FE Report

CHART NOTE

There is a 7-year history of rather severe rhinitis, beginning each Memorial Day and ending each July 4.  She has no associated chest symptoms.  Over-the-counter medicines have given little relief and are somewhat soporific.  Physical examination revealed quite allergic-looking nasal mucosa and conjunctivae.  I started her on Vancenase, Opticrom, Nasalcrom, and Dallergy tablets.  I do not think because of the short period of her season that there is any reason to do skin testing or to consider allergen immunotherapy.  Hopefully these medicines will control her symptoms and she can have them once yearly to control that short period.  If her symptoms start to occur during a longer period of time, it would then be appropriate to consider possible immunotherapy.

FE Report

CHART NOTE

The patient is a 68-year-old female looking much older than her stated age, who noted a mass in her left breast.  The radiologist felt that this was clear-cut evidence that there was a carcinoma of the left breast.  Blood pressure was 180/90.  In the left breast and the midportion of the breast, roughly behind the nipple, a mass estimated to be 2 to 2.5 cm in size is palpable.  This was quite firm, no axillary nodes could be palpated.  The alternatives of a lumpectomy and radiation have been discussed with the patient, and she prefers not to consider them.

Endocrinology Case Study

EMERGENCY ROOM REPORT

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

Line 43 (Page 1).  Alternative:  I.M.

Endocrinology Case Study

IDENTIFICATION AND HISTORY

This patient is a 67-year-old Mexican-American female.  She was admitted to the hospital early this morning at approximately
0400 hours.  She was seen in the emergency room at approximately 3 a.m. because of diaphoresis and weakness, with subsequent diagnosis of hypoglycemia.  She was admitted to the hospital and placed in the progressive care unit.  She was admitted with a hemoglobin of 6.9 and a potassium of 6.2, with evidence of renal insufficiency.

It should be noted that she has been admitted to the hospital in the past because of chronic renal insufficiency and hyperkalemia.  This resulted in a program which included DiaBeta 5 mg b.i.d., Inderal 20 mg 3 times a day.  Quinidex Extentabs 1 b.i.d., and ferrous sulfate.

IMPRESSION

1. Diabetes mellitus, type 2.

2. Hypoglycemia secondary to oral hypoglycemic agents in the face of renal insufficiency, leading to hypoglycemia.

3. Hyperkalemia, acute, secondary to her renal insufficiency and being on angiotensin-converting enzyme inhibitors.

RECOMMENDATIONS

1. Discontinue her Vasotec.

2. Hydration with saline since I think at least part of her renal failure is probably on the basis of prerenal azotemia secondary to her furosemide therapy.

3. Sodium bicarbonate for treatment of her metabolic acidosis.

4. Kayexalate p.o. and Kayexalate enemas.

5. Glucose infusion followed by regular insulin.

Endocrinology Case Study

CHART NOTE

Initial examination for this obese 42-year-old female patient with a 2-year history of mild hypertension and NIDDM, controlled by diet.  Medications include Ortho-Novum 10/11.  Patient was started on hydrochlorothiazide 50 mg 2 weeks ago because of elevated diastolic pressures.  Present complaints are increasing fatigue, nocturia, and vaginal pruritus.  Blood sugar by glucose meter is 417.  Urine negative for ketones.  Apical pulse of 90.  Blood pressures are 144/94 and 140/98.  Height 5 feet 2 inches, weight 186.  History and physical unremarkable.

Recommendations to include the following:  Instruction to patient to push fluids for the next several days.  Discontinue hydrochlorothiazide and birth control pills to end possible
drug-induced hyperglycemia.  Start Micronase 2.5 mg o.d. and Capoten 25 mg b.i.d.  Set up appointment on Friday for FBS and for patient to see the nurse practitioner for fitting of a diaphragm and nutritional counseling on a 1200-calorie ADA diet.

FOOTNOTE

Line 7.  Exam was expanded to examination.

Line 9.  The slang term meds was changed to medications.

Line 14.  BPs was changed to blood pressure.

