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4,400 | Patient presents complaining of abdominal pain and discomfort for 3 weeks. | Consult - History and Phy. | Gen Med Consult - 26 | CHIEF COMPLAINT:, Abdominal pain and discomfort for 3 weeks.,HISTORY OF PRESENT ILLNESS:, ,The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdom... | null |
4,401 | 1-year-old male who comes in with a cough and congestion. Clinical sinusitis and secondary cough. | Consult - History and Phy. | Gen Med Consult - 18 | SUBJECTIVE:, This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks. Started off as a congestion but then he started coughing about a week ago. Cough has gotten worsen. Mother was also worried. He had Pop Can just three days ago and she never found the top of that and wa... | consult - history and phy., congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis, |
4,402 | An 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. - Allergic rhinitis, fever history, sinusitis resolved, and teething. | Consult - History and Phy. | Gen Med Consult - 17 | CHIEF COMPLAINT:, Fever.,HISTORY OF PRESENT ILLNESS:, This is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. Mother states he just completed Amoxil several days ago for a sinus infection. Patient does have a past history compatible with allergic rhinitis ... | consult - history and phy., sinusitis, fever, intermittent fever, allergic rhinitis, fever history, teething, |
4,403 | 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet. | Consult - History and Phy. | Gen Med Consult - 19 | SUBJECTIVE:, This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet. The patient is in foster care, has a long history of the prematurity, born at 22 weeks. She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2... | consult - history and phy., chronic lung disease, signs of infection, breathing status, foster mom, foster care, pediasure |
4,404 | Short-term memory loss (probable situational) and anxiety stress issues. | Consult - History and Phy. | Gen Med Consult - 16 | CHIEF COMPLAINT:, Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in N... | consult - history and phy., short-term memory loss, anxiety, short term memory loss, memory loss, stress issues, situational, memory, stress, |
4,405 | Complaint of mood swings and tearfulness. | Consult - History and Phy. | Gen Med Consult - 15 | HISTORY OF PRESENT ILLNESS:, A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stat... | consult - history and phy., tearfulness, mood swings, menopause, postsurgical menopause, mood swings and tearfulness, hormone replacement therapy, breast cancer, wellbutrin, |
4,406 | Consult for hypertension and a med check. History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. | Consult - History and Phy. | Gen Med Consult - 13 | SUBJECTIVE:, The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check. She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Since her last visit she has been followed by Dr. Kumar. Those is... | null |
4,407 | Feeling weak and shaky - Dyspnea on exertion and history of diabetes | Consult - History and Phy. | Gen Med Consult - 12 | CHIEF COMPLAINT:, Weak and shaky.,HISTORY OF PRESENT ILLNESS:, The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky. When questioned further, she described shortness of breath primarily with ambulation. She denies chest pain. She denies cough, hemoptysis, dyspn... | null |
4,408 | Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement. | Consult - History and Phy. | Gastrointestinal Bleed - ER Visit | ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS: ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell. She states that she woke yesterday morning and at approximately 10:30 had a bowel movement. She noticed it was very dark... | null |
4,409 | Complaint of left otalgia (serous otitis) and headache. History of atopic dermatitis. | Consult - History and Phy. | Gen Med Consult - 14 | HISTORY OF PRESENT ILLNESS:, A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache. Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved. She is having some left-sided sinus pressure a... | null |
4,410 | Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia). | Consult - History and Phy. | Gen Med Consult - 11 | CHIEF COMPLAINT:,1. Infection.,2. Pelvic pain.,3. Mood swings.,4. Painful sex.,HISTORY OF PRESENT ILLNESS:, The patient is a 29-year-old female who is here today with the above-noted complaints. She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she h... | null |
4,411 | Checkup - Joints hurting all over - Arthralgias that are suspicious for inflammatory arthritis. | Consult - History and Phy. | Gen Med Consult - 10 | CHIEF COMPLAINT:, Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:, A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Day... | null |
4,412 | Return to work & Fit for duty evaluation. | Consult - History and Phy. | Gen Med Consult - 1 | HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist l... | consult - history and phy., return to work, consult, fit for duty, cleared for work, muscular, paresthesias, shoulder, shoulder pain, strain, waist, x-rays, waist level, neurologic, abnormalities, impingement, examination, |
