Datasets:

HoangHa

/

MedicalTranscriptions

like 0

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 - History and Phy.

Consult - Congestive Heart Failure

REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , 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. Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation. Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS: ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:, Married, active smoker, does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above. The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: History of blurry vision and hearing impaired. No glaucoma.,CARDIOVASCULAR: Shortness of breath, congestive heart failure, and arrhythmia. Prior history of chest pain.,RESPIRATORY: Bronchitis and pneumonia. No valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,SKIN: Non-significant.,NEUROLOGICAL: No TIA. No CVA or seizure disorder.,ENDOCRINE: Non-significant.,HEMATOLOGICAL: Non-significant.,PSYCHOLOGICAL: Anxiety. No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat.,LUNGS: Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART: PMI displaced. S1 and S2, regular. Systolic murmur.,ABDOMEN: Soft and nontender.,EXTREMITIES: Trace edema of the ankle. Pulses are feebly palpable. Clubbing plus. No cyanosis.,CNS: Grossly intact.,MUSCULOSKELETAL: Arthritic changes.,PSYCHOLOGICAL: Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect. Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7. INR 1.8. BUN and creatinine within normal limits. Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for:

Chronic adenotonsillitis with adenotonsillar hypertrophy. Upper respiratory tract infection with mild acute laryngitis.

Consult - History and Phy.

Consult - Enlarged Tonsils

HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils. The patient has been having difficult time with having two to three bouts of tonsillitis this year. She does average about four bouts of tonsillitis per year for the past several years. She notes that throat pain and fever with the actual infections. She is having no difficulty with swallowing. She does have loud snoring, though there have been no witnessed observed sleep apnea episodes. She is a mouth breather at nighttime, however. The patient does feel that she has a cold at today's visit. She has had tonsil problems again for many years. She does note a history of intermittent hoarseness as well. This is particularly prominent with the current cold that she has had. She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home. For the two tonsillitis, she is on antibiotics again on an average about four times per year. They do seem to help with the infections, but they tend to continue to recur. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC: Negative.,CARDIOVASCULAR: Negative.,PULMONARY: Negative.,GASTROINTESTINAL: Negative.,GENITOURINARY: Negative.,NEUROLOGIC: Negative.,VISUAL: Negative.,DERMATOLOGIC: Negative.,ENDOCRINE: Negative.,MUSCULOSKELETAL: Negative.,CONSTITUTIONAL: Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:, No family history of bleeding disorder. She does have a sister with a current ear infection. There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single. She is a student. Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL: The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: The external ears are normal. The ear canals are clean and dry. The drums are intact and mobile. Hearing is grossly normal. Tuning fork examination with normal speech reception thresholds noted.,NASAL: She has clear drainage, large inferior turbinates, no erythema.,ORAL: Her tongue, lip, floor of mouth are noted to be normal. Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic. Mirror examination of the larynx reveals some mild edema of the larynx at this time. The nasopharynx could not be visualized on mirror exam today.,NECK: Obese, supple. Trachea is midline. Thyroid is nonpalpable.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,IMPRESSION: , ,1. Chronic adenotonsillitis with adenotonsillar hypertrophy.,2. Upper respiratory tract infection with mild acute laryngitis.,3. Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy. All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family. This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc. The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks. We will make further recommendations afterwards.

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 - History and Phy.

Consult - Chest Pain - 1

REASON FOR CONSULTATION:, Chest pain.,HISTORY OF PRESENT ILLNESS: , The patient is a 37-year-old gentleman admitted through emergency room. He 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. His history is significant as mentioned below. His workup so far has been negative.,CORONARY RISK FACTORS:, No history of hypertension or diabetes mellitus. Active smoker. Cholesterol status, borderline elevated. No history of established coronary artery disease. Family history positive.,FAMILY HISTORY: , His father died of coronary artery disease.,SURGICAL HISTORY: , No major surgery except for prior cardiac catheterization.,MEDICATIONS AT HOME:, Includes pravastatin, Paxil, and BuSpar.,ALLERGIES:, None.,SOCIAL HISTORY: , Active smoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hyperlipidemia, smoking history, and chest pain. He has been, in October of last year, hospitalized. Subsequently underwent cardiac catheterization. The left system was normal. There was a question of a right coronary artery lesion, which was thought to be spasm. Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed. No relation to exertional activity.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills.,HEENT: No history of cataract, blurring vision, or glaucoma.,CARDIOVASCULAR: As above.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,CNS: No TIA. No CVA. No seizure disorder.,ENDOCRINE: Nonsignificant.,HEMATOLOGICAL: Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute.,HEENT: Head is atraumatic and normocephalic. Neck veins flat.,LUNGS: Clear.,HEART: S1 and S2, regular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis.,CNS: Benign.,PSYCHOLOGICAL: Normal.,MUSCULOSKELETAL: Within normal limits.,DIAGNOSTIC DATA: , EKG, normal sinus rhythm. Chest x-ray unremarkable.,LABORATORY DATA: , First set of cardiac enzyme profile negative. H&H stable. BUN and creatinine within normal limits.,IMPRESSION:,1. Chest pain in a 37-year-old gentleman with negative cardiac workup as mentioned above, questionably right coronary spasm.,2. Hyperlipidemia.,3. Negative EKG and cardiac enzyme profile.,RECOMMENDATIONS:

The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.

Consult - History and Phy.

Consult - CHF & Lymphedema

HISTORY OF PRESENT ILLNESS:, The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema. He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung. This consultation was made for better control of his blood sugars. On questioning, the patient says that he does not have diabetes. He says that he has never been told about diabetes except during his last admission at Jefferson Hospital. Apparently, he was started on glipizide at that time. His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem. He is not sure. He is not following any specific diet. He says "my doctor wants me to lose 30-40 pounds in weight" and he would not mind going on a diet. He has a long history of numbness of his toes. He denies any visual problems.,PAST MEDICAL HISTORY: , As above that includes CA of the lung, COPD, bilateral cataracts. He has had chronic back pain. There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,SOCIAL HISTORY: , The patient has been a smoker since the age of 10. So, he was smoking 2-3 packs per day. Since being started on Chantix, he says he has cut it down to half a pack per day. He does not abuse alcohol.,MEDICATIONS: ,1. Glipizide 5 mg p.o. daily.,2. Theophylline.,3. Z-Pak.,4. Chantix.,5. Januvia 100 mg daily.,6. K-Lor.,7. OxyContin.,8. Flomax.,9. Lasix.,10. Advair.,11. Avapro.,12. Albuterol sulfate.,13. Vitamin B tablet.,14. OxyContin and oxycodone for pain.,FAMILY HISTORY: , Positive for diabetes mellitus in the maternal grandmother.,REVIEW OF SYSTEMS: , As above. He says he has had numbness of toes for a long time. He denies any visual problems. His legs have been swelling up from time to time for a long time. He also has history of COPD and gets short of breath with minimal activity. He is also not able to walk due to his weight. He has had ulcers on his legs, which he gets discharge from. He has chronic back pain and takes OxyContin. He denies any constipation, diarrhea, abdominal pain, nausea or vomiting. There is no chest pain. He does get short of breath on walking.,PHYSICAL EXAMINATION:,The patient is a well-built, obese, white male in no acute distress.,Vital signs: Pulse rate of 89 per minute and regular. Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18.,HEENT: Head is normocephalic and atraumatic. Eyes, PERRLA. EOMs intact. Fundi were not examined.,Neck: Supple. JVP is low. Trachea central. Thyroid small in size. No carotid bruits.,Heart: Shows normal sinus rhythm with S1 and S2.,Lungs: Show bilateral wheezes with decreased breath sounds at the bases.,Abdomen: Soft and obese. No masses. Bowel sounds are present.,Extremities: Show bilateral edema with changes of chronic venostasis. He does have some open weeping sores. Pulses could not be palpated due to leg swelling.,IMPRESSION/PLAN:,1. Diabetes mellitus, type 2, new onset. At this time, the patient is on Januvia as well as glipizide. His blood sugar right after eating his supper was 101. So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet. We will continue to follow his blood sugars closely and make adjustments as needed.,2. Neuropathy, peripheral, query etiology. We will check TSH and B12 levels.,3. Lymphedema.,4. Recurrent cellulitis.,5. Obesity, morbid.,6. Tobacco abuse. He was encouraged to cut his cigarettes down to 5 cigarettes a day. He says he feels like smoking after meals. So, we will let him have it after meals first thing in the morning and last thing at night.,7. Chronic venostasis.,8. Lymphedema. We would check his lipid profile also.,9. Hypertension.,10. Backbone pain, status post back surgery.,11. Status post hernia repair.,12. Status post penile implant and removal.,13. Umbilical hernia repair.

Patient with multiple problems, main one is chest pain at night.

Consult - History and Phy.

Consult - Chest Pain

CHIEF COMPLAINT:, Multiple problems, main one is chest pain at night.,HISTORY OF PRESENT ILLNESS:, This is a 60-year-old female with multiple problems as numbered below:,1. She reports that she has chest pain at night. This happened last year exactly the same. She went to see Dr. Murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month. She wakes in the middle of the night and reports that she has a pressure. It is mild-to-moderate in the middle of her chest and will stay there as long she lies down. If she gets up, it goes away within 15 minutes. It is currently been gone on for the last week. She denies any fast heartbeats or irregular heartbeats at this time.,2. She has been having stomach pains that started about a month ago. This occurs during the daytime. It has no relationship to foods. It is mild in nature, located in the mid epigastric area. It has been better for one week as well.,3. She continues to have reflux, has noticed that if she stops taking Aciphex, then she has symptoms. If she takes her Aciphex, she seems that she has the reflux belching, burping, and heartburn under control.,4. She has right flank pain when she lies down. She has had this off and on for four months. It is a dull achy pain. It is mild in nature.,5. She has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past. It is not painful.,6. She has had spots in her armpits initially on the right side and then going to the left side. They are not itchy.,7. She is having problems with urgency of urine. When she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking. She is wearing a pad now.,8. She is requesting a colonoscopy for screening as well. She is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer.,9. She has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months. There has been no swelling or redness or trauma to these areas.,REVIEW OF SYSTEMS:, She has recently been to the eye doctor. She has noticed some hearing loss gradually. She denies any problems with swallowing. She denies episodes of shortness of breath, although she has had a little bit of chronic cough. She has had normal bowel movements. Denies any black or bloody stools, diarrhea, or constipation. Denies seeing blood in her urine and has had no urinary problems other than what is stated above. She has had no problems with edema or lower extremity numbness or tingling.,SOCIAL HISTORY:, She works at nursing home. She is a nonsmoker. She is currently trying to lose weight. She is on the diet and has lost several pounds in the last several months. She quit smoking in 1972.,FAMILY HISTORY: , Her father has type I diabetes and heart disease. She has a brother who had heart attack at the age of 52. He is a smoker.,PAST MEDICAL HISTORY:, Episodic leukopenia and mild irritable bowel syndrome.,CURRENT MEDICATIONS:, Aciphex 20 mg q.d. and aspirin 81 mg q.d.,ALLERGIES:, No known medical allergies.,OBJECTIVE:,Vital Signs: Weight: 142 pounds. Blood pressure: 132/78. Pulse: 72.,General: This is a well-developed adult female who is awake, alert, and in no acute distress.,HEENT: Her pupils are equally round and reactive to light. Conjunctivae are white. TMs look normal bilaterally. Oropharynx appears to be normal. Dentition is excellent.,Neck: Supple without lymphadenopathy or thyromegaly.,Lungs: Clear with normal respiratory effort.,Heart: Regular rhythm and rate without murmur. Radial pulses are normal bilaterally.,Abdomen: Soft, nontender, and nondistended without organomegaly.,Extremities: Examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the PIP joint and DIP joint. Her armpits are examined. She has what appears to be a tinea versicolor rash present in the armpits bilaterally. She has a lesion on her left shoulder, which is 6 mm in diameter. It has diffuse borders and is slightly red. It has two brown spots in it. In her lower extremities, there is no cyanosis or edema. Pulses at the radial and posterior tibial pulses are normal bilaterally. Her gait is normal.,Psychiatric: Her affect is pleasant and positive.,Neurological: She is grossly intact. Her speech seems to be clear. Her coordination of upper and lower extremities is normal.,ASSESSMENT/PLAN:,1. Chest pain. At this point, because of Dr. Murphy’s evaluation last year and the symptoms exactly the same, I think this is noncardiac. My intonation is that this is reflux. I am going have her double her Aciphex or increase it to b.i.d., and I am going to have her see Dr. XYZ for possible EGD if he thinks that would be appropriate. She is to let me know if her symptoms are getting worse or if she is having any severe episodes.,2. Stomach pain, uncertain at this point, but I feel like this is probably related as well to chest pain.,3. Suspicious lesions on the left shoulder. We will do a punch biopsy and set her up for an appointment for that.,4. Tinea versicolor in the axillary area. I have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days.,5. Cystocele. We will have her see Dr. XYZ for further discussion of repair due to her urinary incontinence.,6. History of leukopenia. We will check a CBC.,7. Pain in the thumbs, probably arthritic in nature, observe for now.,8. Screening. We will have her see Dr. XYZ for discussion of colon cancer screening.,9. Gastroesophageal reflux disease. I have increased Aciphex to b.i.d. for now.

The patient has been suffering from intractable back and leg pain.

Consult - History and Phy.

Consult - Back & Leg Pain

Her axial back pain is greatly improved, but not completely eradicated. There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:, Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:, Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired. Denies tobacco or ethanol use.,FAMILY HISTORY:, Father died of mesothelioma. Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia. Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:, Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN: ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome. Her lumbar facet joints were denervated approximately 6 months ago. The denervation procedure helped her axial back pain approximately 40% when standing. With extension and rotation it helped her axial back pain approximately 70%. She is now able to swing a golf club. She was unable to swing a golf club due to the rotational movements before her rhizotomy. She is currently playing golf. Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d. We will follow her up in 1 month's time.,

consult - history and phy., multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar

Patient presents with complaint of lump in the upper outer quadrant of the right breast

Consult - History and Phy.

Consult - Breast Cancer

CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:, Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.

Patient with a history of right upper pons and right cerebral peduncle infarction.

Consult - History and Phy.

Consult - Cerebral Peduncle Infarction

FAMILY HISTORY AND SOCIAL HISTORY:, Reviewed and remained unchanged.,MEDICATIONS:, List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:, She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS: ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain. Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs: Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General: She was a pleasant person in no acute distress.,HEENT: Normocephalic and atraumatic. No dry mouth. No palpable cervical lymph nodes. Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:, Remained unchanged.,Mental Status: Normal.,Cranial Nerves: Mild decrease in the left nasolabial fold.,Motor: There was mild increased tone in the left upper extremity. Deltoids showed 5-/5. The rest showed full strength. Hip flexion again was 5-/5 on the left. The rest showed full strength.,Reflexes: Reflexes were hypoactive and symmetrical.,Gait: She was mildly abnormal. No ataxia noted. Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement. She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes. She will continue to follow with endocrinology for diabetes and thyroid problems. I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery. I will see her back in about four months or sooner if needed.

consult - history and phy., internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle,

The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.

Consult - History and Phy.

Consult - Breast Cancer - 1

CHIEF COMPLAINT: , Left breast cancer.,HISTORY:, The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center. On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial). The biopsy returned showing infiltrating ductal carcinoma high histologic grade. The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging. She prior to that area, denied any complaints. She had no nipple discharge. No trauma history. She has had been on no estrogen supplementation. She has had no other personal history of breast cancer. Her family history is positive for her mother having breast cancer at age 48. The patient has had no children and no pregnancies. She denies any change in the right breast. Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y. I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy. The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning. The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact. CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:, Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:, She is currently on omeprazole for reflux and indigestion.,ALLERGIES:, SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:, Negative for any recent febrile illnesses, chest pains or shortness of breath. Positive for restless leg syndrome. Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:, Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY: ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL: The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT: Head is atraumatic and normocephalic. Sclerae are anicteric.,NECK: Supple.,CHEST: Clear.,HEART: Regular rate and rhythm.,BREASTS: Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle. There are no nipple retractions. No skin dimpling. There is some, at the time of the office visit, ecchymosis from recent biopsy. There is no axillary adenopathy. The remainder of the left breast is without abnormality. The right breast is without abnormality. The axillary areas are negative for adenopathy bilaterally.,ABDOMEN: Soft, nontender without masses. No gross organomegaly. No CVA or flank tenderness.,EXTREMITIES: Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy. We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection. The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient. The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained. Local numbness, paresthesias or chronic pain was explained. The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers. She was certainly encouraged to obtain further surgical medical opinions prior to proceeding. I believe the patient has given full informed consent and desires to proceed with the above.

Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type.

Consult - History and Phy.

Consult - Alzheimer disease

The patient states that she has been doing fairly well at home. She balances her own checkbook. She does not do her own taxes, but she has never done so in the past. She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving. She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home. She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren. She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression. There is unfortunately no one available to us to corroborate how well she is doing at home. She lives alone and takes care of herself and does not communicate very much with her brother and sister. She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren. She denied any sort of personality change, paranoid ideas or hallucinations. She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it. When these headaches are very severe, she goes to the emergency room to get a single shot. She is unclear if this is some sort of a migraine medication or just a primary pain medication. She takes Fiorinal for these headaches and she states that this helps greatly. She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia. She also denies any sort of movement disorders, tremors, rigidities or clonus. Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness. She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago. The patient was not sure of exactly when it was diagnosed. This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations. The mesothelioma is in her abdomen. She does not know of any history of having lung mesothelioma. She states that she has never gotten chemotherapy or radiation for her mesothelioma. Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable. She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position. These have all occurred over the past five years. She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation. This diagnosis was given in March 2006.,MEDICATIONS:, Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:, Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer. Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg. She is alert and well nourished in no apparent distress. She occasionally fumbles with questions of orientation, missing the day and the date. She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in. She lost three points for recall. Even with prompting, she could not remember the objects that she was given to remember. Her Mini Mental Score was 22/30. There were no naming problems or problems with repetition. There were also no signs of dysarthria. Her pupils were bilaterally reactive to light and accommodation. Her extraocular movements were intact. Her visual fields were full to confrontation. Her sensations of her face, arm, and leg were normal. There were no signs of neglect with double simultaneous stimulation. Tongue was midline. Her palate was symmetric. Her face was symmetric as well. Strength was approximately 5/5. She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain. Her reflexes were symmetric and +2 except for her toes, which were +1 to trace. Her plantar reflexes were mute. Her sensation was normal for pain, temperature, and vibration. There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia. Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:, Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type. We tactfully discussed the patient's diagnosis with her, and she felt reassured. We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept. She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept. The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV. It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment. She will follow up with us in the next six months and will call us if she has any problems with the Aricept. She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day. We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.,

consult - history and phy., neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma,

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 - History and Phy.

