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4,200 | Toenails are discolored, thickened, and painful - Onychomycosis | Consult - History and Phy. | Onychomycosis - H&P | CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,... | null |
4,201 | Medical management, status post left total knee arthroplasty. | Consult - History and Phy. | Orthopedic Consult | REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1. Polyarthritis.,2. Acromegaly.,3. Hypothyroidism.,4. Borderline hypertension.,5. Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bil... | null |
4,202 | Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty. | Consult - History and Phy. | Orthopedic Consult - 2 | SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain. She has a history of prior laminectomy for spinal stenosis. She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, an... | consult - history and phy., scoliosis, lumbar, laminectomy, spinal stenosis, radiculopathy, chronic pain syndrome, low back pain, facet and sacroiliac joint, degenerative disk disease, sacroiliac joint syndrome, lumbar spinal stenosis, disk disease, sacroiliac joint, hip arthroplasty, hip injection, hip replacement, lu... |
4,203 | Occupational medicine consult with questions-answers and records review. | Consult - History and Phy. | Occupational Medicine Consult - 3 | ALLOWED CONDITIONS:, Sprain of left knee and leg.,CONTESTED CONDITION:, Left knee tear medial meniscus, left knee ACL tear.,EMPLOYER:, YYYY,REQUESTING PARTY:, XXXX,Mr. XXXXXX is a xx-year-old male who was evaluated for an independent medical examination on September 20, 2007, because of an injury sustained to the l... | null |
4,204 | Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs | Consult - History and Phy. | Orthopedic Consult - 3 | CHIEF COMPLAINT:, Back pain and right leg pain. The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:, The patient is on my schedule today to explore treatment of the above complaints. She has a two-year history of small cell lung cancer, which she says has spre... | null |
4,205 | Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having d... | Consult - History and Phy. | Organic Brain Syndrome | REASON FOR CONSULT:, Organic brain syndrome in the setting of multiple myeloma.,SOURCE OF HISTORY: ,The patient himself is not able to give a good history. History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.,HISTORY OF P... | null |
4,206 | Occupational medicine consult with questions-answers and records review. | Consult - History and Phy. | Occupational Medicine Consult - 2 | ALLOWED CONDITIONS:, 726.31 right medial epicondylitis; 354.0 right carpal tunnel syndrome.,CONTESTED CONDITIONS:, 354.2 right cubital tunnel syndrome.,EMPLOYER:, ABCD, ,I examined Xxxxx today for the allowed conditions and also the contested conditions listed above. I obtained her history from company medical rec... | null |
4,207 | Occupational medicine consult with questions-answers. | Consult - History and Phy. | Occupational Medicine Consult - 1 | ALLOWED CONDITIONS:, Left knee strain, meniscus tear left knee.,CONTESTED CONDITION:, Osteoarthritis of the left knee.,EMPLOYER:, ABCD.,I examined Xxxxx today September 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee. He is a 57-year-old assembly worker... | null |
4,208 | Pelvic Pain and vaginal discharge | Consult - History and Phy. | OB/GYN Consultation - 4 | CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap: 1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history ... | null |
4,209 | A 17-year-old male with oligoarticular arthritis of his right knee. | Consult - History and Phy. | Oligoarticular Arthritis - 1 | HISTORY:, A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic. A is a 17-year-old male with oligoarticular arthritis of his right knee. He had a joint injection back in 03/2007 and since then he has been doing relatively well. He is taking Indocin only as needed even... | consult - history and phy., rheumatology, rheumatology clinic, lower extremities, oligoarticular arthritis, arthritis, oligoarticular, knee, swelling, |
4,210 | Consultation for an ASCUS Pap smear. | Consult - History and Phy. | OB/GYN Consultation - 3 | Pap smear in November 2006 showed atypical squamous cells of undetermined significance. She has a history of an abnormal Pap smear. At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia. She underwent a cone biopsy that per her report was negative for any pathology. She had no vulva... | consult - history and phy., lmp, ascus, pap smear, abnormal pap smear, atypical, bacterial vaginosis, chlamydia, cone biopsy, infection, interstitial cystitis, intraepithelial, mammogram, neoplasia, perirectal condyloma, squamous, vaginal bleeding, vulvar, yeast infection, pap smears, pap, ob/gyn, colposcopy, smear, |
4,211 | Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features. | Consult - History and Phy. | OB/GYN Consultation - 1 | PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:, Prozac 20 mg q.d. She desires to be on the NuvaRing.,ALLERGIES:, Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:, VITALS: Stable. Weight: 114 lb. Height: 5 feet 2 inches. ... | consult - history and phy., gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade, |
4,212 | Occupational medicine consult with questions-answers and records review. | Consult - History and Phy. | Occupational Medicine Consult | ALLOWED CONDITION: , Right shoulder sprain and right rotator cuff tear (partial).,CONTESTED CONDITION:, AC joint arthrosis right aggravation.,DISALLOWED CONDITION: , | null |
4,213 | Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter. | Consult - History and Phy. | 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... | consult - history and phy., review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling, |
4,214 | Consultation because of irregular periods and ovarian cyst. | Consult - History and Phy. | OB/GYN Consultation - 2 | She started her periods at age 13. She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice. She describes the pain as bilateral, intermittent, and non-radiating. It decreases slightly when she eats and increases with activity. She states the pain when i... | consult - history and phy., irregular periods, lactaid, abdominal pain, birth control pills, cyst, ovarian cyst, ovaries, ovary, pelvic exam, sexually active, uterus, lymphadenopathy, pelvic, irregular, periods |
