A 64-year-old white male with a longstanding history of ASHD, intermittent episodes of chest pain for sometime.Has a known positive treadmill.Has been on Procardia and Sorbitrate, but stopped Sorbitrate because of headaches.During the past 24 hours, he has noticed some increase in his pain and has had 5 separate episodes lasting 10 to 15 minutes each, which usually respond to nitroglycerin.Because of this problem and the increasing severity of the pain, he was admitted to the hospital with a blood pressure of 140/70, pulse 60 and regular, respirations were 14.Lungs were clear.Heart regular sinus rhythm, sounds were of pretty good quality.
The patient was seen in the office, admitted to the hospital where an admission panel revealed only a BUN of 23.8, the CPK isoenzymes were normal.Chest x-ray was essentially unremarkable.Initial ECG was consistent with his disease, and following discussion with a cardiologist, the patient was transferred with the diagnosis of preinfarction angina for studies and possible corrective procedure.
This 67-year-old female was evaluated by me in the emergency department at approximately 0630 hours for complaints of repeated episodes of vomiting, numbering at least 5 during the preceding 8 or so hours. She stated that she is a known diabetic and has taken fingerstick readings of 423 and 241 at home. She is on multiple medications including regular insulin 10 units in the a.m., along with Ultralente 16 units at h.s., along with Trental, Pamelor, and niacin. She is a known diabetic for 54 years. She also admits to some chest pain, somewhat burning in nature, without radiation into her face, neck, or arms. There is no history of diarrhea. She has a previous history of coronary artery bypass surgery some 4 years earlier.
PHYSICAL ASSESSMENT
Physical assessment reveals her temperature to be 98.2, pulse 60, respirations 20, and a blood pressure of 102/50. Initially her color was pale. Her mucous membranes did appear dry. Heart rate was regular without murmurs. There was a well-healed cicatrix to the anterior midsternal region. Lungs were clear to auscultation. The abdomen was soft with generalized tenderness. No unusual pulsating masses. Lower extremities were free of any pretibial edema.
IMPRESSION
1. Diabetes mellitus, out of control.
2. Dehydration.
3. Electrolyte imbalance.
PLAN
While in the emergency department, multiple diagnostic studies were performed, including CBC, glucose, BUN, potassium, sodium, UA, Panel A, ABG, PT, PTT, electrocardiogram, CPK-MB via electrophoresis. Her serum glucose was noted to be 511, serum sodium of 129, and a BUN of approximately 30.
During her ER stay she was given normal saline with some subjective improvement. She was also given Compazine 10 mg IM for repeated vomiting. Her condition at the time of admission was slightly improved.
FOOTNOTE
Line 9 (Page 1). In duration was deleted. (Duration indicates time span. Five episodes of vomiting is the amount, not the duration.)
Line 11 (Page 1). Alternative: Finger stick.
Line 36-40 (Page 1). The abbreviations used were expanded for clarity.
Line 42 (Page 1). Plan was deleted since it had already been dictated in
The patient is a 71-year-old female who was noted to have a slowly enlarging lesion in the right lobe of her thyroid. Scans revealed this to be a cold nodule. Thyroid function studies were within normal limits. Fine-needle aspiration of this was thought to be a Hurthle cell adenoma.
The patient’s physical examination revealed a 2 x 1 x 1 mass in the right upper pole of the thyroid. There were no lymph nodes palpable. Patient was moderately obese but otherwise was unremarkable.
The patient did have an exploration of her right neck, and this was found to reveal a smooth mass in the right lobe of the thyroid, and a total right thyroid lobectomy was performed. The left lobe was totally unremarkable and was not resected.
FINAL DIAGNOSIS
Follicular adenoma of the right lobe of the thyroid with Hurthle cell change.
FOOTNOTE
Line 13. The dictator does not give the unit of measure. The transcriptionist on the job would ask the physician for clarification.
