She is Allergic to DEMEROL - CHEST - CARDIAC - ABDOMEN - EXTREMITIES

HISTORY

The patient is an 84-year-old female who called 911 last night around 11 o'clock.  She said during the day she had just felt kind of weak.  She said to one of her neighbors on the phone that said she was not speaking as clearly, but she noticed both hands were weak and she had dropped some things, but during this whole episode and timeframe, which was about 7 hours, she said about 4 or 5 o'clock in the afternoon, she managed to wash dishes and feed herself.  She did not take any of her night medicines because she was kind of concerned and she started thinking she might be having a stroke, so she just stayed home until she went to sleep, then she woke up, because she never could go to bed worrying about something was wrong with her, so she called 911.  They came and evaluated her and brought her to the emergency room with all her medications.  She states she did not take her nighttime medicine of Betapace or the Klonopin or Mirapex for restless legs because she did not want to interfere with anything. 

ALLERGIES

She is allergic to DEMEROL.

CURRENT MEDICATIONS

Include: 

1.            Norvasc 5 milligrams a day.

2.            Hyzaar 100/25 milligrams a day.

3.            Betapace 80 milligrams b.i.d.

4.            Mirapex 0.25 at night.

5.            She has been taking Relafen 500 b.i.d. intermittently for arthritis.

6.            She has Soma tabs as needed for muscle pain.

7.            She takes Klonopin 1 milligram at night for sleep.

8.            She takes GoLYTELY on a p.r.n. basis for constipation.

PAST MEDICAL HISTORY

She has a history of atrial fibrillation for the past number of years.  She is intolerant to the Coumadin as she has had falls.  She is now walking with a walker and is not the most stable person.  She lives at home with a sitter coming in 3 to 4 times a week and friends taking over because she is a widow, with no immediate family close by except in Mobile.  She had a right hip fracture 10 years ago and after that had a DVT.  She had bladder surgery about 2 years ago for bladder tack.  She has had hypertension for a number of years and restless legs syndrome and insomnia for a number of years.

FAMILY HISTORY

Noncontributory.

SOCIAL HISTORY

She is widowed.  She has a son who is estranged, she has not seen for years.  She has 2 granddaughters in Mobile to check on her.  They have been asking to come to Mobile for years, but she is always refusing because they have young kids and she does not want to interfere with their life, so she has lived at home.

REVIEW OF SYSTEMS

Patient was on Coumadin a while for the atrial fib, sustained a fall.  Balance got progressively worse, and it was felt that she is not a candidate for Coumadin any longer secondary to her risk to falls, and she uses a walker at this time.

OBJECTIVE

VITAL SIGNS:  In the ER, her blood pressure 187/106, her pulse is 98, O2 sats are 96.

GENERAL:  Her speech is clear and I can understand every word she says, but it sounds almost lethargic, but she said she has not slept all night.  I see her at 7:30 in the morning, and she said she has been in the ER since 1 o'clock and they did not get her up to a room until 5:30, and she told the nurses that she was just tired, and that was possibly it.

HEENT:  Her pupils are equal, round, and reactive to light.  Her extraocular movements are intact.  Her oropharynx, she has an equal smile.  Her speech is understandable.  She can close her eyes tight.

CHEST:  She has bilateral breath sounds, clear.

CARDIAC:  Her cardiac exam revealed an irregularly irregular rhythm, but rate controlled in the 80s.

ABDOMEN:  Her abdomen is soft.

EXTREMITIES:  She has bilateral nonpitting edema, which is chronic.  Her left leg is worse than the right.  This is the one that she had sustained the DVT, and then she also had trauma to it a few years back with a golf cart incident.

NEURO EXAMINATION:  She is alert and oriented x4.  She knows her address, where she lives and home or social situation, but she is very obstinate in that she is going to go back home if possible.  She has a negative ulnar drift.  She has equal grip strength.  Both legs move okay, the right leg moves a little stiffer secondary to hip replacement.  She has got equal strength, albeit weak, but this is a chronic finding in this lady.

GU AND RECTAL:  Deferred at this time.

