Sample Type / Medical Specialty: Consult - History and Phy.

Consultations, initial evaluations, new patient visits, history and physicals, etc.

Consult - History and Phy.
A 5-month-old boy with cough
A 5-month-old boy brought by his parents because of 2 days of cough.
Abdominal Pain - Consult
The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.
Abnormal Echocardiogram
Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. The patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.
Abnormal Stress Test
Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.
Abrasions & Lacerations - ER Visit
A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.
Acne Vulgaris - H&P
Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris
Acute Cystitis & Diabetes Type II
The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.
Acute Inferior Myocardial Infarction
Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.
Adjustment Disorder & Encopresis
The patient was referred due to concerns regarding behavioral acting out as well as encopresis.
Admission History & Physical - Nausea
Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.
Adult Hydrocephalus
The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.
Agitation - ER Visit
Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.
Air Under Diaphragm - Consult
Possible free air under the diaphragm. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. No intra-abdominal pathology.
Airway Compromise & Foreign Body - ER Visit
The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.
Allergy Evaluation Consult
Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.
Anemia - Consult
Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.
Angina - Consult
Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.
Ankle Pain - Consult
The patient was running and twisted her right ankle - right ankle sprain.
Ankle Sprain - H&P
History and Physical for right ankle sprain
Annual Health Maintenance Exam
Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.
Ant Bait Exposure - ER Visit
Possible exposure to ant bait. She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.
Antibiotic Management Consult
Antibiotic management for a right foot ulcer and possible osteomyelitis.
Antibiotic Therapy Consult
Questionable need for antibiotic therapy for possible lower extremity cellulitis.
Arm Pain - Neuro Consult
Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.
Asbestos Exposure - Hemoptysis
Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.
Atrial Fibrillation - Consult
A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath.
Atrial Fibrillation Management
The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.
Attempted Suicide - Consult
The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.
Azotemia Consult
Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.
Bariatric Consult - Surgical Weight Loss - 1
Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.
Bariatric Consult - Surgical Weight Loss - 2
Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.
Bariatric Consult - Surgical Weight Loss - 3
Evaluation for bariatric surgery.
Bariatric Consult - Surgical Weight Loss - 4
Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.
Barium Swallow Study & Speech Evaluation
The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.
Barium Swallow Study & Speech Evaluation - 1
Barium Swallow Study Evaluation
Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and chocking with meals.
Barium Swallow Study Evaluation - 1
The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.
Bilateral Hip Pain
A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The pain is located laterally as well as anteriorly into the groin.
Bipolar Affective Disorder - Consult
The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.
Bladder Cancer
Patient with a history of gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.
Bladder Instillation
Bladder instillation for chronic interstitial cystitis.
Bladder Tumor
Recurrent bladder tumor. The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.
Blood In Toilet
Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.
Blood in Urine - ER Visit
Patient has prostate cancer with metastatic disease to his bladder. The patient has had problems with hematuria in the past. The patient was encouraged to drink extra water and was given discharge instructions on hematuria.
Brain Tumor - Consult
The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.
Breast Augmentation Consult
Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,
Breast Calcifications - Preop Consult
Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.
Breast Reconstruction
Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.
Bunion & Pes Planovalgus Deformity
Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.
Burn - Consult
First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.
Buttock Abscess
Left buttock abscess, status post incision and drainage. Recommended some local wound care
C. Diff Colitis Consult
The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.
Cancer of the nasopharynx
T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.
Carbohydrate Counting
Dietary consultation for carbohydrate counting for type I diabetes.
Cardiac Consult & Cardioversion
Patient with a history of atrial fibrillation in the past, more recently who has had atrial flutter. The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred.
Cardiac Consultation
A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD.
Cardiac Consultation - 1
To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.
Cardiac Consultation - 2
To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.
Cardiac Consultation - 3
Patient with atrial fibrillation with slow ventricular response, partially due to medications.
Cardiac Consultation - 4
Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.
Cardiac Consultation - 5
Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.
Cardiac Consultation - 6
Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.
Cardiac Consultation - 7
The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.
Cardiomyopathy & Hypotension - Consult
Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.
Cervical Cord Lesion - Consult
Patient reports a six to eight-week history of balance problems with later fatigue and weakness.
Cervical Spondylosis - Neuro Consult
Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe.
Chest discomfort & palpitations - Consult.
Patient with palpitations and rcent worsening of chronic chest discomfort.
Chest Pain - Cardiac Consult
Chest pain, possible syncopal spells. She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.
