REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Chronic kidney disease.

HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old woman who has a history of hypertension, diabetes mellitus, and chronic kidney disease, who presented for the purposes of elective laminectomy. The patient had been complaining of worsening right foot drop as well as lumbar and lower back pain. Recent MRI suggests progression of her degenerative changes in the lower lumbar spine as well as severe spinal stenosis.

She underwent lumbar laminectomy, and she tolerated the procedure well. Her systolic blood pressures remained well above 100 mmHg throughout surgery, and her estimated blood loss was approximately 200 mL. She was admitted to the ICU for close monitoring, and during her stay, her blood pressures had been somewhat labile and elevated, which may be directly related to her degree of pain. Her blood pressure at one point was as high as 182/80. Cardiology has been assisting in management of her hypertension, and her hydralazine and metoprolol were both recently increased. Since that time, her blood pressures have been more reasonable.

Her renal function has been stable, and today her creatinine was approximately 2. Her baseline serum creatinine appears to be between 1.6 and 2.4. We are currently being consulted to assist in management of her chronic kidney disease.

PAST MEDICAL HISTORY: Chronic kidney disease, baseline serum creatinine 1.6 to 2.4; hypertension; insulin-dependent diabetes mellitus; diabetic neuropathy; proteinuria, near nephrotic range; gastroesophageal reflux disease; spinal stenosis; degenerative joint disease; hyperlipidemia; rhinitis; and history of vitamin D deficiency.

MEDICATIONS: Current medications include amiodarone 100 mg p.o. daily, Celexa 10 mg p.o. daily, simvastatin 10 mg p.o. q.p.m., lorazepam 0.5 mg p.o. q.h.s., insulin sliding scale, Tylenol 650 mg p.o. q. 6 hours p.r.n., diazepam 5 mg p.o. t.i.d. p.r.n., Colace 100 mg p.o. b.i.d., morphine 1 mg IV push q. 2 hours p.r.n., magnesium hydroxide 10 mL p.o. daily p.r.n., omeprazole 40 mg p.o. daily, Zofran 4 mg IV push q. 6 hours p.r.n., metoprolol 40 mg IV piggyback daily, Norco one tablet p.o. q. 4 hours p.r.n., hydralazine 25 mg p.o. t.i.d., metoprolol XL 50 mg p.o. daily, labetalol 20 mg IV push q. 4 hours p.r.n., and 0.9 normal saline at 80 mL per hour.

ALLERGIES: Multiple, listed in the chart.

FAMILY HISTORY: Negative for chronic kidney disease, including dialysis and transplantation.

SOCIAL HISTORY: No tobacco, alcohol or illicit drug use. She is divorced.

REVIEW OF SYSTEMS: As above, significant for worsening foot drop and weakness to her right lower extremity. She has had ongoing issues with chronic back pain and lumbar pain. She denies any numbness or tingling in her hands or fingers. No shortness of breath, chest pain, palpitations, lower extremity edema, dizziness or syncope. She denies any fever or chills. She denies any bright red blood per rectum or melena. Her vision is not changed, and she is legally blind. She denies any dysuria, flank pain or changes in urinary frequency or urgency. All other systems were reviewed and were negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.6, heart rate 92, respirations 16, blood pressure 160/70, oxygen saturation 100% on 2 liters nasal cannula.
GENERAL: The patient is in no apparent distress, alert and pleasant, and is oriented x3.
HEENT: Extraocular muscles are intact. Sclerae nonicteric. Mucous membranes are moist.
NECK: Supple with no lymphadenopathy. No jugular venous distention.
LUNGS: Clear to auscultation bilaterally. No crackles, wheezes, rales or rhonchi.
HEART: Regular rate and rhythm. S1, S2 normal with no murmur, rub or gallop.
ABDOMEN: Soft, nontender, and nondistended with normoactive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema noted.

LABORATORY DATA: Sodium 138, potassium 4.5, chloride 106, bicarbonate 24, BUN 44, creatinine 2, glucose 266, calcium 7.8. CBC: White blood cell count 11.5, hemoglobin 9.8, hematocrit 29.6, and platelet count 212.

IMAGING STUDIES: Chest x-ray revealed lungs that are clear of infiltrates and heart size is borderline.