4,215 | 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. | Consult - History and Phy. | 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 |
4,216 | Negative for any nausea, vomiting, fevers, chills, or weight loss. | Consult - History and Phy. | 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... | consult - history and phy., review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting, |
4,217 | Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies. | Consult - History and Phy. | 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 ... | consult - history and phy., respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness |
4,218 | Initial obstetrical examination - Normal first pregnancy. Inadequate naternal nutrition. | Consult - History and Phy. | OB/GYN - H&P | CHIEF COMPLAINT,: This 32 year-old female presents today for an initial obstetrical examination. Home pregnancy test was positive.,The patient indicates fetal activity is not yet detected (due to early stage of pregnancy). LMP: 02/13/2002 EDD: 11/20/2002 GW: 8.0 weeks. Patient has been trying to conceive for 6 m... | null |
4,219 | 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. | Consult - History and Phy. | 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... | consult - history and phy., 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 andar... |
4,220 | Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies. | Consult - History and Phy. | 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... | consult - history and phy., nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness, |
4,221 | Most commonly used phrases in physical exam. | Consult - History and Phy. | 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... | consult - history and phy., ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination, |
4,222 | Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss. | Consult - History and Phy. | 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... | consult - history and phy., cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss, |
4,223 | Normal physical exam template. Normocephalic. Negative lesions, negative masses. | Consult - History and Phy. | 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... | |
4,224 | Normal physical exam template. Well developed, well nourished, in no acute distress. | Consult - History and Phy. | 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... | |
4,225 | 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. | Consult - History and Phy. | 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 |
4,226 | An example normal physical exam | Consult - History and Phy. | 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... | consult - history and phy., vital signs, equal, round, reactive, normal physical exam, physical exam, |
4,227 | Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill. | Consult - History and Phy. | 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... | consult - history and phy., jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds, |
4,228 | An example of a physical exam | Consult - History and Phy. | 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... | consult - history and phy., mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam, |
4,229 | Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress. | Consult - History and Phy. | 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... | consult - history and phy., respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical, |
4,230 | Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress. | Consult - History and Phy. | 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... | consult - history and phy., fontanelle, normocephalic, newborn infant, physical exam, acute respiratory, newborn, respiratory, distress, head, infant, |
4,231 | An example/template for a routine normal male ROS. | Consult - History and Phy. | 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... | consult - history and phy., review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary |
4,232 | Normal female review of systems template. Negative for fever, weight change, fatigue, or aching. | Consult - History and Phy. | 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... | consult - history and phy., cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint, |
4,233 | Template for History and Physical for a newborn. | Consult - History and Phy. | 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 |
4,234 | An example/template for a routine normal male physical exam. | Consult - History and Phy. | 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 |
4,235 | An example/template for a routine normal male physical exam. | Consult - History and Phy. | 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... | consult - history and phy., digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue, |
4,236 | Sample/template for a normal male multisystem exam. | Consult - History and Phy. | 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: ... | consult - history and phy., within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue, |
4,237 | Sample normal ear, nose, mouth, and throat exam. | Consult - History and Phy. | 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... | consult - history and phy., 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 transcr... |
4,238 | An example/template for a routine normal female physical exam. | Consult - History and Phy. | 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... | consult - history and phy., heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue, |
4,239 | An example/template for a routine normal male physical exam. | Consult - History and Phy. | 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... | consult - history and phy., male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx |
4,240 | An example/template for a routine normal male physical exam. | Consult - History and Phy. | 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... | consult - history and phy., male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape, |