Chest Wall Lump - Consult
Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor.
Cholangiocarcinoma Consult
Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.
Cholestasis Of Pregnancy
Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.
Chronic Atrial Fibrillation
A routine return appointment for a 71-year-old woman with chronic atrial fibrillation. Chief complaint today is shortness of breath.
Chronic Kidney Disease - Consult
This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.
Chronic Otitis Media
A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.
Chronic Sinusitis
Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.
Clogged AV Shunt - Consult
Clogged AV shunt. The patient complains of fatigue, nausea, vomiting and fever.
Colon Cancer Consult
Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.
Colon Cancer Screening
Routine colorectal cancer screening. He occasionally gets some loose stools.
Colon Polyps - Genetic Counseling
Genetic counseling for a strong family history of colon polyps. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps.
Comprehensive Neurological Evaluation
A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis.
Congestion - 21-day-old
Congestion, tactile temperature.
Congestion & Cough - 5-month-Old
A 5-month-old infant with cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot.
Congestion & Fever - 2-month-old
A 2-month-old female with 1-week history of congestion and fever x2 days.
Connective Tissue Disorder
She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.
Consult - Abnormal EKG
Abnormal EKG and rapid heart rate. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.
Consult - Alzheimer disease
Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.
Consult - Atrial Fibrillation
Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.
Consult - Atrial Fibrillation - 1
Atrial fibrillation and shortness of breath. The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.
Consult - Back & Leg Pain
The patient has been suffering from intractable back and leg pain.
Consult - Breast Cancer
Patient presents with complaint of lump in the upper outer quadrant of the right breast
Consult - Breast Cancer - 1
The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.
Consult - Cerebral Peduncle Infarction
Patient with a history of right upper pons and right cerebral peduncle infarction.
Consult - Chest Pain
Patient with multiple problems, main one is chest pain at night.
Consult - Chest Pain - 1
A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors.
Consult - CHF & Lymphedema
The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.
Consult - Congestive Heart Failure
Congestive heart failure (CHF). The patient is a 75-year-old gentleman presented through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness. Main complaints are right-sided and abdominal pain. Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.
Consult - Coronary Artery Disease
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 except for fatigue and tiredness.
Consult - Enlarged Tonsils
Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.
Consult - Facial Twitching
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 - Hydronephrosis
Marked right hydronephrosis without hydruria.
Consult - Hypertension
Patient with a past medical history of hypertension for 15 years.
Consult - ICU Management
Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.
Consult - Jaw Pain
Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.
Consult - Knee Pain
Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet.
Consult - Laparoscopic Cholecystectomy
Patient with mid-epigastric abdominal pain. Sonogram revealed gallstones.
Consult - Migraine
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 - Multiple Colon Polyps
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 - Normal Pressure Hydrocephalus
The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.
Consult - Palpitations & Presyncope
The patient admitted with palpitations and presyncope.
Consult - Prostate Cancer
Consult for prostate cancer
Consult - Pulsatile Tinnitus
Chronic headaches and pulsatile tinnitus.
Consult - Rectal Bleeding
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 - Screening Colonoscopy
Patient comes for discussion of a screening colonoscopy.
Consult - Seizures
Patient referred for evaluation of her left temporal lobe epilepsy.
Consult - Seizures - 1
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 - Sepsis
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 epigastric pain for at least a month.
Consult - Stasis Ulcer
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 - Syncope
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 - Vomiting & Nausea
A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.
Consult - Weankness & Polymyositis
Consultation - an 87-year-old white female with weakness and a history of polymyositis.
Consult for Colostomy Reversal
Patient presents for a colostomy reversal as well as repair of an incisional hernia.
Consult for New Wheelchair
A male referred to Wheelchair Clinic for evaluation for a new wheelchair.
Consult/ER Report - OB/GYN
A female with unknown gestational age who presents to the ED after a suicide attempt.
Conversion Disorder
The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder.
Cough & Abdominal Pain
Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.
Cut on Foot - ER Visit
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.
CVA Consult - ER Visit
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.
Cystic Fibrosis
A 10 years of age carries a diagnosis of cystic fibrosis
Decreased Vision Consult
One-week history of decreased vision in the left eye. Past ocular history includes cataract extraction with lens implants in both eyes.
Dental Pain
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.
Detox from Heroin
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.
Dietary Consult - 1
Elevated cholesterol and is on medication to lower it.
Dietary Consult - 2
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.
Dietary Consult - 3
The patient is brought in by an assistant with some of his food diary sheets.
Dietary Consult - 4
Counting calorie points, exercising pretty regularly, seems to be doing well
Dietary Consult - Diabetes - 1
Dietary consultation for diabetes during pregnancy.
Dietary Consult - Diabetes - 2
Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.
Dietary Consult - Gestational Diabetes
Dietary consultation for gestational diabetes.
Dietary Consult - Hyperlipidemia
Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome
Dietary Consult - Weight Reduction
Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.
Dietary Consultation - 1
Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia.
Dietary Consultation - 2
Dietary consultation for weight reduction secondary to diabetes.
Difficulty Distance Vision & Fine Print at Near
Difficulty with both distance vision and with fine print at near.
Dilated Cardiomyopathy - Consult
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.
Diplopia
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.
Discoid Lupus
A 12-year-old with discoid lupus on the control with optimal regimen.
Disseminated Intravascular Coagulation
Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.
Dizziness - Recurrent
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 in one place or lies down for several minutes.
Dog Bite
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.
Dural AVM
Patient with episode of lightheadedness and suddenly experienced vertigo.
Dysphagia & Hematemesis
Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis
Ear Pain - Drainage
Right ear pain with drainage - otitis media and otorrhea.
Ear pain - Pediatric Consult
13 years old complaining about severe ear pain - Chronic otitis media.
Ecstasy Ingestion - ER Visit
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.
Elbow Pain - Consult
Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.
Elevated BNP - Consult
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.
Elevated Cardiac Enzymes
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.
Elevated PSA - H&P
Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.
Encephalopathy - Rehab Consult
Encephalopathy related to normal-pressure hydrocephalus.
End Stage Renal Disease - Consult
Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.
ENT Consult
Persistent dysphagia. Deviated nasal septum. Inferior turbinate hypertrophy. Chronic rhinitis. Conductive hearing loss. Tympanosclerosis.
ENT Consult - 1
Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy.
Epidural Fluid Collection
Fall/loss of consciousness.
Epidural Hematoma
Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.
ER Report - Rib Cage Pain
This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.
Erythema Nodosum - Consult
The patient presents for a followup for history of erythema nodosum.
Essential Tremor & Torticollis
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.
Exudative Tonsillitis
Severe tonsillitis, palatal cellulitis, and inability to swallow.
Eye Examination - H&P
Complete eye examination - Normal eye and vision exam.
Feet & Hand Cramping
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.
First Followup - Shunt Surgery
Patient returns for his first followup after shunt surgery.
First Pap smear.
First Pap smear, complaining of irregular periods. - Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.
Flank Pain - Consult
Left flank pain and unable to urinate.
Flank Pain - Consult - 1
Left flank pain, ureteral stone.
Foot Infection Management
Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.
Foot pain Consultation
Consultation for left foot pain.
Foreign Body - Fingernail
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.
Foreign Body - Right Nose
Questionable foreign body, right nose. Belly and back pain. Mild constipation.
Foul-Smelling Urine
Foul-smelling urine and stomach pain after meals.
Gagging - 3-year-old
Pediatric Gastroenterology - History of gagging.
Gastric Bypass Discussion - 1
Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7
Gastric Bypass Discussion - 2
Patient scheduled for laparoscopic gastric bypass.
Gastric Bypass Discussion - 3
Patient presented to the bariatric surgery service for consideration of laparoscopic roux en Y gastric bypass surgery.
Gastrointestinal Bleed - ER Visit
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.
Gen Med Consult - 1
Return to work & Fit for duty evaluation.
Gen Med Consult - 10
Checkup - Joints hurting all over - Arthralgias that are suspicious for inflammatory arthritis.
Gen Med Consult - 11
Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).
Gen Med Consult - 12
Feeling weak and shaky - Dyspnea on exertion and history of diabetes
Gen Med Consult - 13
Consult for hypertension and a med check. History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.
Gen Med Consult - 14
Complaint of left otalgia (serous otitis) and headache. History of atopic dermatitis.
Gen Med Consult - 15
Complaint of mood swings and tearfulness.
Gen Med Consult - 16
Short-term memory loss (probable situational) and anxiety stress issues.
Gen Med Consult - 17
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.
Gen Med Consult - 18
1-year-old male who comes in with a cough and congestion. Clinical sinusitis and secondary cough.
Gen Med Consult - 19
2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.
Gen Med Consult - 2
Initial clinic visit for foreign body in left eye.
