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4,100 | Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. | Consult - History and Phy. | Ureteral Calculus - Consult | CHIEF COMPLAINT: , Right distal ureteral calculus.,HISTORY OF PRESENT ILLNESS: ,The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower urete... | null |
4,101 | The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness. | Consult - History and Phy. | Vertigo Consult - 1 | Patient had a normal MRI and normal neurological examination on August 24, 2010.,Assessment for peripheral vestibular function follows:,Most clinical tests were completed with difficulty and poor cooperation.,OTOSCOPY:, showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.,RO... | consult - history and phy., tinnitus, deafness, imbalance, nystagmus, hypofunction, electronystagmography, vertigo, vestibular, |
4,102 | History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days. | Consult - History and Phy. | 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 |
4,103 | Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. | Consult - History and Phy. | URI & Eustachian Congestion | HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting o... | consult - history and phy., upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar |
4,104 | Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis. | Consult - History and Phy. | Thyroid Mass Consult | REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS: ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now b... | null |
4,105 | Patient referred for evaluation of tracheostomy tube placement and treatment recommendations. | Consult - History and Phy. | Tracheostomy Tube Consult | HISTORY: ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations. As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement abo... | null |
4,106 | Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale. | Consult - History and Phy. | TIA & Lumbar Stenosis | CHIEF COMPLAINT: , Transient visual loss lasting five minutes.,HISTORY OF PRESENT ILLNESS: , This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible... | null |
4,107 | Consultation for evaluation of thrombocytopenia. | Consult - History and Phy. | 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 |
4,108 | A 54-year-old patient, here for evaluation of new-onset swelling of the tongue. | Consult - History and Phy. | 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 |
4,109 | 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.. | Consult - History and Phy. | 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... | consult - history and phy., odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental, |
4,110 | Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. | Consult - History and Phy. | Tethered Cord Evaluation | REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:, Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 0... | consult - history and phy., tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele, |
4,111 | A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours. | Consult - History and Phy. | TIA - Cosult | REASON FOR CONSULTATION: , This 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours. However, the chart indicates that she had recurrent TIAs x3 yesterday, each lasting about 5 minutes with facial drooping and some mental confusion. Sh... | consult - history and phy., atrial fibrillation, carotid bruit, slurred speech, numbness, calcified mass lesion, neurological examination, tias, carotid, benign, |
4,112 | Itchy red rash on feet - Tinea Pedis | Consult - History and Phy. | Tinea Pedis - H&P | CHIEF COMPLAINT (1/1): ,This 24 year-old female presents today complaining of itchy, red rash on feet. Associated signs and symptoms: Associated signs and symptoms include tingling, right. Context: Patient denies any previous history, related trauma or previous treatments for this condition. Duration: Condition ... | null |
4,113 | Newly diagnosed T-cell lymphoma. The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. | Consult - History and Phy. | T-Cell Lymphoma Consult | CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess... | consult - history and phy., t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck, |
4,114 | Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis. | Consult - History and Phy. | Therapeutic Recreation Initial Evaluation | HISTORY:, Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,Patient is currently living in ABC with his son as this was closer his to his job. At discharge, he will live with his spouse in a new job. The home is single level with no steps.,Prior to admission, his wife reports that ... | consult - history and phy., endurance, ball activities, therapeutic recreation, hemiparesis, tolerance, recreation, restorator, leisure, therapeutic, |
4,115 | The patient had a syncopal episode last night. She did not have any residual deficit. She had a headache at that time. She denies chest pains or palpitations. | Consult - History and Phy. | Syncope - ER Visit - 1 | REASON FOR VISIT:, Syncope.,HISTORY:, The patient is a 75-year-old lady who had a syncopal episode last night. She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor. She did not have any residual deficit. She had a headache at that ... | consult - history and phy., residual deficit, headache, ct scan, syncopal episode, stress test, blood pressure, syncope, |
4,116 | A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. | Consult - History and Phy. | Status Epilepticus | CHIEF COMPLAINT:, Status epilepticus.,HISTORY OF PRESENT ILLNESS: ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. At baseline, he can put about 2 to 4 words... | null |
