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4,300 | The patient comes in today because of feeling lightheaded and difficulty keeping his balance. | Consult - History and Phy. | Lightheadedness | HISTORY OF PRESENT ILLNESS: ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up... | consult - history and phy., lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness, |
4,301 | Urine leaked around the ostomy site for his right sided nephrostomy tube. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure. | Consult - History and Phy. | Leaking Nephrostomy Tube | CHIEF COMPLAINT: ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube. The leaking began this a.m. The patient denies any pain, does not have fever and has no other problems or... | consult - history and phy., nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes, |
4,302 | The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain. | Consult - History and Phy. | Left Lower Quadrant Pain - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hour... | null |
4,303 | Lightheaded, dizziness, and palpitation. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time wh... | Consult - History and Phy. | Lightheaded & Dizziness | REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episod... | null |
4,304 | Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d. | Consult - History and Phy. | Knee DJD - Consult | CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are ... | null |
4,305 | Consult for laparoscopic gastric bypass. | Consult - History and Phy. | Laparoscopic Gastric Bypass Consult - 1 | HISTORY OF PRESENT ILLNESS: , I have seen ABC today. He is a very pleasant gentleman who is 42 years old, 344 pounds. He is 5'9". He has a BMI of 51. He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260. He is pursuing surgical attempts of weight loss to fee... | consult - history and phy., laparoscopic gastric bypass, heart attacks, body weight, pulmonary embolism, potential complications, sleep study, weight loss, gastric bypass, anastomosis, loss, sleep, laparoscopic, gastric, bypass, heart, pounds, weight, |
4,306 | Consult for laparoscopic gastric bypass. | Consult - History and Phy. | Laparoscopic Gastric Bypass Consult - 2 | PAST MEDICAL HISTORY:, He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor. He exercises three times a week at home and does cardio. He has difficulty walking two blocks or five flights of stairs. Difficulty with snoring. He has mu... | consult - history and phy., laparoscopic gastric bypass, weight loss programs, gastric bypass, atkin's diet, weight watcher's, body weight, laparoscopic gastric, weight loss, pounds, months, weight, laparoscopic, band, loss, diets, overweight, lost |
4,307 | The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time. | Consult - History and Phy. | Kyphoplasty - Consult | HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months,... | consult - history and phy., leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture, |
4,308 | A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture. | Consult - History and Phy. | Kyphosis | REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis. The patient has a family history in a maternal aunt and grandfather of kyphosis. She was noted by her parents to have round back posture. They have previously seen another... | consult - history and phy., thoracic kyphosis, round back posture, physical therapy, kyphosis, patientfor, orthopedist, |
4,309 | This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. | Consult - History and Phy. | Itchy Rash - ER Visit | CHIEF COMPLAINT:, Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breat... | consult - history and phy., urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash, |
4,310 | Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. | Consult - History and Phy. | Knee Injury | HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time, she... | consult - history and phy., acl graft, acl reconstruction, knee, anterior cruciate ligament, internal derangement, contact injury, knee injury, injury, cruciate, acl, anterior, |
4,311 | Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture. | Consult - History and Phy. | Jaw Pain - ER Visit | CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS: ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointmen... | consult - history and phy., jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema, |
4,312 | Pneumatosis coli in the cecum. Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer. | Consult - History and Phy. | Ischemic Cecum - Consult | REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS: ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia. The patient is very difficult to obtain information from; however, he appears to be having frequent nausea ... | consult - history and phy., ischemic cecum, metastatic disease, bilateral hydronephrosis, chronic alcohol abuse, acute renal failure, copd, anemia, gastric ulcer, pneumatosis coli, cecum, aspiration pneumonia, aspiration, ischemic, atrial, metastatic, hydronephrosis, fibrillation, pneumatosis, pneumonia, |