Gen Med Consult - 20
11-year-old female. History of congestion, possibly enlarged adenoids.
Gen Med Consult - 21
A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis
Gen Med Consult - 22
A 12-year-old young man with sinus congestion.
Gen Med Consult - 23
Patient in with mom for possible ear infection.
Gen Med Consult - 24
Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.
Gen Med Consult - 25
Patient with a past medical history of atrial fibrillation and arthritis complaining of progressively worsening shortness of breath.
Gen Med Consult - 26
Patient presents complaining of abdominal pain and discomfort for 3 weeks.
Gen Med Consult - 27
Nausea, vomiting, diarrhea, and fever.
Gen Med Consult - 28
The patient brought in by EMS with a complaint of a decreased level of consciousness.
Gen Med Consult - 29
Patient with intermittent episodes of severe nausea and abdominal pain.
Gen Med Consult - 3
Examination due to blood-borne pathogen exposure.
Gen Med Consult - 30
Patient was found to have decrease in mental alertness
Gen Med Consult - 31
Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.
Gen Med Consult - 32
Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency
Gen Med Consult - 33
Patient with hypertension, dementia, and depression.
Gen Med Consult - 34
A male patient presented for evaluation of chronic abdominal pain.
Gen Med Consult - 35
Patient with confusion and hallucinations.
Gen Med Consult - 36
Patient coughing up blood and with severe joint pain.
Gen Med Consult - 37
Patient with complaint of dark urine and generalized weakness.
Gen Med Consult - 38
Patient admitted with abdominal pain, nausea and vomiting.
Gen Med Consult - 39
Patient with abdominal pain, nausea, vomiting, fever, altered mental status.
Gen Med Consult - 4
Consultation for jaw pain.
Gen Med Consult - 40
Patient with a diagnosis of stroke.
Gen Med Consult - 41
Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.
Gen Med Consult - 42
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
Gen Med Consult - 43
A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.
Gen Med Consult - 44
An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.
Gen Med Consult - 45
For evaluation of left-sided chest pain, 5 days post abdominal surgery.
Gen Med Consult - 46
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.
Gen Med Consult - 47
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.
Gen Med Consult - 48
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.
Gen Med Consult - 49
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.
Gen Med Consult - 5
Patient with swelling of lips and dysphagia and Arthritis.
Gen Med Consult - 50
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.
Gen Med Consult - 51
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.
Gen Med Consult - 52
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.
Gen Med Consult - 53
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.
Gen Med Consult - 54
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.
Gen Med Consult - 6
Patient with several medical problems - numbness, tingling, and a pain in the toes.
Gen Med Consult - 7
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.
Gen Med Consult - 8
Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.
Gen Med Consult - 9
Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.
Gen Med H&P - 1
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).
Gen Med H&P - 2
Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency,
GI Consultation - 1
GI Consultation due to rectal bleeding, positive celiac sprue panel
GI Consultation - 2
GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.
GI Consultation - 3
GI Consultation for Chrohn's disease.
GI Consultation - 4
Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.
Glioblastoma Multiforme - Consult
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.
Glioma - 1
Dysarthria. Probable brainstem glioma.
Glioma - 2
Headache. Right frontal lobe glioma.
Glioma - Consult
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.
Granulomatous Inflammation
Headache and diplopia.
Guillain-Barre Syndrome
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.
H&P - Cardio (Angina)
H&P for a female with Angina pectoris.
H&P - Gen Med - 1
An 85-year-old female with diarrhea, vomiting, and abdominal pain.
H&P - Gen Med - 2
History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis.
H&P - Infant with fever
Irritable baby, 6-week-old, with fever for approximately 24 hours.
H&P - Nausea & Vomiting
Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis.
H&P - Weakness
Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2
Hand Pain - Consult
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.
Head & Neck Cancer Consult
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.
Head Trauma
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.
Hematology Consult
Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.
Hematology Consult - 1
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.
Hematuria - Consult
Patient presents with gross hematuria that started this morning.
Hematuria - ER Visit
Presents to the ER with hematuria that began while sleeping last night. He denies any pain, nausea, vomiting or diarrhea.
Hematuria & Urinary Retention
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.
Hip Fracture - ER Consult
Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.
Hip Fracture - Rehab Consult
Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.
HPV Consult
Likely molluscum contagiosum (genital warts) caused by HPV. It is not clear where this came from but it is most likely sexually transmitted.
Huntington's Disease
Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.
Huntington's Disease - Consult
This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.
