History and Physical Sample Report (General)

HISTORY OF PRESENT ILLNESS:  This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills, and sweats.  He denies cough and diarrhea.  He has mild anorexia.  Past Medical History:  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.

MEDICATIONS:  Advil and Ibuprofen.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  He occasionally drinks.  He is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982, which he described as "very active." He denies intravenous drug use.  The patient is currently employed.

FAMILY HISTORY:  Unremarkable.

PHYSICAL EXAMINATION:
General:  This is a thin, black cachectic man speaking in full sentences with oxygen.
Vital Signs:  Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.
HEENT:  Funduscopic examination normal. He has oral thrush.
Lymph:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.
Neck:  No goiter, no jugular venous distention.
Chest:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.
Heart:  Regular rate and rhythm, no murmur, rub or gallop.
Abdomen:  Soft and nontender.
Genitourinary:  Normal.
Rectal:  Unremarkable.
Skin:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms.

LABORATORY:  Sodium 133, potassium 5.3, BUN 29, creatinine 1.8, hemoglobin 14, white count 7100, platelet count 515, total protein 10, albumin 3.1, AST 131, ALT 31, urinalysis shows 1+ protein, trace blood, total bilirubin 2.4, and direct bilirubin 0.1.

X-RAYS:  Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.

IMPRESSION:
1.   Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.
2.   Thrush.
3.   Elevated unconjugated bilirubin.
4.   Hepatitis.
5.   Elevated globulin fraction.
6.   Renal insufficiency.
7.   Subcutaneous nodules.
8.   Risky sexual behavior in 1982 in Haiti.
PLAN:
1.   Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.
2.   Begin intravenous Bactrim and erythromycin.
3.   Begin prednisone.
4.   Oxygen.
5.   Nystatin swish and swallow.
6.   Dermatologic biopsy of lesions.
7.   Check HIV and RPR.
8.   Administer Pneumovax, tetanus shot, and Heptavax if indicated.

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Hematology Oncology History and Physical Medical Transcription Sample Reports

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old woman with diffuse large B-cell lymphoma, complicated by spinal cord compression, right lower lobe pulmonary embolism, and bilateral leg deep venous thromboses. She began the R-CHOP chemotherapy regimen on MM/DD/YYYY. Cycle 2 started on MM/DD/YYYY and cycle 3 started on MM/DD/YYYY. The patient presented to my office today for a Neupogen injection. Today is cycle 3, day 10. In my office, the patient had a temperature of 101.5 degrees, and she was found to be neutropenic with WBC 0.4. She was admitted for treatment of neutropenic fever. Symptomatically, the patient reports subjective fevers, although she has no localizing symptoms suggestive of infection. She has no other complaints today. Regarding the lymphoma, the patient presented on MM/DD/YYYY with spinal cord compression. CT-guided needle biopsy of a lumbar mass on MM/DD/YYYY showed lymphocytes, which were positive for CD19, CD20, CD22, and lambda light chain, and negative for CD10. Cytology was consistent with large cell lymphoma. Bone marrow biopsy was negative. CT scans of the chest, abdomen, and pelvis showed lymphadenopathy in the left lower neck, supraclavicular areas, retroperitoneum, bilateral psoas muscles, and L1 vertebral body. LDH was mildly elevated at 276, and the patient did not have any significant symptoms. In summary, the patient has stage IV diffuse large B-cell lymphoma, based on extranodal involvement of the L1 vertebral body. On MM/DD/YYYY, the patient was admitted to the hospital with sinus tachycardia. Workup revealed pulmonary embolism and bilateral leg deep venous thromboses. The patient has been on anticoagulation. She should be taking Coumadin 2.5 mg alternating with 5 mg per day, although her compliance with this regimen has been questionable. Recently, she was found to be supratherapeutic with INR greater than 7. I instructed her to withhold Coumadin for two days, then resume at the prescribed dose. She did not have any significant hemorrhagic complications. 

PAST MEDICAL HISTORY:  Peptic ulcer disease and osteoporosis. 

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Coumadin 2.5 mg alternating with 5 mg per day and Protonix 40 mg per day. 

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient denies alcohol and tobacco use.

FAMILY HISTORY:  There is no known history of inherited hematologic or oncologic disorders. 

REVIEW OF SYSTEMS:  CONSTITUTIONAL:  The patient reports subjective fevers x1 day. Otherwise, she denies night sweats, weight loss, fatigue or bleeding. GASTROINTESTINAL:  The patient has chronic dyspepsia, which is temporarily relieved with Mylanta or Maalox. All other systems in a 10-point review of systems were reviewed and were negative.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 110/56, heart rate 112, respiratory rate 22, and temperature 102.5.