Consult - Atrial Fibrillation

REASON FOR CONSULTATION:, Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke. She was found to have confusion while in her facility. She then came to the emergency room and found to have a right sided acute stroke. 12-lead EKG performed on August 10, 2009, found to have atrial fibrillation. Telemetry also revealed atrial fibrillation with rapid ventricular response. Currently, the telemetry is normal sinus rhythm. Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian. She did not recall why she is in the hospital, she said she had a stroke. She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1. Coronary artery disease status post bypass grafting surgery. Unable to obtain the place, location, anatomy, and the year it was performed.,2. Carotid artery stenosis status post right carotid artery stenting. Again, the time was unknown.,3. Diabetes.,4. Hypertension.,5. Hyperlipidemia.,6. History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, The patient is a resident of Lake Harris Port Square. She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air. Temperature 99, respiratory rate 16.,GENERAL: The patient is sitting in the chair at bedside. Appears comfortable. Left facial droop. Left side hemiplegia.,HEAD AND NECK: No JVP seen. Right side carotid bruit heard.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI not displaced, regular rhythm. Normal S1 and S2. Positive S4. There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN: Soft.,EXTREMITIES: Not edematous.,DATA:, A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute. Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7. The patient's hemoglobin was 8.2 a few days ago before blood transfusion. Chemistry-7 within normal limits. Lipid profile: Triglycerides 64, total cholesterol 106, HDL 26, LDL 17. Liver function tests are within normal limits. INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%. Mild apical hypokinesis. Mild dilated left atrium. Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. No intracardiac masses or thrombus were noted. The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1. Paroxysmal atrial fibrillation. It is unknown if this is a new onset versus a paroxysmal atrial fibrillation. Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated. However, given the patient's current neurologic status, the safety of falling is unclear. We need to further discuss with the patient's primary care physician, probably rehab physician. If the patient's risk of falling is low, then Coumadin is indicated. However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended. Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management. Therefore, I will not recommend transesophageal echocardiogram at this point. Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2. Carotid artery stenosis. The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery. It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting. If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency. However, given the patient's current acute stroke, revascularization is not indicated at this time.,3. Coronary artery disease. Clinically stable. No further test is indicated at this time.

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 - History and Phy.

Consult - Atrial Fibrillation - 1

REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman. The patient had shortness of breath over the last few days, progressively worse. Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea. Coronary artery disease workup many years ago. He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:, Married, ex-smoker, and does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness. The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: Weakness, fatigue, tiredness.,HEENT: No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR: Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL: Some frequency, urgency, no hematuria.,MUSCULOSKELETAL: Arthritis, muscle weakness.,SKIN: Chronic skin changes.,CNS: History of TIA. No CVA, no seizure disorder.,ENDOCRINE: Nonsignificant.,HEMATOLOGICAL: Nonsignificant.,PSYCHOLOGICAL: No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins flat. No significant carotid bruits.,LUNGS: Air entry bilaterally fair, decreased in basal areas. No rales or wheezes.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft and nontender. Bowel sounds present.,EXTREMITIES: Chronic skin changes. Pulses are palpable. No clubbing or cyanosis.,CNS: Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits. First set of cardiac enzymes profile negative. BNP 4810.,Chest x-ray confirms unremarkable findings. EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:

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.

Consult - History and Phy.

Congestion & Cough - 5-month-Old

CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a 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. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS: ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY: ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY: ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her respiratory rate was approximately 60 to 65.,GENERAL: She was very congested and she looked miserable. She had no retractions at this time.,HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.,NECK: Supple. Full range of motion.,CARDIOVASCULAR EXAM: She was tachycardic without murmur.,LUNGS: Revealed diffuse expiratory wheezing.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Showed no clubbing, cyanosis or edema.,LABORATORY DATA: ,Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN: ,RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.

She is sent for evaluation of ocular manifestations of systemic connective tissue disorders. Denies any eye problems and history includes myopia with astigmatism.

Consult - History and Phy.

Connective Tissue Disorder

Her past medical history includes a presumed diagnosis of connective tissue disorder. She has otherwise, good health. She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically. She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye. Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD. She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS. Intraocular pressures are 13 OU and by applanation. Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes. Gonioscopy showed normal anterior segment angle morphology in both eyes. She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes. Conjunctivae were quite, OU. Cornea were clear in both eyes. The anterior chamber is deep and quiet, OU. She has clear lenses, which are in good position, OU. Dilated fundus exam shows moderately optically clear vitreous, OU. The optic nerves are normal in size. The cup-to-disc ratios were approximately 0.4, OU. The nerve fiber layers are excellent, OU. The macula, vessels, and periphery were normal in both eyes. No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous. She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur. Otherwise, I can see her in 1 to 2 years.

consult - history and phy., systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes

A 2-month-old female with 1-week history of congestion and fever x2 days.

Consult - History and Phy.

Congestion & Fever - 2-month-old

CHIEF COMPLAINT:, A 2-month-old female with 1-week history of congestion and fever x2 days.,HISTORY OF PRESENT ILLNESS:, The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions. The mother states that the cough is at times paroxysmal and associated with posttussive emesis. The patient has had short respiratory pauses following the coughing events. The patient's temperature has ranged between 102 and 104. She has had a decreased oral intake and decreased wet diapers. The brother is also sick with URI symptoms, and the patient has had no diarrhea. The mother reports that she has begun to regurgitate after her feedings. She did not do this previously.,MEDICATIONS: , None.,SMOKING EXPOSURE: , None.,IMMUNIZATIONS: , None.,DIET: ,Similac 4 ounces every 2 to 3 hours.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY: ,The patient delivered at term. Birth weight was 6 pounds 1 ounce. Postnatal complications: Neonatal Jaundice. The patient remained in the hospital for 3 days. The in utero ultrasounds were reported to be normal.,PRIOR HOSPITALIZATIONS: , None.,FAMILY/SOCIAL HISTORY: , Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.,DEVELOPMENT: , Normal. The patient tests normal on the newborn hearing screen.,REVIEW OF SYSTEMS: GENERAL: , The patient has had fever, there have been no chills. SKIN: No rashes. HEENT: Mild congestion x1 week. Cough, at times paroxysmal, no cyanosis. The patient turns red in the face during coughing episodes, posttussive emesis. CARDIOVASCULAR: No cyanosis. GI: Posttussive emesis, decreased oral intake. GU: Decreased urinary output. ORTHO: No current issues. NEUROLOGIC: No change in mental status. ENDOCRINE: There is no history of weight loss. DEVELOPMENT: No loss of developmental milestones.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,GENERAL: This is a well-appearing infant in no acute distress.,HEENT: Shows anterior fontanelle to be open and flat. Pupils are equal and reactive to light with red reflex. Nares are patent. Oral mucosa is moist. Posterior pharynx is clear. Hard palate is intact. Normal gingiva.,HEART: Regular rate and rhythm without murmur.,LUNGS: A few faint rales. No retractions. No stridor. No wheezing on examination. Mild tachypnea.,EXTREMITIES: Warm, good perfusion. No hip clicks.,NEUROLOGIC: The patient is alert. Normal tone throughout. Deep tendon reflexes are 2+/4. No clonus.,SKIN: Normal.,LABORATORY DATA:, CBC shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. Electrolytes were within normal limits. C-reactive protein 0.3. Chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. UA shows 10 to 25 bacteria.,ASSESSMENT/PLAN: ,This is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. The patient is currently stable in the emergency room. We will admit the patient to the pediatric floor. We will send out pertussis PCR. We will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. The patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. We will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.

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 - History and Phy.

Consult - Abnormal EKG

REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female. From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena. The patient relates to have some low-grade fever. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. As per the medications, they are not very clear. Husband has gone out to brief her medications. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above.,CORONARY RISK FACTORS: , No hypertension or diabetes mellitus. Nonsmoker. Cholesterol status is normal. Questionable history of coronary artery disease. Family history noncontributory.,FAMILY HISTORY:, Nonsignificant.,PAST SURGICAL HISTORY: , Questionable coronary artery bypass surgery versus valve replacement.,MEDICATIONS: , Unclear at this time, but she does take Coumadin.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY: , She is married, nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: , Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: No history of cataract, history of blurry vision and hearing impairment.,CARDIOVASCULAR: Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,RESPIRATORY: Shortness of breath, questionable pneumonia. No valley fever.,GASTROINTESTINAL: No nausea, no vomiting, hematemesis or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Arthritis, muscle weakness.,CNS: No TIA. No CVA. No seizure disorder.,SKIN: Nonsignificant.,PSYCHOLOGIC: Anxiety and depression.,ALLERGIES: Nonsignificant except as mentioned above for medications.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,HEENT AND NECK: Neck is supple. Atraumatic and normocephalic. Neck veins are flat. No thyromegaly.,LUNGS: Air entry bilaterally fair. Decreased breath sounds especially in the right basilar areas. Few crackles.,HEART: Normal S1 and S2, irregular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulse is palpable. No clubbing or cyanosis.,CNS: Grossly intact.,MUSCULOSKELETAL: Arthritic changes.,PSYCHOLOGICAL: None significant.,DIAGNOSTIC DATA: , EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes. INR of 4.5, H and H 10 and 30. BUN and creatinine are within normal limits. Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,IMPRESSION:,1. The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2. Symptoms as above.,RECOMMENDATIONS:,1. We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia. Once, if she is stable, we will consider further cardiac workup.,2. We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.

Routine colorectal cancer screening. He occasionally gets some loose stools.

Consult - History and Phy.

Colon Cancer Screening

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation.

consult - history and phy., colon cancer screening, loose stools, colorectal, colonoscopy,

Congestion, tactile temperature.

Consult - History and Phy.

Congestion - 21-day-old

CHIEF COMPLAINT:, Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness. Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:, Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, Tylenol.,IMMUNIZATIONS:, None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:, At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. Both brothers at home are sick with cold symptoms including diarrhea and vomiting. The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription. A nephew of the mom with an ear infection. Mom also states that she herself was sick with the flu soon after delivery. There has been recent travel exposure to dad's family over the Christmas holidays. At this time, there is also exposure to indoor cats and dogs. This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION: ,VITALS: Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air. Weight was 4.1 kg.,GENERAL: Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT: Normocephalic, atraumatic head. Anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR: Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. Capillary refill was less than 3 seconds.,LUNGS: Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN: Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. Umbilical site was with scant dried yellow discharge.,GU: Tanner stage 1 male, circumcised. There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS: Negative Barlow or Ortolani maneuvers.,SKIN: Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. The hemoglobin was 14.4, hematocrit was 40. The platelet count was elevated at 698,000. A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89. A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1. Rule out sepsis.,2. Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria. We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER. Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV. The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. Also, there is negative apnea in this patient.,PLAN: ,1. We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2. We will follow up with his blood, urine, and CSF cultures.

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.

Consult - History and Phy.

Colon Cancer Consult

REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:, The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy. Unfortunately, she had miscarriage at about seven weeks. She again had abdominal cramping, severe, in late March 2007. She underwent colonoscopy on 04/30/2007 by Dr. Y. Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure. She was not able to have the scope passed past this lesion. Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday. The surgery was laparoscopic assisted with anastomosis. At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis. There was no angiolymphatic invasion noted. Radial margin was 0.1 mm. Other margins were 5 and 6 mm. Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis. This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs. The degenerative changes were noted at L5-S1. The ovaries were normal. An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:, She has otherwise been feeling well. She has not had fevers, night sweats, or noticed lymphadenopathy. She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber. She was eating well up until the time of her surgery. She is up-to-date on mammography, which will be due again in June. She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:, None.,PAST MEDICAL HISTORY: , No significant medical problem. She has had three miscarriages, all of them at about seven weeks. She has no prior surgeries.,SOCIAL HISTORY: ,She smoked cigarettes socially while in her 20s. A pack of cigarettes would last for more than a week. She does not smoke now. She has two glasses of wine per day, both red and white wine. She is married and has no children. An IUD was recently placed. She works as an esthetician.,FAMILY HISTORY: ,Father died of stage IV colon cancer at age 45. This occurred when the patient was young and she is not sure of the rest of the paternal family history. She does believe that aunts and uncles on that side may have died early. Her brother died of pancreas cancer at age 44. Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago. Otherwise, he has no medical problem. Mother is aged 82 and healthy. She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL: She is in no acute distress.,VITAL SIGNS: The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN: Warm and dry. She has no jaundice.,LYMPHATICS: No cervical or supraclavicular lymph nodes are palpable.,LUNGS: There is no respiratory distress.,CARDIAC: Regular rate.,ABDOMEN: Soft and mildly tender. Dressings are clean and dry.,EXTREMITIES: No peripheral edema is noted. Sequential compression devices (SCDs) are in place.,LABORATORY DATA:, White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6. Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133. Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis. Firstly, she has a good prognosis for being cured without adjuvant therapy. I would consider her borderline for chemotherapy given her young age. Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit. Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects. We did not review all that information today.,She has a family history of early colon cancer. Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can. Tumor is being tested for microsatellite instability and we will discuss this when those results are available. She has one sibling and he is up-to-date on colonoscopy. She does report multiple tubes of blood were drawn prior to her admission. I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed. If not, those can be drawn tomorrow.

A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis.

Consult - History and Phy.

Comprehensive Neurological Evaluation

As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. She had HMO insurance at that time and saw a neurologist, whose name she does not recall. She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests. She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved. She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia. She saw a urologist and underwent urodynamic testing. She was diagnosed as having "overactive bladder", but the cause of this was never determined. She was treated with medications, possibly Ditropan, without much benefit. She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable "stiffness" in her feet and slight swelling of the ankles. Apparently, the swelling was not visible by others. She saw multiple physicians and was told that it was "not arthritis", but no definite diagnosis was ever established. She saw at least two rheumatologists on several occasions and blood tests were all normal. No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat. She states from time-to-time she could "barely walk". She felt as if her balance is impaired and she felt as if she were "walking on stilts". She tried arch supports from a podiatrist without any benefit. She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X. He ordered an MRI scan of her brain and lumbar spine. He also did some sort of nerve testing and possibly visual evoked response testing. After reviewing everything, he diagnosed multiple sclerosis. However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003. Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex. She continued on it for about six months. However, it made her feel much more stiff and delayed and so she finally stopped it. She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy. So, she discontinued it also.,At that point in time, she decided to try a program of "good nutrition, vitamin supplements, and fish oil".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities. She began to have to use a cane. She was seen in neurological consultation by Dr. Z. She was treated with a Medrol Dosepak. Her spasticity and swelling seemed to improve dramatically. However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005). This seemed to be less helpful than the oral steroids, but was partially beneficial. However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to "look better". She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets. She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs. She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability. There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:, The patient is allergic to LOBSTER and VICODIN. She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:, She does not smoke. She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries. Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:, The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet. There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum. There appear to be Dawson's fingers. The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05. The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal. Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord. It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs: Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General: Well-developed, well-nourished female in no acute distress.,Head: Normocephalic, without evidence of trauma or bruits.,Neck: Supple, with full range of motion. No spasm or tenderness. Carotid pulsations are of normal volume and contour bilaterally without bruits. No thyromegaly or adenopathy.,Extremities: No clubbing, cyanosis, edema, or deformity. Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status: Awake, alert, oriented to time, place, and person; appropriate. Recent and remote memory intact. No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II: Visual fields full to confrontation. Fundi benign.,III, IV, VI: Extraocular movements full throughout, without nystagmus. No ptosis. Pupils equal, round and react briskly to light and accommodation.,V: Normal sensation to light touch and pinprick bilaterally. Corneal reflexes equal bilaterally. Motor function normal.,VII: No facial asymmetry.,VIII: Hears finger rub bilaterally. Weber and Rinne tests normal.,IX & X: Palate elevates symmetrically bilaterally with phonation. Gag reflex equal bilaterally.,XI: Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII: Tongue midline without atrophy or fasciculations. Rapid alternating movements normal. No dysarthria.,Motor: Tone, bulk, and strength are normal in both upper extremities. In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left. There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left): Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5. There are no tremors, fasciculations or abnormal involuntary movements.

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.

Consult - History and Phy.

Colon Polyps - Genetic Counseling

REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. 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. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history.,PAST MEDICAL HISTORY:, Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin. She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially.,REVIEW OF SYSTEMS: ,The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:

consult - history and phy., family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps,

Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. Primary low transverse cesarean section.

Consult - History and Phy.

Cholestasis Of Pregnancy

FINAL DIAGNOSES:, Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. The patient underwent a 2-day induction. On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress. During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration. Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication. There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery. It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay. The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit. The maternal tachycardia resolved within a day. The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns. The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%. It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively. Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state. An alert and oriented patient who is desirous at discharge. Full range of motion, all extremities; fully ambulatory. Pulse is regular and strong. Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus. The incision is beautiful and soft and nontender. There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet. Follow up with me in 1 to 2 weeks. Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No. 3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.

consult - history and phy., delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis

Clogged AV shunt. The patient complains of fatigue, nausea, vomiting and fever.

Consult - History and Phy.

Clogged AV Shunt - Consult

REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint. The patient complains of fatigue, nausea, vomiting and fever. The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement. The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked. The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem. At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed. As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read "did not work". The patient has had dialysis since January secondary to hypertension-induced renal failure. He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center. He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago. The patient's history at this point is a little sketchy; however, he states that he left AMA. All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years. No alcohol, occasional marijuana, and no IV drug use. He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs: In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air. General: This is an alert and oriented African-American male x3 and in no acute distress. The patient is extremely lethargic and had to be aroused multiple times to answer questions. Mucous membranes are moist. HEENT: Head is normocephalic and atraumatic. There is no scleral icterus noted. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Cardiovascular: Shows a heart rate that is regular with a laterally displaced point of maximum intensity. There is no murmur, gallop, or rub noted. Lungs: Clear to auscultation bilaterally. No wheeze, rhonchi or rales. Abdomen: Soft, nontender and nondistended. Bowel sounds are present. Extremities: Show left forearm with an incision that is well healed from a left AV fistula. There is a distal thrill palpable and there is some tenderness over the incisional area. There is no erythema or pus noted. Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131. Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1. Nonfunctional AV fistula.,2. End-stage renal disease.,3. Hypertension.,4. Status post MI.,5. Clogged PermCath.,PLAN:,1. Give the patient TPA to the shunt, PermCath in both feet.,2. To board for Tuesday for shunt repair if needed.,3. To dialyze as soon as possible.,4. To review previous operative report.,5. The patient will be contacted in the morning and told whether to go to dialysis or not.