Hyperesthesia
Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.
Hypergranulation - Consult
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.
Hypersensitivity to Coumadin
Probable Coumadin hypersensitivity.
Hypertension - Consult
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.
Hypertension & Cardiomyopathy
Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.
Hyperthyroidism Following Pregnancy
Chief complaint of chest pain, previously diagnosed with hyperthyroidism.
Iliopsoas Hematoma - 1
Left Iliopsoas hematoma. Gait difficulty.
Iliopsoas Hematoma - 2
Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.
Impairment Rating
Right shoulder impingement syndrome, right suprascapular neuropathy.
Infant Not Gaining Weight
A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.
Infantile Spasms
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.
Insect Sting
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.
Intractable Epilepsy
Intractable epilepsy, here for video EEG.
Iron deficiency anemia
Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.
Ischemic Cecum - Consult
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.
Itchy Rash - ER Visit
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.
Jaw Pain - ER Visit
Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.
Knee DJD - Consult
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.
Knee Injury
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.
Kyphoplasty - Consult
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.
Kyphosis
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.
Laparoscopic Gastric Bypass Consult - 1
Consult for laparoscopic gastric bypass.
Laparoscopic Gastric Bypass Consult - 2
Consult for laparoscopic gastric bypass.
Leaking Nephrostomy Tube
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.
Left Lower Quadrant Pain - ER Visit
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.
Lesions - Adrenal and Pancreatic
Pancreatic and left adrenal lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.
Lightheaded & Dizziness
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 when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia.
Lightheadedness
The patient comes in today because of feeling lightheaded and difficulty keeping his balance.
Limbic Encephalitis
Patient with a 1-year history of progressive anterograde amnesia
Lobar Holoprosencephaly
A 21-month-old male presented for delayed motor development, "jaw quivering" and "lazy eye."
Low Back Pain - Consult
New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.
Lower back pain
Lumbar muscle strain and chronic back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.
Lower Quadrant Pain
Abdominal pain right lower quadrant, radiating around her side to her right flank. Etiology is unclear.
Lumbar Radiculopathy - Consult
Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.
Lumbar Spine HNP - Consult
Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.
Lumbosacral Polyradiculopathy
Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.
Lung Cancer & MI - Hospice Cosult
Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI. The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.
Lymphoblastic Leukemia - Consult
Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.
Lymphoma - Consult
Marginal B-cell lymphoma, status post splenectomy. Testicular swelling - possible epididymitis or possible torsion of the testis.
Major Depressive Disorder - IME Consult
Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.
Malignant Meningioma - Consult
Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.
Mantle Cell Lymphoma - Consult
Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.
Marginal Zone Lymphoma
Marginal zone lymphoma (MALT-type lymphoma). A mass was found in her right breast on physical examination. she had a mammogram and ultrasound, which confirmed the right breast mass.
MCA Aneurysm
Patient with sudden onset dizziness and RUE clumsiness. Giant Left MCA Aneurysm.
Medical Management Consult Request
Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management
Meningioma
Progressive loss of color vision OD.
Mental Status Changes - Consult
Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved.
Mesothelioma - Consult
Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.
Metastatic Ovarian Cancer - Consult
A very pleasant 66-year-old woman with recurrent metastatic ovarian cancer.
Microhematuria - Consult
A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.
Migraine without Aura - Consult
The patient with gradual onset of a headache problem, located behind both eyes.
Multilobar Pneumonia
Loculated left effusion, multilobar pneumonia. Patient had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency.
Multiple Meningiomas
Patient with stable expressive aphasia and decreased vision.
Multiple Neurological Symptoms
The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.
Murmur & Bacteremia.
A female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever.
Neck & Back Pain
Initial evaulation - neck and back pain.
Neck & Lower Back Pain - Consult
Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.
Neonatal Consult
This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.
Nephrology Consultation - 1
Nephrology Consultation - Patient with renal failure.
Nephrology Consultation - 2
Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.
Nephrology Consultation - 3
Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.
Nephrology Consultation - 4
The patient is admitted with a diagnosis of acute on chronic renal insufficiency.
Neuro Consult - Depression & Dementia
Neuro Consult - Leg Weakness
The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.
Neuroblastoma - Consult
The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.
Neurogenic Bladder - Consult
Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week
Neurologic Consultation
Neurologic consultation was requested to evaluate her seizure medication and lethargy.
Neurologic Consultation - 1
Neurologic consultation and follow-up.
Neurologic Consultation - 2
Patient has trouble with walking and balance, with bladder control, and with thinking and memory.