4,413 | Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery. | Consult - History and Phy. | Gastric Bypass Discussion - 3 | PAST MEDICAL HISTORY:, Significant for hypertension. The patient takes hydrochlorothiazide for this. She also suffers from high cholesterol and takes Crestor. She also has dry eyes and uses Restasis for this. She denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleedi... | consult - history and phy., weight watchers, roux en y, atkins, medifast, meridia, south beach, cabbage, diets, laparoscopic roux en y gastric bypass surgery, rice, weight loss, six weeks of medifast, weight loss modalities, body mass index, gastric bypass surgery, bariatric surgery, gastric bypass, |
4,414 | Patient scheduled for laparoscopic gastric bypass. | Consult - History and Phy. | Gastric Bypass Discussion - 2 | HISTORY: , The patient is scheduled for laparoscopic gastric bypass. The patient has been earlier seen by Dr. X, her physician. She has been referred to us from Family Practice. In short, she is a 33-year-old lady with a BMI of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. ,She was on l... | consult - history and phy., medifast, laparoscopic gastric bypass, short-term complications, long-term complications, gastric bypass, complications of gastric bypass, weight loss, |
4,415 | Pediatric Gastroenterology - History of gagging. | Consult - History and Phy. | Gagging - 3-year-old | HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging. She was doing well until about 2 days ago, when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rec... | consult - history and phy., g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube, |
4,416 | Foreign body of the left fifth fingernail (wooden splinter). He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him. | Consult - History and Phy. | Foreign Body - Fingernail | HISTORY OF PRESENT ILLNESS:, Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.,The patient believes it... | consult - history and phy., horse serum, wooden splinter, foreign body, nail plate, grasp, fingernail, splinter, |
4,417 | Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 | Consult - History and Phy. | Gastric Bypass Discussion - 1 | HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremiti... | consult - history and phy., medifast, medifast dieting, hypertension, atrial fibrillation, hyperlipidemia, sleep apnea, morbid obesity, metabolic comorbidities, weight loss, supermorbid obesity, gastric bypass, bypass, |
4,418 | Abscess of the left foot, etiology unclear at this time. Possibility of foreign body. | Consult - History and Phy. | Foot Infection Management | REASON FOR CONSULTATION: ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot. He noticed a small dark spot. He did not remember having had any injuries to that ... | consult - history and phy., accutane, possibility of foreign body, foot etiology, foreign body, infection, foot, abscess, |
4,419 | Foul-smelling urine and stomach pain after meals. | Consult - History and Phy. | Foul-Smelling Urine | CHIEF COMPLAINT:, Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:, Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time. She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI. This visit was i... | null |
4,420 | Consultation for left foot pain. | Consult - History and Phy. | Foot pain Consultation | CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to contin... | consult - history and phy., foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness |
4,421 | Complete eye examination - Normal eye and vision exam. | Consult - History and Phy. | Eye Examination - H&P | CHIEF COMPLAINT:, This 26-year-old male presents today for a complete eye examination.,ALLERGIES:, Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:, Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. Gener... | null |
4,422 | Questionable foreign body, right nose. Belly and back pain. Mild constipation. | Consult - History and Phy. | Foreign Body - Right Nose | CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels... | |
4,423 | Left flank pain, ureteral stone. | Consult - History and Phy. | Flank Pain - Consult - 1 | REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain. The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history. The patient has had pain in the abdomen ... | consult - history and phy., flank pain, ureteral stone, shockwave lithotripsy, shockwave, nausea, vomiting, lithotripsy, ureteral, stone, |
4,424 | Patient returns for his first followup after shunt surgery. | Consult - History and Phy. | First Followup - Shunt Surgery | REASON FOR VISIT:, Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS: ,I have followed Mr. A since May 2008. He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control. We established a diagnos... | null |
4,425 | First Pap smear, complaining of irregular periods. - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods. | Consult - History and Phy. | First Pap smear. | CHIEF COMPLAINT:, The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:, The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods. She notes that her periods are out of weck. She says that she has cramping and pa... | null |