IMAGING

EKG showed atrial fibrillation.  CT scan of the head was read with some old cerebellar ischemia, but nothing new on this time.

LABORATORY DATA

Laboratory data reviewed.

ADMISSION DIAGNOSES

1.            Cerebrovascular accident versus transient ischemic attack.  At this time, she seems to be back to her baseline, although she was lying in bed and I did not get her up and walk her, but she seemed to be back to baseline.  She says that she can get up and go to the restroom.

2.            Chronic atrial fibrillation.  Patient is not on Coumadin any longer.  She is at risk for falls and has fallen, and she walks with a walker.

3.            Hypertension, elevated in the emergency room, but now has come down.

4.            Restless legs syndrome.

5.            Status post right hip fracture.

6.            Advanced age.

7.            Hypokalemia.

8.            Hypomagnesemia.

PLAN

At this time, I am going to consult neurology.  __________ has seen her husband.  That is one person she knows.  We will call and see if he is in town.  We will get echo and carotids.  We will also start on a full aspirin a day since she has been on a baby aspirin.  We will get speech and PT evaluation, monitor her blood pressure, replace her magnesium and potassium

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 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.

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

Dear Al,

This 21-year-old lady stated that she has been having some problems with a “swollen gland on the right side”.  She had seen you about a week and a half ago, and you had ruled out the presence of a stone within the salivary gland.  She states the swelling “tends to go up and down”.

Her general health is described as good, but she does have asthma.  She is presently taking Motrin, Marax, and an inhaler.

Physical examination reveals ear canals are clear.  Tympanic membranes normal.  Nasal airway adequate, no discharge.  Throat reveals normal mucous membrane.  No postnasal drainage.  Her right submandibular gland is slightly enlarged but soft and nontender.

Under the operating microscope, I was able to dilate Wharton duct on the right, and after dilatation the gland resumed its normal size.  There was no evidence of purulent discharge or calculi.  Hopefully, this will do the trick.

I explained to her that we can only treat this either symptomatically or excise the gland, and I suggested that symptomatic treatment for a while is indicated.

Thank you for the referral.  If I can be of any further assistance, please let me know.

Best regards,

Name.

FOOTNOTE

Line 13.  Re was not dictated but was added to demonstrate proper letter format.

Line 39.  Alternative:  Awhile.

ENT Case Study

CHART NOTE

PHYSICAL EXAMINATION

Ear canals are clear.  Tympanic membranes are normal.  Nasal airway is adequate.  Septum slightly deviated to the right.  No discharge.  Throat reveals normal mucous membrane.  No evidence of inflammation.  No PND (postnasal drainage).  She does have a couple of little lymphoid plaques, both in the pharynx and in the area where tonsils were removed.  These are not neoplasms and not presently inflamed, just a tiny bit juicy.  Neck reveals no adenopathy.  Thyroid and trachea are normal.

IMPRESSION

Very mild lymphoid hyperplasia of the tonsillar fossae postoperative and the nasopharynx.

DISPOSITION

Reassured, explained what is going on, and she is to return p.r.n.  Encouraged her not to take antibiotics for just every sore throat.

FOOTNOTE

Line 7.  Exam was expanded to Examination in the report.

Line 11.  The abbreviation PND was expanded to postnasal drainage in this report.

Line 18.  Fossas was changed to fossae, plural of fossa.

ENT Case Study

CONSULTATION

This 17-year-old woman was seen in consultation with her mother regarding problems referable to her nose.  The patient has had progressive problems of congestion and sniffing with difficulty moving air through her nose and sensation of pressure.  She is a “mouth breather,” and has a history of allergy to pollens and dust.  Patient feels these problems are becoming more severe.  Her complaints are fairly consistent.

EXAMINATION

She presents with edema of her nasal mucosa, increase in the size of the turbinates, deviation of the nasal septum, and a rather narrowed nasal airway.