A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.

Consult - History and Phy.

Chronic Otitis Media

CHIEF COMPLAINT:, Chronic otitis media.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection. He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:, None.,MEDICATIONS:, None.,FAMILY HISTORY:, Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:, None.,SOCIAL HISTORY: , The patient is not in daycare. There are no pets in the home. There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present. Left ear is still little bit black. Nose, moderate inferior turbinate hypertrophy. No polyps or purulence. Oral cavity, oropharynx 2+ tonsils. No exudates. Neck, no nodes, masses or thyromegaly. Lungs are clear to A&P. Cardiac exam, regular rate and rhythm. No murmurs. Abdomen is soft and nontender. Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:, The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.

consult - history and phy., chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,

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.

Consult - History and Phy.

Cholangiocarcinoma Consult

REASON FOR CONSULTATION:, Newly diagnosed cholangiocarcinoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon.,PAST MEDICAL HISTORY: ,Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000.,CURRENT MEDICATIONS: , Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,ALLERGIES: ,No known drug allergies.,FAMILY HISTORY: , Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health.,SOCIAL HISTORY: , The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol.,REVIEW OF SYSTEMS: ,The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:

Lump in the chest wall. Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor.

Consult - History and Phy.

Chest Wall Lump - Consult

CHIEF COMPLAINT:, Lump in the chest wall.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. It is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.,CHRONIC/INACTIVE CONDITIONS,1. Hypertension.,2. Hyperlipidemia.,3. Glucose intolerance.,4. Chronic obstructive pulmonary disease?,5. Tobacco abuse.,6. History of anal fistula.,ILLNESSES:, See above.,PREVIOUS OPERATIONS: , Anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery.,PREVIOUS INJURIES: , He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. He told me that he hit a moose once, but he does not remember hitting his chest.,ALLERGIES: , TO BACTRIM, SIMVASTATIN, AND CIPRO.,CURRENT MEDICATIONS,1. Lisinopril.,2. Metoprolol.,3. Vitamin B12.,4. Baby aspirin.,5. Gemfibrozil.,6. Felodipine.,7. Levitra.,8. Pravastatin.,FAMILY HISTORY: , Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke.,SOCIAL HISTORY: ,The patient is married. He works as a truck driver and he drives in town. He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Denies weight loss/gain, fever or chills.,ENMT: Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision.,CV: See history of present illness. Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains.,RESPIRATORY: He has a chronic cough. Denies shortness of breath, wheezing, sputum production or bloody sputum.,GI: Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation.,GU: Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain.,MS: Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness.,NEURO: Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis.,PSYCH: Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts.,INTEGUMENTARY: Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds. The patient is well developed, well nourished, and with fair attention to grooming. The patient is moderately overweight.,NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATION: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs. There is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum.,CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click, or rub. Carotid pulses 2+ without bruits. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 2+ bilaterally, without audible bruits. Extremities show no edema or varicosities.

A routine return appointment for a 71-year-old woman with chronic atrial fibrillation. Chief complaint today is shortness of breath.

Consult - History and Phy.

Chronic Atrial Fibrillation

REASON FOR VISIT:, This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:, I last saw her in 09/2008. Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode. She was found to have a fast heart rate in the atrial fibrillation. She was also found to be in heart failure and so they diuresed her. They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise. My plan advent is to control her heart rate. This has been a bit difficult with her retaining fluid. We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation. She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights. I think these are manifestations of heart failure. She has peripheral edema. She is short of breath when she tries to walk a city block. I believe she takes her medications as directed, but I am never sure she actually is taking them correctly. In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute. There is a nonspecific IVCD. This is unchanged from her last visit except that her heart rate is faster. In addition, I reviewed her echocardiogram done at XYZ. Her ejection fraction is 50% and she has paradoxical septal motion. Her right ventricular systolic pressure is normal. There are no significant valvular abnormalities.,MEDICATIONS: ,1. Fosamax - 70 mg weekly.,2. Lisinopril - 20 mg daily.,3. Metformin - 850 mg daily.,4. Amlodipine - 5 mg daily.,5. Metoprolol - 150 mg twice daily.,6. Warfarin - 5 mg daily.,7. Furosemide - none.,8. Potassium - none.,9. Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, she again looks the same which is in heart failure. Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular. She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit. She is breathing 1two times per minute and it is unlabored. Eyelids are normal. She has vitiligo. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. She has marked keloid formation on both sides of her neck, the left being worse than the right. The jugular venous pressure is elevated. Carotids are brisk are without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is irregularly irregular. She has a variable first and second heart sounds. No murmurs today. Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux. She has no clubbing or cyanosis, but does have 1+ peripheral edema. Distal pulses are good. On neurological examination, her mentation is normal. Her mood and affect are normal. She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES: ,1. Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2. Heart failure and she needs more diuretic.,3. High blood pressure controlled.,4. Hyperlipidemia.,5. Diabetes mellitus type 2.,6. Nonspecific intraventricular conduction delay.,7. History of alcohol abuse.,8. Osteoporosis.,9. Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic. There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily. If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.

Patient with palpitations and rcent worsening of chronic chest discomfort.

Consult - History and Phy.

Chest discomfort & palpitations - Consult.

CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn.

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.

Consult - History and Phy.

Chronic Kidney Disease - Consult

HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments. He was last seen in this clinic on 05/29/2007 by Dr. X. This is the first time that I have met the patient. The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication. He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year. He had a baseline creatinine during that time of between 3.2 to 3.3. When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen. Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic. He is currently on three-drug antiretroviral therapy. His last CD4 count in 03/2008 was 350. He has had no HIV complications since he was last seen in our clinic. The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year. The patient has an AV fistula that was placed in late 2006. The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9. These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation. The only complaint that the patient has at this time is some difficulty sleeping. He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping. He says that he has trouble getting to sleep. The Ambien will allow him to sleep for about two hours, and then he is awake again. He is tired during the day, but is not taking any daytime naps. He has no history of excessive snoring or apneic periods. He has no history of falling asleep at work or while driving. He has never had a formal sleep study. He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS: ,He denies any change in his appetite. He has actually gained some weight in recent months. He denies any nausea, vomiting, or abdominal discomfort. He denies any pruritus. He denies any lower extremity edema. All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1. Stage IV chronic kidney disease with most recent GFR of 22.,2. HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3. Hyperlipidemia.,4. Hypertension.,5. Secondary hyperparathyroidism.,6. Status post right upper extremity AV fistula in the fall of 2006.,7. History of a right brachial plexus palsy.,8. Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:, HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1. Kaletra daily.,2. Epivir one daily.,3. Ziagen two daily.,4. Lasix 20 mg b.i.d.,5. Valsartan 20 mg b.i.d.,6. Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD. He is employed at the sales counter of a local butcher shop. He continues to smoke one pack of cigarettes daily, as he has for the past 28 years. He denies any alcohol or illicit substances.,FAMILY HISTORY:, His mother is deceased. He said that she had some type of paralysis before she died. His father is deceased at age 64 of a head and neck cancer. He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy. He has a 41-year-old brother who has hypertension. He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight is 191 pounds. His temperature is 97.1. Pulse is 94. Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT: His oropharynx is clear without thrush or ulceration.,NECK: Supple without lymphadenopathy or thyromegaly.,HEART: Regular with normal S1 and S2. There are no murmurs, rubs, or gallops. He has no JVD.,LUNGS: Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN: Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL: He has difficulty with abduction of his right shoulder.,ACCESS: He has a right forearm AV fistula with an audible bruit and a palpable thrill. There is no sign of stenosis. The vascular access looks like it is ready to use.,EXTREMITIES: No peripheral edema.,SKIN: No bruises, petechiae, or rash.,LABS: ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18. BUN is 49, creatinine 4.3. GFR is 19. Albumin 3.2. Protein 7. AST 17, ALT 16, alkaline phosphatase 106. Total bilirubin 0.4. Calcium 9.1., phosphorus 4.7, PTH of 448. The corrected calcium was 9.7. WBC is 8.9, hemoglobin 13.4, platelet 226. Total cholesterol 234, triglycerides 140, LDL 159, HDL 47. His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION: ,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.,RECOMMENDATIONS:,1. Renal. His serum creatinine is progressively worsening. His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3. This represents a GFR of 19. This is stage IV chronic kidney disease. He does have vascular access and this appears to be ready to use. He is having some difficulty sleeping and it is possible that this represents some early signs of uremia. Otherwise, he has no signs or symptoms of uremia at this time. I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes. He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes. I have encouraged him to continue to exercise his right forearm. I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant. Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2. Hypertension. I have added labetolol 100 mg b.i.d. to his antihypertensive regimen. He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased. Goal blood pressure would be less than 130/80.,3. Hyperkalemia. I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily. I will have him return in one week to recheck his potassium. If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4. Bone metabolism. His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals. His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5. Acid base. His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6. Anemia. His hemoglobin is at goal for this stage of chronic kidney disease. His iron stores are adequate.

Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.

Consult - History and Phy.

Chronic Sinusitis

HISTORY:, I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis. As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics. She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left. She currently is not taking any medication for her sinuses. She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness. Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination. She has tried topical nasal corticosteroid therapy without much improvement. She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen. She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears. She denies any previous history of sinus surgery or nasal injury. She believes she has some degree of allergy symptoms.,PAST MEDICAL HISTORY: ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change. She is currently 180 pounds.,PAST SURGICAL HISTORY:, Lower extremity vein stripping, tonsillectomy and adenoidectomy.,FAMILY HISTORY: , Strong for heart disease and alcoholism.,CURRENT MEDICATIONS: , DynaCirc.,ALLERGIES: , Egg-based products cause hives.,SOCIAL HISTORY: ,The patient used to smoke cigarettes for about 20 years, one-half pack a day. She currently does not, which was encouraged to continue. She rarely drinks any alcohol-containing beverages.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally. No nystagmus.,EARS: During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position. No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice. No evidence of any orthostatic hypotension was noted during the exam. Tympanic membranes were noted to be intact. No signs of middle ear effusion or ear canal inflammation.,NOSE: The patient appears congested. Turbinate hypertrophy is noted. There are no signs of any acute sinusitis. Septum is midline, slightly deviated to the left.,THROAT: There is clear postnasal drip. Oral hygiene is good. No masses or lesions noted. Both vocal cords move well to midline.,NECK: The neck is supple with no adenopathy or masses palpated. The trachea is midline. The thyroid gland is of normal size with no nodules.,LUNGS: Clear to auscultation bilaterally. No wheeze noted.,HEART: Regular rate and rhythm. No murmur noted.,NEUROLOGIC: Facial nerve is intact bilaterally. The remaining cranial nerves are intact without focal deficit.,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,IMPRESSION: ,1. Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2. Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3. Inferior turbinate hypertrophy.,4. Nasal septum deformity.,RECOMMENDATIONS:, An ENG was ordered to evaluate vestibular function. She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening. A Medrol Dosepak was prescribed as directed. The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended. After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations. In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,Thank you for allowing me to participate with the care of your patient.

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.

Consult - History and Phy.

Chest Pain - Cardiac Consult

REASON FOR REFERRAL:, Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy. Since then she just says "things have changed". She just does not want to go out anymore and just does not feel the same. Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband. Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, 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. She is also tender in the left breast area and gets numbness in her left hand. She has also had three spells of "falling", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes. Twice it happened, when getting up quickly at night and another time in the grocery store. She suffered no trauma. She has no remote history of syncope. Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:, Sulfa.,SOCIAL HISTORY: , She does not smoke or drink. She is married with two children.,REVIEW OF SYSTEMS:, Otherwise unremarkable.,PEX:, BP: 130/70 without orthostatic changes. PR: 72. WT: 206 pounds. She is a healthy young woman. No JVD. No carotid bruit. No thyromegaly. Cardiac: Regular rate and rhythm. There is no significant murmur, gallop, or rub. Chest: Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed). Lungs: Clear. Abdomen: Soft. Moderately overweight. Extremities: No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1. Syncopal spells - These do sound, in fact, to be syncopal. I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good. I have asked her to drink plenty of fluids and to not to get up suddenly at night. I think this should take care of the problem. I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2. Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors. The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1. Reassurance that her cardiac checkup looks excellent, which it does.,2. Drink plenty of fluids and arise slowly from bed.,3. Flexeril 10 mg q 6 p.r.n.,4. I have asked her to return should the syncopal spells continue.

consult - history and phy., chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest,

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.

Consult - History and Phy.

Cervical Spondylosis - Neuro Consult

REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, 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. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1. Ocular migraines.,2. Myomectomy.,3. Infertility.,4. Hyperglycemia.,5. Asthma.,6. Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing.,PERTINENT DATA: ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN: ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically.

consult - history and phy., kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord,

Cardiomyopathy and hypotension. A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.

Consult - History and Phy.

Cardiomyopathy & Hypotension - Consult

REASON FOR CONSULTATION:, Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:, I am seeing the patient upon the request of Dr. X. The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that. Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient. The patient denies any chest pain or chest pressure. Denies any palpitations. No bleeding difficulty. No dizzy spells.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No fever or chills.,EYES: No visual disturbances.,ENT: No difficulty swallowing.,CARDIOVASCULAR: Basically, no angina or chest pressure. No palpitations.,RESPIRATORY: No wheezes.,GI: No abdominal pain, although she had diarrhea.,GU: No specific symptoms.,MUSCULOSKELETAL: Have sores on the back.,NEUROLOGIC: Have dementia.,All other systems are otherwise unremarkable as far as the patient can give me information.,PAST MEDICAL HISTORY:,1. Positive for coronary artery disease for about two to three years.,2. Hypertension.,3. Anemia.,4. Chronic renal insufficiency.,5. Congestive heart failure with EF of 25% to 30%.,6. Osteoporosis.,7. Compression fractures.,8. Diabetes mellitus.,9. Hypothyroidism.,PAST SURGICAL HISTORY:,1. Coronary artery bypass grafting x3 in 2008.,2. Cholecystectomy.,3. Amputation of the right second toe.,4. ICD implantation.,CURRENT MEDICATIONS AT HOME:,1. Amoxicillin.,2. Clavulanic acid or Augmentin every 12 hours.,3. Clopidogrel 75 mg daily.,4. Simvastatin 20 mg daily.,5. Sodium bicarbonate 650 mg twice daily.,6. Gabapentin 300 mg.,7. Levothyroxine once daily.,8. Digoxin 125 mcg daily.,9. Fenofibrate 145 mg daily.,10. Aspirin 81 mg daily.,11. Raloxifene once daily.,12. Calcium carbonate and alendronate.,13. Metoprolol 25 mg daily.,14. Brimonidine ophthalmic once daily.,ALLERGIES: , She has no known allergies.,FAMILY HISTORY:

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.

Consult - History and Phy.

Cardiac Consultation - 7

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me. He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation. There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission. He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation. The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1. Type I diabetes mellitus.,2. Hyperlipidemia.,3. Hypertension.,4. Morbid obesity.,5. Sleep apnea syndrome.,6. Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General: Unremarkable.,Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal: Unremarkable.,Genitourinary: See above.,Musculoskeletal: Unremarkable.,Neurologic: Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease. His mother has congestive heart failure.,SOCIAL HISTORY: ,The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1. Clonidine 0.3 mg b.i.d.,2. Atenolol 50 mg daily.,3. Simvastatin 80 mg daily.,4. Furosemide 40 mg daily.,5. Metformin 1000 mg b.i.d.,6. Hydralazine 25 mg t.i.d.,7. Diovan 320 mg daily.,8. Lisinopril 40 mg daily.,9. Amlodipine 10 mg daily.,10. Lantus insulin 50 units q.p.m.,11. KCl 20 mEq daily.,12. NovoLog sliding scale insulin coverage.,13. Warfarin 7.5 mg daily.,14. Levothyroxine 0.2 mg daily.,15. Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General: A well-appearing, obese black male.,Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.,HEENT: Grossly normal.,Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.,Chest: Midline sternotomy scar.,Lungs: Clear.,Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.,Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.

Patient reports a six to eight-week history of balance problems with later fatigue and weakness.

Consult - History and Phy.

Cervical Cord Lesion - Consult

HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was "rebuilt." He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.

Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.

Consult - History and Phy.

Cardiac Consultation - 4

REASON FOR CONSULTATION:, Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout. Patient used to take medicine for hyperlipidemia and then that was stopped. He used to live in Canada and he moved to Houston four months ago. He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side. It lasts around 10-15 minutes at times. It is 5/10 in quality. It is not associated with shortness of breath, nausea, vomiting, or sweating. It is not also associated with food. He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. No palpitations, syncope or presyncope. He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma. No fever, chills, cough, hemoptysis, hematemesis or hematochezia. His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:, Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease. His father died in his 50s with an acute myocardial infarction.,MEDICATION:, Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:, No known allergies.,REVIEW OF SYSTEMS:, As mentioned above,EXAMINATION:, This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt: 238

To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.

Consult - History and Phy.

Cardiac Consultation - 2

CHIEF REASON FOR CONSULTATION:, Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:, This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time, patient felt extremely short of breath and dizzy. Palpitations lasted for about five to ten minutes without any recurrence. Patient also gives history of having tightness in the chest after she walks briskly up to a block. Chest tightness starts in the retrosternal area with radiation across the chest. Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest. Patient gives history of having hypertension for the last two months. Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1. Astelin nasal spray.,2. Evista 60 mg daily.,3. Lopressor 25 mg daily.,4. Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:, The patient underwent right foot surgery and C-section.,FAMILY HISTORY:, The patient is married, has six children who are doing fine. Father died of a stroke many years ago. Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks. ,ALLERGIES:, THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:, Otherwise negative. ,PHYSICAL EXAMINATION: , ,GENERAL: Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good.,NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°.,CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard. ,CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard.,ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels.,EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO: Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes. Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,

Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.

Consult - History and Phy.