Neurologic Consultation - 3
Neurologic consultation was requested to assess and assist with seizure medication.
Neurologic Consultation - 4
Muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance. Probable painful diabetic neuropathy. Symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.
Neurologic Consultation - 5
Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.
Neurologic Examination
Neurologic examination sample.
Neuropsychological Evaluation
Patient demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment for stroke.
Neuropsychological Evaluation - 1
Sample for Neuropsychological Evaluation
Neuropsychological Evaluation - 2
A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.
Neuropsychological Evaluation - 3
Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.
Neuropsychological Evaluation - 4
The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.
Neuropsychological Evaluation - 5
The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.
New Onset Seizure
A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.
Non-Q-wave Myocardial Infarction
A patient with non-Q-wave myocardial infarction. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.
Non-Small Cell Lung Cancer - Consult
New diagnosis of non-small cell lung cancer stage IV metastatic disease. At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.
Normal Child Exam Template
Normal child physical exam template.
Normal ENT Exam
Sample normal ear, nose, mouth, and throat exam.
Normal ENT Exam - 1
Sample normal ear, nose, mouth, and throat exam.
Normal Female Exam Template
Sample/template for a normal female multisystem exam
Normal Female Exam Template - 1
An example/template for a routine normal female physical exam.
Normal Female Exam Template - 2
An example/template for a routine normal female physical exam.
Normal Female ROS Template
Normal female review of systems template. Negative for fever, weight change, fatigue, or aching.
Normal Male Exam Template
Sample/template for a normal male multisystem exam.
Normal Male Exam Template - 1
An example/template for a routine normal male physical exam.
Normal Male Exam Template - 2
An example/template for a routine normal male physical exam.
Normal Male Exam Template - 3
An example/template for a routine normal male physical exam.
Normal Male Exam Template - 4
An example/template for a routine normal male physical exam.
Normal Male ROS Template - 1
An example/template for a routine normal male ROS.
Normal Newborn H&P Template
Template for History and Physical for a newborn.
Normal Newborn Infant Physical Exam
Normal newborn infant physical exam. A well-developed infant in no acute respiratory distress.
Normal Physical Exam Template
An example of a physical exam
Normal Physical Exam Template - 1
An example normal physical exam
Normal Physical Exam Template - 2
Normal physical exam template. This is a well-developed and well-nourished. The pupils were equal, round and reactive to light. Extraocular movements are intact.
Normal Physical Exam Template - 3
Normal physical exam template. Well developed, well nourished, in no acute distress.
Normal Physical Exam Template - 4
Normal physical exam template. Normocephalic. Negative lesions, negative masses.
Normal Physical Exam Template - 5
Normal Physical Exam Template. Well developed, well nourished, alert, in no acute distress.
Normal Physical Exam Template - 6
Normal physical exam template. Normal appearance for chronological age, does not appear chronically ill.
Normal Physical Exam Template - 7
Most commonly used phrases in physical exam.
Normal ROS Template
Normal review of systems template. The patient denies fever, fatigue, weakness, weight gain or weight loss.
Normal ROS Template - 1
There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing.
Normal ROS Template - 2
Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.
Normal ROS Template - 3
Normal review of systems template. No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.
Normal ROS Template - 4
Negative for any nausea, vomiting, fevers, chills, or weight loss.
Normal ROS Template - 5
Normal review of systems template. Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.
Not Feeling Well - ER Visit
A 93-year-old female called up her next-door neighbor to say that she was not feeling well. The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.
OB/GYN - H&P
Initial obstetrical examination - Normal first pregnancy. Inadequate naternal nutrition.
OB/GYN Consultation - 1
Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.
OB/GYN Consultation - 2
Consultation because of irregular periods and ovarian cyst.
OB/GYN Consultation - 3
Consultation for an ASCUS Pap smear.
OB/GYN Consultation - 4
Pelvic Pain and vaginal discharge
Occupational Medicine Consult
Occupational medicine consult with questions-answers and records review.
Occupational Medicine Consult - 1
Occupational medicine consult with questions-answers.
Occupational Medicine Consult - 2
Occupational medicine consult with questions-answers and records review.
Occupational Medicine Consult - 3
Occupational medicine consult with questions-answers and records review.
Oligoarticular Arthritis - 1
A 17-year-old male with oligoarticular arthritis of his right knee.