One grain of thyroid did not work as well as 1-1/2 in terms of reducing facial and neck edema. When she sleeps away from home, however, the edema does not occur. It is almost certainly an allergy to some component of her house. I suggested, since she is going to college, that she try to taper and discontinue the thyroid over a 3-month period. Will return in 6 months if still on 1-1/2 grains, otherwise 1 year if on a lower dose of thyroid. Pulse 75, blood pressure normal. Heart and lungs okay. Has a small mole which does not appear to be a problem.
This 9-year-old black girl was well until yesterday morning, when she awakened with fever and sore throat. Mother states her temperature was 99.6 orally at noon yesterday, 100.6 at about 8 p.m., and 101.2 this morning. Temperature comes down with Tylenol but then shoots up again. Sore throat has become increasingly severe, and today the child will not swallow anything. She also complains of pain in the right ear on swallowing. She is not coughing and has had no rhinitis or GI symptoms. Past medical history is negative. She has no known allergies. Some of the other kids at school have been out with strep.
OBJECTIVE
Examination shows a normally developed, chubby child in moderately severe distress. She is crying. Oral temperature is 102.4, pulse 108, respirations 28. The skin is hot and moist. There is no rash. The pharynx is diffusely edematous and deeply injected, and a small amount of exudate is noted over the tonsils. No ulcers are noted, and the oral mucosa is normal. There are large, tender nodes in the jugulodigastric areas bilaterally, and a few small nontender posterior cervical nodes are palpable as well. The ear canals are clear. The tympanic membranes are flat and gray. Hearing is grossly normal bilaterally. Heart is regular without murmurs or clicks. Lungs are clear to auscultation. The abdomen is soft and nontender, without masses or organomegaly. A streptococcal screen in the office is positive.
ASSESSMENT
Acute streptococcal pharyngitis.
PLAN
1. Penicillin V potassium 250 mg per teaspoonful to be taken in a dose of 1 teaspoonful q.i.d. x10 days.
2. Tylenol up to 1 g q.4h. for pain and fever.
3. Encourage oral fluids, soup, pop, Popsicles.
4. Hot saline gargles p.r.n. for throat pain.
5. Mother is to call in, in 24 hours, to report progress.
6. Mother is reminded not to give ASA.
FOOTNOTE
Lines 3-22. Alternative: Transcribe in SOAP format.
The patient is an elderly, pleasant female who is quite cooperative.She was admitted to the hospital because of cellulitis of the right lower extremity.There has been blistering of the area on the dorsum of the foot as well as higher up towards the ankle.She has redness extending all the way up to the mid-pretibial area.There is no history of lymphadenopathy, and judging from the chart, she has been afebrile.She was started, after finding out that her white count was abnormal, on Cefobid and tobramycin and infectious disease consultation sought.
PHYSICAL EXAMINATION
Exam today shows a temperature of 37 degrees Centigrade, a blood pressure of 130/70, a respiratory rate of 20, and pulse rate of 80.
GENERAL APPEARANCE:An elderly female in no acute distress.
ABDOMEN:Scars of surgery.The abdomen is not obese but protruding.She has some left lower quadrant discomfort that is mild.
VAGINAL AND RECTAL:Not done.
LYMPH NODES:No enlargement.
Exam of the extremities reveals blistering cellulitis over the dorsum of the foot with swelling and extension of the abnormal coloration to the mid-pretibial area.The foot appears warmer than the other.
After sterile preparation the 2 blisters were aspirated, 0.2 cc of fluid was taken out, and this was sent for Gram stain and culture.
IMPRESSION
Probable streptococcus cellulitis.
DISCUSSION
The patient has had a Gram stain done yesterday, and it does show gram-positive cocci.This may well be staph, but I think we should give her penicillin till the culture reports are out.The blistering is typical of strep.I would go ahead and give her 2 million q.6h. of the penicillin and modify therapy according to culture report.
I thank you for allowing me to participate in the care of this pleasant, elderly female and will reassess p.r.n.