4,313 | Intractable epilepsy, here for video EEG. | Consult - History and Phy. | Intractable Epilepsy | CHIEF COMPLAINT:, Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms. Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callo... | consult - history and phy., brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg, |
4,314 | Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis. | Consult - History and Phy. | Iron deficiency anemia | CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage he... | consult - history and phy., trilineage hematopoiesis, cellular marrow, bone marrow biopsy, iron deficiency anemia, bone marrow, anemia, hemoglobin, lymphadenopathy, deficiency, tobacco, |
4,315 | Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization. | Consult - History and Phy. | Iliopsoas Hematoma - 2 | CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillat... | consult - history and phy., cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac, |
4,316 | A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. | Consult - History and Phy. | Infantile Spasms | CHIEF COMPLAINT:, Arm and leg jerking.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These mo... | null |
4,317 | Right shoulder impingement syndrome, right suprascapular neuropathy. | Consult - History and Phy. | Impairment Rating | CHIEF COMPLAINT: , Right shoulder pain.,HISTORY: , The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried ... | consult - history and phy., ama guide, evaluation of permanent impairment, impairment rating, permanent impairment, suprascapular nerve, suprascapular neuropathy, injured, extremity, shoulder, impairment, neuropathy, suprascapular, |
4,318 | Chief complaint of chest pain, previously diagnosed with hyperthyroidism. | Consult - History and Phy. | Hyperthyroidism Following Pregnancy | HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain. She had been previously diagnosed with hyperthyroidism. Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm. She had been experiencing palpitations and tachycardia. She ... | consult - history and phy., hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy, |
4,319 | Left Iliopsoas hematoma. Gait difficulty. | Consult - History and Phy. | Iliopsoas Hematoma - 1 | CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual chan... | null |
4,320 | Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C. | Consult - History and Phy. | Hypertension & Cardiomyopathy | PROBLEMS LIST:,1. Nonischemic cardiomyopathy.,2. Branch vessel coronary artery disease.,3. Congestive heart failure, NYHA Class III.,4. History of nonsustained ventricular tachycardia.,5. Hypertension.,6. Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharge... | consult - history and phy., congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea, |
4,321 | Local reaction secondary to insect sting. Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today. | Consult - History and Phy. | Insect Sting | HISTORY OF PRESENT ILLNESS:, Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness and swelling to his le... | consult - history and phy., stung by a bee, local reaction, insect sting, reaction, insect, bee, knee, edema, sting, swelling, hand |
4,322 | A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur. | Consult - History and Phy. | Infant Not Gaining Weight | CHIEF COMPLAINT:, Not gaining weight.,HISTORY OF PRESENT ILLNESS:, The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. The patient appeared to have failure-to-t... | null |
4,323 | This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. | Consult - History and Phy. | Huntington's Disease - Consult | CHIEF COMPLAINT: , "A lot has been thrown at me.",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 3... | null |
4,324 | Probable Coumadin hypersensitivity. | Consult - History and Phy. | Hypersensitivity to Coumadin | PROBLEM:, Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty. At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postopera... | null |
4,325 | Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared. | Consult - History and Phy. | Hip Fracture - Rehab Consult | ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture ... | null |
4,326 | Likely molluscum contagiosum (genital warts) caused by HPV. It is not clear where this came from but it is most likely sexually transmitted. | Consult - History and Phy. | HPV Consult | He has no voiding complaints and no history of sexually transmitted diseases.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Back surgery with a fusion of L5-S1.,MEDICATIONS: , He does take occasional Percocet for his back discomfort.,ALLERGIES:, HE HAS NO ALLERGIES.,SOCIAL HISTORY:, He is a smoker. He takes... | consult - history and phy., sexually transmitted, molluscum contagiosum, genital warts, hpv, |