4,426 | Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. | Consult - History and Phy. | Feet & Hand Cramping | HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports... | null |
4,427 | The patient presents for a followup for history of erythema nodosum. | Consult - History and Phy. | Erythema Nodosum - Consult | REASON FOR VISIT:, The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specif... | null |
4,428 | Severe tonsillitis, palatal cellulitis, and inability to swallow. | Consult - History and Phy. | Exudative Tonsillitis | CHIEF COMPLAINT: ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse. He was unable to swallow. He complained to his parent. He was taken to Med Care and did not g... | null |
4,429 | Left flank pain and unable to urinate. | Consult - History and Phy. | Flank Pain - Consult | CHIEF COMPLAINT: , Left flank pain and unable to urinate.,HISTORY: , The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She ... | consult - history and phy., flank pain, unable to urinate, urinary tract infection, flank, |
4,430 | This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. | Consult - History and Phy. | Essential Tremor & Torticollis | REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade. She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for ... | consult - history and phy., clonazepam, difficulty writing, head tremor, voice tremor, migraine headaches, mri brain, essential tremor, torticollis, carcinoma, |
4,431 | Fall with questionable associated loss of consciousness. Left parietal epidural hematoma. | Consult - History and Phy. | Epidural Hematoma | CC:, Fall with questionable associated loss of consciousness.,HX: ,This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he ... | consult - history and phy., loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma, |
4,432 | Fall/loss of consciousness. | Consult - History and Phy. | Epidural Fluid Collection | CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UI... | consult - history and phy., loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone, |
4,433 | This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology. | Consult - History and Phy. | ER Report - Rib Cage Pain | HISTORY:, The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today. He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had "rib cage pain" for the last few days. He denies any history of trauma. He does have incr... | null |
4,434 | Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis. | Consult - History and Phy. | ENT Consult | HISTORY:, The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss. The patient reports that she has been having history of recurrent sinus infection, averages about three times per year. D... | null |
4,435 | Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain. | Consult - History and Phy. | End Stage Renal Disease - Consult | REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:, This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status ... | null |
4,436 | Encephalopathy related to normal-pressure hydrocephalus. | Consult - History and Phy. | Encephalopathy - Rehab Consult | ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:, Diminished function secondary to above.,HISTORY: ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was dia... | null |
4,437 | Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream. | Consult - History and Phy. | Elevated PSA - H&P | CHIEF COMPLAINT:, This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. Timing (onset/frequency): Onset was 6 mon... | null |
4,438 | Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy. | Consult - History and Phy. | ENT Consult - 1 | CHIEF COMPLAINT: , Chronic otitis media, adenoid hypertrophy.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions. He also has a history of chronic mouth breathing and heroic snoring with examination reveal... | consult - history and phy., chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy, pe tubes, otitis media with effusion, adenoidectomy and bilateral myringotomy, eustachian tube dysfunction, insertion of pe, chronic otitis media, bilateral myringotomy... |
4,439 | Elevated BNP. Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension. | Consult - History and Phy. | Elevated BNP - Consult | REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:, The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Card... | null |
4,440 | Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia. | Consult - History and Phy. | Elbow Pain - Consult | CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS: ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He ... | |
4,441 | 13 years old complaining about severe ear pain - Chronic otitis media. | Consult - History and Phy. | Ear pain - Pediatric Consult | PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain. He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS: ,Patient reports that he felt good after taking antibioti... | null |
4,442 | Abnormal cardiac enzyme profile. The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. | Consult - History and Phy. | Elevated Cardiac Enzymes | REASON FOR CONSULTATION:, Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profi... | null |