FOOTNOTE
Line 42.The brief form strep was expanded to streptococcus in the Impression.
Patient is 36 years old and has a 16-year history of patchy psoriasis.On examination today he has a localized area of psoriasis on the right frontal scalp and involvement of both elbows but is otherwise clear.The impression today is stable plaque psoriasis.
For the scalp he was started on Neutrogena T/Gel shampoo to be used on a daily basis, with Diprolene lotion to be applied b.i.d. until clear; 2 ounces were dispensed plus 3 refills.For the elbow lesions he was given a refill of the Diprolene ointment to be applied b.i.d. when active, and the left elbow was injected and one-third of the right elbow was injected using a total of 4 cc of 2.5 mg/cc of Kenalog diluted in solution.The patient is to recheck in 1 month so that the injections can be completed.
FOOTNOTE
Line 19.Two and a half was changed to 2.5 because metric numbers use decimals, not fractions.
This is a 33-year-old quadriplegic male.Patient presents with a chief complaint, “I have a sore on my right hip.”The patient states that several weeks ago he fell out of his wheelchair and injured the skin over his right hip.The patient stated that this sore started in a pinpoint area and became larger and larger, and sought medical attention at my office.Patient is a quadriplegic, was involved in a diving accident.The patient states that he dove approximately 60 feet off of a cliff into approximately 4 feet of water.At that time the patient severed his spinal cord in the area of C5-C6, and the patient has been quadriplegic since that time.
Physical examination reveals a very large decubitus ulcer in the area of his right hip.This ulcer is very deep and has required a great deal of debridement and will require much more.This patient is an obvious quadriplegic.He has some motion of his shoulders and his elbows and has very little or no wrist flexion; however, he does have some wrist extension.
Laboratory studies were as follows:On admission, his white count was 10.4 with 61% segmented neutrophils and 6 band neutrophils.His urine was infected 4+ with bacteria; of course, this patient has had a chronic urinary tract infection.Culture of the decubitus revealed a heavy growth of beta strep.Another laboratory study was an SMA-20.This patient had a total protein of 5.4, albumin level was 3.2, chloride was 106, and a total bilirubin was 1.2.
HOSPITAL COURSE
The patient was placed in the hospital, was placed on IV Mefoxin.Several periods of extensive surgical debridement opened this ulcer to an area which is approximately 8 x 12 cm.This ulcer was packed with a 50% solution of Betadine with a 50% solution of honey twice a day.The patient was sent to a whirlpool treatment daily, and patient tolerated this procedure very well.
DISCHARGE INSTRUCTIONS
This patient is instructed to return to home, and I wrote an order for Home Health to consult and help in the care of this decubitus ulcer.Instructions have been given and will be given to the mother in the care of this ulcer.It should be noted that it was my opinion that this patient should be placed in a hospital where there is a special unit that cares for extensive decubitus patients.They are also very adept at caring for quadriplegics with decubitus ulcers.The patient stated that he refused to go to that facility.I tried to convince his mother that he should be there, and his mother was even more adamant that the patient should return home and have care at the home.I instructed both the patient and the mother that there could be severe sequelae to having a large open sore of this type, and after a great deal of discussion, it was clear that this patient refused to follow my suggestion.
FOOTNOTE
Line 7 (Page 1).Present was changed to presents for subject-verb agreement.Is was deleted.
Line 9 (Page 1).The redundant that was deleted.
Line 13 (Page 1).With was changed to in.
Line 30 (Page 1).The dictator said B strep, meaning beta strep or beta streptococcus.
Line 36 (Page 1).Alternative:I.V.
Lines 38, 39 (Page 1).“The patient was” was corrected by the physician to “the ulcer was”.
Line 44 (Page 1).The redundant for was deleted.
Line 45 (Page 1).Home Health was capitalized because it is a division of an organization.
Line 45 (Page 1).Help in the care with was edited to help in the care of.
Lines 47 (Page 1), 7 (Page 2).The unnecessary period was deleted.