Cardiac Consultation - 6

INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old white female with no prior cardiac history. She sustained a mechanical fall with a subsequent left femoral neck fracture. She was transferred to XYZ Hospital for definitive care. In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms. Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL. She also had a left axis deviation. Serial troponins were obtained. She has had four negative troponins since admission. Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1. Mesothelioma.,2. Recurrent urinary tract infections.,3. Gastroesophageal reflux disease/gastritis.,4. Osteopenia.,5. Right sciatica.,6. Hypothyroidism.,7. Peripheral neuropathy.,8. Fibromyalgia.,9. Chart review also suggests she has atherosclerotic heart disease and pneumothorax. The patient denies either of these.,PAST SURGICAL HISTORY:,1. Tonsillectomy.,2. Hysterectomy.,3. Appendectomy.,4. Thyroidectomy.,5. Coccygectomy.,6. Cystoscopies times several.,7. Bladder neck resuspension.,8. Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, At the time of evaluation include, 1. Cefazolin 1 g intravenous (IV). 2. Morphine sulfate. 3. Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1. Robaxin. 2. Detrol 4 mg q.h.s. 3. Neurontin 300 mg p.o. t.i.d. 4. Armour Thyroid 90 mg p.o. daily. 5. Temazepam, dose unknown p.r.n. 6. Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known. She knows nothing of her father's history. She has no siblings. There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband. She is a lifetime nonsmoker, nondrinker. She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL: The patient is able to walk one block or less prior to the onset of significant leg pain. She ever denies any cardiac symptoms with this degree of exertion. She denies any dyspnea on exertion or chest pain with activities of daily living. She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea. She does have chronic lower extremity edema. Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis. She denies any palpitations or tachycardia. She has remote history of presyncope, no true syncope.,HEMATOLOGIC: Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC: Remarkable for past medical history.,PULMONARY: Remarkable for childhood pneumonia times several. No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL: Remarkable for past medical history.,GENITOURINARY: Remarkable for past medical history.,MUSCULOSKELETAL: Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM: Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC: Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman. No recurrence.,PHYSICAL EXAMINATION:,GENERAL: This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS: She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6. Pulse ranges from 123 to 86 beats per minute. Blood pressure ranges from 124/65 to 152/67 mmHg. Oxygen saturation on 2 L nasal cannula was 94%.,HEENT: Exam is benign. Normocephalic and atraumatic. Extraocular motions are intact. Sclerae anicteric. Conjunctivae noninjected. She does have bilateral arcus senilis. Oral mucosa is pink and moist.

Patient with atrial fibrillation with slow ventricular response, partially due to medications.

Consult - History and Phy.

Cardiac Consultation - 3

HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.

Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.

Consult - History and Phy.

Cardiac Consultation - 5

REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:, This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries. Since then, she has generally done well. She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well. Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. She denies any rest or exertional chest discomfort. Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m. The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding. Later on she was nauseous, but she did not have any vomiting. She denied any diarrhea. No history of fever or chills. Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same. She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids. Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning. The patient was admitted however for further workup and treatment. At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind. She has not been fed any food, however. The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area. The patient has had left nephrectomy and splenectomy, which has been described. A 1.5-mm solid mass is described to be in the lower pole of the kidney. The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:, She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so. She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated. She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that. She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis. She was described to have had a hemorrhagic cyst of the right kidney. She has mild arthritis for the last 10 or 15 years. She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding. She has a history of diverticulosis as mentioned. No history of TIA or CVA. She has one kidney. She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture. The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery. She describes this to be a clot on left lung. I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer. She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow. She lives alone. She does have three daughters, two of them live in Georgia and one lives in Tennessee. She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago. She never drank any alcohol. She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:, Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:, Appetite is good. She sleeps good at night. She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit. Moderate obesity is present.,CARDIAC: Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS: Slightly decreased air entry at both bases. No rales or rhonchi heard.,CARDIOVASCULAR: PMI in the left fifth intercostal space in the midclavicular line. Regular heart rhythm. S1 and S2 normal. S4 is present. No S3 heard. Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN: Soft, obese, no tenderness, no masses felt. Bowel sounds are present.,EXTREMITIES: Bilateral trace edema. The extremities are heavy. There is no pitting at this stage. No clubbing or cyanosis. Distal pulses are fair.,CENTRAL NERVOUS SYSTEM: Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block. This is overall unchanged compared to previous electrocardiogram, which also has the same present. Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia. Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000. Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7. AST and ALT are normal. Albumin is 4.1. Lipase and amylase are normal. INR is 0.92. Urinalysis is relatively unremarkable except for trace protein. Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures. No infiltrates seen. Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia. Volvulus or adhesions have been considered. Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1. Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2. Possible small old myocardial infarction.,3. Hypertension with hypertensive cardiovascular disease.,4. Non-insulin-dependent diabetes mellitus.,5. Moderate obesity.,6. Hyperlipidemia.,7. Chronic non-pitting leg edema.,8. Arthritis.,9. GERD and positive history of peptic ulcer disease.,CONCLUSION:,1. Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2. Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3. Lower left quadrant pain, which could be due to diverticulosis.,4. Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1. At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.

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.

Consult - History and Phy.

Cardiac Consult & Cardioversion

HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged. He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here. Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide. He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia. Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1. Atenolol 25 mg once a day.,2. Altace 2.5 mg once a day.,3. Zocor 20 mg once a day.,4. Flecainide 200 in the morning and 100 in the evening.,5. Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE. HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well. The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine. No use of illicit drugs. He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife. He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish. He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi. There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18. On general exam, he is a pleasant overweight gentleman, in no acute distress. HEENT: Shows cranium is normocephalic and atraumatic. He has moist mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin warm and perfused. Affect appropriate. He is quite oriented and pleasant. No significant kyphoscoliosis on recumbent back exam. Lungs are clear to auscultation anteriorly. No wheezes. No egophony. Cardiac Exam: S1, S2. Regular rate, controlled. No significant murmurs, rubs or gallops. PMI is nondisplaced. Abdomen is soft, nondistended, appears benign. Extremities without significant edema. Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:, Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so. I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of. After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null. The patient expressed understanding of this risk, benefit, and alternative analysis. I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE: ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions. The patient did actively participate in this time-out procedure. After the universal protocol was done, he then received the cardioversion attempt with 50 joules using "lollipop posterior patch" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy. There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22. We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed. I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself. Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.

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.

Consult - History and Phy.

Cardiac Consultation

HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she 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. The patient and her husband live in ABC but they have family in XYZ. She came to our office today as she is in the area visiting her family. She complains of having shortness of breath for the past month that has been increasingly getting worse. She developed a frequent nonproductive cough about 2 weeks ago. She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath. She has also gained about 15 pounds in the past few months and has significant peripheral edema. In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY: ,The patient is married. Lives with her husband. They are retired from ABC.,MEDICATIONS:,1. Plavix 75 mg p.o. daily.,2. Aspirin 81 mg p.o. daily.,3. Isosorbide mononitrate 60 mg p.o. daily.,4. Colace 100 mg p.o. b.i.d.,5. Atenolol 50 mg p.o. daily.,6. Lantus insulin 15 units subcutaneously every evening.,7. Protonix 40 mg p.o. daily.,8. Furosemide 40 mg p.o. daily.,9. Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Positive for generalized fatigue and malaise.,HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing.,ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms.,NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC: Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact.,CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs.,EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish.,RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded.,ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated.,GENITOURINARY: Deferred.,MUSCULOSKELETAL: Adequate range of motion along with extremities.,SKIN: Warm and dry. No lesions or ulcerations are noted.,NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits.,PSYCHIATRIC: Normal affect.,IMPRESSION,1. Coronary artery disease.

T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.

Consult - History and Phy.

Cancer of the nasopharynx

DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:, 0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well. He is working. He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics. Overall when he compares his strength to six or eight months ago he notes that he feels much stronger. He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs: Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT: Extraocular muscles intact. Sclerae not icteric. Oral cavity free of exudate or ulceration. Dry mouth noted.,Lymph: No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs: Clear.,Cardiac: Rhythm regular.,Abdomen: Soft, nondistended. Neither liver, spleen, nor other masses palpable.,Lower Extremities: Without edema.,Neurologic: Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1. This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal. I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. He has made a good recovery. We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up. We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.

consult - history and phy., radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx,

Dietary consultation for carbohydrate counting for type I diabetes.

Consult - History and Phy.

Carbohydrate Counting

SUBJECTIVE:, This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes. The patient reports that she was hospitalized over the weekend for DKA. She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477. She gave herself, in smaller increments, a total of 70 extra units of her Humalog. Ten of those units were injectable; the others were in the forms of pump. Her blood sugar was over 600 when she went to the hospital later that day. She is here at this consultation complaining of not feeling well still because she has a cold. She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:, Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper. Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours. A diet history was obtained. I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended. A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended. The Lilly guide for meal planning was provided and reviewed. Additional carbohydrate counting book was provided.,ASSESSMENT:, The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall. It is based on the 500 rule which suggests this ratio. We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents. We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources. She does seem to have a pattern of fixing blood sugars later in the day after they are elevated. We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals. With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner. Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately. The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:, Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed. Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day. This was a one-hour consultation. Provided my name and number should additional needs arise.

consult - history and phy., insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin

To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.

Consult - History and Phy.

Cardiac Consultation - 1

CHIEF REASON FOR CONSULTATION:, Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:, This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals. This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope. Patient does not get any chest pain or choking in the neck or pain in the back. Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood. Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:, Patient does not take any specific medications.,PAST HISTORY:, The patient underwent hysterectomy in 1986.,FAMILY HISTORY:, The patient is married, has four children who are doing fine. Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.

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.

Consult - History and Phy.

C. Diff Colitis Consult

REASON FOR CONSULT: ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea. After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin. She was also placed on IV Reglan because of nausea and vomiting. In spite of the above, her white count still continues to be elevated today. On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X. Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY: ,Noncontributory.,SOCIAL HISTORY: ,No history of smoking, alcohol, or drug use. She lives at home.,HOME MEDICATIONS: ,She is on atenolol and Mevacor.,ALLERGIES: NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS: ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness. She denies any cough, sputum production, or dysuria at this time. Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL: She is awake and alert, currently in no apparent distress.,VITAL SIGNS: She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT: Pupils are round and reactive to light and accommodation.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: S1 and S2 are present. No rales appreciated.,ABDOMEN: She does have tenderness to palpation all over with some mild rebound tenderness also. No guarding noted. Bowel sounds present.,EXTREMITIES: No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89. UA on 6/18/2009 showed no evidence of UTI. Sodium today 130, potassium 2.7, and creatinine 0.4. AST and ALT on 6/20/2009 were normal. Blood cultures from admission were negative. Urine culture on admission was negative. C. diff was positive. Stool culture was negative.,ASSESSMENT:,1. A 72-year-old female with Clostridium difficile colitis.,2. Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3. Leukocytosis secondary to above, mild improvement today though.,4. Bilateral pleural effusion by CT of the chest, although could represent thickening.,5. New requirement for oxygen, rule out pneumonia.,6. Hypertension.,PLAN:,1. Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2. Continue p.o. vancomycin. Add Florastor to help replenish the gut flora.,3. Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4. We will check a chest x-ray especially given her new requirement for oxygen.

Left buttock abscess, status post incision and drainage. Recommended some local wound care

Consult - History and Phy.

Buttock Abscess

CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY: ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock. Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL: This is an overweight African-American female not in any distress.,VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range.,HEENT: Normal to inspection.,NECK: No bruits or adenopathy.,LUNGS: Clear to auscultation.,CV: Regular rate and rhythm.,ABDOMEN: Protuberant, soft, and nontender.,EXTREMITIES: No clubbing, cyanosis or edema.,RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details.

consult - history and phy., buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess,

First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

Consult - History and Phy.

Burn - Consult

CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY: ,Noncontributory.,MEDICATIONS: ,None.,ALLERGIES: ,None.,PHYSICAL EXAMINATION: , GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine.,FINAL DIAGNOSIS:,1. First-degree and second-degree burns, right arm secondary to hot oil spill.,2. Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.

consult - history and phy., burn, workers' compensation industrial injury, workers' compensation, degree

Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.

Consult - History and Phy.

Breast Calcifications - Preop Consult

REASON FOR HOSPITALIZATION: ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08. That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position. Additional imaging studies confirmed the suspicious nature of these calcifications. The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08. The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis. No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast. She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy. I was called to see the patient in the emergency consultation in the breast center. At the same time, Dr. Y was consulted in Interventional Radiology. Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material. This resulted in immediate occlusion of the false aneurysm. The patient was seen in my office for followup appointment on 06/24/08. At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy. There was, however, no evidence of reforming of the false aneurysm. There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,I discussed the issues with the patient and her husband. The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings. For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization. Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months. The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04. This revealed benign histologic findings. The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40. Other than her age, the patient has no other risk factors for development of breast cancer. She is not receiving any hormone replacement therapy. She has had five children with the first pregnancy occurring at the age of 24. Other than her daughter, there are no other family members with breast cancer. There are no family members with a history of ovarian cancer.,PAST MEDICAL HISTORY: , Other hospitalizations have occurred for issues with asthma and pneumonia.,PAST SURGICAL HISTORY: , Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,CURRENT MEDICATIONS:,1. Plavix.,2. Arava.,3. Nexium.,4. Fosamax.,5. Advair.,6. Singulair.,7. Spiriva.,8. Lexapro.,DRUG ALLERGIES:, ASPIRIN, PENICILLIN, IODINE AND CODEINE.,FAMILY HISTORY:, Positive for heart disease, hypertension and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.,SOCIAL HISTORY: , The patient does not smoke. She does have an occasional alcoholic beverage.,REVIEW OF SYSTEMS: ,The patient has multiple medical problems, for which she is under the care of Dr. X. She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease. There is a history of anemia and there is a history of sciatica, which has been caused by arthritis. The patient has had skin cancers, which have been treated with local excision.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly aged female who is alert and in no distress.,HEENT: Head, normocephalic. Eyes, PERRL. Sclerae are clear. Mouth, no oral lesions.,NECK: Supple without adenopathy.,HEART: Regular sinus rhythm.,CHEST: Fair air entry bilaterally. No wheezes are noted on examination.,BREASTS: Normal topography bilaterally. There are no palpable abnormalities in either breast mound. Nipple areolar complexes are normal. Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses. The previous tissue changes from the stereotactic core needle biopsy have resolved. Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,ABDOMEN: Obese. No masses. Normal bowel sounds are present.,BACK: No CVA tenderness.,EXTREMITIES: No clubbing, cyanosis or edema.,ASSESSMENT:,1. Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2. Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3. History of chronic obstructive lung disease and asthma, controlled with medications.,4. History of gastroesophageal reflux disease, controlled with medications.,5. History of transient ischemic attack managed with medications.,6. History of osteopenia and osteoporosis, controlled with medications.,7. History of anxiety controlled with medications.,PLAN: , Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography. This will be performed on an outpatient basis.

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.

Consult - History and Phy.

Brain Tumor - Consult

REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor.,HISTORY OF PRESENT ILLNESS: , The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift, and therefore he was transferred here. He has been seen by Hospitalists Service. He has not had a recurrent seizure. Electroencephalogram shows slowing. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery. There is inhomogeneous uptake consistent with potential necrosis. He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm. The patient was diagnosed with a brain tumor in 1999. All details are still not available to us. He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic. That is not available on the chart as I dictate.,After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone. He tolerated that reasonably well. His wife says it's been several years since he had a scan. His behavior had not been changed, until it changed as noted earlier in this summary.,PAST MEDICAL HISTORY: , He has had a lumbar fusion. I believe he's had heart disease. Mental status changes are either due to the tumor or other psychiatric problems.,SOCIAL HISTORY:, He is living with his wife, next door to one of his children. He has been disabled since 2001, due to the back problems.,REVIEW OF SYSTEMS: , No headaches or vision issues. Ongoing heart problems, without complaints. No weakness, numbness or tingling, except that related to his chronic neck pain. No history of endocrine problems. He has nocturia and urinary frequency.,PHYSICAL EXAMINATION: , Blood pressure 146/91, pulse 76. Normal conjunctivae. Ears, nose, throat normal. Neck is supple. Chest clear. Heart tones normal. Abdomen soft. Positive bowel sounds. No hepatosplenomegaly. No adenopathy in the neck, supraclavicular or axillary regions. Neurologically alert. Cranial nerves are intact. Strength is 5/5 throughout.,LABORATORY WORK: , White blood count 10.4, hemoglobin 16, platelets not noted. Sodium 137, calcium 9.1.,IMPRESSION AND PLAN:, Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings. Dr. X's note suggests discussing the situation in the tumor board on Wednesday. He is stable enough. The pause in his care would not jeopardize his current status. It would be helpful to get old films and pathology from Abbott Northwestern. However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis. Optimizing his treatment would probably be helped by knowing his current grade of tumor.

consult - history and phy., spect, electroencephalogram, middle cerebral artery, brain tumor, inhomogeneous, frontotemporal, neoplasm, recurrent

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.

Consult - History and Phy.

Blood in Urine - ER Visit

CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS: ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine. The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool. The patient has not had any fever. There is no abdominal pain and the patient is still able to pass urine. The patient has not had any melena or hematochezia. There is no nausea or vomiting. The patient has already completed chemotherapy and is beyond treatment for his cancer at this time. The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer. The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: No fever or chills. The patient does report generalized fatigue and weakness over the past several days. HEENT: No headache, no neck pain, no rhinorrhea, no sore throat. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days. GASTROINTESTINAL: The patient denies any abdominal pain. No nausea or vomiting. No changes in the bowel movement. No melena or hematochezia. GENITOURINARY: A gross hematuria since yesterday as previously described. The patient is still able to pass urine without difficulty. The patient denies any groin pain. The patient denies any other changes to the genital region. MUSCULOSKELETAL: The chronic lower back pain which has not changed over these past few days. The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either. SKIN: No rashes or lesions. No easy bruising. NEUROLOGIC: No focal weakness or numbness. No incontinence of urine or stool. No saddle paresthesia. No dizziness, syncope or near-syncope. ENDOCRINE: No polyuria or polydipsia. No heat or cold intolerance. HEMATOLOGIC/LYMPHATIC: The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:, Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be pale, but otherwise looks well. The patient is calm, comfortable. The patient is pleasant and cooperative. HEENT: Eyes normal with clear conjunctivae and corneas. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx normal without any sign of infection. Mucous membranes are moist. NECK: Supple. Full range of motion. No JVD. CARDIOVASCULAR: Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop. Peripheral pulses are +2. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruit. No masses or pulsatile masses. GENITOURINARY: The patient has normal male genitalia, uncircumcised. There is no active bleeding from the penis at this time. There is no swelling of the testicles. There are no masses palpated to the testicles, scrotum or the penis. There are no lesions or rashes noted. There is no inguinal lymphadenopathy. Normal male exam. MUSCULOSKELETAL: Back is normal and nontender. There are no abnormalities noted to the arms or legs. The patient has normal use of the extremities. SKIN: The patient appears to be pale, but otherwise the skin is normal. There are no rashes or lesions. NEUROLOGIC: Motor and sensory are intact to the extremities. The patient has normal speech. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: There is no evidence of bruising noted to the body. No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:, CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6. Neutrophils were 81%. The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable. Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable. Alkaline phosphatase was 770 and albumin was 2.4. Rest of the values all are within normal limits of the LFTs. Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's. The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen. Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect. The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect. The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department. The patient did not have an adverse reaction to these medicines either. Phenergan resolved his nausea and morphine did relieve his pain and make him pain free. I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion. It was all a matter of what the patient wished to do given the advanced stage of his cancer. Dr. X was willing to assist in any way the patient wished him to. I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion. The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight. The patient's son felt comfortable with his father's choice. This was done. The patient was transfused 2 units of packed red blood cells after appropriately typed and match. The patient did not have any adverse reaction at any point with his transfusion. There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength. Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction. Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder. The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1. HEMATURIA.,2. PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3. SIGNIFICANT ANEMIA.,4. URINARY OBSTRUCTION.,CONDITION ON DISPOSITION: ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation. The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight. The patient was encouraged to drink extra water. The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.

Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.

Consult - History and Phy.

Breast Reconstruction

REASON FOR CONSULTATION:, Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year. She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer. This apparently was positive in two separate locations within the suspicious area. She also underwent MRI, which suggested that there was significant size to the area involved. Her contralateral left breast appeared to be uninvolved. She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications. She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight. Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps. There are no any significant scars on the right breast as she has only undergone needle biopsy at this point. Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:, A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction. We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction. I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim. A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy. I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration. I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure. We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant. In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery. Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed. In any case, she does prefer this option in order to avoid the need for an implant. We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen. We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction. At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy. For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days. We may cancel this if the chance of postoperative irradiation is high. If this is the case, I think we can do a better job on the reconstruction if we defer it. The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist.

consult - history and phy., breast reconstruction, mastectomy, lump, breast, mammogram, needle biopsy, breast cancer, hypertrophy, tram flap, latissimus dorsi,

Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.

Consult - History and Phy.

Bunion & Pes Planovalgus Deformity

HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:, See Patient History sheet, which was reviewed with the patient and is signed in the chart. Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds. She has palpable pulses. Neurologic sensation is intact. Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy. There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement. She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right. Gait analysis: The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:, X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy. Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle. No evidence of arthrosis in the joint is noted. Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1. Recurrent bunion deformity, right forefoot.,2. Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal. Anticipated length of healing was noted for the patient as were potential risks and complications. The patient ultimately would probably require surgery on her left foot at a later date as well.,2. The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3. All questions were answered.

consult - history and phy., x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion

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.

Consult - History and Phy.

Bladder Tumor

CHIEF COMPLAINT:, Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who 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. The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006. This was followed by bladder instillation of BCG. At this time, the patient denies any voiding symptoms or hematuria. The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health. No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented. Her lungs are clear. Heart, regular sinus rhythm. Back, no CVA tenderness. Abdomen, soft and nontender. No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.

consult - history and phy., bladder neck, voiding symptoms, hematuria, transitional cell carcinomas, ureteric orifice, bladder tumor, bladder, cystoscopy, papillomatosis, transitional, carcinomas, orifice,

Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

Consult - History and Phy.

Blood In Toilet

CHIEF COMPLAINT: ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY: ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable.,GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact.,NECK: No lymphadenopathy or JVD.,HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs.,LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi.,ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted.,GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES: No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:, Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

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.

Consult - History and Phy.

Bladder Cancer

CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this 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. Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan. This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement. All of this workup was found to be grossly negative. Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis. The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication. The patient denies coronary artery disease.,PAST SURGICAL HISTORY:, Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2. The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1. Metoprolol 100 mg b.i.d.,2. Diltiazem 120 mg daily.,3. Hydrocodone 10/500 mg p.r.n.,4. Pravastatin 40 mg daily.,5. Lisinopril 20 mg daily.,6. Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints. The patient states he has one uncle who died of lung cancer. He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years. He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month. He denies any drug use. He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL: He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age. VITAL SIGNS: Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds. HEAD AND NECK: Normocephalic atraumatic. LUNGS: Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. The liver and spleen are not palpably enlarged. There is a large midline defect covered by skin, of which the fascia has numerous holes poking through. These small hernias are of approximately 2 cm in diameter at the largest and are nontender. GU: The penis is circumcised and there are no lesions, plaques, masses or deformities. There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place. Testes are bilaterally descended and there are no masses or tenderness. There is bilateral mild atrophy. Epididymidis are grossly within normal limits bilaterally. Spermatic cords are grossly within normal limits. There are no palpable inguinal hernias. RECTAL: The prostate is mildly enlarged with a small focal firm area in the midline near the apex. There is however no other focal nodules. The prostate is grossly approximately 35 to 40 g and is globally firm. Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault. EXTREMITIES: Demonstrate no cyanosis, clubbing or edema. There is dark red urine in the Foley bag collection.,LABORATORY EXAM:, Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42. Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup. CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam. There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:, Bladder cancer.,PLAN: ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery. Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop. The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia. The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging. The patient understands these instructions and also agrees to quit smoking prior to his next visit. This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.

consult - history and phy., retrograde pyelogram, bladder biopsy, muscularis propria, bladder cancer, gross hematuria, bladder wall, ct scan, bladder, hematuria,

Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,

Consult - History and Phy.

Breast Augmentation Consult

REASON FOR VISIT: , This is a cosmetic consultation.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 34-year-old white female who is a nurse in the operating room. She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her. She is very bright and well informed about cosmetic surgery. She has recently had some neck surgery for a re-fusion of her neck and is currently on methadone for chronic pain regarding this. Her current desires are that she obtain a breast augmentation and liposuction of her abdomen, and she came to me mostly because I offer transumbilical breast augmentation. Her breasts are reportedly healthy without any significant problems. Her weight is currently stable.,PAST MEDICAL AND SURGICAL HISTORY: , Negative. Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02/05 and in 09/06. She has had no previous cosmetic or aesthetic surgery.,FAMILY HISTORY AND SOCIAL HISTORY:, Significant for Huntington disease in her mother and diabetes in her father. Her brother has an aneurysm. She does occasionally smoke and has been trying to quit recently. She is currently smoking about a pack a day. She drinks about once a week. She is currently a registered nurse, circulator, and scrub technician in the operating room at Hopkins. She has no children.,REVIEW OF SYSTEMS: ,A 12-system review is significant for some musculoskeletal pain, mostly around her neck and thoracic region. She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain. She has considered difficult airway due to anterior cervical disk fusion and instability. Her last mammogram was in 2000. She has a size 38C breast.,MEDICATIONS: , Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed.,ALLERGIES: , None.,FINDINGS: , On exam today, the patient has good posture, good physique, good skin tone. She is tanned. Her lower abdomen has some excess adiposity. There is some mild laxity of the lower abdominal skin. Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation. There was no piercing in that region. Her breasts are C shaped. They are not ptotic. They have good symmetry with no evidence of tubular breast deformity. She has no masses or lesions noted. The nipples are of appropriate size and shape for a woman of her age. Her scar on her neck from her anterior cervical disk fusion is well healed. Hopefully, our scars would be similar to this.,IMPRESSION AND PLAN: , Hypomastia. I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely. This would make her fill out her clothes much better, and I think transumbilical technique in her is a good option. I have discussed with her the other treatment options, and she does not want scars around her breasts if at all possible. I think her lower abdominal skin is of good tone. I think suction lipectomy in this region would bring down her size and accentuate her waist nicely. I am a little concerned about the lower abdominal skin laxity, and I will discuss with her further that in the near future if this continues to be a problem, she may need a mini tummy tuck. I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed. I will try to set this up in the near future. I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure. Due to her neck issues, we may not be able to perform her surgery but I will check with Dr. X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused.

consult - history and phy., breast augmentation and liposuction, liposuction of her abdomen, transumbilical breast augmentation, cosmetic surgery, abdominal skin, breast augmentation, augmentation, liposuction, cosmetic, transumbilical, breast,

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.

Consult - History and Phy.

Barium Swallow Study Evaluation

HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her 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. The patient's complete medical history is unknown to me at this time. The patient was cooperative and compliant throughout this evaluation.,STUDY:, Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair. To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1). The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE: ,The patient had no difficulty with bolus control and transport. No spillage out lips. The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars. The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state. Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation. We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE: ,No aspiration or penetration occurred during this evaluation. The patient's hyolaryngeal elevation and anterior movements are within the functional limits. Epiglottic inversion is within functional limits. She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: ,The patient had no aspiration or penetration occurred during this evaluation. She does appear to have a diverticulum in the area between her right faucial pillars. Additional evaluation is needed by an ENT physician.,PLAN: ,Based on this evaluation, the following is recommended:,1. The patient's diet should consist regular consistency food with thin liquids. She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2. The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care. She is not in need of skilled speech therapy and is discharged from my services.

consult - history and phy., globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods,

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.

Consult - History and Phy.

Barium Swallow Study Evaluation - 1

HISTORY: ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study. The patient stated that the results of that modified revealed aspiration with thin liquids only. He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips. Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow. Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid. Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow. The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule. The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids. The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food. The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling. Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation. The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid. No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1. The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2. The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3. The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4. The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient. I look forward to working with him in the outpatient setting to improve his swallowing function and safety. Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety.

consult - history and phy., oral stage, pharyngeal stage, cervical esophageal stage, nectar-thick liquids, aspiration, modified barium swallow, barium swallow study, dysphagia status, cup sips, barium swallow, swallow, teaspoon, barium, swallowing,

Bladder instillation for chronic interstitial cystitis.

Consult - History and Phy.

Bladder Instillation

CHIEF COMPLAINT:, The patient comes for bladder instillation for chronic interstitial cystitis.,SUBJECTIVE:, The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not think she can take any more pain. She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help. They seem to be intensifying her pain. She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine. So, she has to have somebody come with her and that is kind of troublesome to her. We discussed this at length. I did suggest that it was completely appropriate for her to decide. She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality. She had Hysterectomy in the past.,MEDICATIONS: , Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.,ALLERGIES:, Compazine and Allegra.,OBJECTIVE:,Vital Signs: Weight: 140 pounds. Blood pressure: 132/90. Pulse: 102. Respirations: 18. Age: 27.,PLAN:, We discussed going for another evaluation by Dr. XYZ and seeking his opinion. She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete. The instillations give that a full trial and then he would be willing to see her back. As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her. She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend. I thought that was reasonable and agreed that that would work out.,PROCEDURE:,: She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine. We waited about 20 minutes. The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed. The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder. She seemed to tolerate it moderately well. She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it. If not, she will cancel and will start over next week or she will see Dr. Friesen.

consult - history and phy., urethra, dmso, bladder, chronic interstitial cystitis, interstitial cystitis, bladder instillation, instillation, instillations,

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.

Consult - History and Phy.

Bilateral Hip Pain

HISTORY OF PRESENT ILLNESS: ,The patient is a 38-year-old 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 patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.,PAST MEDICAL HISTORY: ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES: ,The patient has no known drug allergies.,SOCIAL HISTORY: ,The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:, X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:, After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed.

consult - history and phy., bilateral hip pain, femoroacetabular, impingement, hip,

Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.

Consult - History and Phy.

Bariatric Consult - Surgical Weight Loss - 4

HISTORY OF PRESENT ILLNESS:, Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss. At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46. She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:, Significant for hypertension, for which the patient takes Norvasc and Lopressor for. She also suffers from high cholesterol and is on lovastatin for this. She has depression, for which she takes citalopram. She also stated that she had a DVT in the past prior to her hysterectomy. She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones. She also had a hysterectomy in 1994 secondary to hemorrhage. The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker. She is married, with 2 children aged 22 and 28. She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY: ,Significant for high blood pressure and diabetes as well as cancer on her father side. He did pass away from congestive heart failure. Mother suffers from high blood pressure, cancer, and diabetes. Her mother has passed away secondary to cancer. She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling. The patient also wears glasses for vision and has dentures. She does complain of shortness of breath with exertion. She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain. The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease. She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION: ,The patient is a well-nourished, well-developed female, in no distress. Eye Exam: Pupils equal and reactive to light. Extraocular motions are intact. Neck Exam: No cervical lymphadenopathy. Midline trachea. No carotid bruits. Nonpalpable thyroid. Neuro Exam: Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted. Lung Exam: Clear breath sounds without rhonchi or wheezes. Cardiac Exam: Regular rate and rhythm without murmur or bruits. Abdominal Exam: Positive bowel sounds. Soft, nontender, obese, and nondistended abdomen. Lap cholecystectomy scars noted. No obvious hernias. No organomegaly appreciated. Lower extremity Exam: Edema 1+. Dorsalis pedis pulses 2+.,ASSESSMENT: ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery. The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels. I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy. Also the patient will meet with the dietitian and psychologist as per her usual routine. I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.

consult - history and phy., jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,

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.

Consult - History and Phy.

Barium Swallow Study & Speech Evaluation

CURRENT MEDICATIONS:, Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY: ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis. The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration. A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps. Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes. On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS: ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve. He reported no discomfort on the inhalation; however, he felt some resistance on exhalation. Instructions were given on care placement and cleaning of the Passy-Muir valve. The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day. The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion. Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis. The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation. The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities. The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1. Completion of modified barium swallow study.,2. The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3. The patient will increase laryngeal elevation by 50% for airway protection.,4. The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5. The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6. The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1. The patient will improve secretion management to tolerable levels.,2. The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3. The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve.

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.

Consult - History and Phy.

Bipolar Affective Disorder - Consult

IDENTIFYING DATA: ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT: ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband. She then turned on the oven and put her head in the oven and then tried to climb over the second storied balcony. All of these behaviors were interrupted by her husband who called 911. He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,HISTORY OF PRESENT ILLNESS: ,The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked. After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium. Her husband states that he restrained her from jumping, "so she would not kill herself," and this was taken as a statement in his affidavit. The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital. She arrives here and is today pacing on the unit and in and out of the large TV room area. She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner. She is highly tangential, delusional, and disorganized. She refused to sign all admit papers and a considerable part of her immediate history is unknown.,PAST PSYCHIATRIC HISTORY: ,The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009. Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present. She is currently treated by Dr. Y. She has been involuntarily detained at least 7 times and revoked at least 6 times. She was on XYZ Inpatient in 2001 and in 01/2009. She states that she "feels invincible" when she becomes manic and this is also the description given by her husband.,MEDICAL HISTORY: ,The patient has a history of a herniated disc in 1999.,MEDICATIONS: , Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o. AM and 600 mg p.o. q.p.m., Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard. She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc. Of note, she also has a history of abusing Vicodin.,ALLERGIES: ,Said to be PENICILLIN, LAMICTAL, and ZYPREXA.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with her husband. There are no children. She reportedly has a college education and has 2 brothers.,SUBSTANCE AND ALCOHOL HISTORY: , Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin. The X Hospital tox screen of last night was positive for opiates. Her lithium level per last night at X Hospital was 0.42 mEq/L. She smokes nicotine, the amount is not known although she has asked and received Nicorette gum.,LEGAL HISTORY: , She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated.,MENTAL STATUS EXAM:,ATTITUDE: ,The patient's attitude is agitated when asked questions, loud and evasive.,APPEARANCE:, Disheveled and moderately well nourished.,PSYCHOMOTOR: , Restless with erratic sudden movements.,EPS:, None.,AFFECT: , Hyperactive, hostile, and labile.,MOOD: , Her mood is agitated, suspicious, and angry.,SPEECH: ,Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,THOUGHT CONTENT: , Delusional, disorganized, psychotic, and paranoid. Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,COGNITIVE ASSESSMENT: ,The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital. Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,JUDGMENT AND INSIGHT:, Nil. When asked, are there situations when you lose control, she refuses to answer. When asked, are meds helpful, she refuses to answer. She refuses to give her family information nor release of information to contact them.,ASSETS:, The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,LIMITATIONS:, The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,FORMULATION,: The patient has bipolar affective disorder in a manic state at present. She also may be depressed and is struggling with marital issues.,DIAGNOSES:

Evaluation for bariatric surgery.

Consult - History and Phy.

Bariatric Consult - Surgical Weight Loss - 3

PAST MEDICAL HISTORY: , Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke. She denies any history of cancer. She does have a history of hepatitis which I will need to further investigate. She complains of multiple joint pains, and heavy snoring.,PAST SURGICAL HISTORY: , Includes hysterectomy in 1995 for fibroids and varicose vein removal. She had one ovary removed at the time of the hysterectomy as well.,SOCIAL HISTORY:, She is a single mother of one adopted child.,FAMILY HISTORY: ,There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family. Her mother is alive. Her father is deceased from alcohol. She has five siblings.,MEDICATIONS: , As you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, Actos 15 mg, Crestor 10 mg and CellCept 500 mg two times a day.,ALLERGIES: , She has no known drug allergies.,PHYSICAL EXAM: , She is a 54-year-old obese female. She does not appear to have any significant residual deficits from her stroke. There may be slight left arm weakness.,ASSESSMENT/PLAN:, We will have her undergo routine nutritional and psychosocial assessment. I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss. She is otherwise at increased risk for future complications given her history, and weight loss will be a good option. We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.

consult - history and phy., evaluation for bariatric surgery, bariatric surgery, varicose veins, weight loss, varicose, veins, diabetes, bariatric, surgical, loss, surgery, hypertension, weight,

Consult - History and Phy.

Barium Swallow Study & Speech Evaluation - 1

SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heartburn and/or gastroesophageal reflux disorder. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC. The patient was seated upright in a video imaging chair throughout this assessment. To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:, Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid. Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation. Penetration was noted with cup sips of thin liquid only. Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies. The patient's hyolaryngeal elevation and anterior movement are within functional limits. Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus. Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:, No aspiration was noted during this evaluation. Penetration with cup sips of thin liquid. The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1. The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2. The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3. The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.

consult - history and phy., gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration

Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.

Consult - History and Phy.

Bariatric Consult - Surgical Weight Loss - 2

PAST MEDICAL HISTORY: ,She had a negative stress test four to five years ago. She gets short of breath in walking about 30 steps. She has had non-insulin dependent diabetes for about eight years now. She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married. She is an office manager for a gravel company. Her spouse is also overweight. She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time. She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:, Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:, She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass. ABC will be asking for a letter of medical necessity from XYZ. She will also need an EKG and clearance for surgery. She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.

consult - history and phy., elective surgical weight loss, surgical weight loss, weight loss, lap band, gastric bypass, loss, weight, lap, band, lost, gained, diabetes, gastric, bypass, overweight, surgical

Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

Consult - History and Phy.