4,117 | Sports physical with normal growth and development. | Consult - History and Phy. | Sports Physical - 1 | HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:, She takes meats, vegetables, and fruits. Eats well. Has may be 1 to 2 cups a day of milk. Her calcium intake could be better. She does not drink that much pop but she likes koolaid. Her stools are normal. Brushes her teeth. Sees a dentis... | |
4,118 | Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode. | Consult - History and Phy. | Syncope - ER Visit | REASON FOR CONSULTATION:, Syncope.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode. According to the patient and t... | null |
4,119 | The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis. | Consult - History and Phy. | Supraventricular Tachycardia - Consult | HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis. The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised. Parents; however, did note the patient to be quite dusky since the time of her birth; however, ... | consult - history and phy., congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary, |
4,120 | The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy. She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy. She is now referred to the thoracic surgery clinic for evaluation. | Consult - History and Phy. | Supraclavicular Lymphadenopathy | On review of systems, the patient admits to hypertension and occasional heartburn. She undergoes mammograms every six months, which have been negative for malignancy. She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, ano... | null |
4,121 | Consult and Spinal fluid evaluation in a 15-day-old | Consult - History and Phy. | Spinal fluid evaluation | HISTORY: ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation. Information is obtained in discussion with the mother and the grandmother in review of previous medical records. This patient had the onset on the day of presentation of a jelly... | null |
4,122 | Status post brain tumor with removal. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. | Consult - History and Phy. | Speech Therapy Evaluation - 1 | DIAGNOSIS: , Status post brain tumor with removal.,SUBJECTIVE: ,The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy. The patient stated that on 10/24/08 she had a brain tumor removed with subseque... | consult - history and phy., linguistic skills, memory, mental flexibility, deductive reasoning, skilled speech therapy, speech therapy, cognitive linguistic, therapy, linguistic, speech, cognitive, |
4,123 | Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally. | Consult - History and Phy. | Sports Physical - 3 | SUBJECTIVE:, This is a 12-year-old male who comes in for healthy checkups and sports physical. No major concerns today. He is little bit congested at times. He has been told he is allergic to grasses. They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports. He has... | null |
4,124 | Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain. | Consult - History and Phy. | Sinus problems - Consult | CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe.... | null |
4,125 | Global aphasia. The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. | Consult - History and Phy. | Speech Therapy Evaluation | MEDICAL DIAGNOSIS:, Strokes.,SPEECH AND LANGUAGE THERAPY DIAGNOSIS: ,Global aphasia.,SUBJECTIVE: ,The patient is a 44-year-old female who is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. The patient's sister-in-law was present throughout this asses... | consult - history and phy., speech automatic tasks, minimal cueing, sentence completion, western aphasia battery, skilled speech therapy, global aphasia, speech therapy, speech, aphasia, |
4,126 | Well-child check and school physical. | Consult - History and Phy. | School Physical - 2 | CHIEF COMPLAINT:, Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:, This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially ... | null |
4,127 | History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction. | Consult - History and Phy. | Small Bowel Obstruction | CHIEF COMPLAINT:, Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements. He has not eaten anythi... | null |
4,128 | 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. | Consult - History and Phy. | 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 |
4,129 | Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction | Consult - History and Phy. | Sick Sinus Syndrome | HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker. Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle. He also has a fairly advanced d... | null |
4,130 | 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. | Consult - History and Phy. | 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 |
4,131 | Consultation for right shoulder pain. | Consult - History and Phy. | Shoulder Pain Consult | CHIEF COMPLAINT:, Right shoulder pain.,HISTORY OF PRESENT PROBLEM: | consult - history and phy., shoulder pain, history of present problem:, cortisone shot, no numbness or tingling, rhomboids, scapula, shoulder impingement, focal findings, shoulder, |
4,132 | Well-child check sports physical - Well child asthma with good control, allergic rhinitis. | Consult - History and Phy. | Sports Physical - 2 | CHIEF COMPLAINT:, Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:, This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. He is here with his mother for a well-child check. Mother states he has been doing well with regard to his asthma and allergies. He is currently on immun... | null |