4,327 | An 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation. | Consult - History and Phy. | Hypertension - Consult | HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her beca... | consult - history and phy., hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary, |
4,328 | Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. | Consult - History and Phy. | Hypergranulation - Consult | CHIEF COMPLAINT:, Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted... | null |
4,329 | Patient comes in for initial evaluation of a hyperesthesia on his right abdomen. | Consult - History and Phy. | Hyperesthesia | SUBJECTIVE:, This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. It cleared for awhile. This has been an intermittent problem. N... | consult - history and phy., dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation |
4,330 | Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease. | Consult - History and Phy. | Huntington's Disease | CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the mainte... | null |
4,331 | The patient had hematuria, and unable to void. The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. | Consult - History and Phy. | Hematuria & Urinary Retention | REASON FOR CONSULTATION:, Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia. The patient had hematuria, and unable to void. The patient h... | null |
4,332 | Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur. | Consult - History and Phy. | Hip Fracture - ER Consult | REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight. History was obtained from the patient. As per ... | consult - history and phy., calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma, |
4,333 | Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea. | Consult - History and Phy. | Hematuria - ER Visit | HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old gentleman who follows as an outpatient with Dr. A. He is known to us from his last admission. At that time, he was admitted with a difficulty voiding and constipation. His urine cultures ended up being negative. He was seen by Dr. B and discharged home on ... | null |
4,334 | Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis. | Consult - History and Phy. | Hematology Consult - 1 | HISTORY OF PRESENT ILLNESS:, The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis. We corrected her hematocrit last year with intravenous (IV) iron. Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis. Her course has been very... | null |
4,335 | Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation. | Consult - History and Phy. | Hematology Consult | REASON FOR CONSULTATION:, Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS: ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or sur... | null |
4,336 | Closed head injury with evidence of axonal injury vs. vascular injury to the left substantia nigra, right subdural hematoma and possible subarachnoid hemorrhage, vascular/ischemic injury in the right occipital lobe-right basal ganglia/caudate nucleus-right frontal lobe, and right temporal lobe contusion. | Consult - History and Phy. | Head Trauma | CC: ,Depressed mental status.,HX: ,29y/o female fell down a flight of stairs on 2/20/95, striking the right side of her head. She then walked over to and lay down on a living room couch. She was found there, the next morning, by her boyfriend, poorly responsive and amidst a coffee ground like emesis. She was taken to a... | consult - history and phy., closed head injury, axonal injury, vascular injury, substantia nigra, subdural hematoma, subarachnoid hemorrhage, vascular, ischemic, injury, occipital lobe, retinal hemorrhages, temporal region, axonal, hemorrhages, hemorrhage, |
4,337 | Patient presents with gross hematuria that started this morning. | Consult - History and Phy. | Hematuria - Consult | HISTORY OF PRESENT ILLNESS:, This is a 77-year-old male, who presents with gross hematuria that started this morning. The patient is a difficult historian, does have a speech impediment, slow to answer questions, but daughter was able to answer lot of questions too. He is complaining of no other pain. He denies any... | consult - history and phy., prostate cancer, bleeding, gross hematuria, speech impediment, hematuria, coagulopathy, blood, |
4,338 | Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2 | Consult - History and Phy. | H&P - Weakness | CHIEF COMPLAINT:, Right-sided weakness.,HISTORY OF PRESENT ILLNESS:, The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including l... | null |
4,339 | New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. | Consult - History and Phy. | Hand Pain - Consult | REASON FOR VISIT: ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation. He complained of ulnar-sided right hand pain and was seen in the emergency room. Reportedly, he had some joints in his... | consult - history and phy., hand pain, pain, hand, metacarpals |