Line 15.  H&P was expanded to history and physical.

Line 18.  The slang term DC was translated as discontinue.

Line 20.  The abbreviation o.d. means every day, not to be confused with O.D., right eye.

Endocrinology Case Study

DISCHARGE SUMMARY

ADMITTING DIAGNOSES

1. Diabetic ketoacidosis — mild to moderate in severity.

2. Type 1 diabetes mellitus.

3. Bronchitis and gastroenteritis.

4. Mild dehydration.

DISCHARGE DIAGNOSES

1. Diabetic ketoacidosis — resolved.

2. Type 1 diabetes mellitus.

3. Bronchitis and gastroenteritis.

4. Mild dehydration.

ADMITTING HISTORY AND PHYSICAL FINDINGS

The patient a 17-year-old white female with 8-year history of type 1 diabetes, now on 14 units of Ultralente insulin and
13 units of regular Humulin q.a.m.; 12 units of regular Humulin every noon; 14 units of Ultralente and 14 units of regular Humulin q.p.m., who insists she has been taking her insulin regularly but complains of 2- to 3-week history of cough with yellow phlegm for 2 days and emesis and abdominal pain for the day prior to admission.

LABORATORY

Arterial blood gases analysis shows pH 7.28, PCO2 29, PO2 85, bicarbonate 13, glucose 626.  Urinalysis unremarkable.

HOSPITAL COURSE

The patient was admitted to the medical floor and given IV insulin bolus of 10 units of regular and then placed on an insulin drip.  Blood sugar rapidly normalized, and her bicarbonate gradually rose to a level of 25.  She was given IV fluid hydration with normal saline and potassium chloride initially.  She received dietary counseling before discharge.  She seemed to understand the instruction adequately.  Her fasting blood sugar on the day of discharge on her usual insulin dose was 130.  This was on a 2000-calorie ADA diet (patient states she had been taking a 2800-calorie diet).

MEDICATIONS

Patient to continue the usual outpatient insulin dosage regimen.  Ampicillin 500 mg q.i.d. x10 days.

DISPOSITION

Discharged to home.  Patient was instructed to stop or minimize her smoking.  She will see her endocrinologist in 1 week and will be seen by me in 2 weeks as she has recently moved to this area.  She was instructed to call if blood sugars run less than 80 or greater than 300 — she will be checking these at home.

FOOTNOTE

Lines 13-17 (Page 1).  The physician indicates that the Discharge Diagnoses are the same as the Admitting Diagnoses, with the exception of diagnosis #1.  The Discharge Diagnoses should be transcribed in full.

Lines 21-22 (Page 1).  Humulin, Ultralente, and Lente insulin are trade names; regular insulin is generic.

Line 23 (Page 1).  Latin and English abbreviations are preferably not mixed, so q.noon was changed to every noon.

Line 29 (Page 1).  Lab was expanded in the heading.

Line 34, 37 (Page 1).  Alternative:  I.V.

Line 45 (Page 1).  Medications was taken as a different subheading prior to disposition to follow correct format.

Endocrinology Case Study Report 5

DISCHARGE SUMMARY

This was one of several admissions for this nearly 3-year-old boy for bilateral inguinal hernia repairs.  Swelling in the left groin was noted several weeks prior to admission.  He has had pains in the groins on and off.  He was found to have bilateral inguinal hernia repairs.  The child is also followed because of congenital Addison disease.  He is on Cortef and Florinef Acetate.

Because of the Addison disease, he was treated with cortisone acetate IM, 50 mg on admission, and Solu-Cortef 50 mg IM 1 hour prior to surgery.  Solu-Cortef 50 mg was run during the surgery.  Four hours after completion of the surgery, he received 12.5 mg of Solu-Cortef IM.

LABORATORY DATA

Hemoglobin 12.1, WBC 5500, BUN 18, and electrolytes 140, 3.9, and 23.

DISCHARGE DIAGNOSES

1. Addison disease.

2. Bilateral inguinal hernias.

DISCHARGE MEDICATIONS

Discharge medication included only his usual medications for Addison disease.