4,133 | This patient was seen in clinic for a school physical. | Consult - History and Phy. | School Physical - 1 | SUBJECTIVE:, This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:, She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited. She does not drink a whole lot of pop. Her stools are normal. Brushes her teeth, sees a dentist.,Developmental History: Hearing and visio... | consult - history and phy., school physical, calcium intake, hearing and vision, hepatitis a vaccine, booster, anticipatory guidance, developmental, percentile, physical, school, rash, |
4,134 | A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She is not on DMARD, but as she recently had a surgery followed by a probable infection. | Consult - History and Phy. | Rheumatoid Arthritis - Consult | HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She was followed by another rheumatologist. She says she has been off and on, on prednisone and Arava. The rheumatologist, as per the patient, would not want her to ... | consult - history and phy., prednisone, joint pains, rheumatoid arthritis, arthritis, dmard, rheumatologist, rheumatoid, pains, |
4,135 | Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids. | Consult - History and Phy. | Renal Failure Evaluation | REASON FOR CONSULTATION:, Renal failure evaluation for possible dialysis therapy.,HISTORY OF PRESENT ILLNESS:, This is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was... | null |
4,136 | Request for consultation to evaluate stomatitis, possibly methotrexate related. | Consult - History and Phy. | 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... | consult - history and phy., stomatitis, nsaid, blistering, blisters, buccal mucosa, dermatitis, erosive stomatitis, gastrointestinal, methotrexate, mouth, rheumatoid arthritis, stomatitis conditions, superficial erosions, upper respiratory infection, illness, medication |
4,137 | Patient presents for treatment of suspected rheumatoid arthritis. | Consult - History and Phy. | Rheumatoid Arthritis - H&P | CHIEF COMPLAINT:, This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has exi... | null |
4,138 | Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right. | Consult - History and Phy. | Rotator cuff syndrome - H&P | CHIEF COMPLAINT: ,This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. Patient relates pain on a scale from 0 to 10 as 5/10. Severity... | null |
4,139 | Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency. | Consult - History and Phy. | 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 |
4,140 | Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used. | Consult - History and Phy. | 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 |
4,141 | Acute renal failure, suspected, likely due to multi-organ system failure syndrome. | Consult - History and Phy. | Renal Failure - Consult | REASON FOR CONSULTATION:, Acute renal failure.,HISTORY: , Limited data is available; I have reviewed his admission notes. Apparently this man was found down by a family member, was taken to Medical Center, and subsequently flown here. He has got respiratory failure, multi-organ system failure syndrome, and has renal in... | null |
4,142 | 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. | Consult - History and Phy. | 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 |
4,143 | Patient with suspected nasal obstruction, possible sleep apnea. | Consult - History and Phy. | Recurrent nasal obstruction | CHIEF COMPLAINT: , Recurrent nasal obstruction.,HISTORY OF PRESENT ILLNESS:, The patient is a 5-year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea. Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even se... | consult - history and phy., recurrent nasal obstruction, allergic rhinitis, apneic events, sleep apnea, nasal obstruction, nasal, apnea, allergic, obstruction, sleep, |
4,144 | A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. | Consult - History and Phy. | Rectal Bleeding - Consult | REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. He has had some physic... | null |
4,145 | Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study. | Consult - History and Phy. | Pulmonary Consultation - 1 | 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 ... | null |
4,146 | A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago. | Consult - History and Phy. | Pubic Cellulitis | DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:, A 16-month-old with history of penile swelling for 4 days. The patient was transferred for higher level of care. This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent. Apparently, the patient developed adhe... | null |
4,147 | Patient with complaints of significant coughing and wheezing. | Consult - History and Phy. | Pulmonary Consultation - 2 | PAST MEDICAL HISTORY:, Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:, PENICILLIN.,CURRENT MEDICATIONS:, Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,The pat... | consult - history and phy., pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing, |
4,148 | Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger. | Consult - History and Phy. | Records Review - Epicondylitis | ALLOWED CONDITIONS:, Lateral epicondylitis, right elbow,EMPLOYER:, ABCD,REQUESTED ALLOWANCE:, Carpal tunnel syndrome right.,Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars. He does state he was employe... | null |
4,149 | This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. | Consult - History and Phy. | Pulmonary Edema - Consult | HISTORY: ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure. History dates back to about six months of intermittent shortness of breath, intermittent very slight e... | null |
4,150 | Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose. | Consult - History and Phy. | Records Review - Orthopedic | Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work harden... | null |
4,151 | Increasing oxygen requirement. Baby boy has significant pulmonary hypertension. | Consult - History and Phy. | Pulmonary Hypertension - Pediatric Consult | INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant. His mother had premature rupture of membranes on 12/20/08. She then presented to the Labor and Delivery with symptoms of flu. The baby was then induced and delivered. The mother had a history o... | consult - history and phy., high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary |
4,152 | She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. | Consult - History and Phy. | Psychiatric Consult - 2 | HISTORY OF PRESENT ILLNESS:, This is a 41-year-old registered nurse (R.N.). She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. She notes starting in January, her husband of five yea... | consult - history and phy., citalopram, depressive disorder, overdose, warfarin, restless legs syndrome, disorder, mood |
4,153 | Pediatric Gastroenterology - Rectal Bleeding Consult. | Consult - History and Phy. | Rectal Bleeding - 1-year-old | HISTORY OF PRESENT ILLNESS:, This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding. He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. He had one more episode that day of stool; the stool was ha... | null |
4,154 | Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. | Consult - History and Phy. | Pulmonary Embolism | REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:, The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life. The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest p... | null |
4,155 | Psychiatric History and Physical - Patient with schizoaffective disorder. | Consult - History and Phy. | Psych H&P - 2 | HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old single Caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and dyslipidemia who presents to the emergency room with the complaint of "manic" symptoms due to recent medication adjustments. Th... | null |
4,156 | Psychiatric History and Physical - Patient with major depression | Consult - History and Phy. | Psych H&P - 1 | HISTORY OF PRESENT ILLNESS: , This 40-year-old white single man was hospitalized at XYZ Hospital in the mental health ward, issues were filled up by his sister and his mother. The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and... | consult - history and phy., history of present illness:, global assessment of functioning, mental status examination, major depression, psychiatric, abuse, behavior, depression, mental health, mental health ward, psychiatric disability, sexually abused, substance abuse, health, |
4,157 | Bipolar disorder, apparently stable on medications. Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse. | Consult - History and Phy. | Psychiatric Consult - 1 | HISTORY OF PRESENT ILLNESS:, This is a 53-year-old widowed woman, she lives at ABC Hotel. She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis. She has been refusing cardiac catheter and she may well need aortic valve replacement. She states that she does not want heart surgery ... | consult - history and phy., organic brain syndrom, substance abuse, bipolar disorder, mental, abuse, |
4,158 | Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior. | Consult - History and Phy. | Psychiatric Consult | HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. Psychiatric consultation has been requested as the patient has been noncompliant with treatment,... | consult - history and phy., noncompliant, confusion, graft versus host reaction, psychiatric consultation, willful behavior, cannabis, |
4,159 | Psychiatric consultation for management of pain medications. | Consult - History and Phy. | Psych Consult - Pain Meds | REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden ch... | null |
4,160 | A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. | Consult - History and Phy. | Psych Consult - Paranoia | IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , "I am not sure." The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , T... | null |
4,161 | Psychiatric consultation for substance abuse. | Consult - History and Phy. | Psych Consult - Substance abuse | REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use. The patient says he had been sober from any illicit substance for 15 months prior to most rece... | null |
4,162 | Patient with a history of PTSD, depression, and substance abuse. | Consult - History and Phy. | Psych Consult - Psychosis | IDENTIFYING DATA:, Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker. Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior. She had lived with her parents and son, but parents removed son from ... | consult - history and phy., ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis, |
4,163 | The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home. | Consult - History and Phy. | Psych Consult - Psychosis - 1 | IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of uri... | null |
4,164 | A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months. | Consult - History and Phy. | Psych Consult - Schizophrenia | IDENTIFYING DATA:, The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner.,CHIEF COMPLAINT: , "I'm in jail because I was wrongly arrested." The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability.,HISTORY OF PRESENT ILLNESS: , The pat... | null |
4,165 | Psychiatric Consultation of patient with recurring depression. | Consult - History and Phy. | Psych Consult - Depression - 1 | CC: , "Five years ago, I stopped drinking and since that time, I have had severe depression. I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again. I started lithium three weeks ago.",HPI: ,The patient is a 45-year-old married white female without children currently ... | null |
4,166 | Psychiatric consultation of patient with lethargy. | Consult - History and Phy. | Psych Consult - Lethargy | REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:, The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depressi... | null |
4,167 | A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability. | Consult - History and Phy. | Psych Consult - Bipolar Affective Disorder | IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for tr... | null |
4,168 | Psychiatric Consultation of patient with major depression disorder. | Consult - History and Phy. | Psych Consult - Depression - 2 | REASON FOR CONSULT:, Depression.,HPI:, The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006. The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty. Soon after discharge, the patient was readm... | null |
4,169 | Psychiatric consultation for alcohol withdrawal and dependance. | Consult - History and Phy. | Psych Consult - Alcohol Withdrawal | REASON FOR CONSULT:, Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal. The patient had been on a drinking binge for t... | null |
4,170 | Psychiatric Consultation of patient with dementia. | Consult - History and Phy. | Psych Consult - Dementia | REASON FOR CONSULT,: Dementia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions. Symptoms started in June of 2006, when the patient complained of vision problems and disorientation. The patient was seen... | consult - history and phy., reason for consult:, concentration, dementia, mood, psychiatric consultation, sensorial memory, affect, disorientation, illusions, information, insight, intelligence, judgment, loss of vision, motor activity, neurologist, thought process, unusual behaviors, mental status examination, consult... |
4,171 | The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission. | Consult - History and Phy. | Psych Consult - Assaultive Behavior | IDENTIFYING DATA: ,The patient is a 40-year-old white male. He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION: ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated... | null |
4,172 | Psychiatric Consultation of patient with altered mental status. | Consult - History and Phy. | Psych Consult - Altered Mental Status | REASON FOR CONSULT:, Altered mental status.,HPI:, The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month. Last night, ... | null |
4,173 | Psychiatric Consultation of patient with anxiety. | Consult - History and Phy. | Psych Consult - Anxiety | REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:, "I felt anxious yesterday.",HPI:, A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.... | null |
4,174 | The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches. | Consult - History and Phy. | Pseudotumor Cerebri | REASON FOR VISIT: ,The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches. She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS: , Dr. X has cared for her since 2002. She has a Codman-Hakim shunt set at 90 mmH2O. She last saw us in clinic... | consult - history and phy., migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema |
4,175 | Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical | Consult - History and Phy. | Prostate Adenocarcinoma - H&P | HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing... | consult - history and phy., gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate, |
4,176 | The patient was referred due to a recent admission for pseudoseizures. | Consult - History and Phy. | Pseudoseizures | REASON FOR REFERRAL: , The patient was referred to me by Dr. X of the Hospitalist Service at Children's Hospital due to a recent admission for pseudoseizures. This was a 90-minute initial intake completed on 10/19/2007 with the patient's mother. I have reviewed with her the boundaries of confidentiality and the treat... | consult - history and phy., conversion disorder, global assessment of functioning, primary support group, peer problems, developmental delays, seizures, developmentally, axis, pseudoseizures, |
4,177 | Adenocarcinoma of the prostate. The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base. | Consult - History and Phy. | Prostate Adenocarcinoma | ADMISSION DIAGNOSIS: ,Adenocarcinoma of the prostate.,HISTORY:, The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5). The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7... | null |
4,178 | Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery | Consult - History and Phy. | Preop Cardiac Consult | HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery. She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell. She suf... | null |
4,179 | Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma. | Consult - History and Phy. | Pneumothorax & Subcutaneous Emphysema | REASON FOR CONSULTATION:, Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain. The patient presented the following day with subcutaneous emphysema and continued complaints of pa... | consult - history and phy., trauma, tracheobronchial, bronchoscopy, scapular pain, subcutaneous emphysema, pneumothorax, subcutaneous, emphysema, |
4,180 | Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. | Consult - History and Phy. | 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 |
4,181 | A white female presents for exam and Pap. | Consult - History and Phy. | Physical Exam and Pap - 1 | SUBJECTIVE:, This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap. Last Pap was a year ago and normal. LMP was 08/29/2004. Her cycles are usually regular, although that one came about a week early. Her husband has had a vasectomy. Overall, she is feeling well.,Health history form was r... | null |