4,340 | An 85-year-old female with diarrhea, vomiting, and abdominal pain. | Consult - History and Phy. | H&P - Gen Med - 1 | CHIEF COMPLAINT:, Diarrhea, vomiting, and abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS... | null |
4,341 | Newly diagnosed head and neck cancer. The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. | Consult - History and Phy. | Head & Neck Cancer Consult | REASON FOR CONSULTATION:, Newly diagnosed head and neck cancer.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa. He was also noted to have ... | null |
4,342 | Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. | Consult - History and Phy. | H&P - Nausea & Vomiting | CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revea... | null |
4,343 | History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis. | Consult - History and Phy. | H&P - Gen Med - 2 | HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency ... | null |
4,344 | This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant. | Consult - History and Phy. | Guillain-Barre Syndrome | CHIEF COMPLAINT: , Followup of hospital discharge for Guillain-Barre syndrome.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had ons... | null |
4,345 | Irritable baby, 6-week-old, with fever for approximately 24 hours. | Consult - History and Phy. | H&P - Infant with fever | CHIEF COMPLAINT:, Irritable baby with fever for approximately 24 hours.,HISTORY OF PRESENT ILLNESS:, This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room... | null |
4,346 | H&P for a female with Angina pectoris. | Consult - History and Phy. | H&P - Cardio (Angina) | CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Con... | null |
4,347 | Dysarthria. Probable brainstem glioma. | Consult - History and Phy. | Glioma - 1 | CC:, Dysarthria,HX: ,This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a ... | null |
4,348 | Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled. | Consult - History and Phy. | GI Consultation - 4 | CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female. Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 ... | null |
4,349 | Headache and diplopia. | Consult - History and Phy. | Granulomatous Inflammation | CC:, Headache and diplopia.,HX:, This 39 y/o African American female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. The pain localized to bifronto-temporal regions of the head and did not radiate. There was no associated nausea, vomiting, photophobia or phonophobia. The... | null |
4,350 | Headache. Right frontal lobe glioma. | Consult - History and Phy. | Glioma - 2 | CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches,... | consult - history and phy., frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma, |
4,351 | Asked to see the patient in regards to a brain tumor. She was initially diagnosed with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. | Consult - History and Phy. | Glioblastoma Multiforme - Consult | REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. She was seen by Dr. X in our... | null |
4,352 | Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery. | Consult - History and Phy. | Glioma - Consult | REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982. She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery. She did well for the... | null |
4,353 | Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency, | Consult - History and Phy. | Gen Med H&P - 2 | HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats... | null |
4,354 | GI Consultation for Chrohn's disease. | Consult - History and Phy. | GI Consultation - 3 | PROBLEM: ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran. He is taking it at a dose of 100 mg per day. He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. In fact,... | null |
4,355 | History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT). | Consult - History and Phy. | Gen Med H&P - 1 | CHIEF COMPLAINT:, Left leg pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage IIIC papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on Saturday. The patient noticed the pain in her left groin and ... | null |
4,356 | Patient with several medical problems - numbness, tingling, and a pain in the toes. | Consult - History and Phy. | Gen Med Consult - 6 | SUBJECTIVE:, The patient is in with several medical problems. She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain. She initially describes it as a sharp quality pain, but is unable to characterize it more fully. She has had it for about a year, but se... | null |
4,357 | Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia. | Consult - History and Phy. | Gen Med Consult - 9 | SUBJECTIVE:, The patient is well-known to me. He comes in today for a comprehensive evaluation. Really, again he borders on health crises with high blood pressure, diabetes, and obesity. He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health de... | |
