Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Onychomycosis - H&P

Description: Toenails are discolored, thickened, and painful - Onychomycosis
(Medical Transcription Sample Report)


CHIEF COMPLAINT (1/1): This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.

ALLERGIES: Patient admits allergies to dairy products, penicillin.

MEDICATION HISTORY: None.

PAST MEDICAL HISTORY: Past medical history is unremarkable.

PAST SURGICAL HISTORY: Patient admits past surgical history of eye surgery in 1999.

SOCIAL HISTORY: Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.

FAMILY HISTORY: Unremarkable.

REVIEW OF SYSTEMS: Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.

PHYSICAL EXAM: Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.
Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed. Varicosities are not observed.
Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.
Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.
Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.

TEST RESULTS: No tests to report at this time.

IMPRESSION: Onychomycosis.

PLAN: Debrided 10 nails.

PRESCRIPTIONS: Penlac Dosage: 8% Topical Solution Sig: Dispense: Refills: 0 Allow Generic: No

Keywords: consult - history and phy., toenails, discolored, thickened, painful, onychomycosis,