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Medical Specialty:
Consult - History and Phy.
Sample Name: Pseudotumor Cerebri
Description: The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches.
(Medical Transcription Sample Report)
REASON FOR VISIT: The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches. She comes to clinic by herself.
HISTORY OF PRESENT ILLNESS: Dr. X has cared for her since 2002. She has a Codman-Hakim shunt set at 90 mmH2O. She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches. We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself. Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08. She states that since that time her headaches have been bad. They woke her up at night. She has not been able to sleep. She has not had a good sleep cycle since that time. She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up. She states that they feel a little bit better when lying down. Medication shave not helped her. She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief. The pain is generalized, but also noted to be quite intense in the frontal region of her head. She also reports ringing in the ears and states that she just does not feel well. She reports no nausea at this time. She also states that she has been experiencing intermittent blurry vision and dimming lights as well. She tells me that she has an appointment with Dr. Y tomorrow. She reports no other complaints at this time.
MAJOR FINDINGS: On examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty. She is well developed, well nourished, and kempt.
Vital Signs: Blood pressure 153/86, pulse 63, and respiratory rate 16.
Cranial Nerves: Intact for extraocular movements. Facial movement, hearing, head turning, tongue, and palate movements are all intact. I did not know any papilledema on exam bilaterally.
I examined her shut site, which is clean, dry, and intact. She did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir. It looks like there is a little bit of dry blood there.
PROBLEMS/DIAGNOSES:
1. Pseudotumor cerebri without papilledema.
2. Migraine headaches.
PROCEDURES: I programmed her shunt to 90 mmH2O.
PLAN: It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago. I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x-ray. However, the picture of the x-ray was not the most desirable picture. Thus, I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x-ray to confirm the setting at 90. In addition, she told me that she is scheduled to see Dr. Y tomorrow, so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment. She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally.
See More Samples on Consult - History and Phy.
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Abdominal Pain - Consult
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Acne Vulgaris - H&P
Acute Cystitis & Diabetes Type II
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Lower back pain
Lower Quadrant Pain
Lumbar Radiculopathy - Consult
Lumbar Spine HNP - Consult
Lumbosacral Polyradiculopathy
Lung Cancer & MI - Hospice Cosult
Lymphoblastic Leukemia - Consult
Lymphoma - Consult
Major Depressive Disorder - IME Consult
Malignant Meningioma - Consult
Mantle Cell Lymphoma - Consult
Marginal Zone Lymphoma
MCA Aneurysm
Medical Management Consult Request
Meningioma
Mental Status Changes - Consult
Mesothelioma - Consult
Metastatic Ovarian Cancer - Consult
Microhematuria - Consult
Migraine without Aura - Consult
Multilobar Pneumonia
Multiple Meningiomas
Multiple Neurological Symptoms
Murmur & Bacteremia.
Neck & Back Pain
Neck & Lower Back Pain - Consult
Neonatal Consult
Nephrology Consultation - 1
Nephrology Consultation - 2
Nephrology Consultation - 3
Nephrology Consultation - 4
Neuro Consult - Depression & Dementia
Neuro Consult - Leg Weakness
Neuroblastoma - Consult
Neurogenic Bladder - Consult
Neurologic Consultation
Neurologic Consultation - 1
Neurologic Consultation - 2
Neurologic Consultation - 3
Neurologic Consultation - 4
Neurologic Consultation - 5
Neurologic Examination
Neuropsychological Evaluation
Neuropsychological Evaluation - 1
Neuropsychological Evaluation - 2
Neuropsychological Evaluation - 3
Neuropsychological Evaluation - 4
Neuropsychological Evaluation - 5
New Onset Seizure
Non-Q-wave Myocardial Infarction
