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Medical Specialty:
Consult - History and Phy.
Sample Name: Gen Med H&P - 2
Description: Weakness, malaise dyspnea on exertion, 15-pound weight loss - Bilateral pneumonia, hepatitis, renal insufficiency,
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia.
PAST MEDICAL HISTORY: Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use. The patient is currently employed.
PHYSICAL EXAMINATION:
GENERAL: This is a thin, black cachectic man speaking in full sentences with oxygen.
VITAL SIGNS: Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.
HEENT: Funduscopic examination normal. He has oral thrush.
LYMPH: He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.
NECK: No goiter, no jugular venous distention.
CHEST: Bilateral basilar crackles, and egophony at the right and left middle lung fields.
HEART: Regular rate and rhythm, no murmur, rub or gallop.
GENITOURINARY: Normal.
RECTAL: Unremarkable.
SKIN: The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. He has very pale palms.
LABORATORY AND X-RAY DATA: Sodium 133, potassium 5.3, BUN 29, creatinine 1.8. Hemoglobin 14, white count 7100, platelet count 515. Total protein 10, albumin 3.1, AST 131, ALT 31. Urinalysis shows 1+ protein, trace blood. Total bilirubin 2.4, direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room air. Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.
IMPRESSION:
1. Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.
2. Thrush.
4. Hepatitis.
5. Elevated globulin fraction.
6. Renal insufficiency.
7. Subcutaneous nodules.
8. Risky sexual behavior in 1982 in Haiti.
PLAN:
1. Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.
2. Begin intravenous Bactrim and erythromycin.
4. Oxygen.
5. Nystatin swish and swallow.
6. Dermatologic biopsy of lesions.
7. Check HIV and RPR.
8. Administer Pneumovax, tetanus shot and Heptavax if indicated.
See More Samples on Consult - History and Phy.
A 5-month-old boy with cough
Abdominal Pain - Consult
Abnormal Echocardiogram
Abnormal Stress Test
Abrasions & Lacerations - ER Visit
Acne Vulgaris - H&P
Acute Cystitis & Diabetes Type II
Acute Inferior Myocardial Infarction
Adjustment Disorder & Encopresis
Admission History & Physical - Nausea
Adult Hydrocephalus
Agitation - ER Visit
Air Under Diaphragm - Consult
Airway Compromise & Foreign Body - ER Visit
Allergy Evaluation Consult
Anemia - Consult
Angina - Consult
Ankle Pain - Consult
Ankle Sprain - H&P
Annual Health Maintenance Exam
Ant Bait Exposure - ER Visit
Antibiotic Management Consult
Antibiotic Therapy Consult
Arm Pain - Neuro Consult
Asbestos Exposure - Hemoptysis
Atrial Fibrillation - Consult
Atrial Fibrillation Management
Attempted Suicide - Consult
Azotemia Consult
Bariatric Consult - Surgical Weight Loss - 1
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Barium Swallow Study & Speech Evaluation
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Barium Swallow Study Evaluation
Barium Swallow Study Evaluation - 1
Bilateral Hip Pain
Bipolar Affective Disorder - Consult
Bladder Cancer
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Brain Tumor - Consult
Breast Augmentation Consult
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Breast Reconstruction
Bunion & Pes Planovalgus Deformity
Burn - Consult
Buttock Abscess
C. Diff Colitis Consult
Cancer of the nasopharynx
Carbohydrate Counting
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Cardiac Consultation - 3
Cardiac Consultation - 4
Cardiac Consultation - 5
Cardiac Consultation - 6
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Chest discomfort & palpitations - Consult.
Chest Pain - Cardiac Consult
Chest Wall Lump - Consult
Cholangiocarcinoma Consult
Cholestasis Of Pregnancy
Chronic Atrial Fibrillation
Chronic Kidney Disease - Consult
Chronic Otitis Media
Chronic Sinusitis
Clogged AV Shunt - Consult
Colon Cancer Consult
Colon Cancer Screening
Colon Polyps - Genetic Counseling
Comprehensive Neurological Evaluation
Congestion - 21-day-old
Congestion & Cough - 5-month-Old
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Connective Tissue Disorder
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Consult - Enlarged Tonsils
Consult - Facial Twitching
Consult - Hydronephrosis
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Consult - ICU Management
Consult - Jaw Pain
Consult - Knee Pain
Consult - Laparoscopic Cholecystectomy
Consult - Migraine
Consult - Multiple Colon Polyps
Consult - Normal Pressure Hydrocephalus
Consult - Palpitations & Presyncope
Consult - Prostate Cancer
Consult - Pulsatile Tinnitus
Consult - Rectal Bleeding
Consult - Screening Colonoscopy
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Consult - Seizures - 1
Consult - Sepsis
Consult - Stasis Ulcer
Consult - Syncope
Consult - Vomiting & Nausea
Consult - Weankness & Polymyositis
Consult for Colostomy Reversal
Consult for New Wheelchair
Consult/ER Report - OB/GYN
Conversion Disorder
Cough & Abdominal Pain
Cut on Foot - ER Visit
CVA Consult - ER Visit
Cystic Fibrosis
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Dental Pain
Detox from Heroin
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Dilated Cardiomyopathy - Consult
Diplopia
Discoid Lupus
Disseminated Intravascular Coagulation
Dizziness - Recurrent
Dog Bite
Dural AVM
Dysphagia & Hematemesis
Ear Pain - Drainage
Ear pain - Pediatric Consult
Ecstasy Ingestion - ER Visit
Elbow Pain - Consult
Elevated BNP - Consult
Elevated Cardiac Enzymes
Elevated PSA - H&P
Encephalopathy - Rehab Consult
End Stage Renal Disease - Consult
ENT Consult
ENT Consult - 1
Epidural Fluid Collection
Epidural Hematoma
ER Report - Rib Cage Pain
Erythema Nodosum - Consult
Essential Tremor & Torticollis
Exudative Tonsillitis
Eye Examination - H&P
Feet & Hand Cramping
First Followup - Shunt Surgery
First Pap smear.