FOOTNOTE

Lines 15-19.  Alternative:  I.M.

Line 17.  To avoid beginning the sentence with a numeral, the sentence was rephrased.

Line 22.  Alternative:  BUN 18.  Electrolytes:  Sodium 140, potassium 3.9, and CO2 23.

Endocrinology Case Study

CHART NOTE

A 34-year-old lady who comes to clinic today with longstanding history of hypothyroidism, for which she has taken Cytomel in the past.  Comes in today for a refill of medication and further evaluation.

Examination shows her to be in no acute distress.  Blood pressure 120/88.  HEENT normal.  Chest is clear.  Cardiac examination reveals regular rate and rhythm without murmur.

ASSESSMENT

A 34-year-old lady with longstanding hypothyroidism.  I would prefer to switch her to Synthroid 0.1 mg as I think the packaging is more uniform in this product.  Then test thyroid-stimulating hormone in 1 month.

FOOTNOTE

Line 7.  The article A was added to avoid beginning the sentence with a numeral.

Line 13.  The blood pressure value 120 by 88 is written 120/88.

Line 18.  A zero was inserted before the decimal point for clarity.

Lines 19, 20.  TSH is expanded in the assessment for clarity.

Endocrinology Case Study

CHART NOTE

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.

CHART NOTE

ACTH injection given for adrenal function tests.

Endocrinology Case Study

CHART NOTE

A 26-year-old referred for Graves disease.  Patient first found to be hyperthyroid shortly after she became pregnant, was placed on PTU 350 mg taken in divided doses until 1 week prior to delivery.  She has all the classical symptoms of hyperthyroidism, including tremors, soft frequent stool, being hot, insomnia, weakness in her legs, and exophthalmos.

On physical examination, extraocular movements were fairly full except that she could not converge.  Examination of her thyroid revealed the gland to be at least 2 times the normal size with classical, rather mushy, soft feeling of hyperthyroidism.  No nodules were noted.  Examination of her skin revealed normal amounts of forearm hair but extension of hair on the backs of her hands.  She was also beginning to get hair formed on the upper lip at the corners of her mouth.  There is no periareolar hair; however, she has a well-developed male escutcheon.

I talked with the patient about this, and when she has been euthyroid for a bit, we will consider measuring her androgen level.  Patient was asked to discontinue PTU and obtain a T4 and T3.  Appointment was made with Nuclear Medicine for her to have an uptake scan and therapy next week.  I decided to investigate the androgen problem at a later date when we will not have the effect of thyroxine on liver metabolism.

FOOTNOTE

Line 7.  The article A was inserted before 26 to avoid beginning the sentence with a numeral.

Line 27.  Alternative:  Nuclear medicine.

Endocrinology Case Study

HISTORY

This is a 68-year-old woman who was seen probably about 3 years ago with a large colloid goiter.  She was going to have surgery then but declined and came back in more recently because of increasing size of the goiter and the pressure symptoms in her neck and throat.  Studies previously done showed this to be a nontoxic goiter.  She was essentially euthyroid.  Because of its increasing size, the possibility of malignancy had to be considered.

Physical examination was not remarkable except the patient being somewhat overweight and the large goiter which was visible and the right side being larger than the left.  The patient, because of religious customs, would not allow a pelvic or rectal examination.

Following surgery, the patient had no problem speaking.  She is swallowing and eating solid food.  Throat is sore.  She did develop a temperature up to 101 and had some rhonchi in both bases on auscultation.  Chest x-ray shows discoid atelectasis with probable pneumonitis.  Her white count was elevated at a little over 12,000 with a left shift.  Temperature this morning is 100 degrees.  The wound is clean and dry.  The drain has been removed, and one-half of the staples are removed.  She will be continued on tetracycline 500 mg q.i.d., and she is instructed to take her Lanoxin daily and her Dyazide as well.  We are giving her Synthroid, and she is to take that every day.  I have stressed the importance to her son of taking the Synthroid, as she should have no thyroid function.  Her calcium was 8.6.

