Medical Specialty: General Medicine

A branch of medicine that deals with diagnosis and treatment of nonsurgical diseases.

General Medicine
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.
Accidental Celesta Ingestion - ER Visit
Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.
Acute Cystitis & Diabetes Type II
The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.
Admission History & Physical - Nausea
Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.
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.
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.
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.
Asbestos Exposure - Hemoptysis
Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.
Atrial Fibrillation - SOAP
Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.
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.
Breast Calcifications - Preop Consult
Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.
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.
Care Conference With Family
Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.
Cellulitis - Discharge Summary
Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.
Chest Pain & Respiratory Insufficiency
A lady was admitted to the hospital with chest pain and respiratory insufficiency. She has chronic lung disease with bronchospastic angina.
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.
Chronic Abscesses - Discharge Summary
Multiple extensive subcutaneous abscesses, right thigh. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.
Chronic Medical Conditions - Followup
Followup evaluation and management of chronic medical conditions. Congestive heart failure, stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, chronic renal insufficiency, and arthritis.
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.
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 - 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 - Hypertension
Patient with a past medical history of hypertension for 15 years.
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.
COPD & Pneumonia - SOAP
Acute on chronic COPD exacerbation and community acquired pneumonia both resolving. However, she may need home O2 for a short period of time.
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.
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.
Diabetes Mellitus - SOAP Note - 1
Followup diabetes mellitus, type 1.
Diabetes Mellitus - SOAP Note - 2
Patient today with ongoing issues with diabetic control.
Discharge Summary - 1
Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.
Discharge Summary - 11
Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.
Discharge Summary - 12
A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.
Discharge Summary - 13
Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.
Discharge Summary - 14
The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.
Discharge Summary - 15
Gastroenteritis and autism. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.
Discharge Summary - 16
Upper respiratory illness with apnea, possible pertussis. a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, and questionable fever.
Discharge Summary - 17
The patient underwent a scalp skin biopsy with pathology specimen obtained. At the time of discharge, the patient had improved.
Discharge Summary - 18
The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Serotonin syndrome secondary to high doses of Prozac and atypical chest pain with myocardial infarction ruled out.
Discharge Summary - 19
The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.
Discharge Summary - 2
Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.
Discharge Summary - 3
Patient with increased shortness of breath of one day duration.
Discharge Summary - 4
Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.
Discharge Summary - 5
A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.
Discharge Summary - 6
A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.
Discharge Summary - 7
Patient with fever of unknown origin.
Discharge Summary - 8
A white female with a history of fevers.
Discharge Summary - 9
A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.
Discharge Summary - Migraine
Intractable migraine with aura. The patient is discharged home. Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.
Discharge Summary - Multiple Trauma
Aftercare of multiple trauma from an motor vehicle accident.
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.
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.
Down's syndrome
A 46-year-old white male with Down’s syndrome presents for followup of hypothyroidism, as well as onychomycosis.
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.
ER Report - Chest Pain & Fever
A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.
ER Report - URI
Patient in ER with upper respiratory infection
Fall - ER Visit
The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.
Fall & Laceration
Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.
Feeling Dizzy - ER Visit
A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.
Female Exam & ROS
Sample female exam and review of systems.
Female Physical Exam - 1
Sample female physical exam
Female Physical Exam - 2
Sample female physical exam.
Female ROS
Sample female review of systems.
Fifth Disease - SOAP
Fifth disease with sinusitis
Flank Pain - Consult
Left flank pain and unable to urinate.
Flank Pain - Consult - 1
Left flank pain, ureteral stone.
Followup on Asthma
A female for a complete physical and follow up on asthma with allergic rhinitis.
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.
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,
Gen Med Office Note - 1
Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.
Gen Med Progress Note
The patient states that he feels sick and weak.
Gen Med Progress Note - 1
Sample progress note - Gen Med.
Gen Med Progress Note - 10
Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.
Gen Med Progress Note - 11
5-month recheck on type II diabetes mellitus, as well as hypertension.
Gen Med Progress Note - 12
Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.
Gen Med Progress Note - 13
Sepsis due to urinary tract infection.
Gen Med Progress Note - 2
Sample progress note - Gen Med.
Gen Med Progress Note - 3
Sample progress note - Gen Med.
Gen Med Progress Note - 4
The patient is in complaining of headaches and dizzy spells.
Gen Med Progress Note - 5
A 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder.
Gen Med Progress Note - 6
A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.