Bariatric Consult - Surgical Weight Loss - 1

PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single. She drinks alcohol once a week. She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM: ,This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear to auscultation bilaterally. Cardiovascular is normal sinus rhythm. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band. ABC will be asking for a letter of medical necessity from Dr. XYZ. She will also see my nutritionist and social worker and have an upper endoscopy. Once this is completed, we will submit her to her insurance company for approval.

consult - history and phy., elective surgical weight loss, surgical weight loss, weight loss, loss, weight, bmi, surgical, pounds,

Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.

Consult - History and Phy.

Azotemia Consult

REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath. He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home. His wife called paramedics and he was brought to the emergency room.,The patient has had a workup at this time which shows bilateral pulmonary infarcts. He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.,The patient has no past history of any renal problems. He feels that he has been in good health until this current episode. His appetite has been good. He denies swelling in his feet or ankles. He denies chest pain. He denies any problems with bowel habits. He denies any unexplained weight loss. He denies any recent change in bowel habits or recent change in urinary habits.,PHYSICAL EXAMINATION:,GENERAL: A gentleman seen who appears his stated age.,VITAL SIGNS: Blood pressure is 130/70.,CHEST: Chest expands equally bilaterally. Breath sounds are heard bilaterally.,HEART: Had a regular rhythm, no gallops or rubs.,ABDOMEN: Obese. There is no organomegaly. There are no bruits. There is no peripheral edema. He has good pulse in all 4 extremities. He has good muscle mass.,LABORATORY DATA: , The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5. On admission to the hospital, his creatinine on 6/27/2009 was 0.9.,The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.,IMPRESSION:,1. Acute renal failure, probable renal vein thrombosis.,2. Hypercoagulable state.,3. Deep venous thromboses with pulmonary embolism.,DISCUSSION: , We are presented with a 36-year-old gentleman who has been in good health until this current event. He most likely has a hypercoagulable state and has bilateral pulmonary emboli. Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher. Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.,The patient's urine output is about 30 to 40 mL per hour.,Several chemistries have been ordered. A triple renal scan has been ordered.,I reviewed all of this with the patient and his wife. Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis. If not and his renal failure progresses, we are looking at dialytic intervention. Both he and his wife were aware of this. ,Thank you very much for asking to see this acutely ill gentleman in consultation with you.

consult - history and phy., urine output, deep venous thromboses, renal failure, pulmonary embolism, renal, azotemia, hypercoagulable, vein, thrombosis, pulmonary,

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.

Consult - History and Phy.

Atrial Fibrillation - Consult

HISTORY OF PRESENT ILLNESS:, I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history. By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor. She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension. She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done. She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg. Other findings were not significantly changed including pericardial effusion description. She has a history of longstanding hypertension. She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion. She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula. She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1. Norvasc 10 mg once a day.,2. Aspirin 81 mg once a day.,3. Colace 200 mg two at bedtime.,4. Labetalol 100 mg p.o. b.i.d.,5. Nephro-Vite one tablet p.o. q.a.m.,6. Dilantin 100 mg p.o. t.i.d.,7. Renagel 1600 mg p.o. t.i.d.,8. Sensipar 120 mg p.o. every day.,9. Sertraline 100 mg p.o. nightly.,10. Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM: ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%. Height is 5 feet 1 inch, weight 147 pounds. On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted. HEENT shows the cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins are difficult to assess, but do not appear clinically distended. No carotid bruits. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla. No rub, no gallop. PMI is nondisplaced. Abdomen: Soft, nondistended. CVA is benign. Extremities with no significant edema. Pulses appear grossly intact. She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change. The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one. Echocardiogram results as above. Chest x-ray shows mild pulmonary vascular congestion. BNP shows 3788. Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90. Troponin was 0.40 followed by 0.34. INR 1.03 on 05/18/07. White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time. She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report. One of the questions we were asked was whether the patient would be a candidate for Coumadin. Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk. If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year. I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1. Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin. Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2. The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3. Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade. I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification. I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4. Continue Norvasc for history of hypertension as well as labetalol.,5. The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6. Continue Dilantin for history of seizures.

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.

Consult - History and Phy.

Attempted Suicide - Consult

IDENTIFYING DATA: , 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. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: , The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS: ,The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:, Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion. He describes "allergy" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1. Klonopin 1 mg t.i.d. p.r.n.,2. Extended-release lithium 450 mg b.i.d.,3. Depakote 1000 mg b.i.d.,4. Seroquel 1000 mg per day.,SOCIAL HISTORY: ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:, Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1. Bipolar disorder.,2. Major depression with anxiety and panic attacks.,3. Polysubstance abuse, benzodiazepines, and others street meds.,4. ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:, History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan.

Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.

Consult - History and Phy.

Asbestos Exposure - Hemoptysis

REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure. The patient also has a very extensive cardiac history that would be outlined below. He is being admitted with worsening shortness of breath and constipation. He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1. Benign prostatic hypertrophy.,2. Peptic ulcer disease.,3. Atrial fibrillation.,4. Coronary artery disease.,5. Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6. ICD implantation.,7. Peripheral vascular disease.,8. CABG in 1991 and 1998.,9. Congestive heart failure, EF 40%.,10. Asbestos exposure.,MEDICATIONS,1. Coumadin 6 mg alternating with 9 mg.,2. Prevacid 30 mg once a day.,3. Diovan 160 mg every day.,4. Flomax 0.4 mg every day.,5. Coreg 25 mg in the morning and 12.5 mg at night.,6. Aldactone 25 mg a day.,7. Lasix 20 mg a day.,8. Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL: The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS: Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT: Significant for peripheral cyanosis.,NECK: Supple.,LUNGS: Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR: Regular rate and rhythm with murmur and metallic click.,ABDOMEN: Soft and benign.,EXTREMITIES: 1+ cyanosis. No clubbing. No edema.,LABORATORY DATA:, Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000. CK 266, PTT 37, PT 34, and INR 3.7. Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1. Hemoptysis.,2. Acute bronchitis.,3. Coagulopathy.,4. Asbestos exposure.,5. Left pleural effusion.,RECOMMENDATIONS,1. Antibiotics.

Questionable need for antibiotic therapy for possible lower extremity cellulitis.

Consult - History and Phy.

Antibiotic Therapy Consult

REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema. She follows up at the wound care center at Hospital. Her lower extremity edema is being managed there. She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her. As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management. She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas. Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,PAST MEDICAL HISTORY:, Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities. She has had a hysterectomy and a cholecystectomy in the remote past.,SOCIAL HISTORY: , The patient lives by herself and has three pet cats. She is an ex-smoker, quit smoking about five years ago. She occasionally drinks a glass of wine. She denies any other recreational drugs use. She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.,FAMILY HISTORY: , Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia.,ALLERGIES: , ADHESIVE TAPE ALLERGIES.,REVIEW OF SYSTEMS:, At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left. She denies any nausea, vomiting or diarrhea. She denies any pain, tenderness, increased warmth or drainage from the lower extremities. Denies chest pain, cough or phlegm production. All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General: A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.,Vital signs: Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.,HEENT: Pupils are equal, round, and reactive to light. Extraocular movements intact. Head is normocephalic and external ear exam is normal.,Neck: Supple. There is no palpable lymphadenopathy.,Cardiovascular system: Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop. Heart sounds are little distant secondary to thick chest wall.,Lungs: Clear to auscultation and percussion bilaterally.,Abdomen: Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus. There is no evidence of cutaneous candidiasis in the inguinal folds. There is no palpable lymphadenopathy in the inguinal and femoral areas.,Extremities: Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis. There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area. It has minimal serosanguineous drainage and there is no surrounding erythema. Therefore, in my opinion, there is no current evidence of cellulitis or wound infection. There is no cyanosis or clubbing. There is no peripheral stigmata of endocarditis.,Central nervous system: The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.,LABORATORY DATA: , White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils. The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5. Liver function tests are also within normal limits.,The nasal screen for MRSA is negative. Urine culture is negative so far from admission. Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,IMPRESSION AND PLAN:, A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema. Admitted for inpatient management of bilateral lower extremity lymphedema. I have been consulted to rule out possibility of active cellulitis and wound infection.,At present, I do not find evidence of active cellulitis that needs antibiotic therapy. In my opinion, lymphedema wraps could be initiated. We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week. If she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,Her stage II ulcer on the right leg does not look infected. I would recommend continuation of wound care along with lymphedema wraps.,Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization. Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.,I appreciate the opportunity of participating in this patient's care. If you have any questions, please feel free to call me at any time. I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.

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.

Consult - History and Phy.

Atrial Fibrillation Management

REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation. The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam. EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation. The patient states that for the last 3 years, she has had episodes of her heart racing. It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake. Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain. They subsequently resolve on their own and do not limit her in anyway. However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe. She said she can walk no more than 25 feet without becoming tired. She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint. Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills. She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Myocardial infarction in 2003.,3. Left heart catheterization at University Hospital.,4. Hypercholesterolemia.,5. Arthritis.,6. CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1. Left total knee replacement in 2002.,2. Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer. There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years. She retired 7 years ago because of low back pain. She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995. Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1. Coumadin 5 mg a day.,2. Toprol-XL 50 mg a day.,3. Aspirin 81 mg a day.,4. Hydrochlorothiazide 25 mg a day.,5. Plendil 10 mg daily.,6. Lipitor 40 mg daily.,REVIEW OF SYSTEMS: ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg. GENERAL: A well-developed, well-nourished, middle-aged African American female in no acute distress. NECK: Supple. No JVD. No carotid bruits. CARDIOVASCULAR: Irregularly irregular rate and rhythm. Normal S1 and S2. No murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive, soft, nontender, and nondistended. No masses. EXTREMITIES: No clubbing, cyanosis or edema. Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION: ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1. Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2. We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3. We will check a thyroid function panel.,4. We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5. Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6. Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization. We will await results of transthoracic echocardiogram.,7. We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period. She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology.

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.

Consult - History and Phy.

Ant Bait Exposure - ER Visit

CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative. Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient was afebrile. Stable vital signs and normal pulse oximetry. GENERAL: The child is very active, cheerful youngster, in no distress whatsoever. HEENT: Unremarkable. Oral mucosa is clear, moist, and well hydrated. I do not see any evidence of any sort of liquid on the face. Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso. Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:, I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely. She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation. So, the patient is discharged in stable condition.

consult - history and phy., borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,

Antibiotic management for a right foot ulcer and possible osteomyelitis.

Consult - History and Phy.

Antibiotic Management Consult

REASON FOR CONSULTATION: , Antibiotic management for a right foot ulcer and possible osteomyelitis.,HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old Caucasian male with past medical history of diabetes mellitus. He was doing fairly well until last week while mowing the lawn, he injured his right foot. He presented to the Hospital Emergency Room. Cultures taken from the wound on 06/25/2008, were reported positive for methicillin-sensitive Staphylococcus aureus (MSSA). The patient was started on intravenous antibiotic therapy with Levaquin and later on that was changed to oral formulation. The patient underwent debridement of the wound on 07/29/2008. Apparently, MRI and a bone scan was performed at that facility, which was reported negative for osteomyelitis. The patient was then referred to the wound care center at General Hospital. From there, he has been admitted to Long-Term Acute Care Facility for wound care with wound VAC placement. On exam, he has a lacerated wound on the plantar aspect of the right foot, which extends from the second metatarsal area to the fifth metatarsal area, closed with the area of the head of these bones. The wound itself is deep and stage IV and with exam of her gloved finger in my opinion, the third metatarsal bone is palpable, which leads to the clinical diagnosis of osteomyelitis. The patient has serosanguineous drainage in this wound and it tracks under the skin in all directions except distal.,PAST MEDICAL HISTORY: , Positive for:,1. Diabetes mellitus.,2. Osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back.,FAMILY HISTORY: , Positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that. One of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: , Positive findings of the foot that have been mentioned above. All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General: A 68-year-old Caucasian male who was not in any acute hemodynamic distress at present.,Vital Signs: Show a maximum recorded temperature of 98, pulse is rating between 67 to 80 per minute, respiratory rate is 20 per minute, blood pressure is varying between 137/63 to 169/75.,HEENT: Pupils equal, round, reactive to light. Extraocular movements intact. Head is normocephalic. External ear exam is normal.,Neck: Supple. There is no palpable lymphadenopathy.,Cardiovascular: Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.,Lungs: Clear to auscultation and percussion bilaterally.,Abdomen: Soft, nontender, and nondistended without any organomegaly and bowel sounds are positive. There is no palpable lymphadenopathy in the inguinal and femoral area.,Extremities: There is no cyanosis, clubbing or edema. There is no peripheral stigmata of endocarditis. On the plantar aspect of the distal part of the right foot, the patient has a lacerated wound, which extends from the second metatarsal area to the fifth metatarsal area. Tracking under the skin is palpable with a gloved finger in all direction except the distal one. On the proximal tracking, the area of the wound, the third metatarsal bone is palpable. Therefore, clinically, the patient has diagnoses of osteomyelitis.,Central nervous system: The patient is alert, oriented x3. Cranial nerves II through XII are intact. There is no focal deficit appreciated.,LABORATORY DATA:, No laboratory or radiological data is available at present in the chart.,IMPRESSION/PLAN: , A 68-year-old Caucasian male with history of diabetes mellitus who had an accidental lawn mower-associated injury on the right foot. He has undergone debridement on 07/29/2008. Culture results from the debridement procedure are not available. Wound cultures from 07/25/2008 showed methicillin-sensitive Staphylococcus aureus.,From the Infectious Disease point of view, the patient has the following problems, and I would recommend following treatments strategy.,1. Right foot infected ulcer with clinical evidence of osteomyelitis. Even if the MRI and bone scan are negative, the treatment should be guided with diagnosis on clinical counts in my opinion. Cultures have been reported positive for methicillin-sensitive Staphylococcus aureus. Therefore, I would discontinue the current antibiotic regimen of oral Levaquin, Zyvox, and intravenous Zosyn, and start the patient on intravenous Ancef 2 g q.8 h. We will need to continue this treatment for 6 weeks for treatment of osteomyelitis and deep wound infection. I would also recommend continuation of wound care and wound VAC placement that would start tomorrow. We will get a PICC line placed to complete the 6-week course of intravenous antibiotic therapy.,2. We would check labs including CBC with differential, chemistry 7 panel, LFTs, ESR, and C-reactive protein levels every Monday and chemistry 7 panel and CBC every Thursday for the duration of antibiotic therapy.,3. I will continue to monitor wound healing 2 to 3 times a week. Wound care will be managed by the wound care team at the Long-Term Acute Care Facility.,4. The treatment plan was discussed in detail with the patient and his daughter who was visiting him when I saw him.,5. Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.,6. I appreciate the opportunity of participating in this patient's care. If you have any questions please feel free to call me at any time. I will continue to follow the patient along with you for the next few days during this hospitalization. We would also try to get the results of the deep wound cultures from 07/29/2008, MRI, and bone scan from Hospital.

The patient was running and twisted her right ankle - right ankle sprain.

Consult - History and Phy.

Ankle Pain - Consult

IDENTIFICATION: , The patient is a 15-year-old female.,CHIEF COMPLAINT: , Right ankle pain.,HISTORY OF PRESENT ILLNESS:, The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician is Dr. Brown.,REVIEW OF SYSTEMS:, Otherwise negative except as stated above.,PAST MEDICAL HISTORY:, None.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:, None.,SOCIAL HISTORY: , Mother appears loving and caring. There is no evidence of abuse.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , General: The patient is alert and oriented x4 in mild distress without diaphoresis. She is nonlethargic and nontoxic. Vitals: Within normal limits. The right ankle shows no significant swelling. There is no ecchymosis. There is no significant tenderness to palpation. The ankle has good range of motion. The foot is nontender. Vascular: +2/2 dorsalis pedis pulse. All compartments are soft. Capillary refill less than 2 seconds.,DIAGNOSTIC TEST:, The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation.,MEDICAL DECISION MAKING: , Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home. She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain. She may need to see a specialist, but at this time this is a very mild ankle injury. There is no significant physical finding, and I foresee no complications. I will give her 1 week off of PE.,MORBIDITY/MORTALITY:, I expect no acute complications. A full medical screening exam was done and no emergency medical condition exists upon discharge.,COMPLEXITY:, Moderate. The differential includes fracture, contusion, abrasion, laceration, and sprain.,ASSESSMENT:, Right ankle sprain.,PLAN:, Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist. She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.

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.

Consult - History and Phy.

Arm Pain - Neuro Consult

HISTORY OF PRESENT ILLNESS: ,The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he 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.,He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,PAST MEDICAL HISTORY: , He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia.,CURRENT MEDICATIONS: , He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral. He also uses Lidoderm patches and multiple eye drops and creams.,ALLERGIES:, He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.,FAMILY HISTORY:, His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders.,SOCIAL HISTORY:, He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago.,REVIEW OF SYSTEMS: , He has intermittent chest discomfort. He has chronic tinnitus. He has urinary dribbling. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: HR 72. RR 16.,General Appearance: Patient is well appearing, in no acute distress.,Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.,Chest: The lungs are clear to auscultation bilaterally.,Skin: There are no rashes or lesions.,NEUROLOGICAL EXAMINATION:,Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact.,Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.,Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent.,Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,Deep Tendon Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk.,Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal.,RADIOLOGIC DATA:, MRI of the cervical spine, 05/19/08: I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.,IMPRESSION: ,The patient is a 58-year-old gentleman with one-year history of right arm pain. He also has a longstanding history of neck pain. His neurological examination is normal. He has an MRI that shows some degenerative changes. I do believe that his symptoms are probably referable to his neck. However, I do not think that they are severe enough for him to undergo surgery at this point in time. Perhaps another course of physical therapy may be helpful for him. I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal. We could still try to treat him with neuropathic pain medications.,RECOMMENDATIONS:,1. I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.,2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with him.,3. We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations.

Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.

Consult - History and Phy.