4,358 | GI Consultation due to rectal bleeding, positive celiac sprue panel | Consult - History and Phy. | GI Consultation - 1 | PROBLEM: ,Rectal bleeding, positive celiac sprue panel.,HISTORY: ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits. She noted that her symptoms were getting i... | consult - history and phy., bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet, |
4,359 | The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis. | Consult - History and Phy. | Gen Med Consult - 53 | HISTORY OF PRESENT ILLNESS: , Goes back to yesterday, the patient went out for dinner with her boyfriend. The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night. She was found down on the floor this morning, soiled her bowel... | null |
4,360 | GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests. | Consult - History and Phy. | GI Consultation - 2 | PROBLEM: ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further e... | null |
4,361 | Right-sided facial droop and right-sided weakness. Recent cerebrovascular accident. he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident. | Consult - History and Phy. | Gen Med Consult - 7 | CHIEF COMPLAINT:, Right-sided facial droop and right-sided weakness.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferr... | null |
4,362 | Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control. | Consult - History and Phy. | Gen Med Consult - 8 | SUBJECTIVE:, The patient comes in today for a comprehensive evaluation. She is well-known to me. I have seen her in the past multiple times.,PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: , Noted and reviewed today. They are on the health care flow sheet. She has significant anxiety which has been under fair ... | |
4,363 | Patient with swelling of lips and dysphagia and Arthritis. | Consult - History and Phy. | Gen Med Consult - 5 | CHIEF COMPLAINT: , Swelling of lips causing difficulty swallowing.,HISTORY OF PRESENT ILLNESS:, This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago, she developed a res... | consult - history and phy., swelling, iv hydration, osteoporosis, swelling of lips, allergic reaction, arthritis, difficulty swallowing, leucovorin, low-grade fever, methotrexate, respiratory infection, rheumatoid arthritis, flare of arthritis, rheumatoid, mucosa, dysphagia, |
4,364 | A female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot. | Consult - History and Phy. | Gen Med Consult - 49 | HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot. ... | null |
4,365 | An 86-year-old female with persistent abdominal pain, nausea and vomiting, during evaluation in the emergency room, was found to have a high amylase, as well as lipase count and she is being admitted for management of acute pancreatitis. | Consult - History and Phy. | Gen Med Consult - 50 | CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: , This is an 86-year-old female who is a patient of Dr. X, who was transferred from ABCD Home due to persistent abdominal pain, nausea and vomiting, which started around 11:00 a.m. yesterday. During evaluation in the emergency room, the patient was found t... | null |
4,366 | The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders. | Consult - History and Phy. | Gen Med Consult - 54 | HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders. As per the patient, she also has a history of s... | null |
4,367 | Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction. The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. | Consult - History and Phy. | Gen Med Consult - 51 | CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. He described the pain as 8/10 in severity and the intensity varied. The sym... | null |
4,368 | For evaluation of left-sided chest pain, 5 days post abdominal surgery. | Consult - History and Phy. | Gen Med Consult - 45 | REASON FOR CONSULT: , For evaluation of left-sided chest pain, 5 days post abdominal surgery.,PAST MEDICAL HISTORY:, None.,HISTORY OF PRESENT COMPLAINT: , This 87-year-old patient has been admitted in this hospital on 12/03/08. The patient underwent laparoscopic appendicectomy by Dr. X. The patient had postoperative ... | null |
4,369 | Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia. | Consult - History and Phy. | Gen Med Consult - 46 | DIAGNOSES:,1. Pneumonia.,2. Crohn disease.,3. Anasarca.,4. Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY: ,The patient is a 41-year-old gentleman with a long history of Crohn disease. He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroe... | null |
4,370 | Anxiety, alcohol abuse, and chest pain. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. | Consult - History and Phy. | Gen Med Consult - 52 | CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:, This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain. The patient states that he complained of this chest pain, which is reproducible, pleuritic in ... | consult - history and phy., anxiety, alcohol abuse, chest pain, digoxin toxicity, digoxin overuse, atrial fibrillation, opioid dependence, toxicity, dilaudid, |