IMPRESSION:
1.  Chronic kidney disease, stage III/IV, stable.
2.  Hypertension, improved.
3.  Degenerative joint disease/spinal stenosis, status post lumbar laminectomy and foraminectomy.
4.  Diabetes mellitus.
5.  Proteinuria.
6.  Legally blind.
7.  Anemia.

RECOMMENDATIONS:  As above, the patient’s creatinine today was 2, and this seems to be right in the middle of her baseline of 1.6 to 2.4. Her blood pressure has responded nicely to increasing her hydralazine as well as increasing her metoprolol, which is also being managed by Cardiology. Indeed, some of her hypertensive issues may be directly related to her degree of ongoing pain post surgery. We will place parameters on her hydralazine, to hold should her systolic blood pressure drop to less than 130, as we wish to avoid any potential hypertensive episodes with her ongoing blood pressure medications in combination with her analgesics. We will continue to monitor renal function very closely while she is in the hospital.

We will place parameters on her hydralazine, to hold should her systolic blood pressure drop to less than 130, as we wish to avoid any potential hypertensive episodes with her ongoing blood pressure medications in combination with her analgesics. We will continue to monitor renal function very closely while she is in the hospital.

Her anemia is noted, with a slight decline in her hemoglobin from 10.6 to 9.8. We will check iron stores and place the patient on iron therapy if necessary. She may require appropriate therapy at this time. We will hold for now assuming her hemoglobin does improve postoperatively.

The post Chronic Kidney Disease Consult Sample Report appeared first on Medical Transcription Sample Reports.

DATE OF CONSULTATION: MM/DD/YYYY

REASON FOR CONSULTATION: Left upper lung mass.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with past medical history significant for anxiety, depression, and hepatitic C. The patient does have history of tobacco use. The patient presented with a complaint of left shoulder pain. The patient stated that the pain is achy in nature, comes and goes over the past 24 hours. The pain had been worsening to the point of left-sided chest pain, worsening, and radiated down to the left upper extremity with increased shortness of breath, especially during these episodes.

The patient stated that she was seen in the emergency department yesterday for back pain and was sent home. However, the pain continued to persist. The patient complained of shortness of breath, especially on exertion. No history of fever or chills. No history of infectious disease exposure or ill contacts. The patient has a history of tobacco use for many years. The patient denied any abdominal pain, nausea, vomiting or diarrhea.

PAST MEDICAL AND SURGICAL HISTORY: Depression, anxiety, and hepatitis C.

CURRENT MEDICATIONS: The patient is taking no medications.

ALLERGIES: She has no known drug allergies.

SOCIAL HISTORY: The patient smokes cigarettes and drinks beer every day.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: No other positive pertinents reported by the patient beside information provided above.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99, pulse 70, respiratory rate 18, blood pressure 116/74, and saturations 100%.
HEENT: Normocephalic and anicteric. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact.
LUNGS: Diminished breath sounds with crackles at the right base.
HEART: Normal S1 and S2. No S3, S4. No murmur, gallop or regurgitation.
ABDOMEN: Soft and nontender. Nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing or cyanosis.
NEUROLOGIC: The patient is awake, alert, and oriented x3. Cranial nerves are grossly intact. No focal deficits.

INITIAL LABORATORY FINDINGS: WBC 9.6, hemoglobin 12.4, hematocrit 36.2, and platelets 58. Sodium 134, potassium 4.6, chloride 106, bicarbonate 21, glucose 88. INR 1.5.

DIAGNOSTIC DATA: Chest x-ray showed right lower lobe pneumonia; however, CT scan of the chest show left upper lobe density compatible with infectious versus malignancy.

ASSESSMENT AND PLAN:
1.  Left upper lobe lung mass, rule out infectious etiology versus malignancy.
2.  Tobacco use.
3.  Anxiety.
4.  History of hepatitis C.

PLAN:  We will follow the patient’s platelets and possible CT-guided biopsy of the lung mass to evaluate for infectious disease versus malignancy. We will continue to follow the patient closely.

The post Upper Lung Mass Consult Sample Report appeared first on Medical Transcription Sample Reports.

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION:
1.  Dysphagia.
2.  History of esophageal stricture.
3.  Severe anemia, hemoglobin of 4.6, causing weakness.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old pleasant African-American man with a history of esophageal stricture, foreign body impaction x2, and disimpaction with endoscopies with history of status post Billroth surgery, glucose intolerance, complaining of severe weakness, who presented to the emergency department complaining of epigastric pain and also dysphagia to solids at times. On further workup, he was noted to have hemoglobin as mentioned above, 4.6, and so far, the patient was on 4 units of PRBCs and repeat CBC is pending.