Flank Pain - Consult
Flank Pain - Consult - 1
Foot Infection Management
Foot pain Consultation
Foreign Body - Fingernail
Foreign Body - Right Nose
Foul-Smelling Urine
Gagging - 3-year-old
Gastric Bypass Discussion - 1
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Granulomatous Inflammation
Guillain-Barre Syndrome
H&P - Cardio (Angina)
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H&P - Nausea & Vomiting
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Hand Pain - Consult
Head & Neck Cancer Consult
Head Trauma
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HPV Consult
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Hypergranulation - Consult
Hypersensitivity to Coumadin
Hypertension - Consult
Hypertension & Cardiomyopathy
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Impairment Rating
Infant Not Gaining Weight
Infantile Spasms
Insect Sting
Intractable Epilepsy
Iron deficiency anemia
Ischemic Cecum - Consult
Itchy Rash - ER Visit
Jaw Pain - ER Visit
Knee DJD - Consult
Knee Injury
Kyphoplasty - Consult
Kyphosis
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Leaking Nephrostomy Tube
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Lesions - Adrenal and Pancreatic
Lightheaded & Dizziness
Lightheadedness
Limbic Encephalitis
Lobar Holoprosencephaly
Low Back Pain - Consult
Lower back pain
Lower Quadrant Pain
Lumbar Radiculopathy - Consult
Lumbar Spine HNP - Consult
Lumbosacral Polyradiculopathy
Lung Cancer & MI - Hospice Cosult
Lymphoblastic Leukemia - Consult
Lymphoma - Consult
Major Depressive Disorder - IME Consult
Malignant Meningioma - Consult
Mantle Cell Lymphoma - Consult
Marginal Zone Lymphoma
MCA Aneurysm
Medical Management Consult Request
Meningioma
Mental Status Changes - Consult
Mesothelioma - Consult
Metastatic Ovarian Cancer - Consult
Microhematuria - Consult
Migraine without Aura - Consult
Multilobar Pneumonia
Multiple Meningiomas
Multiple Neurological Symptoms
Murmur & Bacteremia.
Neck & Back Pain
Neck & Lower Back Pain - Consult
Neonatal Consult
Nephrology Consultation - 1
Nephrology Consultation - 2
Nephrology Consultation - 3
Nephrology Consultation - 4
Neuro Consult - Depression & Dementia
Neuro Consult - Leg Weakness
Neuroblastoma - Consult
Neurogenic Bladder - Consult
Neurologic Consultation
Neurologic Consultation - 1
Neurologic Consultation - 2
Neurologic Consultation - 3
Neurologic Consultation - 4
Neurologic Consultation - 5
Neurologic Examination
Neuropsychological Evaluation
Neuropsychological Evaluation - 1
Neuropsychological Evaluation - 2
Neuropsychological Evaluation - 3
Neuropsychological Evaluation - 4
Neuropsychological Evaluation - 5
New Onset Seizure
Non-Q-wave Myocardial Infarction
Non-Small Cell Lung Cancer - Consult
Normal Child Exam Template
Normal ENT Exam
Normal ENT Exam - 1
Normal Female Exam Template
Normal Female Exam Template - 1
Normal Female Exam Template - 2
Normal Female ROS Template
Normal Male Exam Template
Normal Male Exam Template - 1
Normal Male Exam Template - 2
Normal Male Exam Template - 3
Normal Male Exam Template - 4
Normal Male ROS Template - 1
Normal Newborn H&P Template
Normal Newborn Infant Physical Exam
Normal Physical Exam Template
Normal Physical Exam Template - 1
Normal Physical Exam Template - 2
Normal Physical Exam Template - 3
Normal Physical Exam Template - 4
Normal Physical Exam Template - 5
Normal Physical Exam Template - 6
Normal Physical Exam Template - 7
Normal ROS Template
Normal ROS Template - 1
Normal ROS Template - 2
Normal ROS Template - 3
Normal ROS Template - 4
Normal ROS Template - 5
Not Feeling Well - ER Visit
OB/GYN - H&P
OB/GYN Consultation - 1
OB/GYN Consultation - 2
OB/GYN Consultation - 3
OB/GYN Consultation - 4
Occupational Medicine Consult
Occupational Medicine Consult - 1
Occupational Medicine Consult - 2
Occupational Medicine Consult - 3
Oligoarticular Arthritis - 1
Oligoarticular Arthritis - 2
Onychomycosis - H&P
Organic Brain Syndrome
Orthopedic Consult
Orthopedic Consult - 1
Orthopedic Consult - 2
Orthopedic Consult - 3
Orthopedic Consult - 4
Orthopedic Consult - 5
Otitis Media - H&P
Pain from Hernia - ER Consult
Pain Management Consult - 1
Pain Management Consult - 2
Paroxysmal Atrial Fibrillation
Pediatric Rheumatology Consult
Penile Cellulitis
Penile Discharge
Pericardial Effusion
Perioperative Elevated Blood Pressure
Peripheral Effusion - Consult
Physical Exam and Pap - 1
Physical Exam and Pap -2
Pneumoconiosis
Pneumothorax & Subcutaneous Emphysema
Postop Medical Management
Preeclampsia
Preop Cardiac Consult
Prostate Adenocarcinoma
Prostate Adenocarcinoma - H&P
Pseudoseizures
Pseudotumor Cerebri
Psych Consult - Alcohol Withdrawal
Psych Consult - Altered Mental Status
Psych Consult - Anxiety
Psych Consult - Assaultive Behavior
Psych Consult - Bipolar Affective Disorder
Psych Consult - Dementia
Psych Consult - Depression - 1
Psych Consult - Depression - 2
Psych Consult - Lethargy
Psych Consult - Pain Meds
Psych Consult - Paranoia
Psych Consult - Psychosis
Psych Consult - Psychosis - 1
Psych Consult - Schizophrenia
Psych Consult - Substance abuse
Psych H&P - 1
Psych H&P - 2
Psychiatric Consult
Psychiatric Consult - 1
Psychiatric Consult - 2
Pubic Cellulitis
Pulmonary Consultation - 1
Pulmonary Consultation - 2
Pulmonary Edema - Consult
Pulmonary Embolism
Pulmonary Hypertension - Pediatric Consult
Records Review - Epicondylitis
Records Review - Orthopedic
Rectal Bleeding - 1-year-old
Rectal Bleeding - Consult
Recurrent Abscesses - Consult
Recurrent nasal obstruction
Renal Failure - Consult
Renal Failure Evaluation
Renal Insufficiency - Consult
Request For Consultation
Revocation Admission
Rheumatoid Arthritis - Consult
Rheumatoid Arthritis - H&P
Rotator cuff syndrome - H&P
School Physical - 1
School Physical - 2
Sepsis - Consult
Shoulder Pain Consult
Sick Sinus Syndrome
Sinus problems - Consult
Sleepiness - Consult
Small Bowel Obstruction
Speech Therapy Evaluation
Speech Therapy Evaluation - 1
Spinal fluid evaluation
Sports Physical - 1
Sports Physical - 2
Sports Physical - 3
Status Epilepticus
Supraclavicular Lymphadenopathy
Supraventricular Tachycardia - Consult
Syncope - ER Visit
Syncope - ER Visit - 1
T-Cell Lymphoma Consult
Tethered Cord Evaluation
Therapeutic Recreation Initial Evaluation
Thrombocytopenia - Consult
Thyroid Mass Consult
TIA - Cosult
TIA & Lumbar Stenosis
Tinea Pedis - H&P
Tongue Swelling
Toothache - ER Visit
Tracheostomy Tube Consult
Trouble Breathing - H&P
Ureteral Calculus - Consult
URI & Eustachian Congestion
Urinary Retention
Urology Consut - 1
Uveitis
Ventricular Ectopy - Consult
Vertigo Consult
Vertigo Consult - 1
Viral Gastroenteritis
Weight Gain and Edema
Weight Loss Evaluation
Well-Child Check - 1
Well-Child Check - 2
Well-Child Check - 3
Well-Child Check - 4
Well-Child Check - 5
Well-Child Check - 6
Well-Child Check - 7
Well-woman checkup
Worker's Compensation Injury
Wound Care Consult
Wrist Pain
Keywords: consult - history and phy., weakness, malaise, dyspnea on exertion, weight loss, atypical pneumonia, unconjugated bilirubins, globulin fraction, heptavax, pneumocystis carinii, pneumocystis, tuberculosis, pneumonia,