4,241 | An example/template for a routine normal female physical exam. | Consult - History and Phy. | 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 |
4,242 | Normal child physical exam template. | Consult - History and Phy. | 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... | consult - history and phy., child physical examination, physical, genitalia, child, |
4,243 | Sample/template for a normal female multisystem exam | Consult - History and Phy. | 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: ,... | |
4,244 | New diagnosis of non-small cell lung cancer stage IV metastatic disease. At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable. | Consult - History and Phy. | Non-Small Cell Lung Cancer - Consult | REASON FOR CONSULTATION:, New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease. We are consulted at this time to discuss furthe... | null |
4,245 | A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures. | Consult - History and Phy. | New Onset Seizure | REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febri... | null |
4,246 | Sample normal ear, nose, mouth, and throat exam. | Consult - History and Phy. | 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... | consult - history and phy., oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling, |
4,247 | A patient with non-Q-wave myocardial infarction. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND. | Consult - History and Phy. | Non-Q-wave Myocardial Infarction | REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks. The patient re... | null |
4,248 | The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. | Consult - History and Phy. | Neuropsychological Evaluation - 5 | PROBLEMS AND ISSUES:,1. Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2. Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercis... | consult - history and phy., nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia, |
4,249 | Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decis... | Consult - History and Phy. | Neuropsychological Evaluation - 3 | REASON FOR REFERRAL:, The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney. He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well.... | null |
4,250 | Neurologic examination sample. | Consult - History and Phy. | Neurologic Examination | NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of ny... | consult - history and phy., station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE |
4,251 | Sample for Neuropsychological Evaluation | Consult - History and Phy. | Neuropsychological Evaluation - 1 | REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room. I had seen him the day before in my office and recommended him to go into the hospital. He had just come from a trip to Taho in Nevada and he became homicidal while there. He started having th... | consult - history and phy., neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis, |
4,252 | Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. | Consult - History and Phy. | Neurologic Consultation - 5 | HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before ... | null |
4,253 | A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope. | Consult - History and Phy. | Neuropsychological Evaluation - 2 | REASON FOR REFERRAL: ,The patient was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS... | null |
4,254 | Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke. | Consult - History and Phy. | Neuropsychological Evaluation | REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July. A comprehen... | null |
4,255 | Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance. Probable painful diabetic neuropathy. Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper... | Consult - History and Phy. | Neurologic Consultation - 4 | REASON FOR NEUROLOGICAL CONSULTATION:, Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,HISTORY OF PRESENT ILLNESS: , The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-s... | null |
4,256 | The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. | Consult - History and Phy. | Neuropsychological Evaluation - 4 | REASON FOR REFERRAL:, The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment th... | null |
4,257 | Neurologic consultation and follow-up. | Consult - History and Phy. | Neurologic Consultation - 1 | SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed. There are no changes, otherwise.,REVIEW OF SYSTEMS:, Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulde... | consult - history and phy., neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone, |
4,258 | Neurologic consultation was requested to assess and assist with seizure medication. | Consult - History and Phy. | Neurologic Consultation - 3 | HISTORY: , Neurologic consultation was requested to assess and assist with her seizure medication. The patient is a 3-year 3 months old girl with refractory epilepsy. She had been previously followed by XYZ, but has been under the care of the UCSF epilepsy program and recently by Dr. Y. I reviewed her pertinent prev... | consult - history and phy., eye blinking, status epilepticus, seizure medication, valproic acid, allergic reactions, neurologic consultation, seizure, neurologic, seizures, |
4,259 | Patient has trouble with walking and balance, with bladder control, and with thinking and memory. | Consult - History and Phy. | Neurologic Consultation - 2 | REASON FOR VISIT: ,The patient is a 76-year-old man referred for neurological consultation by Dr. X. The patient is companied to clinic today by his wife and daughter. He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walki... | null |
4,260 | Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week | Consult - History and Phy. | Neurogenic Bladder - Consult | HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blo... | consult - history and phy., neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization, |
4,261 | Consult - History and Phy. | Neuro Consult - Depression & Dementia | Subsequently, the patient developed a moderately severe depression. She was tried on various medications, which caused sweating, nightmares and perhaps other side effects. She was finally put on Effexor 25 mg two tablets h.s. and trazodone 100 mg h.s., and has done fairly well, although she still has significant depr... | null | |
4,262 | Nephrology Consultation - Patient with renal failure. | Consult - History and Phy. | Nephrology Consultation - 1 | REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:, Thank you for referring Ms. Abc to ABCD Nephrology. As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital. She had been admitted at that time with chest pain and was subsequ... | null |
4,263 | The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness. | Consult - History and Phy. | Neuro Consult - Leg Weakness | HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness. He has difficulty recollecting the exact details and chronology of his problem. To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg. ... | null |
4,264 | Neurologic consultation was requested to evaluate her seizure medication and lethargy. | Consult - History and Phy. | Neurologic Consultation | REASON FOR CONSULTATION: , Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.,HISTORY OF PRESENT ILLNESS: , The patient is well known to me. She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prema... | consult - history and phy., lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal |
4,265 | This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. | Consult - History and Phy. | Neonatal Consult | INFORMANT:, Dad on phone. Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY: ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being... | null |
4,266 | The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection. | Consult - History and Phy. | Neuroblastoma - Consult | REASON FOR VISIT:, The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and... | null |
4,267 | A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. | Consult - History and Phy. | Murmur & Bacteremia. | REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:, The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. The patient states that apart from the fever, she was having no other symptoms and denies any... | null |
4,268 | The patient is admitted with a diagnosis of acute on chronic renal insufficiency. | Consult - History and Phy. | Nephrology Consultation - 4 | HISTORY: , The patient is a 61-year-old male patient. I was asked to evaluate this patient because of the elevated blood urea and creatinine. The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD. The patient ... | consult - history and phy., mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency, |
4,269 | Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation. | Consult - History and Phy. | Nephrology Consultation - 3 | PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for l... | consult - history and phy., kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension |
4,270 | Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure. | Consult - History and Phy. | Nephrology Consultation - 2 | HISTORY:, The patient was in the intensive care unit setting; he was intubated and sedated. The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated. He has been signif... | consult - history and phy., intubated, consultation, hypercalcemia, hypoalbuminemia, iv fluid, nephrology, acidosis, creatinine, hemodiafiltration, hypokalemia, hypotension, intravenous, pancreatitis, renal failure, respiratory, urine output, continuous venovenous hemodiafiltration, electrolyte derangements, convention... |
4,271 | Patient status post vehicular trauma. Low Back syndrome and Cervicalgia. | Consult - History and Phy. | Neck & Lower Back Pain - Consult | CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off th... | null |
4,272 | Initial evaulation - neck and back pain. | Consult - History and Phy. | Neck & Back Pain | CHIEF COMPLAINT:, Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:, Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse. She has previo... | null |
4,273 | A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer. | Consult - History and Phy. | Metastatic Ovarian Cancer - Consult | REASON FOR CONSULTATION:, Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has r... | null |
4,274 | A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. | Consult - History and Phy. | Microhematuria - Consult | HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He was seen a few weeks ago for routine followup, and he was noted for microhematuria. Due to his history of kidney stone, renal ultrasound as well as IVP was done. He presents today for followup. H... | consult - history and phy., intrarenal stone, ivp, ultrasound, microhematuria, hydration, kidney stone, renal ultrasound |
4,275 | Patient with stable expressive aphasia and decreased vision. | Consult - History and Phy. | Multiple Meningiomas | CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she develope... | consult - history and phy., sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: 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 rep... |
4,276 | The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves. | Consult - History and Phy. | Multiple Neurological Symptoms | HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms. I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems. He first mentioned that he has neck pain. He state... | null |
4,277 | Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency. | Consult - History and Phy. | Multilobar Pneumonia | REASON FOR CONSULTATION: , Loculated left effusion, multilobar pneumonia. | consult - history and phy., neck bruits, nasal cannula, rhythm, pneumonia, chest tube, fluid collection, pleural effusion, multilobar pneumonia, pleural, loculations, multilobar, |
4,278 | Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease. | Consult - History and Phy. | Mesothelioma - Consult | REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization. He has also been seen by me in the clinic in the last few weeks. He was admitted on January 18, 2008, with recurrent malignant pleural effus... | null |
4,279 | The patient with gradual onset of a headache problem, located behind both eyes. | Consult - History and Phy. | Migraine without Aura - Consult | CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. ... | null |
4,280 | Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. | Consult - History and Phy. | Mantle Cell Lymphoma - Consult | CHIEF COMPLAINT:, Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006. On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone. ... | null |
4,281 | Progressive loss of color vision OD. | Consult - History and Phy. | Meningioma | CC: ,Progressive loss of color vision OD,HX:, 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There h... | consult - history and phy., goldman visual field examination, loss of color vision, visual field examination, visual acuity, cavernous sinus, color vision, visual field, optic nerve, meningioma, |
4,282 | Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved. | Consult - History and Phy. | Mental Status Changes - Consult | CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had ... | consult - history and phy., alzheimer's, no loss consciousness, mental status, |
4,283 | Marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. she had a mammogram and ultrasound, which confirmed the right breast mass. | Consult - History and Phy. | Marginal Zone Lymphoma | CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. On 07/19/10, she had a mammogram an... | null |
4,284 | Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management | Consult - History and Phy. | 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 |
4,285 | Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. | Consult - History and Phy. | Major Depressive Disorder - IME Consult | IDENTIFYING DATA: ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence, his energy le... | consult - history and phy., muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric, |
4,286 | Patient with sudden onset dizziness and RUE clumsiness. Giant Left MCA Aneurysm. | Consult - History and Phy. | MCA Aneurysm | HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not ... | consult - history and phy., mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral, |
4,287 | Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. | Consult - History and Phy. | Malignant Meningioma - Consult | REASON FOR VISIT: , This is a new patient evaluation for Mr. A. There is a malignant meningioma. He is referred by Dr. X.,HISTORY OF PRESENT ILLNESS: , He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07. He then had a problem with seizures, hemiparesis, has been to the hospital, d... | consult - history and phy., seizures, hemiparesis, tumor, seizures hemiparesis, malignant meningioma, chemotherapy, malignant, meningioma, aspirin |
4,288 | Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear. | Consult - History and Phy. | Lower Quadrant Pain | REASON:, Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank. She states that is particularly bad when u... | null |
4,289 | Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism. | Consult - History and Phy. | Lumbar Radiculopathy - Consult | FAMILY HISTORY:, Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:,... | consult - history and phy., back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia, |
4,290 | Marginal B-cell lymphoma, status post splenectomy. Testicular swelling - possible epididymitis or possible torsion of the testis. | Consult - History and Phy. | Lymphoma - Consult | HISTORY OF PRESENT ILLNESS:, The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago. The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction. The patient again went into complete remission. The patient has been doing ... | null |
4,291 | Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter. | Consult - History and Phy. | 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 |
4,292 | Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus. | Consult - History and Phy. | Lumbar Spine HNP - Consult | CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The sy... | null |
4,293 | Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. | Consult - History and Phy. | Lung Cancer & MI - Hospice Cosult | REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her... | null |
4,294 | Lumbar muscle strain and chronic back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago. | Consult - History and Phy. | Lower back pain | HISTORY OF PRESENT ILLNESS:, Patient is a 50-year-old white male complaining of continued lower back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago. He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after wh... | consult - history and phy., back pain, lumbar muscle strain, chronic back pain, illness, lower, medications, |
4,295 | Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008. | Consult - History and Phy. | Lumbosacral Polyradiculopathy | HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. I do not have the records from this hospital admission, but apparently the ep... | null |
4,296 | New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation. | Consult - History and Phy. | Low Back Pain - Consult | FAMILY HISTORY: , His parents are deceased. He has two brothers ages 68 and 77 years old, who are healthy. He has siblings, a brother and a sister who were twins who died at birth. He has two sons 54 and 57 years old who are healthy. He describes history of diabetes and heart attack in his family.,SOCIAL HISTORY: ... | consult - history and phy., back pain, ligamentum flavum hypertrophy, annular disc bulge, degenerative disc disease, spinal stenosis, cranial nerves, degenerative, |
4,297 | A 21-month-old male presented for delayed motor development, "jaw quivering" and "lazy eye." | Consult - History and Phy. | Lobar Holoprosencephaly | CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intraute... | consult - history and phy., delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine, |
4,298 | Patient with a 1-year history of progressive anterograde amnesia | Consult - History and Phy. | Limbic Encephalitis | CC:, Rapidly progressive amnesia.,HX: ,This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally ... | consult - history and phy., mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory, |
4,299 | 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. | Consult - History and Phy. | 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 |
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