DIAGNOSES

1. Probable allergic rhinitis with hypertrophy of the turbinates.

2. Deviated nasal septum.

3. Narrow inadequate nasal airway.

COMMENTS

1. I have discussed with this patient and with her mother the surgical approach to improving her nasal airway with septoplasty, possible submucous resection of deviated portions of the septum, and possible reduction of the inferior turbinates.  At the same time I would be performing a rhinoplasty procedure to smooth out the dorsal nose as well.

2. Because of the history of allergies to pollens, dust, and environmental pollutants, it is quite possible patient will continue to have some sniffing, and consequently the degree of improvement of her nasal airway with surgery cannot be precisely determined.

FOOTNOTE

Line 7.  This was added to avoid beginning the sentence with a numeral.

Lines 20-23.  Enumerate the diagnoses.

ENT Case Study

CHART NOTE

Has continued to have episodes of coughing and wheezing over the course of the past several years along with persistence of some rhinitis.  His hearing is apparently fine, although he has had some serous otitis media again as well.

We decided to skin-test him again, and there is a marked change in his skin tests.  He now shows reactions to tree, grass, and weed pollens, house dust, cat dander, multiple genera of mold spores, animal feathers, and house dust mites.  The dog was removed from the house with no change in the patient’s symptoms; indeed, there was some progression of his symptoms.  I therefore have decided that a course of immunotherapy would be appropriate, and he is going to start that.  Since his brother is coming to my office for administration of his injections, will be getting his injections in my office as well at his mother’s request.

FOOTNOTE

Line 16.  His was changed to the patient’s for clarity.

ENT Case Study

CHART NOTE

Patient is seen for nasal blockage.  Found to have nasal polyps, swollen turbinates, and also chronic sinusitis on the right.  He improved somewhat on medicine, but still had the basic problems, so finally scheduled for right Caldwell-Luc, cautery of the turbinates, and polypectomy.

Dermatology Case Study 9

HISTORY AND PHYSICAL EXAMINATION

HISTORY

This 17-year-old was admitted via the emergency room.  She gives a history of shooting crank.  Since that time, the left antecubital space has been infected.

PAST HISTORY

Patient has been shooting for at least a year.

She denies use of drugs other than crank.

The patient has a 2-year-old and a 3-week-old child, has been in the hospital only for that.  Denies accidents, injuries, or other infections.

SOCIAL HISTORY

Patient is a 17-year-old IV drug user.

PHYSICAL EXAMINATION

VITAL SIGNS:  Temperature 102.2 degrees.  Pulse 112.  Respirations 20.  Blood pressure 104/60.

GENERAL:  Well-developed, well-nourished, English-speaking, Caucasian 17-year-old.

EENT:  No gross abnormalities.  Pupils constricted.  Fair dental repair.

NECK:  Neck supple, no palpable nodes.

CHEST:  Lungs are clear.

HEART:  Heart regular, not enlarged, no murmurs.

BREASTS:  Normal.

ABDOMEN:  Soft.  No palpable masses.

PELVIC AND RECTAL:  Not done.

ORTHOPEDIC:  Examination of the left antecubital space reveals there is a generalized area of tender cellulitis with a moderate amount of swelling on the left as compared with the right.

X-RAYS

No x-rays are available for review.

DIAGNOSES

1. Chronic intravenous drug user.

2. Cellulitis, left arm.

PLAN

The patient should be admitted to the hospital for IV antibiotics and possible opening of the wound.

FOOTNOTE

Line 9 (Page 1).  The street drug crank or speed is an amphetamine; not the same as crack (cocaine).

Line 12 (Page 1).  The dictator changes Physical Examination to Past History

Line 13 (Page 1).  The dictator changes using to shooting.

Lines 25-39 (Page 1).  Some subheadings were added.

Line 45 (Page 1).  Abbreviations in the Diagnosis or Impression should be expanded; thus, IV was expanded to intravenous.

Line 1 (Page 2).  Alternative:  I.V.

Dermatology Case Study 3

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CHART NOTE

Has dermatitis on the chest, which looks fungal.  Nonpruritic.  Will use Lotrimin cream b.i.d. for 2 to 3 weeks.  If not effective, use Valisone cream b.i.d. for 2 weeks.  Resume vitamin A 25,000 units q.o.d. as her bumps have returned.