The patient feels very well. No chest pain now. No abdominal pain, no fever or no chills. No melena or change in bowel habits. The patient has hematuria after having some bladder problems for his bladder carcinoma.

PAST MEDICAL HISTORY:  As mentioned above.

HOME MEDICATIONS:  Insulin.

ALLERGIES:  NKDA.

FAMILY HISTORY:  No history of colorectal cancer.

REVIEW OF SYSTEMS:  HEENT: No headache. Cardiac: No chest pain. Respiratory: No shortness of breath. Gastrointestinal: As in HPI. Genitourinary: Positive for hematuria.

PHYSICAL EXAMINATION:
VITAL SIGNS: Awake, alert, and oriented x3. Pulse of 54, blood pressure 124/62, and weight not documented.
HEENT: Conjunctivae clear.
NECK: No JVD.
CHEST: Clear.
HEART: Regular.
ABDOMEN: Soft and nontender.
EXTREMITIES: No cyanosis or clubbing.
RECTAL: No stool noted.

LABORATORY DATA:  Admission labs revealed WBC of 4.2, hemoglobin 4.6, hematocrit 17.8, and platelets 194,000. INR 1.12. Sodium 138, potassium 3.9, chloride 108, BUN 15, creatinine 1.0, total bilirubin 1.6, alkaline phosphatase 70, ALT 13, AST 26, CK-MB 7.6, and troponin 0.01 x2.

ASSESSMENT AND PLAN:
1.  This is a (XX)-year-old who presented to the emergency department with history of esophageal stricture, status post food impaction and now recurrent dysphagia, most likely to benign esophageal stricture.
2.  Severe anemia, questionable from genitourinary, from his bladder losses.

PLAN:
1.  Given his dysphagia and severe anemia, we will transfuse to keep his hematocrit greater than 30 and guaiac stools x3.
2.  Urology consultation.
3.  Esophagogastroduodenoscopy with plus or minus dilatation for the above symptomatology.
4.  Clearly discussed the risks, benefits, and alternatives for the above and agrees for above.

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REASON FOR CONSULTATION:  Peritonitis.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic female who was admitted from home for a kidney transplant. Postoperatively, the patient has had delayed graft function. She is receiving Thymoglobulin, CellCept, and Solu-Medrol. She is requiring dialysis via right femoral catheter. On MM/DD/YYYY, she began complaining of severe pain in the right lower quadrant of the abdomen, and positive rebound tenderness was noted. She was felt to have an acute abdomen.

A CT scan of the abdomen showed free intraperitoneal air. The patient had an emergency exploratory surgery this morning for a suspected perforated viscus. The patient had an exploratory laparotomy, repair of colon, diverting colostomy. Ascites fluid was felt to be infected. ID evaluation was requested. The patient is currently in the recovery department. She says she is in a lot of abdominal pain.

PAST MEDICAL HISTORY:  End-stage renal disease for 14 years, status post two previous cadaveric-related kidney transplants, history of hypertension, nephrosclerosis, and question of venous thrombosis. The patient had a nephrectomy of the second failed transplant previously, also history of a hysterectomy and history of cervical carcinoma.

CURRENT MEDICATIONS:  Solu-Medrol 10 mg IV every 12 hours, CellCept 500 mg IV every 12 hours, Protonix 40 mg once a day, ganciclovir 150 mg after each dialysis, labetalol drip 8 mg a minute. Maxipime 1 gram IV was given this afternoon. The patient has also got 1 gram of vancomycin this afternoon, and Flagyl 500 mg every 8 hours was ordered.

ALLERGIES:  None to any antibiotics.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  No alcohol, tobacco or illicit drug use.

REVIEW OF SYSTEMS:  No fever, chills or rigors. No head, ears, eyes, nose, and throat symptoms. No shortness of breath, cough, chest pain or palpitations. Positive abdominal pain. No nausea, vomiting or diarrhea. No flank pain. No muscle aches or arthralgias. No headaches or stiff neck.

PHYSICAL EXAMINATION:
GENERAL:  The patient is a young Hispanic female who was seen in the recovery room. She was ill appearing and in moderate distress due to abdominal pain. With beginning of morphine infusion, she became much more comfortable.
VITAL SIGNS:  Temperature 99.2 degrees, blood pressure 122/92, heart rate 98, respiratory rate 20, and O2 saturation 100%.
SKIN:  There was no rash. There were no peripheral stigmata of endocarditis. There was no jaundice.
HEENT:  Grossly intact. The patient was already extubated and had a face mask on.
NECK:  Supple. No carotid bruits. No thyroid masses.
LUNGS:  Clear.
HEART:  Regular rate and rhythm.
ABDOMEN:  Showed a new diverting colostomy. There was a transplant incision in the left iliac fossa. The abdomen was soft, but diffusely tender. Bowel sounds were absent. A dialysis catheter was placed in the right femoral vein.
EXTREMITIES:  Lower extremities revealed no cyanosis, clubbing or edema.
NEUROLOGIC:  The patient appeared nonfocal.

LABORATORY DATA:  From yesterday revealed a white count of 9200, hemoglobin 9.6, and platelet count 122,000. PT 16.2, INR 1.3, PTT 42. Glucose 114, BUN 76, creatinine 9.2, sodium 136, potassium 4.4, chloride 100, and CO2 20.

IMPRESSION:  Peritonitis secondary to perforated viscus.

PLAN:  Current antibiotic therapy is very appropriate. We will follow vancomycin levels. Continue Maxipime 1 gram IV daily and Flagyl 500 mg IV every 8 hours pending more information.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Episode of bradyarrhythmia.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Caucasian female with a past medical history of hypertension, paroxysmal atrial fibrillation, and diffuse osteoarthritis. The patient presented to the emergency department with a complaint of atypical chest pain, mostly in the upper shoulder and both arms and radiating into the back. Cardiac enzymes were negative. EKG showed atrial fibrillation with no acute ST or T wave changes. The patient underwent an adenosine Myoview stress test, which was reported to be negative.

The patient was scheduled to be discharged home when she was noticed to have an episode of atrial fibrillation with very slow ventricular response. Heart rate was ranging in the 30s. During this episode, the patient was feeling dizzy and lightheaded associated with significant fatigue and weakness. Cardiology consultation was requested for further evaluation and treatment. Last year, her 2D echo was showing normal left ventricular size and systolic function, sclerotic aortic valve, and no evidence of stenosis. No significant regurgitation noted.

PAST SURGICAL HISTORY: Includes hysterectomy, cholecystectomy, and cataract surgery.

MEDICATIONS: She is on Diovan, hydrochlorothiazide, digoxin, potassium supplement, diclofenac, and Tylenol.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient denies smoking, ETOH abuse or drug abuse.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient is denying any visual or hearing disturbances. She denies any difficulty swallowing, change in appetite or weight.
CARDIOVASCULAR: She had a history of paroxysmal atrial fibrillation. Currently, the patient is in atrial fibrillation with unknown duration of her current episodes. No history of CHF. She denies any PND, orthopnea or leg swelling. No history of frank syncope reported.
RESPIRATORY: She had a history of sleep apnea. She is on CPAP support. She denies any COPD, asthma or recurrent pneumonia.
GASTROINTESTINAL: She denies any nausea, vomiting, diarrhea or constipation. She does have a history of gastroesophageal reflux disease.
GENITOURINARY: She denies any frequency, dysuria, or change in the color of the urine.
NEUROLOGIC: She denies any TIA, strokes or significant headache.

PHYSICAL EXAMINATION:
GENERAL: The patient is awake, alert, and oriented x3, not in acute respiratory distress.
VITAL SIGNS: Blood pressure 140/68, pulse 50 and irregular, respiratory rate 14, and temperature afebrile.
HEENT: Head is normocephalic. Pupils are equal and reactive to light. Sclerae nonicteric.
NECK: Supple. JVD negative. No carotid bruit. No lymphadenopathy or thyromegaly.
HEART: S1, S2 normal. Irregularly regular. Systolic murmur 2/6 in the aortic position.
CHEST: Shows air entry fair bilaterally. No rales, no wheezing.
ABDOMEN: Soft. Bowel sounds positive. No organomegaly or masses.
EXTREMITIES: Edema negative, femoral pulses are 2+ bilaterally.
NEUROLOGIC: No focal neurologic deficits. Cranial nerves II through XII are grossly intact.

DIAGNOSTIC DATA: Her EKG is showing atrial fibrillation with ventricular response at 94 beats per minute, left axis deviation, nonspecific intraventricular conduction defect, an old anteroseptal infarct, age undetermined, lateral ST-T wave changes, nonspecific. Her EKG is showing atrial fibrillation with ventricular response of 70, ventricular premature contraction, and borderline intraventricular conduction defect, diffuse nonspecific T wave changes.

Cardiac telemetry showed an episode of atrial fibrillation with a slow ventricular response, heart rate ranging between 30 and 40 at that time, and the patient was symptomatic during those episodes.

LABORATORY DATA: No recent labs seen. Lab from two days ago showed WBC 6.8, hemoglobin and hematocrit 11.8 and 36.8, platelet count 158. PT and INR normal. D-dimer was 0.4. Sodium 138, potassium 3.6, chloride 98. BUN and creatinine 14 and 1.0. Cardiac enzymes x3 were negative and BNP was 178.

IMPRESSION:
1.  Atrial fibrillation with a slow ventricular response, symptomatic, with a heart rate between 30 and 40 at that time.
2.  Hypertension.
3.  Osteoarthritis.
4.  Gastroesophageal reflux disease.

PLAN:  The plan is to hold digoxin at this point and check digoxin level. Continue monitoring. If the patient continues to be bradycardic, she may need permanent pacemaker implantation. The patient also will require anticoagulation with Coumadin with adjusted INR of 2 to 3 if no other contraindications, but we will hold off on the Coumadin until we decide about permanent pacemaker implantation. Further recommendations according to hospital course.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Near syncope, near drowning.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gentleman who apparently had an episode of near drowning four days ago, preceded by a near syncopal episode causing him to fall into water. He was in the intensive care unit on a ventilator for some time before he extubated himself. He has done reasonably well since that time; however, evaluation was requested given the patient’s abnormal stress test. The patient had an episode of near syncope a month to two months ago. A stress nuclear study was subsequently performed, and this revealed ischemia in the territory of the right coronary artery. The patient has denied any chest pain in the past and denies shortness of breath in the past as well. Currently, he denies any chest pain.

PAST MEDICAL HISTORY: History of a stroke with a left lacunar infarction in the past, dementia, and benign prostatic hypertrophy.

CURRENT MEDICATIONS: Valium, Exelon, calcium, aspirin, Fosamax, and Remeron.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: Negative for active tobacco use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: An adequate review of systems is unable to be obtained from the patient given the language barrier. He does, however, deny any chest pain or shortness of breath at rest.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8, pulse 82, blood pressure 130/74, respiratory rate 20, and O2 saturation 95%.
GENERAL APPEARANCE: This is an alert, elderly male in no acute distress.
HEENT: Unremarkable.
NECK: Normal carotid upstrokes bilaterally. There are no carotid bruits. There is no jugular venous distention.
HEART: Regular rhythm without any murmurs or gallops.
LUNGS: Diffuse crackles as well as rhonchi in all lung fields.
ABDOMEN: Soft and nontender to palpation.
EXTREMITIES: Warm without any edema. Essentially normal strength in all extremities.
NEUROLOGIC: The patient is alert and oriented.
SKIN: Negative for tattoos, rashes or ulcers in the feet.
SPINE: There is no kyphoscoliosis.

LABORATORY AND DIAGNOSTIC DATA:  Sodium 142, potassium 3.5, chloride 108, carbon dioxide 24, BUN 12, creatinine 0.9, magnesium 1.8, calcium 7.8 with an albumin of 2.6. Hemoglobin 11.4, white count 11.4, and platelet count is 142,000. AST is 84 and ALT is 52. CT of the head revealed an old focal lacunar infarction in the left side. CT of the chest revealed patchy alveolar densities throughout the lungs. Nuclear stress test performed in our office revealed mild to moderately abnormal stress perfusion study with ischemia in the probable territory of the right coronary artery. The ejection fraction was 62%. These findings were new when compared to a prior study performed a year and a half ago.

IMPRESSION:
1.  Near drowning.
2.  Abnormal nuclear stress test with ischemia in the territory of the right coronary artery.
3.  Near syncope with a recurrent episode.
4.  History of a stroke.

RECOMMENDATIONS:  An echocardiogram was apparently done at the outside hospital, which revealed normal ejection fraction, no wall motion abnormalities, and normal valve structure. Etiology for near syncope then could be secondary to an arrhythmia, potentially due to coronary artery disease given the abnormal nuclear stress test. We believe a cardiac catheterization would be the best approach; however, we would want to wait until improvement in the patient’s lung exam is noted. A lipid profile will need to be obtained.

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REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  Regarding aneurysm and recent intracranial hemorrhage.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old right-handed man who presented to the hospital after a syncopal episode. He was mowing his lawn. He developed a tired sensation in his neck. He felt lightheaded. He went down one knee to gather himself. He passed out and rolled over into the road where he was found by someone else. He thinks he was out for a couple of minutes. He awoke feeling confused and dazed. He had a similar, less severe episode in August of this year. This was also preceded by sensation of tiredness in his neck with subsequent lightheadedness and syncope. He states he had a big knot on his head at that time. He does not recall as to whether or not he had intracranial hemorrhage. He states that he occasionally gets lightheaded on arising and he has done so since his heart surgery about a year ago. He denies episodes of blurred or double vision or visual loss, extremity weakness or numbness, or difficulty speaking or understanding other people. He denies any history of previous stroke.

PAST MEDICAL HISTORY:  Significant for coronary artery disease. He is status post coronary artery bypass grafting and mechanical mitral valve replacement about a year ago. He also has a history of lymphoma treated with radiation in the past with no further therapy. He is also treated for hypertension and elevated cholesterol. He is reported also to have a history of renal artery stenosis. In addition to the above, he has had a splenectomy and hernia repair.

ALLERGIES:  He has no known drug allergies.

FAMILY HISTORY:  He has no family history of intracranial aneurysms or subarachnoid hemorrhage.

PHYSICAL EXAMINATION:  The patient is alert and cooperative, in no acute distress. His language is fluent. He is fully oriented. He did become tired during the interview. He was given a dose of Vicodin within the past 30 minutes, however. He has intermittent twitching of both eyes. He states he has had this for many years and related to anxiety. He states this resolves when he takes Xanax. His visual fields are full to confrontation bilaterally. His pupils are about 2 mm and equal. Extraocular movements are full. Face is symmetric. Tongue and palate are midline. Light touch sensation is symmetric and intact in the face, arms, and legs. He has symmetric 5+/5 strength throughout his extremities with no pronator drift including biceps, triceps, handgrip, hip flexion, knee flexion and extension, and plantar and dorsiflexion of the ankles. He does very well with finger tapping, finger-to-nose, and heel-to-shin testing.

DIAGNOSTIC DATA:  We reviewed his CTA of the brain done yesterday. This demonstrates an ectatic cavernous right internal carotid artery. We do not believe he has an aneurysm.

IMPRESSION AND PLAN:  Question of aneurysm has been raised. If present, we believe this is completely unrelated to his presentation. Of concern is his history of syncope. He cannot have an MRA to screen for vertebrobasilar insufficiency. The CTA is not a good screening test for vertebral artery origin stenosis. We would suggest at this point planning cerebral arteriography. This will probably exclude the presence of aneurysm. If he does have an aneurysm, this will allow us to assess treatment options. We will also be able to evaluate him for vertebrobasilar occlusive disease, which may be playing a role in the syncope. We discussed with him cerebral angiography, including its risks and benefits. He is inclined to proceed with this. We will plan to do so soon.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Uncontrolled diabetes.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who came here to the emergency department initially with abdominal pain. He was admitted for abdominal pain workup as well as bad COPD. The patient says he has had diabetes for about 12 years. He takes insulin, he takes Actos, and he takes Glucophage in the house. He says at home his sugars run mostly close to 100. He does not have any problems with polyuria, polydipsia or nocturia. He does have problems with numbness and tingling in the legs. He does have problems with slow healing of wounds. He denies bruising. No problems with diarrhea. No constipation. No nausea. No vomiting. No problem with heartburn. No abdominal cramps. At this point, his abdominal pain is gone. He does have shortness of breath. He did have some cough. He felt fatigued and tired. He also felt chills when he came here. No other complaints for the patient upon review of systems.

PAST MEDICAL HISTORY: Positive for coronary artery disease, diabetes, diverticulitis, status post stent placement.

MEDICATIONS: Medications on the chart have been reviewed along with the dosage.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Positive for diabetes.

SOCIAL HISTORY: The patient used to be a past smoker but does not smoke anymore. There is no history of alcohol abuse.

PHYSICAL EXAMINATION: The patient is currently lying in bed and appears to be a little short of breath. Height is listed as 6 feet 2 inches. Weight is 268 pounds. He has 2+ peripheral edema. Positive pallor. No cyanosis. No raised JVD. No neck or axillary lymphadenopathy. No jaundice. JVD is raised to the lower third of the neck. Oropharynx is clear. Ears are normal. Eyes show conjunctivae are clear. Pupils are equal and reactive. Movement of the eyes is normal. Neck is supple and nontender. No masses are felt in the neck. Lungs revealed air movement in both lungs. There is prolonged respiration. No wheezing, no crackles are heard. Heart reveals normal first and second heart sound. No murmurs are heard. No carotid or abdominal bruits heard. Abdomen is soft and nontender. No masses are felt. It is distended from obesity. External genitals are male. Rectal per primary care. Joints show movement is normal; they are nontender to move. Feet show dorsalis pedis is at 2+. No ulcers. They are dry. Skin is dry. There is no rash. There are no bruises except at IV site. Neurological exam reveals he is awake, alert and oriented to time, place and person. Normal tone. Moves all his limbs. Cranials are normal. The sensory exam shows touch is impaired over the lower part of the legs.

LABORATORY DATA: The patient’s labs show sodium 140, potassium 4, chloride 106, bicarbonate 26, BUN 42, creatinine 1.7, glucose 146, theophylline 7.4. White cell count is 10, hemoglobin 10.2, platelets 184. His Accu-Cheks have been ranging 300 to 400, and right now, its reading is high on the Accu-Chek meter. Obviously, the Solu-Medrol that he is getting is increasing the sugars drastically.

ASSESSMENT:
1.  Chronic obstructive pulmonary disease.
2.  Coronary artery disease.

PLAN:  For now, we will treat him with the NPH dose at bedtime and sliding scale breakfast, lunch and dinner. We will adjust the insulin as the steroids are weaned off. We will try to keep the sugars below 150, preferably close to 100. We will get a hemoglobin A1c in the morning.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Herpes zoster.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who felt a pustular rash on her posterior lower back about four to five days ago. She then developed lower abdominal pain, which has persisted for the past couple of days and hence came to the emergency department. She denies any fevers, chills, cough, chest pain or shortness of breath. She does have nausea and started vomiting at the present time. She denies any headaches and denies any dysuria. No diarrhea. She was constipated and hence took magnesium citrate yesterday. She has had loose stools since then.

PAST MEDICAL HISTORY: Unremarkable.

PAST SURGICAL HISTORY: Unremarkable.

MEDICATIONS: The patient is ordered to get Valtrex and Cipro.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient does smoke, but denies alcohol use.

FAMILY HISTORY: Unremarkable.

REVIEW OF SYSTEMS: As per HPI, otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8 degrees, pulse 82, respirations 20, and blood pressure 188/58.
HEENT: Unremarkable.
NECK: No lymphadenopathy.
LUNGS: Clear to auscultation.
HEART: S1 and S2, regular rhythm.
ABDOMEN: Left lower quadrant tenderness. No rebound, guarding or rigidity. Bowel sounds present.
BACK: Left posterior lower flank area with papular rash almost in the dermatomal distribution.
NEUROLOGICAL: No focal neurological deficits.

LABORATORY DATA: White count 5.8, hemoglobin 14.2 and platelets 212. BUN and creatinine 10.2 and 0.8. Urinalysis shows negative leukocyte esterase.

DIAGNOSTIC DATA: Chest x-ray revealed no acute infiltrate. CT of the abdomen and pelvis was unremarkable, except chronic-appearing interstitial infiltrates on the lung bases. No abdominal pathology.

IMPRESSION:
1. The rash appears to be consistent with herpes zoster.
2. Left lower quadrant abdominal pain could be referred pain.

RECOMMENDATION:
1. Since the patient is vomiting, we would switch oral Valtrex to IV acyclovir.
2. We would discontinue Cipro.
3. If it improves in the next 24 hours, could switch to oral Valtrex.

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REASON FOR CONSULTATION: Substernal chest burning.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with known CAD, status post four angioplasties, with his last stent two years ago. The patient developed substernal chest pressure while walking the dog last night. The symptom lasted approximately 15 minutes. He did not have radiation of the symptoms. He did feel a little short of breath. The patient had resolution of these symptoms 15 minutes after nitroglycerin paste was placed on his chest. The patient has been pain-free. The patient states this is very similar to his prior angina in the past. The patient has had prior MI; the details are not known. He has had several angioplasties in the past, with his last one two years ago. The patient denies any history of heart failure or stroke. He does have hypertension with polycystic kidney disease, status post renal transplant 12 years ago. The patient denies diabetes. He generally takes Lipitor without complaints of myalgias. The patient stopped his aspirin for the last four days due to GI upset, which he has been having for the last three to four weeks. The patient has lost 10 to 15 pounds with some intermittent diarrhea, being evaluated by Dr. John Doe. The patient denies any accelerated palpitations or syncope. Otherwise, he has a negative cardiac review of systems.

PAST MEDICAL HISTORY:
1. Polycystic kidney disease, status post renal failure, status post renal transplant 12 years ago, on cyclosporine.
2. CAD, status post prior MI and multiple angioplasties, including the last stent placed two years ago.
3. Hypertension.
4. Dyslipoproteinemia.
5. History of hernia surgery.
6. Diverticulosis.

MEDICATIONS ON ADMISSION: Neoral; CellCept; prednisone 7.5 mg daily; Adalat 30 b.i.d.; Toprol 25 b.i.d.; Lipitor 10 daily; eyedrops for glaucoma; Prevacid 15 b.i.d.; aspirin 81 at bedtime, held for the last four days; vitamin E 400 a day; calcium; and Fosamax.

ALLERGIES: NKDA.

SOCIAL HISTORY: No tobacco, significant alcohol or drug use. The patient is married. The patient has one child.

FAMILY HISTORY: Mom had an MI in her 40s.

REVIEW OF SYSTEMS: As above. He does have occasional heartburn, otherwise all negative.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented, in no apparent distress.
VITAL SIGNS: Blood pressure 142/82, pulse 72 and regular, respirations 18, afebrile.
HEENT: Eyes, no xanthelasma. ENT, unremarkable.
NECK: Normal JVD. Normal carotid upstrokes. No bruits.
LUNGS: Clear.
HEART: Normal on palpation, soft S4, 1/6 holosystolic murmur. No S3.
ABDOMEN: Somewhat bloated. No tenderness. No rebound. No pulsatile masses. No hepatosplenomegaly.
EXTREMITIES: No edema. Pulses are +2 and symmetric.
NEUROLOGIC: Grossly nonfocal.
NEUROPSYCHIATRIC: Appropriate.
MUSCULOSKELETAL: Limited exam.
SKIN: Unremarkable.

DIAGNOSTICS AND LABORATORY DATA: EKG, sinus bradycardia, probable old inferior wall myocardial infarction, age indeterminate, nonspecific ST changes from earlier this year. Anterior T wave abnormalities, improved compared to EKG done two years ago. Troponin negative x2. BUN 13, creatinine 0.8, potassium 4.2. LFTs within normal limits. CBC unremarkable. Chest x-ray was not available at the time of dictation. O2 saturation in the ER is within normal limits. Temperature in the ER was 97.2 degrees. Magnesium 1.5 in the emergency room. BNP 86 in the ER. PTT is within normal limits. Chest x-ray, no acute abnormality noted per ER report.

ASSESSMENT:
1. Chest pain, suggestive of prior angina.
2. Coronary artery disease with prior myocardial infarction and multiple stents.
3. Hypertension.
4. Dyslipoproteinemia.
5. History of polycystic kidney disease, status post renal transplant 12 years ago, on cyclosporine and prednisone.
6. Recent abdominal bloating and diarrhea, being evaluated by Dr. John Doe.

PLAN: We are concerned about the possibility of recurrent angina. Based on his symptoms and prior history, we would like to risk stratify him with an adenosine Cardiolite stress test. We discussed this with Nuclear Medicine and have held breakfast this morning; the patient had a small amount of decaffeinated tea which has been held at this point. Pending the results of the adenosine Cardiolite, Dr. Jane Doe will follow up with this patient. This has been discussed with Dr. Jane Doe.

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