4,443 | Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets. | Consult - History and Phy. | Ecstasy Ingestion - ER Visit | CHIEF COMPLAINT:, "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets. The patient upon returning to home w... | consult - history and phy., nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy, |
4,444 | A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago. | Consult - History and Phy. | Dog Bite | CHIEF COMPLAINT:, Dog bite to his right lower leg.,HISTORY OF PRESENT ILLNESS:, This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right ... | null |
4,445 | Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. At times, she also feels as though she is going to pass out. These sensations stop if she just sits ... | Consult - History and Phy. | Dizziness - Recurrent | CHIEF COMPLAINT:, Recurrent dizziness x1 month.,HISTORY OF PRESENT ILLNESS:, This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheuma... | null |
4,446 | Patient with episode of lightheadedness and suddenly experienced vertigo. | Consult - History and Phy. | Dural AVM | CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to h... | consult - history and phy., avm, episode of lightheadedness, vascular malformation, cavernous angioma, vascular blush, cerebellar hemisphere, malformation, cavernous, angioma, angiography, lightheadedness, hemisphere, vertigo, cerebellar, |
4,447 | Right ear pain with drainage - otitis media and otorrhea. | Consult - History and Phy. | Ear Pain - Drainage | CHIEF COMPLAINT:, Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:, This is a 12-year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has... | consult - history and phy., drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear, |
4,448 | Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis | Consult - History and Phy. | Dysphagia & Hematemesis | CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cou... | null |
4,449 | A 12-year-old with discoid lupus on the control with optimal regimen. | Consult - History and Phy. | Discoid Lupus | HISTORY: ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit. She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus. A has been doing well with just Plaquenil alone and m... | consult - history and phy., lupus, systemic lupus, acanthosis nigricans, discoid lupus, extremities, rash, erythema, discoid, |
4,450 | He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again. | Consult - History and Phy. | Diplopia | HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dis... | null |
4,451 | A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure. He has noted shortness of breath with exertion and occasional shortness of breath at rest. | Consult - History and Phy. | Dilated Cardiomyopathy - Consult | REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure. He feels in general "OK," but is stressed... | null |
4,452 | Difficulty with both distance vision and with fine print at near. | Consult - History and Phy. | Difficulty Distance Vision & Fine Print at Near | REASON FOR VISIT: , Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient. He states that he has difficulty with both his distance vision and also with fine print at near.,HISTORY OF PRESENT ILLNESS:, Mr. ABC states that over the last year, he has had increasing difficulty with distance vi... | null |
4,453 | Dietary consultation for weight reduction secondary to diabetes. | Consult - History and Phy. | Dietary Consultation - 2 | SUBJECTIVE:, This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes. She did attend diabetes education classes at Abc Clinic. She comes however, wanting to really work at weight reduction. She indicates that she has been on the Atkins' diet for about two years and... | consult - history and phy., consultation, atkins' diet, blood sugar reaction, diabetes, diabetes education, diabetes education classes, diet history, dietary consultation, dietary guidelines, meal plan, protein, veggie diet, weight reduction, caloric intake, blood sugar, reduction, sugar, calories, blood, dietary, weig... |
4,454 | Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. | Consult - History and Phy. | Disseminated Intravascular Coagulation | DIAGNOSES:,1. Disseminated intravascular coagulation.,2. Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and ... | consult - history and phy., intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated, |
4,455 | Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. | Consult - History and Phy. | Dietary Consult - Weight Reduction | SUBJECTIVE:, This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendation... | consult - history and phy., hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food |
4,456 | Dietary consultation for gestational diabetes. | Consult - History and Phy. | Dietary Consult - Gestational Diabetes | SUBJECTIVE:, This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historically however, she likes to eat out with ... | consult - history and phy., blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning |
4,457 | Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia. | Consult - History and Phy. | Dietary Consultation - 1 | SUBJECTIVE:, This is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia. The patient reports that she has resumed food record keeping which she feels like it has given her greater control. Her physical activity level has remained high. Her struggle times are in the mid-afternoon if s... | consult - history and phy., dietary consultation, calorie count, calorie points, consultation, food choices, food record, hyperlipidemia, low-fat cheese, many fruits and vegetables, physical activity, polycystic ovarian syndrome, snack, dietary, polycystic, food, afternoon |
4,458 | Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome | Consult - History and Phy. | Dietary Consult - Hyperlipidemia | SUBJECTIVE:, This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome. The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it. She is not sure that she was... | consult - history and phy., hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight |
4,459 | Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983. | Consult - History and Phy. | Dietary Consult - Diabetes - 2 | SUBJECTIVE:, The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds. She was diagnosed with type 2 diabetes in 1983. She is not allergic to any medicines.,DIABETES MEDICATIONS:, Her diabetes medications include Humulin insulin 70/30, 44 units at ... | consult - history and phy., dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes, |
4,460 | The patient is brought in by an assistant with some of his food diary sheets. | Consult - History and Phy. | Dietary Consult - 3 | SUBJECTIVE:, The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.,OBJECTIVE:, The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went o... | consult - history and phy., weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food |
4,461 | The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. | Consult - History and Phy. | Dietary Consult - 2 | SUBJECTIVE:, The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.,OBJECTIVE:, Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food d... | consult - history and phy., food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food |
4,462 | Dietary consultation for diabetes during pregnancy. | Consult - History and Phy. | Dietary Consult - Diabetes - 1 | SUBJECTIVE:, This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. Patient reports that she had gestational diabetes with her first pregnancy. She did use insulin at that time as well. She does not fully understand what ketones are. She walks her daughter to school and back... | consult - history and phy., diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks |
4,463 | One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes. | Consult - History and Phy. | Decreased Vision Consult | She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003. She also has a history of glaucoma diagnosed in 1990 and macular degeneration. She has been followed in her home country and is here visiting family. She had the above-mentioned observation and was brought i... | consult - history and phy., cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision, |
4,464 | Counting calorie points, exercising pretty regularly, seems to be doing well | Consult - History and Phy. | Dietary Consult - 4 | SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. Th... | consult - history and phy., overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly |
4,465 | This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. | Consult - History and Phy. | Dental Pain | CHIEF COMPLAINT:, Dental pain.,HISTORY OF PRESENT ILLNESS:, This is a 27-year-old female who presents with a couple of days history of some dental pain. She has had increasing swelling and pain to the left lower mandible area today. Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pa... | consult - history and phy., dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental, |
4,466 | Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. | Consult - History and Phy. | CVA Consult - ER Visit | ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this... | null |
4,467 | A 10 years of age carries a diagnosis of cystic fibrosis | Consult - History and Phy. | Cystic Fibrosis | INTERVAL HISTORY:, ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit. He was accompanied by his adopted mother. He is attending the fourth grade and has not missed significant days for illness. He has a chronic cough that has been slightly in... | null |
4,468 | A male referred to Wheelchair Clinic for evaluation for a new wheelchair. | Consult - History and Phy. | Consult for New Wheelchair | HISTORY OF PRESENT ILLNESS:, This 42-year-old male was referred to Wheelchair Clinic for evaluation for a new wheelchair. The client has a power wheelchair at home and it is two years old. However, he is unable to transfer throughout the community. The client does have two teenage children for which he does need to... | null |
4,469 | A female with unknown gestational age who presents to the ED after a suicide attempt. | Consult - History and Phy. | Consult/ER Report - OB/GYN | The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period. She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus. She states that upon removal of a tampon, she saw a ta... | null |
4,470 | The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder. | Consult - History and Phy. | Conversion Disorder | REASON FOR REFERRAL: ,The patient was referred to me by Dr. X of Children's Hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder. I had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time. After h... | consult - history and phy., developmental history, academic background, global assessment of functioning, normal school environment, conversion reactions, conversion disorder, conversion, background, environment, peers, disorder, axis, |
4,471 | Patient presents for a colostomy reversal as well as repair of an incisional hernia. | Consult - History and Phy. | Consult for Colostomy Reversal | CHIEF COMPLAINT: , "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital wi... | null |
4,472 | A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe. | Consult - History and Phy. | Consult - Vomiting & Nausea | CHIEF COMPLAINT:, Vomiting and nausea.,HPI: , The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe. She states she has it at least once a day. It can be any time, but can also be postprandial. She states she will vomit up some dark brown-to-green fluid.... | null |
4,473 | A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse. | Consult - History and Phy. | Detox from Heroin | CHIEF COMPLAINT:, Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mos... | consult - history and phy., phenergan, detox from heroin, alcohol abuse, heroin abuse, detox, heroin, alcohol, cocaine, abuse, |
4,474 | Elevated cholesterol and is on medication to lower it. | Consult - History and Phy. | Dietary Consult - 1 | SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has sta... | consult - history and phy., vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol |
4,475 | Patient had a piece of glass fall on to his right foot. A 4-mm laceration. Acute foot pain, now resolved. The patient was given discharge instructions on wound care. | Consult - History and Phy. | Cut on Foot - ER Visit | CHIEF COMPLAINT:, Cut on foot.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has n... | consult - history and phy., foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body, |
4,476 | Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis. | Consult - History and Phy. | Cough & Abdominal Pain | CHIEF COMPLAINT: , Cough and abdominal pain for two days.,HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient sta... | null |
4,477 | Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. | Consult - History and Phy. | Consult - Seizures - 1 | CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS: ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. The patient stated she was... | |
4,478 | Nonhealing right ankle stasis ulcer. A 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers was admitted for scheduled vascular surgery. | Consult - History and Phy. | Consult - Stasis Ulcer | REASON FOR THE CONSULT:, Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for... | null |
4,479 | Patient was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. | Consult - History and Phy. | Consult - Syncope | REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS: ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies ... | null |
4,480 | Consultation - an 87-year-old white female with weakness and a history of polymyositis. | Consult - History and Phy. | Consult - Weankness & Polymyositis | REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnor... | null |
4,481 | Sepsis, possible SBP. A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigast... | Consult - History and Phy. | Consult - Sepsis | REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees. He complained of b... | null |
4,482 | Patient referred for evaluation of her left temporal lobe epilepsy. | Consult - History and Phy. | Consult - Seizures | REASON FOR CONSULTATION: ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:, This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002. At that time, she had one... | null |
4,483 | Consult for prostate cancer | Consult - History and Phy. | Consult - Prostate Cancer | CONSULT FOR PROSTATE CANCER,The patient returned for consultation for his newly diagnosed prostate cancer. The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding, infection, rectal injury, impotence, and incontinence. These were discussed at length... | consult - history and phy., prostate cancer, cryosurgery, hdr radiation, prostate surgery, bladder, bleeding, bowel, consultation, impotence, incontinence, infection, prostatectomy, radiation therapy, radical, rectal, rectal fistula, rectal injury, prostate cancer consult, cancer, radiation, prostateNOTE,: Thesetranscr... |
4,484 | Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. | Consult - History and Phy. | Consult - Rectal Bleeding | PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. The patient states that he had his first colonoscopy 6 year... | consult - history and phy., heartburn, family history of esophageal cancer, repeat colonoscopy, colonoscopy, egd, irc, barrett's esophagus, restless legs syndrome, esophageal cancer, rectal bleeding, colon cancer, rectal, bleeding, cancer, |
4,485 | Chronic headaches and pulsatile tinnitus. | Consult - History and Phy. | Consult - Pulsatile Tinnitus | HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus. The patient reports she has been having daily headaches since 02/25/2008. She has been getting pulsations in the head with heartbeat sounds. Headaches are... | null |