Oligoarticular Arthritis - 2
A lady with symptoms consistent with possible oligoarticular arthritis of her knees.
Onychomycosis - H&P
Toenails are discolored, thickened, and painful - Onychomycosis
Organic Brain Syndrome
Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.
Orthopedic Consult
Medical management, status post left total knee arthroplasty.
Orthopedic Consult - 1
Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.
Orthopedic Consult - 2
Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.
Orthopedic Consult - 3
Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs
Orthopedic Consult - 4
Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.
Orthopedic Consult - 5
Patient with back and hip pain.
Otitis Media - H&P
A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture. Adenoid hyperplasia bilateral.
Pain from Hernia - ER Consult
This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.
Pain Management Consult - 1
Pain management for post-laminectomy low back syndrome and radiculopathy.
Pain Management Consult - 2
Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.
Paroxysmal Atrial Fibrillation
A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.
Pediatric Rheumatology Consult
A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis.
Penile Cellulitis
The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.
Penile Discharge
Penile discharge, infected-looking glans. A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease.
Pericardial Effusion
The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors.
Perioperative Elevated Blood Pressure
Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.
Peripheral Effusion - Consult
Peripheral effusion on the CAT scan. The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy. She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.
Physical Exam and Pap - 1
A white female presents for exam and Pap.
Physical Exam and Pap -2
A white female who presents for complete physical, Pap and breast exam.
Pneumoconiosis
Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.
Pneumothorax & Subcutaneous Emphysema
Consult for subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.
Postop Medical Management
Post-surgical medical management; right total knee replacement.
Preeclampsia
Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure. The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncontrolled blood pressure.
Preop Cardiac Consult
Cardiology consultation regarding preoperative evaluation for right hip surgery. Patient with a history of coronary artery disease status post bypass surgery
Prostate Adenocarcinoma
Adenocarcinoma of the prostate. The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.
Prostate Adenocarcinoma - H&P
Adenocarcinoma of the prostate, Erectile dysfunction - History & Physical
Pseudoseizures
The patient was referred due to a recent admission for pseudoseizures.
Pseudotumor Cerebri
The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches.
Psych Consult - Alcohol Withdrawal
Psychiatric consultation for alcohol withdrawal and dependance.
Psych Consult - Altered Mental Status
Psychiatric Consultation of patient with altered mental status.
Psych Consult - Anxiety
Psychiatric Consultation of patient with anxiety.
Psych Consult - Assaultive Behavior
The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.
Psych Consult - Bipolar Affective Disorder
A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.
Psych Consult - Dementia
Psychiatric Consultation of patient with dementia.
Psych Consult - Depression - 1
Psychiatric Consultation of patient with recurring depression.
Psych Consult - Depression - 2
Psychiatric Consultation of patient with major depression disorder.
Psych Consult - Lethargy
Psychiatric consultation of patient with lethargy.
Psych Consult - Pain Meds
Psychiatric consultation for management of pain medications.
Psych Consult - Paranoia
A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.
Psych Consult - Psychosis
Patient with a history of PTSD, depression, and substance abuse.
Psych Consult - Psychosis - 1
The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.
Psych Consult - Schizophrenia
A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.
Psych Consult - Substance abuse
Psychiatric consultation for substance abuse.
Psych H&P - 1
Psychiatric History and Physical - Patient with major depression
Psych H&P - 2
Psychiatric History and Physical - Patient with schizoaffective disorder.
Psychiatric Consult
Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.
Psychiatric Consult - 1
Bipolar disorder, apparently stable on medications. Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.
Psychiatric Consult - 2
She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.
Pubic Cellulitis
A 16-month-old with history of penile swelling for 4 days, had circumcision 1 week ago.
Pulmonary Consultation - 1
Obstructive sleep apnea syndrome. Loud snoring. Schedule an overnight sleep study.
Pulmonary Consultation - 2
Patient with complaints of significant coughing and wheezing.
Pulmonary Edema - Consult
This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema. No confirmed prior history of heart attack, myocardial infarction, heart failure.
Pulmonary Embolism
Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.
Pulmonary Hypertension - Pediatric Consult
Increasing oxygen requirement. Baby boy has significant pulmonary hypertension.
Records Review - Epicondylitis
Records review. The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand. Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.
Records Review - Orthopedic
Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.
Rectal Bleeding - 1-year-old
Pediatric Gastroenterology - Rectal Bleeding Consult.
Rectal Bleeding - Consult
A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks.
Recurrent Abscesses - Consult
Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. In the past, Accutane has been used.