FOOTNOTE

Line 11 (Page 1).  The dictator said same for the Final Diagnosis, indicating it is the same as the Admitting Diagnosis.  For clarity the Final Diagnosis should be repeated in full.

Line 37 (Page 1).  Degrees was not dictated with the temperature of 101 but it is acceptable to add it to be consistent with the later expression.

Endocrinology Case Study

HISTORY AND PHYSICAL EXAMINATION

This 36-year-old man was doing well until 3 years ago, when he developed progressively severe fatigue.  At that time he had been in a stressful job situation.  However, these symptoms have persisted and gotten worse, although the stress has improved.  There is no relation to meals or time of day, although he is somewhat more tired in the afternoons.  He sleeps 7 to 8 hours during the week and 12 hours on weekends.  Chemistry-2, CBC, Epstein-Barr studies, and thyroid function tests have been normal.  Was tried on Thyrolar one-half grain because of low normal T4, but there was no benefit.  Has received Parnate, Nardil, and other antidepressants, including vitamin B12 injections, without any benefit.  He has a 3-year history of constant burning in the eyes.  An ophthalmologist did not find anything wrong.

REVIEW OF SYSTEMS

Has periodic dizziness particularly when standing up rapidly, occasional tinnitus, frequent constipation and occasional diarrhea, nocturia x2 or 3, cold extremities, and dry skin of relatively recent onset.  Has some anxiety and insomnia and is depressed, apparently in relation to his condition.

FAMILY HISTORY

Father has heart disease.  Brother has retinitis pigmentosa.

HABITS

Drinks coffee.  Diet is balanced and low in sugar.

PHYSICAL EXAMINATION

VITAL SIGNS:  Height 6 feet 1 inch, weight 190 pounds.  Blood pressure 130/72, pulse is 68.

HEENT:  HEENT is normal.

NECK:  Neck is normal.

HEART:  Heart is normal.

LUNGS:  Lungs are normal.

ABDOMEN:  Abdomen is normal.

PULSES:  Pulses are normal.

EXTREMITIES:  Extremities are normal.

GROSS NEUROLOGIC:  Gross neurologic examination is normal.

SKIN:  Skin is normal.

RECTAL:  Rectal examination not done.

ASSESSMENT

1. Chronic fatigue.

2. Burning eyes.

3. Depression.

4. Signs of possible hypothyroidism.

5. Constipation and diarrhea.

PLAN

We will check basal temperatures and begin thyroid prescription if low.  Gave therapeutic trial of 6-cc vitamin C, 4-cc calcium/magnesium, 1 cc of B6, B12, B5, and B complex IV.  Will repeat if helpful.  Other recommendations as noted and return in 4 weeks.

FOOTNOTE

Line 13 (Page 1).  Chem was expanded to Chemistry.  Exam was expanded to Examination.

Line 35 (Page 1).  Exam was expanded to Physical Examination.  Line 36 (Page 1).  Height and weight was added for clarity.

Lines 36-47 (Page 1).  The subheadings were added in Physical Examination to follow proper format.

Line 9 (Page 2).  Alternative:  I.V. (intravenous).  The slang term cal/mag was expanded to calcium/magnesium for clarity.

ENT Case Study

SUBJECTIVE

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.

S:

O:

A:

P:

ENT Case Study

CHART NOTE

Examination of right postauricular mastoid wound site demonstrates less erythema with mild induration, and packing demonstrates thick, cloudy secretions with no malodor.  There appear to be no frank pus pockets evident, and debridement was performed with application of Betadine ointment. 
Betadine-impregnated iodoform gauze was additionally placed with approximately 1-1/2 inches and patient’s wife instructed in wound care.

ASSESSMENT

Right postauricular mastoid wound infection with fat or hematoma liquefaction.

FOOTNOTE

Lines 9-10.  Appears was changed to appear for proper
subject-verb agreement.  (There appear to be no ... pockets ...)