4,371 | The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally. | Consult - History and Phy. | Gen Med Consult - 47 | HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain. The patient was well visiting in ABC, with her daughter that evening. She had pain in her left posterior pelvic and low back region. They came back to XYZ the following day. By the time they got he... | consult - history and phy., inflammatory, degenerative, fever, lumbar spine, sacroiliac joint, inguinal, sacroiliac, hip, |
4,372 | An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds. | Consult - History and Phy. | Gen Med Consult - 44 | PAST MEDICAL HISTORY: Include:,1. Type II diabetes mellitus.,2. Hypertension.,3. Hyperlipidemia.,4. Gastroesophageal reflux disease.,5. Renal insufficiency.,6. Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7. Enterocutaneous fistula.,8. Respiratory failure.,9. History ... | null |
4,373 | A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. | Consult - History and Phy. | Gen Med Consult - 43 | HISTORY:, A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital. The patient subsequently developed CVA. She also developed thrombosis of the righ... | consult - history and phy., arterial thrombosis, valvular heart disease, atherosclerotic heart disease, type ii diabetes, hypertension, carotid stenosis, heart disease, diabetes, carotid, stenosis, bypass, amputation, heart, atherosclerotic, |
4,374 | The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. | Consult - History and Phy. | Gen Med Consult - 48 | HISTORY:, The patient presents today for medical management. The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. She has been off her supplements for four weeks with some improve... | null |
4,375 | Patient with a diagnosis of stroke. | Consult - History and Phy. | Gen Med Consult - 40 | CHIEF COMPLAINT:, Altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. Whe... | null |
4,376 | Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis. | Consult - History and Phy. | Gen Med Consult - 41 | SUBJECTIVE:, The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night.,PAST MEDICAL HISTORY:, She denies sexual act... | consult - history and phy., backache, stomachache, dysuria, cylert, urinary dysuria, pharyngitis, culture and sensitivity, tenderness, urinary, infection, |
4,377 | Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea. Medifast does fatigue | Consult - History and Phy. | Gen Med Consult - 42 | HISTORY AND CLINICAL DATA: ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, o... | null |
4,378 | Consultation for jaw pain. | Consult - History and Phy. | Gen Med Consult - 4 | CHIEF COMPLAINT:, Jaw pain this morning.,BRIEF HISTORY OF PRESENT ILLNESS:, This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease. The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroid... | null |
4,379 | Patient admitted with abdominal pain, nausea and vomiting. | Consult - History and Phy. | Gen Med Consult - 38 | Chief Complaint:, Abdominal pain, nausea and vomiting.,History of Present Illness:, A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomit... | null |
4,380 | Patient with hypertension, dementia, and depression. | Consult - History and Phy. | Gen Med Consult - 33 | MEDICAL PROBLEM LIST:,1. Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.,2. Dementia and depression.,3. Hypertension.,4. History of atrial fibrillation. The patient has been in sinus rhythm as of late. The patient is not anticoagulated due to fall risk.,5... | null |
4,381 | A male patient presented for evaluation of chronic abdominal pain. | Consult - History and Phy. | Gen Med Consult - 34 | Chief Complaint:, Chronic abdominal pain.,History of Present Illness:, 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing e... | null |
4,382 | Patient with confusion and hallucinations. | Consult - History and Phy. | Gen Med Consult - 35 | Chief Complaint:, Confusion and hallucinations.,History of Present Illness:, The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and ... | null |
4,383 | Patient with abdominal pain, nausea, vomiting, fever, altered mental status. | Consult - History and Phy. | Gen Med Consult - 39 | Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately ... | null |
4,384 | Patient coughing up blood and with severe joint pain. | Consult - History and Phy. | Gen Med Consult - 36 | Chief Complaint:, coughing up blood and severe joint pain.,History of Present Illness:, The patient is a 37 year old African American woman with history of chronic allergic rhinitis who presents to an outpatient clinic with severe pain in multiple joints and hemoptysis for 1 day. The patient was at her baseline state ... | null |
4,385 | Patient with complaint of dark urine and generalized weakness. | Consult - History and Phy. | Gen Med Consult - 37 | Chief Complaint:, Dark urine and generalized weakness.,History of Present Illness:,40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had ... | null |