4,182 | Post-surgical medical management; right total knee replacement. | Consult - History and Phy. | Postop Medical Management | REASON FOR CONSULTATION: , Post-surgical medical management.,PROCEDURE DONE: , Right total knee replacement.,MEDICAL HISTORY:,1. Arthritis of the right knee.,2. Hypertension.,PAST SURGICAL HISTORY: , Hysterectomy, Cesarean section, left hip arthroplasty, and breast biopsy.,MEDICATIONS: , Hyzaar 12.5 mg p.o. daily, Fe... | null |
4,183 | 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. | Consult - History and Phy. | 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 |
4,184 | Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure. The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with... | Consult - History and Phy. | Preeclampsia | REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncon... | null |
4,185 | The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. | Consult - History and Phy. | Penile Cellulitis | CHIEF COMPLAINT: ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. The child initially had a newborn circumcision at about 1 week of life and t... | consult - history and phy., newborn circumcision, suprapubic fat pad, penile cellulitis, penile swelling, cellulitis, penis, penile, suprapubic, circumcision, |
4,186 | The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. | Consult - History and Phy. | Pericardial Effusion | REASON FOR CONSULTATION:, Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region... | null |
4,187 | A white female who presents for complete physical, Pap and breast exam. | Consult - History and Phy. | Physical Exam and Pap -2 | SUBJECTIVE:, The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam. Her last Pap smear was 05/02/2002. Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest. Has awakened her at night on ... | null |
4,188 | A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis. | Consult - History and Phy. | Pediatric Rheumatology Consult | HISTORY: ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic. He was sent here with a chief complaint of joint pain in several joints for few months. This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he s... | consult - history and phy., rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis, |
4,189 | A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation. | Consult - History and Phy. | Paroxysmal Atrial Fibrillation | INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 55-year-old white female with multiple myeloma. She is status post chemotherapy and autologous stem cell transplant. Latter occurred on 02/05/2007. At that time, she was on telemetry monitor and noticed to be in nor... | null |
4,190 | Pain management for post-laminectomy low back syndrome and radiculopathy. | Consult - History and Phy. | Pain Management Consult - 1 | Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history bec... | consult - history and phy., pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, s... |
4,191 | Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. | Consult - History and Phy. | Penile Discharge | CHIEF COMPLAINT: , Penile discharge, infected-looking glans.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for we... | null |
4,192 | A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral. | Consult - History and Phy. | Otitis Media - H&P | CHIEF COMPLAINT:, This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include: cough, fever, irritability and speech and language delay. Duration (ENT): Duration of symptom: 12 rounds of antibiotic... | null |
4,193 | Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis. | Consult - History and Phy. | Peripheral Effusion - Consult | REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.... | null |
4,194 | Patient with back and hip pain. | Consult - History and Phy. | Orthopedic Consult - 5 | Chief Complaint:, Back and hip pain.,History of Present Illness:, The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppress... | null |
4,195 | Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left. | Consult - History and Phy. | Pain Management Consult - 2 | HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing... | null |
4,196 | Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. | Consult - History and Phy. | Orthopedic Consult - 4 | CHIEF COMPLAINT: , Chronic low back, left buttock and leg pain.,HISTORY OF PRESENT ILLNESS: , This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005. Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. He has also tried acupuncture, ... | consult - history and phy., radiculitis, myofascial, acupuncture, tens unit, physical therapy, chiropractic treatment, lumbar disk replacement, lumbar disk, disk replacement, orthopedic |
4,197 | Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome. | Consult - History and Phy. | Orthopedic Consult - 1 | SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radicu... | consult - history and phy., low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet, sacroiliac joint syndrome, lumbar spinal stenosis, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, chronic pain syndrome, degenerative disc disease, pes anserinus burs... |
4,198 | 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. | Consult - History and Phy. | 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... | consult - history and phy., blood in stool, nausea, capillary refill, angiogram, hernia, extremity, |
4,199 | A lady with symptoms consistent with possible oligoarticular arthritis of her knees. | Consult - History and Phy. | Oligoarticular Arthritis - 2 | HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria. A was worked up for collagen vascular diseases and is here to find out the results. Also was recommended to take 7.5 mg of Mobic every day for her joint pains. She sta... | consult - history and phy., arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular, |
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