Recurrent nasal obstruction
Patient with suspected nasal obstruction, possible sleep apnea.
Renal Failure - Consult
Acute renal failure, suspected, likely due to multi-organ system failure syndrome.
Renal Failure Evaluation
Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.
Renal Insufficiency - Consult
Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.
Request For Consultation
Request for consultation to evaluate stomatitis, possibly methotrexate related.
Revocation Admission
A 40-year-old male seen today for a 90-day revocation admission. Noncompliant with medications, refusing oral or IM medications, became agitated. History of hyperlipidemia with elevated triglycerides.
Rheumatoid Arthritis - Consult
A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She is not on DMARD, but as she recently had a surgery followed by a probable infection.
Rheumatoid Arthritis - H&P
Patient presents for treatment of suspected rheumatoid arthritis.
Rotator cuff syndrome - H&P
Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.
School Physical - 1
This patient was seen in clinic for a school physical.
School Physical - 2
Well-child check and school physical.
Sepsis - Consult
Sepsis. The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.
Shoulder Pain Consult
Consultation for right shoulder pain.
Sick Sinus Syndrome
Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction
Sinus problems - Consult
Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.
Sleepiness - Consult
Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.
Small Bowel Obstruction
History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.
Speech Therapy Evaluation
Global aphasia. The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.
Speech Therapy Evaluation - 1
Status post brain tumor with removal. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function.
Spinal fluid evaluation
Consult and Spinal fluid evaluation in a 15-day-old
Sports Physical - 1
Sports physical with normal growth and development.
Sports Physical - 2
Well-child check sports physical - Well child asthma with good control, allergic rhinitis.
Sports Physical - 3
Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.
Status Epilepticus
A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.
Supraclavicular Lymphadenopathy
The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy. She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy. She is now referred to the thoracic surgery clinic for evaluation.
Supraventricular Tachycardia - Consult
The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.
Syncope - ER Visit
Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.
Syncope - ER Visit - 1
The patient had a syncopal episode last night. She did not have any residual deficit. She had a headache at that time. She denies chest pains or palpitations.
T-Cell Lymphoma Consult
Newly diagnosed T-cell lymphoma. The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.
Tethered Cord Evaluation
Evaluation of possible tethered cord. She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.
Therapeutic Recreation Initial Evaluation
Therapeutic recreation initial evaluation. Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.
Thrombocytopenia - Consult
Consultation for evaluation of thrombocytopenia.
Thyroid Mass Consult
Thyroid mass diagnosed as papillary carcinoma. The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.
TIA - Cosult
A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours.
TIA & Lumbar Stenosis
Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale.
Tinea Pedis - H&P
Itchy red rash on feet - Tinea Pedis
Tongue Swelling
A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.
Toothache - ER Visit
Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..
Tracheostomy Tube Consult
Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.
Trouble Breathing - H&P
History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.
Ureteral Calculus - Consult
Right distal ureteral calculus. The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.
URI & Eustachian Congestion
Viral upper respiratory infection (URI) with sinus and eustachian congestion. Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.
Urinary Retention
This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant. He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.
Urology Consut - 1
Blood in urine - Transitional cell cancer of the bladder.
Uveitis
The patient with recurrent nongranulomatous anterior iritis and most recently, pain in left eye associated with headache and photophobia.
Ventricular Ectopy - Consult
Ventricular ectopy and coronary artery disease. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.
Vertigo Consult
The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.
Vertigo Consult - 1
The patient is having recurrent attacks of imbalance rather than true vertigo following the history of head trauma and loss of consciousness. Symptoms are not accompanied by tinnitus or deafness.
Viral Gastroenteritis
Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill.
Weight Gain and Edema
This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism. She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.
Weight Loss Evaluation
Patient with morbid obesity.
Well-Child Check - 1
Well child - Left lacrimal duct stenosis
Well-Child Check - 2
A 9-month well-child check.
Well-Child Check - 3
A two week well-child check.
Well-Child Check - 4
1-year well child check.
Well-Child Check - 5
A well-child check with concern of some spitting up quite a bit.
Well-Child Check - 6
A 3-month well-child check.
Well-Child Check - 7
1-month-old for a healthy checkup - Well child check
Well-woman checkup
Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.
Worker's Compensation Injury
Blunt trauma to the distal right thumb without fracture. Worker’s Compensation Injury
Wound Care Consult
A woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss.
Wrist Pain
Consultation for wrist pain.