Angina - Consult

HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call 911, which she did. While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain. By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months. She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia. I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker. However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room. On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80% mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area. The decision was made to transfer her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel. She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08. She had some left arm discomfort on 08/18/08, but this was mild. Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin. This is her usual angina. She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1. Detrol LA 2 mg once a day.,2. Prilosec for GERD 20 mg once a day.,3. Glucosamine 500/400 mg once a day for arthritis.,4. Multivitamin p.o. daily.,5. Nitroglycerin sublingual as available to her.,6. Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7. Aspirin 325 mg once a day.,8. Plavix 75 mg once a day.,9. Diovan 160 mg once a day.,10. Claritin 10 mg once a day for allergic rhinitis.,11. Norvasc 5 mg once a day.,12. Lipitor 5 mg once a day.,13. Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE. SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY: ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs. She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:, She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. She has moist mucosal membranes.,NECK: Veins are not distended. There are no carotid bruits.,LUNGS: Clear to auscultation and percussion without wheezes.,HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced.,ABDOMEN: Soft and nondistended. Bowel sounds present.,EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. BUN 16 and creatinine 0.9. Glucose 110. Magnesium 2.5. ALT 107 and AST 65 and these were normal on 08/15/08. INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. Aspirin, Plavix, valsartan, Lipitor, and Norvasc. I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes. All this was discussed in detail with the patient and her daughter who expressed understanding and agreement. The patient desires full resuscitation status.

History and Physical for right ankle sprain

Consult - History and Phy.

Ankle Sprain - H&P

CHIEF COMPLAINT:, Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS:,Pulm: No cough, No wheezing, No shortness of breath,CV: No chest pain or palpitations,GI: No abdominal pain. No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE: No acute distress,VITAL SIGNS: Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK: Supple. No lymphadenopathy. No thyromegaly.,CHEST: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs.,ABDOMEN: Non-distended, nontender, normal active bowel sounds.,EXTREMITIES: No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL: The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending., ,IMPRESSION:, Right ankle sprain.,PLAN:,1. Motrin 800 mg t.i.d.,2. Tylenol 1 gm q.i.d. as needed.,3. Walking cast is prescribed.,4. I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.

Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.

Consult - History and Phy.

Anemia - Consult

DIAGNOSIS:, Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY: ,Diabetes.,PAST SURGICAL HISTORY:, Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.,FAMILY HISTORY:, Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.,VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.,HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.,NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC: Noncontributory.,DERMATOLOGIC: Noncontributory.,CARDIOVASCULAR: Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS: ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.

Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.

Consult - History and Phy.

Allergy Evaluation Consult

HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment. Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies. In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection. In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions. He currently is not taking any medication for allergies. He is taking atenolol for blood pressure control. No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,PAST MEDICAL HISTORY:, History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,PAST SURGICAL HISTORY:, PermCath insertion times 3 and peritoneal dialysis.,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite.,ALLERGIES: , Heparin causing thrombocytopenia.,SOCIAL HISTORY: , Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally.,EARS: The tympanic membranes are intact bilaterally with a good light reflex. The external auditory canals are clear with no lesions or masses noted. Weber and Rinne tests are within normal limits.,NOSE: The nasal cavities are patent bilaterally. The nasal septum is midline. There are no nasal discharges. No masses or lesions noted.,THROAT: The oral mucosa appears healthy. Dental hygiene is maintained well. No oropharyngeal masses or lesions noted. No postnasal drip noted.,NECK: The neck is supple with no adenopathy or masses palpated. The trachea is midline. The thyroid gland is of normal size with no nodules.,NEUROLOGIC: Facial nerve is intact bilaterally. The remaining cranial nerves are intact without focal deficit.,LUNGS: Clear to auscultation bilaterally. No wheeze noted.,HEART: Regular rate and rhythm. No murmur noted.,IMPRESSION: ,1. Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.,2. Renal failure requiring dialysis.,3. Hypertension.,RECOMMENDATIONS: ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow. If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions. At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy. Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions. An EpiPen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an EpiPen.

Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.

Consult - History and Phy.

Annual Health Maintenance Exam

HISTORY OF PRESENT ILLNESS: ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker. His mother is 88, living and well, status post lung cancer resection. Two brothers, living and well. One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:, The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:, Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. There are mild hemorrhoids in the anal canal. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative.,IMPRESSION:,1. Comprehensive annual health maintenance examination.,2. Dyslipidemia.,3. Tinnitus, left ear.,4. Hemorrhoids.,PLAN:, At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Followup fasting lipid profile and ALT in 6 months.

consult - history and phy., tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign

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.

Consult - History and Phy.

Air Under Diaphragm - Consult

REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. 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.,PAST MEDICAL HISTORY: , Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY: ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:, Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY: ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT: Atraumatic.,NECK: Soft and supple.,LUNGS: Bilaterally diminished.,HEART: Regular.,ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:, Have her admitted to the medical service for treatment of her hyponatremia.

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.

Consult - History and Phy.

Airway Compromise & Foreign Body - ER Visit

HISTORY OF PRESENT ILLNESS:, 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.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES: ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION: ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed. The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated. If not she would require tracheostomy. The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated. She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. So, the patient is being prepared for discharge at this point. We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home. Dr. Y feels she could be discharged today and will have her return to see him in a week.

consult - history and phy., diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway,

The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.

Consult - History and Phy.

Adult Hydrocephalus

REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X. She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states "I think I walk funny." Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be." She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY: ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea. She has been on Ambien, which is no longer been helpful. She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries.,SOCIAL HISTORY: ,She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,: Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS: Blood pressure 154/72, heart rate 87, and weight 153 pounds. Pain is 0/10.,HEAD: Head is normocephalic and atraumatic. Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE: Spine is straight and nontender. Spinous processes are easily palpable. She has very mild kyphosis, but no scoliosis.,SKIN: There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM: Regular rate and rhythm. No carotid bruits. No edema. No murmur. Peripheral pulses are good. Lungs are clear.,MENTAL STATUS: Assessed for recent and remote memory, attention span, concentration, and fund of knowledge. She scored 30/30 on the MMSE when attention was tested with either spelling or calculations. She had no difficulty with visual structures.,CRANIAL NERVES: Pupils are equal. Extraocular movements are intact. Face is symmetric. Tongue and palate are midline. Jaw muscles strong. Cough is normal. SCM and shrug 5 and 5. Visual fields intact.,MOTOR EXAM: Normal for bulk, strength, and tone. There was no drift or tremor.,SENSORY EXAM: Intact for pinprick and proprioception.,COORDINATION: Normal for finger-to-nose.,REFLEXES: Are 2+ throughout.,GAIT: Assessed using the Tinetti assessment tool. She was fairly quick, but had some unsteadiness and a widened base. She did not need an assistive device. I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008. It shows mild ventriculomegaly with a trace expansion into the temporal horns. The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm. The sylvian aqueduct is patent. There is no pulsation artifact. Her corpus callosum is bowed and effaced. She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT: ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1. Possible adult hydrocephalus (331.5).,2. Mild gait impairment (781.2).,3. Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus. At this point, her symptoms are fairly mild. I explained to them the two methods of testing with CSF drainage. It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test. About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture. Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery. This procedure carries a 2% to 3% risk of meningitis. I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.

Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.

Consult - History and Phy.

Agitation - ER Visit

HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now. The patient apparently had a little bit of dry heaves, but no actual vomiting. She had just finished eating dinner. No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries. She has a pacemaker. She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS: Very difficult to get from the patient herself. She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her. She initially stated that everything was wrong, but could not specify any specific complaints. Denies chest pain, back pain, or abdominal pain. Denies any extremity symptoms or complaints.,SOCIAL HISTORY: The patient is a nonsmoker. She is accompanied here with daughter who brought her over here. They were visiting the patient when this episode occurred.,MEDICATIONS: Please see list.,ALLERGIES: NONE.,PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air. GENERAL: The patient is an elderly frail looking little lady lying on the gurney. She is awake, alert, and not really wanted to answer most of the questions I asked her. She does have a tremor with her mouth, which the daughter states has been there for "many years". HEENT: Eye exam is unremarkable. Oral mucosa is still moist and well hydrated. Posterior pharynx is clear. NECK: Supple. LUNGS: Actually clear with good breath sounds. There are no wheezes, no rales, or rhonchi. Good air movement. CARDIAC: Without murmur. ABDOMEN: Soft. I do not elicit any tenderness. There is no abdominal distention. Bowel sounds are present in all quadrants. SKIN: Skin is without rash or petechiae. There is no cyanosis. EXTREMITIES: No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE: I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly. After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better. Family states she seems more calm. They do not want to pursue any further workup at this time.,IMPRESSION: ACUTE EPISODE OF AGITATION.,PLAN: At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode. The patient herself has good vital signs. She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient. Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC. She is discharged in stable condition.

consult - history and phy., acute episode of agitation, agitation,

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.

Consult - History and Phy.

Abrasions & Lacerations - ER Visit

HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:, None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:, None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES: ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single. He is a student. He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL: The patient denies weight loss/gain, fever, chills.,ENMT: The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV: The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY: The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI: The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU: The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS: The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO: The patient had a loss of consciousness during the accident. He does not recall the details of the accident. Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH: Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY: Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air. The patient shows moderate obesity.,NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click or rub. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 3+ bilaterally, without audible bruits. Extremities show no edema or varicosities.,GASTROINTESTINAL: No palpable tenderness or masses. Liver and spleen are percussed but not palpable under the costal margins. No evidence for umbilical or groin herniae.,LYMPHATIC: No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL: Normal gait and station. The patient is on a stretcher. Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN: There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees. No induration or subcutaneous nodules to palpation.,NEUROLOGIC: Normal sensation by touch. The patient moves all four extremities.,PSYCHIATRIC: Oriented to time, place, and person. Appropriate mood and affect.,LABORATORY DATA: Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1. Concussion.,2. Facial abrasion.,3. Scalp laceration.,4. Knee abrasions.,PLANS/RECOMMENDATIONS:, Admitted for observation.

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.

Consult - History and Phy.

Abnormal Stress Test

HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office 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. He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded. The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1. Aspirin 325 mg once a day.,2. Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. Nexium 40 mg once a day.,4. Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. I see that his LDL was 136 on May 3, 2002.,5. Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.

consult - history and phy., standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress

Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris

Consult - History and Phy.

Acne Vulgaris - H&P

CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use. Location: She indicates the problem location is the chin, right temple and left temple locally. Severity: Severity of condition is worsening.,Menses: Onset: 13 years old. Interval: 22-27 days. Duration: 4-6 days. Flow: light. Complications: none.,ALLERGIES: , Patient admits allergies to penicillin resulting in difficulty breathing.,MEDICATION HISTORY:, Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.,PAST MEDICAL HISTORY:, Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.,PAST SURGICAL HISTORY:, No previous surgeries.,FAMILY HISTORY: , Patient admits a family history of anxiety, stress disorder associated with mother.,SOCIAL HISTORY:, Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.,REVIEW OF SYSTEMS:, Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /,Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,PHYSICAL EXAM:, Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus. Skin: Examination of scalp shows no abnormalities. Hair growth and distribution is normal. Inspection of skin outside of affected area reveals no abnormalities. Palpation of skin shows no abnormalities. Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis. Face shows keratotic papule.,IMPRESSION:, Acne vulgaris.,PLAN:, Recommended treatment is antibiotic therapy. Patient received extensive counseling about acne. She understands acne treatment is usually long-term. Return to clinic in 4 week (s).,PATIENT INSTRUCTIONS:, Patient received literature regarding acne vulgaris. Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.,PRESCRIPTIONS:, Tetracycline Dosage: 250 mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes

Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.

Consult - History and Phy.

Admission History & Physical - Nausea

CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum.,PAST MEDICAL HISTORY: , Significant for hypertension and morbid obesity, now resolved.,PAST SURGICAL HISTORY: , Gastric bypass surgery in December 2007.,MEDICATIONS: ,Multivitamins and calcium.,ALLERGIES: , None known.,FAMILY HISTORY: ,Positive for diabetes mellitus in his father, who is now deceased.,SOCIAL HISTORY: , He denies tobacco or alcohol. He has what sounds like a data entry computer job.,REVIEW OF SYSTEMS: ,Otherwise negative.,PHYSICAL EXAMINATION:, His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84. He is drowsy, but easily arousable and appropriate with conversation. He is oriented to person, place, and situation. He is normocephalic, atraumatic. His sclerae are anicteric. His mucous membranes are somewhat tacky. His neck is supple and symmetric. His respirations are unlabored and clear. He has a regular rate and rhythm. His abdomen is soft. He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. He otherwise has no organomegaly, masses, or abdominal hernias evident. His extremities are symmetrical with no edema. His posterior tibial pulses are palpable and symmetric. He is grossly nonfocal neurologically.,STUDIES:, His white blood cell count is 8.4 with 79 segs. His hematocrit is 41. His electrolytes are normal. His bilirubin is 2.8. His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239.,ASSESSMENT: , Choledocholithiasis, ? cholecystitis.,PLAN: , He will be admitted and placed on IV antibiotics. We will get an ultrasound this morning. He will need his gallbladder out, probably with intraoperative cholangiogram. Hopefully, the stone will pass this way. Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted. Dr. X will see him later this morning and discuss the plan further. The patient understands.

consult - history and phy., gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery,

The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

Consult - History and Phy.

Acute Cystitis & Diabetes Type II

HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp: Patient denies asthma, lung infections and lung lesions.,GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology: Patient denies allergic reactions, rashes and skin lesions.,MEDS:, Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:, No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:, No significant family history.,REVIEW OF SYSTEMS:, Non-contributory.,Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.,Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and conto.,Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.,Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.,Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.,Extremities: There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled. Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC. ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.

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.

Consult - History and Phy.

Abnormal Echocardiogram

REASON FOR CONSULTATION: ,Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency.,HISTORY OF PRESENT ILLNESS: ,The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools. The patient has colitis and also diverticulitis, undergoing treatment. During the hospitalization, 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. This consultation is for further evaluation in this regard. As per the patient, she is an 86-year-old female, has limited activity level. She has been having shortness of breath for many years. She also was told that she has a heart murmur, which was not followed through on a regular basis.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: ,Nonsignificant.,PAST SURGICAL HISTORY: , No major surgery.,MEDICATIONS: , Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.,ALLERGIES: ,AMBIEN, CARDIZEM, AND IBUPROFEN.,PERSONAL HISTORY:, She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: ,Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: History of cataract, blurred vision, and hearing impairment.,CARDIOVASCULAR: Shortness of breath and heart murmur. No coronary artery disease.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Arthritis and severe muscle weakness.,SKIN: Nonsignificant.,NEUROLOGICAL: No TIA or CVA. No seizure disorder.,ENDOCRINE/HEMATOLOGICAL: As above.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.,HEENT/NECK: Head is atraumatic and normocephalic. Neck veins flat. No significant carotid bruits appreciated.,LUNGS: Air entry bilaterally fair. No obvious rales or wheezes.,HEART: PMI displaced. S1, S2 with systolic murmur at the precordium, grade 2/6.,ABDOMEN: Soft and nontender.,EXTREMITIES: Chronic skin changes. Feeble pulses distally. No clubbing or cyanosis.,DIAGNOSTIC DATA: , EKG: Normal sinus rhythm. No acute ST-T changes.,Echocardiogram report was reviewed.,LABORATORY DATA:, H&H 13 and 39. BUN and creatinine within normal limits. Potassium within normal limits. BNP 9290.,IMPRESSION:,1. The patient admitted for gastrointestinal pathology, under working treatment.,2. History of prior heart murmur with echocardiogram findings as above. Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.,RECOMMENDATIONS:,1. From cardiac standpoint, conservative treatment. Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.,2. After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.,3. Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares. She has a normal LV function.

The patient was referred due to concerns regarding behavioral acting out as well as encopresis.

Consult - History and Phy.

Adjustment Disorder & Encopresis

REASON FOR REFERRAL:, The patient was referred to me by Dr. X of the Clinic due to concerns regarding behavioral acting out as well as encopresis. This is a 90-minute initial intake completed on 10/03/2007. I met with the patient's mother individually for the entire session. I reviewed with her the treatment, consent form, as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS: , Mother reported that her primary concern in regard to the patient had to do with his oppositionality. She was more ambivalent regarding addressing the encopresis. In regards to his oppositionality, she reported that the onset of his oppositionality was approximately at 4 years of age, that before that he had been a very compliant and happy child, and that he has slowly worsened over time. She noted that the oppositionality occurred approximately after his brother, who has multiple medical problems, was born. At that time, mother had spent 2 months back East with the brother due to his feeding issues and will have to go again next year. She reported that in terms of the behaviors that he loses his temper frequently, he argues with her that he defies her authority that she has to ask him many times to do things, that she has to repeat instructions, that he ignores her, that he whines, and this is when he is told to do something that he does not want to do. She reported that he deliberately annoys other people, that he can be angry and resentful. She reported that he does not display these behaviors with the father nor does he display them at home, but they are specific to her. She reported that her response to him typically is that she repeats what she wants him to do many, many times, that eventually she gets upset. She yells at him, talks with him, and tries to make him go and do what she wants him to do. Mother also noted that she probably ignores some his misbehaviors. She stated that the father tends to be more firm and more direct with him, and that, the father sometimes thinks that the mother is too easy on him. In regards to symptoms of depression, she denied symptoms of depression, noting that he tends to only become unhappy when he has to do something that he does not want to do, such as go to school or follow through on a command. She denied any suicidal ideation. She denied all symptoms of anxiety. PTSD was denied. ADHD symptoms were denied, as were all other symptoms of psychopathology.,In regards to the encopresis, she reported that he has always soiled, he does so 2 to 3 times a day. She reported that he is concerned about this issue. He currently wears underwear and had a pull-up. She reported that he was seen at the Gastroenterology Department here several years ago, and has more recently been seen at the Diseases Center, seen by Dr. Y, reported that the last visit was several months ago, that he is on MiraLax. He does sit on the toilet may be 2 times a day, although that is not consistent. Mother believes that he is probably constipated or impacted again. He refuses to eat any fiber. In regards to what happens when he soils, mother basically takes full responsibility. She cleans and changes his underwear, thinks of things that she has tried, she mostly gets frustrated, makes negative comments, even though she knows that he really cannot help it. She has never provided him with any sort of rewards, because she feels that this is something he just needs to learn to do. In regards to other issues, she noted that he becomes frustrated quite easily, especially around homework, that when mother has to correct him, or when he has had difficulty doing something that he becomes upset, that he will cry, and he will get angry. Mother's response to him is that either she gets agitated and raises her voice, tells him to stop etc. Mother reported it is not only with homework, but also with other tasks, such as if he is trying to build with his LEGOs and things do not go well.,DEVELOPMENTAL BACKGROUND: , The patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery. The patient presented in a breech position. Mother denied the use of drugs, alcohol, or tobacco during the pregnancy. No sleeping or eating issues were present in the perinatal period. Temperament was described as easy. He was described as a cuddly baby. No concerns expressed regarding his developmental milestones. No serious injuries reported. No hospitalizations or surgeries. No allergies. The patient has been encopretic for all of his life. He currently is taking MiraLax.,FAMILY BACKGROUND: , The patient lives with his mother who is age 37, and is primarily a homemaker, but does work approximately 48 hours a month as a beautician; with his father, age 35, who is a police officer; and also, with his younger brother who is age 3, and has significant medical problems as will be noted in a moment. Mother and father have been together since 1997, married in 1999. The maternal grandmother and grandfather are living and are together, and live in the Central California Coast Area. There is one maternal aunt, age 33, and then, two adopted maternal aunt and uncle, age 18 and age 13. In regards to the father's side of the family, the paternal grandparents are divorced. Grandfather was in Arkansas, grandmother lives in Dos Palos. The patient does not see his grandfather. Mother stated that her relationship with her child was as described, that he very much stresses her out, that she wishes that he was not so defiant, that she finds him to be a very stressful child to deal with. In regards to the relationship with the father, it was reported that the father tends to leave most of the parenting over to the mother, unless she specifically asks him to do something, and then, he will follow through and do it. He will step in and back mother up in terms of parenting, tell the child not to speak to his mother that way etc. Mother reported that he does spend some time with the children, but not as much as mother would like him to, but occasionally, he will go outside and do things with them. The mother reported that sometimes she has a problem in interfering with his parenting, that she steps in and defends The patient. It was reported that mother stated that she tries the parenting technique, primarily of yelling and tried time-out, although her description suggests that she is not doing time-out correctly, as he simply gets up from his time-out, and she does not follow through. Mother reported that she and the patient are very much alike in temperament, and this has made things more difficult. Mother tends to be stubborn and gets angry easily also. Mother reported becoming fatigued in her parenting, that she lets him get away with things sometimes because she does not want to punish him all day long, sometimes ignores problems that she probably should not ignore. There was reported to be jealousy between The patient and his brother, B. B evidently has some heart problems and feeding issues, and because of that, tends to get more attention in terms of his medical needs, and that the patient is very jealous of that attention and feels that B is favored and that he get things that The patient does not get, and that there is some tension between the brothers. They do play well together; however, The patient does tend to be somewhat intrusive, gets in his space, and then, B will hit him. Mother reported that she graduated from high school, went to Community College, and was an average student. No learning problems. Mother has a history of depression. She has currently been taking 100 mg of Zoloft administered by her primary medical doctor. She is not receiving counseling. She has been on the medications for the last 5 years. Her dosage has not been changed in a year. She feels that she is getting more irritable and more angry. I encouraged her to see a primary medical doctor. Mother has no drug or alcohol history. Father graduated from high school, went to the Police Academy, average student. No learning problems, no psychological problems, no drug or alcohol problems are reported. In terms of extended family, maternal grandmother as well as maternal great grandfather have a history of depression. Other psychiatric symptoms were denied in the family.,Mother reported that the marriage is generally okay, that there is some arguing. She reported that it was in the normal range.,ACADEMIC BACKGROUND: , The patient attends the Roosevelt Elementary School, where he is in a regular first grade classroom with Mrs. The patient. This is in the Kingsburg Unified School District. No behavior problems, academic problems were reported. He does not receive special education services.,SOCIAL HISTORY: , The patient was described as being able to make and keep friends, but at this point in time, there has been no teasing regarding smell from the encopresis. He does have kids over to play at the house.,PREVIOUS COUNSELING:, Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , My impression is that the patient has a long history of constipation and impaction, which has been treated medically, but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting, increased fiber, regular medication, so that the problem has likely continued. She also has not used any sort of rewards as a way to encourage him, in the encopresis. The patient clearly qualifies for a diagnosis of disruptive behavior disorder, not otherwise specified, and possibly oppositional defiant disorder. It would appear that mother needs help in her parenting, and that she tends to mostly use yelling and anger as a way, and tends to repeat herself a lot, and does not have a strategy for how to follow through and to deal with defiant behavior. Also, mother and father, may not be on the same page in terms of parenting.,PLAN:, In terms of my plan, I will meet with the child in the next couple of weeks. I also asked the mother to bring the father in, so he could be involved in the treatment also, and I gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher.,DSM IV DIAGNOSES: ,AXIS I: Adjustment disorder with disturbance of conduct (309.3). Encopresis, without constipation, overflow incontinence (307.7),AXIS II: No diagnoses (V71.09).,AXIS III: No diagnoses.,AXIS IV: Problems with primary support group.,AXIS V: Global assessment of functioning equals 65.

consult - history and phy., developmental background, axis, dsm iv, adjustment disorder, behavioral, adjustment, depression, oppositionality, encopresis,

Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.

Consult - History and Phy.

Acute Inferior Myocardial Infarction

CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".,The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath & diaphoresis. He states that he has had nausea & 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:, All other systems reviewed & are negative.,PAST MEDICAL HISTORY:, Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs. Smokes 2 packs of cigarettes per day. Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay. Humulin N. insulin 50 units in a.m. HCTZ 50 mg QDay. Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates

A 5-month-old boy brought by his parents because of 2 days of cough.

Consult - History and Phy.

A 5-month-old boy with cough

CHIEF COMPLAINT:, A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:, A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever. Mother did not measure it.,REVIEW OF SYSTEMS:, No vomiting. No diarrhea. He had runny nose started with the cough two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding, he is bottle-fed 2 ounces every 2 hours. Mother states he urinates like 5 to 6 times a day, stools 1 time a day. He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:, He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said. Mother had good prenatal care at 4 weeks for more than 12 visits. No complications during pregnancy. Rupture of membranes happened two days before the labor. Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales. They have animals, but outside the house and father smokes outside house. No sick contacts as the mother said.,PAST MEDICAL HISTORY:, No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg.,GENERAL: In no acute distress.,HEAD: Normocephalic and atraumatic. Open, soft, and flat anterior fontanelle.,NECK: Supple.,NOSE: Dry secretions.,EAR: Right ear full of yellowish material most probably pus and necrotic tissue. Tympanic membrane bilaterally visualized.,MOUTH: No pharyngitis. No ulcers. Moist mucous membranes.,CHEST: Bilateral audible breath sound. No wheezes. No palpitation.,HEART: Regular rate and rhythm with no murmur.,ABDOMEN: Soft, nontender, and nondistended.,GENITOURINARY: Tanner I male with descended testes.,EXTREMITIES: Capillary refill less than 2 seconds.,LABS:, White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6, segments 41, and bands 41. RSV positive. Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:, A 5-month-old male with 2 days of cough and 1 day of fever. Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,

Work restrictions and disability evaluation

Chiropractic

Permanent & Stationary Report

PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently. She is having difficulty with bending and stooping maneuvers. She cannot lift heavy objects. She states she continues to have pain in her right neck and pain in her right upper extremity. She has difficulty with pushing and pulling and lifting with her right arm. She describes an intermittent tingling sensation in the volar aspect of her right hand. She states she has diminished grip strength in her right hand because of wrist pain complaints. She states that the Wellbutrin samples I had given her previously for depression seem to be helping. Her affect appears appropriate. She reports no suicidal ideation. She states she continues to use Naprosyn as an anti-inflammatory, Biofreeze ointment over her neck and shoulder and back areas of complaints. She also takes Imitrex occasionally for headache complaints related to her neck pain. She also takes Flexeril occasionally for back spasms and Darvocet for pain. She is asking for a refill on some of her medications today. She is relating a VAS pain score regarding her lower back at a 6-7/10 and regarding her neck about 3/10, and regarding her right upper extremity about a 4/10., ,PHYSICAL EXAMINATION: , She is afebrile. Blood pressure is 106/68, pulse of 64, respirations of 20. Her physical exam is unchanged from 03/21/05. Her orthopedic exam reveals full range of motion of the cervical spine. Cervical compression test is negative. Valsalva's maneuver is negative. Hoffmann's sign is negative. DTRs are +1 at the biceps, brachioradialis and trapezius bilaterally. Her sensation is grossly intact to the upper extremity dermatomes. Motor strength appears 5/5 strength in the upper extremity muscle groups tested.,Phalen's and Tinel's signs are negative at both wrists. Passive range of motion of the right wrist is painful for her. Passive range of motion of the left wrist is non painful. Active range of motion of both wrists and hands are full. She is right hand dominant. Circumferential measurements were taken in her upper extremities. She is 11" in the right biceps, 10 1/2" in the left biceps. She is 9 3/4" in both right and left forearms. Circumferential measurements were also taken of the lower extremities. She is 21" at both the right and left thighs, 15" in both the right and left calves. Jamar dynamometry was assessed on three tries in this right-hand-dominant individual. She is 42/40/40 pounds on the right hand with good effort, and on the left is 60/62/60 pounds, suggesting a loss of at least 20% to 25% pre-injury grip strength in the right dominant hand. , ,Examination of her lumbar trunk reveals decreased range of motion, flexion allowing her fingertips about 12" from touching the floor. Lumbar extension is to 30 degrees. The right SLR is limited to about 80 degrees, provoking back pain, with a positive Bragard's maneuver, causing pain to radiate to the back of the thigh. The left SLR is to 90 degrees without back pain. DTRs are +1 at the knees and ankles. Toes are downgoing to plantar reflexes bilaterally. Sensation is grossly intact in the lower extremity dermatomes. Motor strength appears 5/5 strength in the lower extremity muscle groups tested., ,IMPRESSION: , (1) Sprain/strain injury to the lumbosacral spine with lumbar disc herniation at L5-S1, with radicular symptoms in the right leg. (2) Cervical sprain/strain with myofascial dysfunction. (3) Thoracic sprain/strain with myofascial dysfunction. (4) Probable chronic tendonitis of the right wrist. She has negative nerve conduction studies of the right upper extremity. (5) Intermittent headaches, possibly migraine component, possibly cervical tension cephalalgia-type headaches or cervicogenic headaches., ,TREATMENT / PROCEDURE: , I reviewed some neck and back exercises. , ,RX:, I dispensed Naprosyn 500 mg b.i.d. as an anti-inflammatory. I refilled Darvocet N-100, one tablet q.4-6 hours prn pain, #60 tablets, and Flexeril 10 mg t.i.d. prn spasms, #90 tablets, and dispensed some Wellbutrin XL tablets, 150-mg XL tablet q.a.m., #30 tablets., ,PLAN / RECOMMENDATIONS:, I told the patient to continue her medication course per above. It seems to be helping with some of her pain complaints. I told her I will pursue trying to get a lumbar epidural steroid injection authorized for her back and right leg symptoms. I told her in my opinion I would declare her Permanent and Stationary as of today, on 04/18/05 with regards to her industrial injuries of 05/16/03 and 02/10/04. , ,I understand her industrial injury of 05/16/03 is related to an injury at Home Depot where she worked as a credit manager. She had a stack of screen doors fall, hitting her on the head, weighing about 60 pounds, knocking her to the ground. She had onset of headaches and neck pain, and pain complaints about her right upper extremity. She also has a second injury, dated 02/10/04, when apparently a co-worker was goofing around and apparently kicked her in the back accidentally, causing severe onset of back pain. , ,FACTORS FOR DISABILITY:,OBJECTIVE: ,1. She exhibits decreased range of motion in the lumbar trunk.,2. She has an abnormal MRI revealing a disc herniation at L5-S1.,3. She exhibits diminished grip strength in the right arm and upper extremity., ,SUBJECTIVE: ,1. Based on her headache complaints alone, would be considered occasional and minimal to slight at best. ,2. With regards to her neck pain complaints, these would be considered occasional and slight at best. ,3. Regarding her lower back pain complaints, would be considered frequent and slight at rest, with an increase to a moderate level of pain with repetitive bending and stooping and heavy lifting, and prolonged standing. ,4. Regarding her right upper extremity and wrist pain complaints, these would be considered occasional and slight at rest, but increasing to slight to moderate with repetitive gripping, grasping, and torquing maneuvers of her right upper extremity. ,LOSS OF PRE-INJURY CAPACITY: , The patient advises that prior to her industrial dates of injury she was capable of repetitively bending and stooping and lifting at least 60 pounds. She states she now has difficulty lifting more than 10 or 15 pounds without exacerbating back pain. She has trouble trying to repetitively push or pull, torque, twist and lift with the right upper extremity, due to wrist pain, which she did not have prior to her industrial injury dates. She also relates headaches, which she did not have prior to her industrial injury. , ,WORK RESTRICTIONS AND DISABILITY: , I would find it reasonable to place some permanent restrictions on this patient. It is my opinion she has a disability precluding heavy work, which contemplates the individual has lost approximately half of her pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort. The patient should probably no lift more than 15 to 20 pounds maximally. She should probably not repetitively bend or stoop. She should avoid repetitive pushing, pulling or torquing maneuvers, as well as gripping and grasping maneuvers of the right hand. She should probably not lift more than 10 pounds repetitively with the right upper extremity. I suspect that prior to her industrial she could lift repetitively and push, pull, torque and twist at least 20 to 25 pounds with the right upper extremity. , ,CAUSATION AND APPORTIONMENT:, With regards to issues of causation, they appear appropriate to her industrial injuries and histories given per the 05/16/03 and the 02/10/04 injuries., ,With regards issues of apportionment, it is my opinion that 100% of her pain complaints are industrially related to her industrial injuries of 05/16/03 and 02/10/04. There does not appear to be any apportionable issues here.

Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.

Chiropractic

Pain Management Consult - 2

HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,

Qualified medical evaluation report of a patient with back pain.

Chiropractic

Qualified Medical Evaluation Report

HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman. He is complaining chiefly of persistent lower back pain. He states the pain is of a rather constant nature. He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back. He states he has difficulty with prolonged standing or sitting. He can only stand for about 5-10 minutes, then he has to sit down. He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain. He has difficulty with bending and stooping maneuvers. He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot. He gets numbness along the lateral aspect of the foot itself. He also describes chronic pain complaints with associated tension in the back of his neck. He states the pain is of a constant nature in his neck. He states he gets pain that radiates into the right shoulder girdle area and the right forearm. He describes some numbness along the lateral aspect of the right forearm. He states he has trouble trying to use his arm at or above shoulder height. He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity. He describes pain at the anterior aspect of his shoulder, in particular. He denies any headache complaints. He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person. He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck. He lost his footing and fell. He reached out to grab the hand railing. He fell backwards on his back and his right shoulder. He had immediate onset of shoulder pain, neck pain, and low back pain. He had pain into his right leg. He initially came under the care of Dr. H, an occupational physician in Modesto. Initially, he did not obtain any MRIs or x-rays. He did undergo some physical therapy and received some medications. Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful. The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990. He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat. He continues with rather persistent pain in his right shoulder. He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff. The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories. He felt that the patient might require a cortisone injection or possibly a surgical intervention. The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck. There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels. The patient was also seen by Dr. P, a neurologist for a Neurology consult. It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities. The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994. He returned back to regular duty. Dr. N declared him permanent and stationary on 04/04/1995. The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer. At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician. Dr. N took him off work again. He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon. He had a new MRI of his lumbar spine performed. The MRI was performed on 05/20/1997. It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis. The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam. Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation. Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive. The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left. Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities. The patient did see Dr. R for a neurosurgical consult. Dr. R evaluated both his neck and lower back pain complaints on several occasions. Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks. The patient underwent these injections with Dr. K. The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections. It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine. Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness. The patient also was noted to have a C4-5 with rather severe degenerative disc disease. He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6. Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease. He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1. He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain. He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms. He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him. He is currently taking no medications to manage his pain complaints. He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury. He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician. The patient states he has not been back to work since. He has since applied for social security disability and now is receiving social security disability benefits. The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful. Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,

Initial evaulation - neck and back pain.

Chiropractic

Neck & Back Pain

CHIEF COMPLAINT:, Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:, Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse. She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week. She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism. She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s. In 2000, she developed "sciatica" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004. Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages. Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms. She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches. She has been told by Dr. Megahed in the past that she is not considered a surgical candidate. She has done physical therapy twice as recently as three years ago for treatment of her symptoms. She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution. Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing. There is no associated shortness of breath. She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly. She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production. Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day. She complains of occasional subjective weakness to the right lower extremity. Her pain is worse with sitting, standing and is essentially worse in the supine position. Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution. She has noted some subjective atrophy as well of the right calf. She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls. She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications. She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis. Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain. Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying. Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:, As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:, Cholecystectomy, eye surgery, D&C.,MEDICATIONS:, Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:, Multiple. All over-the-counter medications. Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:, Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:, The patient is retired. She is married with three grown children. Has a high school level education. Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:, Significant impact on every aspect of her quality of life. She would like to become more functional.,REVIEW OF SYSTEMS:, A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological. Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins. Pulmonary review of systems negative. GI review of systems is positive for irritable bowel and acid reflux symptoms. Genitourinary, occasional stress urinary incontinence and history of remote hematuria. She is postmenopausal and on hormone replacement. Endocrine is positive for a low libido and thyroid disorder. Integument: Dry skin, itching and occasional rashes. Immunologic is essentially negative. Musculoskeletal: As per HPI. HEENT: Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache. Neurological: As per history of present illness. Constitutional: As history of present illness.,PHYSICAL EXAMINATION:, Weight 180 pounds, temp 97.6, pulse 56, BP 136/72. The patient walks with a normal gait pattern. There is no antalgia, spasticity, or ataxia. She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty. She can flex her lumbar spine and touch the floor with her fingertips. Lumbar extension and ipsilateral bending provoke her axial back pain. There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic. Cranial nerves II through XII are grossly intact. Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation. The neck is supple. The trachea is midline. The thyroid is not particularly enlarged. Lungs are clear to auscultation. Heart has regular rate and rhythm with normal S1, S2. No murmurs, rubs, or gallops. The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses. Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema. I can radial, dorsalis pedis and posterior tibial pulses. The nailbeds on her feet have trophic changes. Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity. She has chronic osteoarthritic changes evident over both hands. There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders. Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline. There is no midline spinous process tenderness over the cervicothoracic regions. Palpation of the articular pillars is met with mild provocation of pain. Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness. There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally. The xiphoid process is not particularly tender. There is no dermatomal sensory abnormality in the thoracic spine appreciated. Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally. I cannot elicit S1 reflexes. There are no long tract signs. Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski. Motor examination of the upper, as well as lower extremities appears to be intact throughout. I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:, As per above.,IMPRESSION:,1. Osteoarthritis.,2. Cervical spinal stenosis.,3. Lumbar spinal stenosis.,4. Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5. History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6. Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN: ,The natural history and course of the disease was discussed in detail with Mr. XYZ. Greater than 80 minutes were spent facet-to-face at this visit. I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures. I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed. Pending the results of her preliminary studies, this should be ruled out. I will see her in followup in about two weeks with the results of her scans.