4,386 | Examination due to blood-borne pathogen exposure. | Consult - History and Phy. | Gen Med Consult - 3 | CHIEF COMPLAINT:, Blood-borne pathogen exposure., ,HISTORY OF PRESENT ILLNESS: ,The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserti... | null |
4,387 | Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency | Consult - History and Phy. | Gen Med Consult - 32 | PROBLEM LIST:,1. Generalized osteoarthritis and osteoporosis with very limited mobility.,2. Adult failure to thrive with history of multiple falls, none recent.,3. Degenerative arthritis of the knees with chronic bilateral knee pain.,4. Chronic depression.,5. Hypertension.,6. Hyperthyroidism.,7. Aortic stenosis ... | null |
4,388 | Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness. | Consult - History and Phy. | Gen Med Consult - 31 | CHIEF COMPLAINT:, A 74-year-old female patient admitted here with altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient started the last 3-4 days to do poorly. She was more confused, had garbled speech, significantly worse from her baseline. She has also had decreased level of consciousness since yesterda... | null |
4,389 | Patient was found to have decrease in mental alertness | Consult - History and Phy. | Gen Med Consult - 30 | CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic med... | null |
4,390 | A 12-year-old young man with sinus congestion. | Consult - History and Phy. | Gen Med Consult - 22 | SUBJECTIVE:, This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home currently.,CURRENT MEDICATIONS:, ... | consult - history and phy., allergic rhinitis, sinus infection, sinus congestion, congestion, sinus |
4,391 | Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. | Consult - History and Phy. | Gen Med Consult - 24 | CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized ... | null |
4,392 | Patient in with mom for possible ear infection. | Consult - History and Phy. | Gen Med Consult - 23 | SUBJECTIVE:, Mom brings the patient in today for possible ear infection. He is complaining of left ear pain today. He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today. He has not had any fever but the congestio... | consult - history and phy., ear infection, productive-sounding cough, purulent rhinitis, serous otitis, sinusitis, wheezing, ear, amoxicillin, |
4,393 | The patient brought in by EMS with a complaint of a decreased level of consciousness. | Consult - History and Phy. | Gen Med Consult - 28 | HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night b... | consult - history and phy., level of consciousness, parkinson disease, altered mental status, dehydration, elderly abuse, decreased level of consciousness, ems, parkinson, consciousness, xanax, sinemet, decreased, |
4,394 | Patient with a past medical history of atrial fibrillation and arthritis complaining of progressively worsening shortness of breath. | Consult - History and Phy. | Gen Med Consult - 25 | CHIEF COMPLAINT:, "I can’t walk as far as I used to.",HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual stat... | null |
4,395 | Nausea, vomiting, diarrhea, and fever. | Consult - History and Phy. | Gen Med Consult - 27 | CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought... | |
4,396 | A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis | Consult - History and Phy. | Gen Med Consult - 21 | SUBJECTIVE:, The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage. She does take Zyrtec on a fairly regular basis. Mom is having some allergy trouble herself right now. She does not know her colors. She knows some of her shapes. She speaks in sentences... | consult - history and phy., allergic rhinitis, nasal drainage, stuffiness, congestion, drainage, |
4,397 | 11-year-old female. History of congestion, possibly enlarged adenoids. | Consult - History and Phy. | Gen Med Consult - 20 | SUBJECTIVE:, This is an 11-year-old female who comes in for two different things. 1. She was seen by the allergist. No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting. They do not notice a lot of snoring at night though, but she seems to be always like that... | consult - history and phy., enlarged adenoids, adenoids, oropharynx, congestion, toenails, toe, |
4,398 | Patient with intermittent episodes of severe nausea and abdominal pain. | Consult - History and Phy. | Gen Med Consult - 29 | CHIEF COMPLAINT: , This is a previously healthy 45-year-old gentleman. For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ not... | consult - history and phy., sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent, |
4,399 | Initial clinic visit for foreign body in left eye. | Consult - History and Phy. | Gen Med Consult - 2 | HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye. He states that he was doing his normal job when he felt a foreign body sensation. He attempted to flush this at work, but has had persistent pain which has progressively worsened thro... | null |
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