Non-Small Cell Lung Cancer - Consult
Normal Child Exam Template
Normal ENT Exam
Normal ENT Exam - 1
Normal Female Exam Template
Normal Female Exam Template - 1
Normal Female Exam Template - 2
Normal Female ROS Template
Normal Male Exam Template
Normal Male Exam Template - 1
Normal Male Exam Template - 2
Normal Male Exam Template - 3
Normal Male Exam Template - 4
Normal Male ROS Template - 1
Normal Newborn H&P Template
Normal Newborn Infant Physical Exam
Normal Physical Exam Template
Normal Physical Exam Template - 1
Normal Physical Exam Template - 2
Normal Physical Exam Template - 3
Normal Physical Exam Template - 4
Normal Physical Exam Template - 5
Normal Physical Exam Template - 6
Normal Physical Exam Template - 7
Normal ROS Template
Normal ROS Template - 1
Normal ROS Template - 2
Normal ROS Template - 3
Normal ROS Template - 4
Normal ROS Template - 5
Not Feeling Well - ER Visit
OB/GYN - H&P
OB/GYN Consultation - 1
OB/GYN Consultation - 2
OB/GYN Consultation - 3
OB/GYN Consultation - 4
Occupational Medicine Consult
Occupational Medicine Consult - 1
Occupational Medicine Consult - 2
Occupational Medicine Consult - 3
Oligoarticular Arthritis - 1
Oligoarticular Arthritis - 2
Onychomycosis - H&P
Organic Brain Syndrome
Orthopedic Consult
Orthopedic Consult - 1
Orthopedic Consult - 2
Orthopedic Consult - 3
Orthopedic Consult - 4
Orthopedic Consult - 5
Otitis Media - H&P
Pain from Hernia - ER Consult
Pain Management Consult - 1
Pain Management Consult - 2
Paroxysmal Atrial Fibrillation
Pediatric Rheumatology Consult
Penile Cellulitis
Penile Discharge
Pericardial Effusion
Perioperative Elevated Blood Pressure
Peripheral Effusion - Consult
Physical Exam and Pap - 1
Physical Exam and Pap -2
Pneumoconiosis
Pneumothorax & Subcutaneous Emphysema
Postop Medical Management
Preeclampsia
Preop Cardiac Consult
Prostate Adenocarcinoma
Prostate Adenocarcinoma - H&P
Pseudoseizures
Pseudotumor Cerebri
Psych Consult - Alcohol Withdrawal
Psych Consult - Altered Mental Status
Psych Consult - Anxiety
Psych Consult - Assaultive Behavior
Psych Consult - Bipolar Affective Disorder
Psych Consult - Dementia
Psych Consult - Depression - 1
Psych Consult - Depression - 2
Psych Consult - Lethargy
Psych Consult - Pain Meds
Psych Consult - Paranoia
Psych Consult - Psychosis
Psych Consult - Psychosis - 1
Psych Consult - Schizophrenia
Psych Consult - Substance abuse
Psych H&P - 1
Psych H&P - 2
Psychiatric Consult
Psychiatric Consult - 1
Psychiatric Consult - 2
Pubic Cellulitis
Pulmonary Consultation - 1
Pulmonary Consultation - 2
Pulmonary Edema - Consult
Pulmonary Embolism
Pulmonary Hypertension - Pediatric Consult
Records Review - Epicondylitis
Records Review - Orthopedic
Rectal Bleeding - 1-year-old
Rectal Bleeding - Consult
Recurrent Abscesses - Consult
Recurrent nasal obstruction
Renal Failure - Consult
Renal Failure Evaluation
Renal Insufficiency - Consult
Request For Consultation
Revocation Admission
Rheumatoid Arthritis - Consult
Rheumatoid Arthritis - H&P
Rotator cuff syndrome - H&P
School Physical - 1
School Physical - 2
Sepsis - Consult
Shoulder Pain Consult
Sick Sinus Syndrome
Sinus problems - Consult
Sleepiness - Consult
Small Bowel Obstruction
Speech Therapy Evaluation
Speech Therapy Evaluation - 1
Spinal fluid evaluation
Sports Physical - 1
Sports Physical - 2
Sports Physical - 3
Status Epilepticus
Supraclavicular Lymphadenopathy
Supraventricular Tachycardia - Consult
Syncope - ER Visit
Syncope - ER Visit - 1
T-Cell Lymphoma Consult
Tethered Cord Evaluation
Therapeutic Recreation Initial Evaluation
Thrombocytopenia - Consult
Thyroid Mass Consult
TIA - Cosult
TIA & Lumbar Stenosis
Tinea Pedis - H&P
Tongue Swelling
Toothache - ER Visit
Tracheostomy Tube Consult
Trouble Breathing - H&P
Ureteral Calculus - Consult
URI & Eustachian Congestion
Urinary Retention
Urology Consut - 1
Uveitis
Ventricular Ectopy - Consult
Vertigo Consult
Vertigo Consult - 1
Viral Gastroenteritis
Weight Gain and Edema
Weight Loss Evaluation
Well-Child Check - 1
Well-Child Check - 2
Well-Child Check - 3
Well-Child Check - 4
Well-Child Check - 5
Well-Child Check - 6
Well-Child Check - 7
Well-woman checkup
Worker's Compensation Injury
Wound Care Consult
Wrist Pain
Keywords: consult - history and phy., migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema,