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Medical Specialty:
Consult - History and Phy.
Sample Name: Bladder Instillation
Description: Bladder instillation for chronic interstitial cystitis.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: The patient comes for bladder instillation for chronic interstitial cystitis.
SUBJECTIVE: The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not think she can take any more pain. She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help. They seem to be intensifying her pain. She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine. So, she has to have somebody come with her and that is kind of troublesome to her. We discussed this at length. I did suggest that it was completely appropriate for her to decide. She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality. She had Hysterectomy in the past.
MEDICATIONS: Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.
ALLERGIES: Compazine and Allegra.
OBJECTIVE:
Vital Signs: Weight: 140 pounds. Blood pressure: 132/90. Pulse: 102. Respirations: 18. Age: 27.
PLAN: We discussed going for another evaluation by Dr. XYZ and seeking his opinion. She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete. The instillations give that a full trial and then he would be willing to see her back. As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her. She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend. I thought that was reasonable and agreed that that would work out.
PROCEDURE:: She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine. We waited about 20 minutes. The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed. The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder. She seemed to tolerate it moderately well. She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it. If not, she will cancel and will start over next week or she will see Dr. Friesen.
See More Samples on Consult - History and Phy.
A 5-month-old boy with cough
Abdominal Pain - Consult
Abnormal Echocardiogram
Abnormal Stress Test
Abrasions & Lacerations - ER Visit
Acne Vulgaris - H&P
Acute Cystitis & Diabetes Type II
Acute Inferior Myocardial Infarction
Adjustment Disorder & Encopresis
Admission History & Physical - Nausea
Adult Hydrocephalus
Agitation - ER Visit
Air Under Diaphragm - Consult
Airway Compromise & Foreign Body - ER Visit
Allergy Evaluation Consult
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Angina - Consult
Ankle Pain - Consult
Ankle Sprain - H&P
Annual Health Maintenance Exam
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Consult - Knee Pain
Consult - Laparoscopic Cholecystectomy
Consult - Migraine
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Consult - Palpitations & Presyncope
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Consult - Rectal Bleeding
Consult - Screening Colonoscopy
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Consult - Sepsis
Consult - Stasis Ulcer
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Cough & Abdominal Pain
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Diplopia
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Dog Bite
Dural AVM
Dysphagia & Hematemesis
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Ecstasy Ingestion - ER Visit
Elbow Pain - Consult
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End Stage Renal Disease - Consult
ENT Consult
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Epidural Fluid Collection
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Essential Tremor & Torticollis
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Eye Examination - H&P
Feet & Hand Cramping
First Followup - Shunt Surgery
First Pap smear.
Flank Pain - Consult
Flank Pain - Consult - 1
Foot Infection Management
Foot pain Consultation
Foreign Body - Fingernail
Foreign Body - Right Nose
Foul-Smelling Urine
Gagging - 3-year-old
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Hypersensitivity to Coumadin
Hypertension - Consult
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Hyperthyroidism Following Pregnancy
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Impairment Rating
Infant Not Gaining Weight
Infantile Spasms
Insect Sting
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Iron deficiency anemia
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Itchy Rash - ER Visit
Jaw Pain - ER Visit
Knee DJD - Consult
Knee Injury
Kyphoplasty - Consult
Kyphosis
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Leaking Nephrostomy Tube
Left Lower Quadrant Pain - ER Visit
Lesions - Adrenal and Pancreatic
Lightheaded & Dizziness
Lightheadedness
Limbic Encephalitis
Lobar Holoprosencephaly
Low Back Pain - Consult
Lower back pain
Lower Quadrant Pain
Lumbar Radiculopathy - Consult
Lumbar Spine HNP - Consult
Lumbosacral Polyradiculopathy
Lung Cancer & MI - Hospice Cosult
Lymphoblastic Leukemia - Consult
Lymphoma - Consult
Major Depressive Disorder - IME Consult
Malignant Meningioma - Consult
Mantle Cell Lymphoma - Consult
Marginal Zone Lymphoma
MCA Aneurysm
Medical Management Consult Request
Meningioma
Mental Status Changes - Consult
Mesothelioma - Consult
Metastatic Ovarian Cancer - Consult
Microhematuria - Consult
Migraine without Aura - Consult
Multilobar Pneumonia
Multiple Meningiomas
Multiple Neurological Symptoms
Murmur & Bacteremia.
