PRESENT ILLNESS:, Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness and swelling to his le... | general medicine, stung by a bee, local reaction, insect sting, reaction, insect, bee, knee, edema, sting, swelling, hand |
3,272 | Pancreatic and left adrenal lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. | General Medicine | Lesions - Adrenal and Pancreatic | CHIEF COMPLAINT: , Both pancreatic and left adrenal lesions.,HISTORY OF PRESENT ILLNESS:, This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland. The patient's history dates back to at the end of the Jan... | null |
3,273 | Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management | General Medicine | Medical Management Consult Request | CONSULT REQUEST FOR:, Medical management.,The patient has been in special procedures now for over 2 hours and I am unable to examine.,HISTORY OF PRESENT ILLNESS:, Obtained from Dr. A on an 81-year-old white female, who is right handed, who by history, had a large stroke to the right brain, causing left body findings, l... | null |
3,274 | This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. | General Medicine | Itchy Rash - ER Visit | CHIEF COMPLAINT:, Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breat... | general medicine, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash, |
3,275 | Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter. | General Medicine | Lymphoblastic Leukemia - Consult | 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 w... | null |
3,276 | Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease. | General Medicine | Hypothermia - Discharge Summary | DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE:... | general medicine, sepsis, organic brain syndrome, seizure disorder, anemia of chronic disease, adrenal insufficiency, blood, cultures |
3,277 | Sample male exam and review of systems. | General Medicine | Male Exam & ROS | GENERAL REVIEW OF SYSTEMS,General: No fevers, chills, or sweats. No weight loss or weight gain.,Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.,Neurologic: No paresis, paresthesias, or syncope.,Eyes: No double vision or blurred vision.,Ears: No tinnitus or decreased aud... | general medicine, male exam, cardiovascular, ent, ears, endocrine, extremities, genitalia, hemoccult, musculoskeletal, pulmonary, auditory acuity, blurred vision, heart rate, nocturia, pedal edema, percussion, polydipsia, rectal mass, regular rhythm, respiratory rate, review of systems, swollen lymph nodes, tinnitus, i... |
3,278 | Chief complaint of chest pain, previously diagnosed with hyperthyroidism. | General Medicine | Hyperthyroidism Following Pregnancy | HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain. She had been previously diagnosed with hyperthyroidism. Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm. She had been experiencing palpitations and tachycardia. She ... | general medicine, hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy, |
3,279 | Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology. | General Medicine | HIV Followup | HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old white male with a history of HIV disease. His last CD4 count was 425, viral load was less than 50 in 08/07. He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus. He also has a history ... | general medicine, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension, |
3,280 | Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C. | General Medicine | Hypertension & Cardiomyopathy | PROBLEMS LIST:,1. Nonischemic cardiomyopathy.,2. Branch vessel coronary artery disease.,3. Congestive heart failure, NYHA Class III.,4. History of nonsustained ventricular tachycardia.,5. Hypertension.,6. Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharge... | general medicine, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea, |
3,281 | Probable Coumadin hypersensitivity. | General Medicine | Hypersensitivity to Coumadin | PROBLEM:, Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty. At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postopera... | null |
3,282 | Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds. | General Medicine | HIV Followup - 1 | PROBLEM LIST:,1. HIV stable.,2. Hepatitis C chronic.,3. History of depression, stable off meds.,4. Hypertension, moderately controlled.,CHIEF COMPLAINT: , The patient comes for a routine followup appointment.,HISTORY OF PRESENTING ILLNESS: , This is a 34-year-old African American female who comes today for routine ... | null |
3,283 | Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. | General Medicine | Hypergranulation - Consult | CHIEF COMPLAINT:, Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted... | null |
3,284 | The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. | General Medicine | Hydrocarbon Aspiration - ER Visit | SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration. The patient ingested "tiki oil" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. He subsequently developed progressive symptoms of d... | null |
3,285 | An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation. | General Medicine | Hypertension - Consult | HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her beca... | general medicine, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, |
3,286 | The patient with continued problems with her headaches. | General Medicine | Headache - Office Visit | She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred ... | general medicine, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran |
3,287 | History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis. | General Medicine | H&P - Gen Med - 2 | HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency ... | null |
3,288 | Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse. | General Medicine | Gen Med SOAP - 9 | SUBJECTIVE: ,This patient presents to the office today for a checkup. He has several things to go over and discuss. First he is sick. He has been sick for a month intermittently, but over the last couple of weeks it is worse. He is having a lot of yellow phlegm when he coughs. It feels likes it is in his chest. ... | general medicine, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart, |
3,289 | Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm. | General Medicine | Headache - Emergency Visit | CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:, This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours... | null |
3,290 | An 85-year-old female with diarrhea, vomiting, and abdominal pain. | General Medicine | H&P - Gen Med - 1 | CHIEF COMPLAINT:, Diarrhea, vomiting, and abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS... | null |
3,291 | Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2 | General Medicine | H&P - Weakness | CHIEF COMPLAINT:, Right-sided weakness.,HISTORY OF PRESENT ILLNESS:, The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including l... | null |
3,292 | Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. | General Medicine | H&P - Nausea & Vomiting | CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revea... | null |
3,293 | Migraine headache - The patient was seen in the urgent care. | General Medicine | Headache - Urgent Care Visit | CC: , Headache.,HPI: , This is a 15-year-old girl presenting with occipital headache for the last six hours. She denies trauma. She has been intermittently nauseated but has not vomited and has some photophobia. Denies fever or change in vision. She has no past history of headaches. ,PMH: , None. ,MEDICATIONS: ,T... | general medicine, photophobia, nausea, migraine headache, tylenol, migraine, headache, |
3,294 | One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well. | General Medicine | Gen Med SOAP - 7 | CHIEF COMPLAINT:, One-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I thin... | null |
3,295 | General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder, | General Medicine | Gen Med SOAP - 5 | S:, The patient is here today with his mom for several complaints. Number one, he has been having issues with his right shoulder. Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. He has been having issues ever since. He is having difficulties raising his a... | general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent |
3,296 | Patient today with multiple issues. | General Medicine | Gen Med SOAP - 8 | SUBJECTIVE: , I am following the patient today for multiple issues. He once again developed gross hematuria, which was unprovoked. His Coumadin has been held. The patient has known BPH and is on Flomax. He is being treated with Coumadin because of atrial fibrillation and stroke. This is the second time he has had ... | general medicine, multiple issues, atrial fibrillation, gross hematuria, multiple, bph, fibrillation, hematuria, |
3,297 | Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain | General Medicine | Gen Med SOAP - 6 | SUBJECTIVE:, The patient is in with several medical problems. He complains his mouth being sore since last week and also some "trouble with my eyes." He states that they feel "funny" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eatin... | general medicine, clostridium difficile enteritis, coronary artery disease, urinary retention, yeast thrush, cough, neck pain, several medical problems, shoulder pain, range of motion, soap, metronidazole, shoulder, neck, |
3,298 | General Medicine SOAP note. | General Medicine | Gen Med SOAP - 3 | S:, XYZ is in today not feeling well for the last three days. She is a bit sick with bodyaches. She is coughing. She has a sore throat, especially when she coughs. Her cough is productive of green colored sputum. She has had some chills. No vomiting. No diarrhea. She is sleeping okay. She does not feel like s... | general medicine, bodyaches, alert and oriented, no acute distress, soap, diarrhea, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented, |
3,299 | General Medicine SOAP note. | General Medicine | Gen Med SOAP - 4 | S:, ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy. She is very adamant that... | general medicine, soap, alert and oriented, no acute distress, no cyanosis, atrial fibrillation, blood draw, dizziness, irregularly irregular, lightheadedness, no clubbing, no edema, shortness of breath, soft and nontender, vertigo, heart, fibrillation, coumadin, atrial, |
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