4,486 | The patient needs refills on her Xanax | Consult - History and Phy. | Consult - Smoking Cessation | CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:, The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cau... | consult - history and phy., quit smoking, chantix, mesothelioma, smoking, xanax, refills |
4,487 | Patient comes for discussion of a screening colonoscopy. | Consult - History and Phy. | Consult - Screening Colonoscopy | HISTORY:, A is a 55-year-old who I know well because I have been taking care of her husband. She comes for discussion of a screening colonoscopy. Her last colonoscopy was in 2002, and at that time she was told it was essentially normal. Nonetheless, she has a strong family history of colon cancer, and it has been a... | consult - history and phy., screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy, |
4,488 | The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus. | Consult - History and Phy. | Consult - Normal Pressure Hydrocephalus | REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus. He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:, I first saw him nearly a year ago on December 20, 2007. At that time, he had had a traumatic deterioration o... | null |
4,489 | A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future. | Consult - History and Phy. | Consult - Multiple Colon Polyps | HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTOR... | consult - history and phy., mesothelioma, risk for colon cancer, constipation, diarrhea, multiple colon polyps, colon cancer, colon polyps, colon, cancer, polyps, |
4,490 | The patient admitted with palpitations and presyncope. | Consult - History and Phy. | Consult - Palpitations & Presyncope | HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable patte... | consult - history and phy., presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart |
4,491 | Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue. | Consult - History and Phy. | Consult - Jaw Pain | HISTORY: ,The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain. This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue. This numbness has been present for approximately two months. It seems to be there "a... | null |
4,492 | Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. | Consult - History and Phy. | Consult - ICU Management | REASON FOR CONSULTATION: , ICU management.,HISTORY OF PRESENT ILLNESS: , The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. T... | null |
4,493 | The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup... | Consult - History and Phy. | Consult - Migraine | HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, ... | null |
4,494 | Marked right hydronephrosis without hydruria. | Consult - History and Phy. | Consult - Hydronephrosis | CHIEF COMPLAINT:, Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and a... | consult - history and phy., hydruria, hydronephrosis, review of systems, uterine cancer, breast cancer, mesothelioma, mastectomy, kidney, cancer, |
4,495 | The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. | Consult - History and Phy. | Consult - Facial Twitching | REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. She reports she is still having right posterior head pressure like sensations approximate... | consult - history and phy., grimacing, headache, clivus and petrous, facial twitching, sleep, facial, twitching, |
4,496 | Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet. | Consult - History and Phy. | Consult - Knee Pain | CHIEF COMPLAINT:, Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when s... | consult - history and phy., medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee, |
4,497 | Patient with mid-epigastric abdominal pain. Sonogram revealed gallstones. | Consult - History and Phy. | Consult - Laparoscopic Cholecystectomy | PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed. She is married. She is in sales. She does not smoke. She drinks wine a few drinks a month.,CURRENT MEDICATIONS: ,... | consult - history and phy., laparoscopic cholecystectomy, mid epigastric, epigastric abdominal, potential complications, laparoscopic, cholecystectomy, epigastric, abdomen, surgery, gallstones, disease, abdominal |
4,498 | Patient with a past medical history of hypertension for 15 years. | Consult - History and Phy. | Consult - Hypertension | HISTORY OF PRESENT ILLNESS:, The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension. According to the patient, s... | consult - history and phy., hypertension, ace inhibitor, accelerated hypertension, hctz, mra of the renal arteries, procrit, sma7, anemia, beta-blocker, doxorubicin, hemiparesis, history of cva, hyperkalemia, no abdominal bruit, uterine cancer, renal artery stenosis, artery stenosis, blood pressure, blood, pressure, re... |
4,499 | Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom exc... | Consult - History and Phy. | Consult - Coronary Artery Disease | REASON FOR CONSULTATION:, Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subseq... | null |
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