Neck & Back Pain
Neck & Lower Back Pain - Consult
Neonatal Consult
Nephrology Consultation - 1
Nephrology Consultation - 2
Nephrology Consultation - 3
Nephrology Consultation - 4
Neuro Consult - Depression & Dementia
Neuro Consult - Leg Weakness
Neuroblastoma - Consult
Neurogenic Bladder - Consult
Neurologic Consultation
Neurologic Consultation - 1
Neurologic Consultation - 2
Neurologic Consultation - 3
Neurologic Consultation - 4
Neurologic Consultation - 5
Neurologic Examination
Neuropsychological Evaluation
Neuropsychological Evaluation - 1
Neuropsychological Evaluation - 2
Neuropsychological Evaluation - 3
Neuropsychological Evaluation - 4
Neuropsychological Evaluation - 5
New Onset Seizure
Non-Q-wave Myocardial Infarction
Non-Small Cell Lung Cancer - Consult
Normal Child Exam Template
Normal ENT Exam
Normal ENT Exam - 1
Normal Female Exam Template
Normal Female Exam Template - 1
Normal Female Exam Template - 2
Normal Female ROS Template
Normal Male Exam Template
Normal Male Exam Template - 1
Normal Male Exam Template - 2
Normal Male Exam Template - 3
Normal Male Exam Template - 4
Normal Male ROS Template - 1
Normal Newborn H&P Template
Normal Newborn Infant Physical Exam
Normal Physical Exam Template
Normal Physical Exam Template - 1
Normal Physical Exam Template - 2
Normal Physical Exam Template - 3
Normal Physical Exam Template - 4
Normal Physical Exam Template - 5
Normal Physical Exam Template - 6
Normal Physical Exam Template - 7
Normal ROS Template
Normal ROS Template - 1
Normal ROS Template - 2
Normal ROS Template - 3
Normal ROS Template - 4
Normal ROS Template - 5
Not Feeling Well - ER Visit
OB/GYN - H&P
OB/GYN Consultation - 1
OB/GYN Consultation - 2
OB/GYN Consultation - 3
OB/GYN Consultation - 4
Occupational Medicine Consult
Occupational Medicine Consult - 1
Occupational Medicine Consult - 2
Occupational Medicine Consult - 3
Oligoarticular Arthritis - 1
Oligoarticular Arthritis - 2
Onychomycosis - H&P
Organic Brain Syndrome
Orthopedic Consult
Orthopedic Consult - 1
Orthopedic Consult - 2
Orthopedic Consult - 3
Orthopedic Consult - 4
Orthopedic Consult - 5
Otitis Media - H&P
Pain from Hernia - ER Consult
Pain Management Consult - 1
Pain Management Consult - 2
Paroxysmal Atrial Fibrillation
Pediatric Rheumatology Consult
Penile Cellulitis
Penile Discharge
Pericardial Effusion
Perioperative Elevated Blood Pressure
Peripheral Effusion - Consult
Physical Exam and Pap - 1
Physical Exam and Pap -2
Pneumoconiosis
Pneumothorax & Subcutaneous Emphysema
Postop Medical Management
Preeclampsia
Preop Cardiac Consult
Prostate Adenocarcinoma
Prostate Adenocarcinoma - H&P
Pseudoseizures
Pseudotumor Cerebri
Psych Consult - Alcohol Withdrawal
Psych Consult - Altered Mental Status
Psych Consult - Anxiety
Psych Consult - Assaultive Behavior
Psych Consult - Bipolar Affective Disorder
Psych Consult - Dementia
Psych Consult - Depression - 1
Psych Consult - Depression - 2
Psych Consult - Lethargy
Psych Consult - Pain Meds
Psych Consult - Paranoia
Psych Consult - Psychosis
Psych Consult - Psychosis - 1
Psych Consult - Schizophrenia
Psych Consult - Substance abuse
Psych H&P - 1
Psych H&P - 2
Psychiatric Consult
Psychiatric Consult - 1
Psychiatric Consult - 2
Pubic Cellulitis
Pulmonary Consultation - 1
Pulmonary Consultation - 2
Pulmonary Edema - Consult
Pulmonary Embolism
Pulmonary Hypertension - Pediatric Consult
Records Review - Epicondylitis
Records Review - Orthopedic
Rectal Bleeding - 1-year-old
Rectal Bleeding - Consult
Recurrent Abscesses - Consult
Recurrent nasal obstruction
Renal Failure - Consult
Renal Failure Evaluation
Renal Insufficiency - Consult
Request For Consultation
Revocation Admission
Rheumatoid Arthritis - Consult
Rheumatoid Arthritis - H&P
Rotator cuff syndrome - H&P
School Physical - 1
School Physical - 2
Sepsis - Consult
Shoulder Pain Consult
Sick Sinus Syndrome
Sinus problems - Consult
Sleepiness - Consult
Small Bowel Obstruction
Speech Therapy Evaluation
Speech Therapy Evaluation - 1
Spinal fluid evaluation
Sports Physical - 1
Sports Physical - 2
Sports Physical - 3
Status Epilepticus
Supraclavicular Lymphadenopathy
Supraventricular Tachycardia - Consult
Syncope - ER Visit
Syncope - ER Visit - 1
T-Cell Lymphoma Consult
Tethered Cord Evaluation
Therapeutic Recreation Initial Evaluation
Thrombocytopenia - Consult
Thyroid Mass Consult
TIA - Cosult
TIA & Lumbar Stenosis
Tinea Pedis - H&P
Tongue Swelling
Toothache - ER Visit
Tracheostomy Tube Consult
Trouble Breathing - H&P
Ureteral Calculus - Consult
URI & Eustachian Congestion
Urinary Retention
Urology Consut - 1
Uveitis
Ventricular Ectopy - Consult
Vertigo Consult
Vertigo Consult - 1
Viral Gastroenteritis
Weight Gain and Edema
Weight Loss Evaluation
Well-Child Check - 1
Well-Child Check - 2
Well-Child Check - 3
Well-Child Check - 4
Well-Child Check - 5
Well-Child Check - 6
Well-Child Check - 7
Well-woman checkup
Worker's Compensation Injury
Wound Care Consult
Wrist Pain
Keywords: consult - history and phy., urethra, dmso, bladder, chronic interstitial cystitis, interstitial cystitis, bladder instillation, instillation, instillations,