Gen Med Progress Note - 7
Patient with a three-day history of emesis and a four-day history of diarrhea
Gen Med Progress Note - 8
Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.
Gen Med Progress Note - 9
Multiple problems including left leg swelling, history of leukocytosis, joint pain left shoulder, low back pain, obesity, frequency with urination, and tobacco abuse.
Gen Med SOAP
Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.
Gen Med SOAP - 1
Sample progress note - Gen Med.
Gen Med SOAP - 10
The patient has NG tube in place for decompression.
Gen Med SOAP - 11
The patient has recently had an admission for pneumonia with positive blood count. She returned after vomiting and a probable seizure.
Gen Med SOAP - 2
Patient with NIDDM, hypertension, CAD status post CABG, hyperlipidemia, etc.
Gen Med SOAP - 3
General Medicine SOAP note.
Gen Med SOAP - 4
General Medicine SOAP note.
Gen Med SOAP - 5
General Medicine SOAP note. Patient with shoulder bursitis, pharyngitis, attention deficit disorder,
Gen Med SOAP - 6
Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain
Gen Med SOAP - 7
One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees. Doing well.
Gen Med SOAP - 8
Patient today with multiple issues.
Gen Med SOAP - 9
Upper respiratory tract infection, persistent. Tinea pedis. Wart on the finger. Hyperlipidemia. Tobacco abuse.
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 - 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
Headache - Emergency Visit
Muscle tension cephalgia. Right trapezius and rhomboid muscle spasm.
Headache - Office Visit
The patient with continued problems with her headaches.
Headache - Urgent Care Visit
Migraine headache - The patient was seen in the urgent care.
HIV Followup
Human immunodeficiency virus disease with stable control on Atripla. Resolving left gluteal abscess, completing Flagyl. Diabetes mellitus, currently on oral therapy. Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.
HIV Followup - 1
Human immunodeficiency virus, stable on Trizivir. Hepatitis C with stable transaminases. History of depression, stable off meds. Hypertension, moderately controlled on meds.
Hydrocarbon Aspiration - ER Visit
The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.
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.
Hypothermia - Discharge Summary
Hypothermia. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. Organic brain syndrome. Seizure disorder. Adrenal insufficiency. Hypothyroidism. Anemia of chronic disease.
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.
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.
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.
Low Back Pain from Exercise
Patient having low back pain after doing exercise
Lymphoblastic Leukemia - Consult
Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.
Male Exam & ROS
Sample male exam and review of systems.
Medical Management Consult Request
Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management
Melena - ICU Followup
Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.
Motor Vehicle Accident
Multiple contusions and abdominal pain, status post motor vehicle collision.
MRI Brain - CO poisoning
MRI Brain, Carbon Monoxide poisoning.
Multiple Medical Problems - Discharge Summary
Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.
Nausea - ER Visit
Nausea and feeling faint. She complains of some nausea. She feels weak. The patient is advised to put salt on her food for the next week.
Nausea & Vomiting - ER Visit
She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.
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.
Obesity Hypoventilation Syndrome
Obesity hypoventilation syndrome. A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.
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.
Patient with High Potassium
Patient in emergency room due to high potassium value.
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.
Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.
Pneumonia - Discharge Summary
Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.
Possible Spider Bite
A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.
Post Thyroidectomy - Discharge Summary
Symptomatic thyroid goiter. Total thyroidectomy.
Pressure decubitus
Pressure decubitus, right hip
Pyelonephritis - Discharge Summary
Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.
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.
Refractory Hypertension - Followup
Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.
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.
Right Hand Laceration
Right hand laceration x3, repaired.
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.
Shortness Of Breath - Progress Note
The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia. Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.
Sleep Apnea
Followup of moderate-to-severe sleep apnea. The patient returns today to review his response to CPAP. Recommended a fiberoptic ENT exam to exclude adenoidal tissue that may be contributing to obstruction.
Sleep Study Followup
Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial.
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.
Chronic snoring in children
SOAP - Substance Abuse
He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom.
Thrombocytopenia - Consult
Consultation for evaluation of thrombocytopenia.
Thrombocytopenia - SOAP Note
Patient with immune thrombocytopenia
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..
Trouble breathing
Patient with worsening shortness of breath and cough.
Trouble Breathing - H&P
History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.
Sore throat - Upper respiratory infection.
Viral Syndrome - ER Visit
This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills.
Weight Loss Evaluation
Patient with morbid obesity.