GENERAL APPEARANCE:  The patient is alert and oriented, in no acute distress, ambulating slowly without assistance.

HEENT:  PERRL. EOMI. Sclerae anicteric. Oral mucosa clear.

PULMONARY:  Clear to auscultation bilaterally.

HEART:  Regular rate and rhythm. No murmurs.

ABDOMEN:  Soft, nontender, and nondistended. No palpable organomegaly.

EXTREMITIES:  No edema.

LYMPH NODES:  No palpable lymphadenopathy.

SKIN:  No rashes, petechiae or ecchymoses.

NEUROLOGIC:  No focal neurologic deficits, although, the patient ambulates slowly because of low back pain, which has been present since her initial presentation for spinal cord compression.

LABORATORY DATA:  WBC 0.4, hemoglobin 9.8, hematocrit 29.6, and platelets 172,000.

ASSESSMENT AND PLAN:  This is a (XX)-year-old woman with diffuse large B-cell lymphoma, pulmonary embolism, and bilateral leg deep venous thromboses, now on R-cyclophosphamide, hydroxydaunorubicin, Oncovin, prednisone cycle 3, day #10. She is now admitted with neutropenic fever without localizing signs or symptoms suggestive of infection. The patient will start empiric cefepime, and blood and urine cultures will be drawn. Neupogen 300 mcg per day will be continued. Antibiotic coverage will be adjusted based on culture findings and clinical examination. Regarding the anticoagulation for pulmonary embolism and deep venous thromboses, the patient will start Coumadin 2.5 mg per day tomorrow. Currently, she is likely to be supratherapeutic. For peptic ulcer disease, the patient will continue Protonix with the addition of p.r.n. Mylanta or Maalox.

 

 

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History and Physical Sample Report (Optha case)

HISTORY AND PHYSICAL EXAMINATION


PREOPERATIVE DIAGNOSIS:
1. Cataract of left eye.
2. Pseudophakia of the right eye.
3. Dermatomyositis.
4. Rheumatoid arthritis.

HISTORY OF PRESENT ILLNESS: Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function. She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye. She has had dry eyes and uses artificial tears frequently. She had had ectropion repair of the right lower lid. She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this. She is presently taking Persantine twice daily and Inderal 40 mg twice daily. She is allergic to penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.

PHYSICAL FINDINGS:
VITAL SIGNS: Blood pressure 110/80, pulse 76 and regular.
HEENT: Eyes; Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left. Pupils and extraocular motility were normal. Intraocular pressures where 18. Slit-lamp exam showed the eyelids in good position with weakness of the orbicularis and facial muscles. There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left. Fundus examination in each eye was normal.
EARS, NOSE, AND THROAT: Tympanic membranes are normal. The oral cavity showed dentures in place, and the pharynx had no lesions.
NECK: The neck showed a slight right carotid bruit, and the left was normal.
CHEST: The chest was clear to auscultation.
HEART: Heart had a regular sinus rhythm without murmur.
EXTREMITIES: Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.

PLAN: Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient. The risks of the procedure, including possible loss of the eye, were discussed.

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History and Physical Sample Report

REASON FOR ADMISSION: Urinary tract infection and fever.

CHIEF COMPLAINT: "Problems with bladder."

HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old white male with a history of urinary frequency, burning, and recent fever. His urine was loaded with white cells in the office, and he is being admitted for intravenous antibiotics. Last night, he presented to the ER and had a temperature to 102.5 degrees, then subsequently developed worsening fever. His fever ultimately broke about 2:30 in the morning with a temperature that ended at approximately 103 degrees.

PAST MEDICAL HISTORY: Significant for oral agent diabetes mellitus and hypertension.

REGULAR MEDICATIONS: Include: (1) Glucovance. (2) Avandia. (3) Zantac. (4) Tricor. (5) Zestril.

ALLERGIES: PENICILLIN (he is unsure of the reaction - he thinks it has something to do with swelling).

FAMILY HISTORY: Significant for a father who died of myocardial infarction and mother died of a stroke. He has had a previous urinary tract infection, Escherichia coli type, in 1998, with admission to the hospital then. He has not had any other hospitalizations.

SOCIAL HISTORY: He is a truck driver. He is not an abuser of alcohol or tobacco.

REVIEW OF SYSTEMS: Significant for dysuria; PSA score of only 3.

PHYSICAL EXAMINATION:
VITAL SIGNS: Recorded in nursing notes: Temperature maximum of 101.5 degrees. He is slightly hypertensive at 145/75. His pulse oximetry is normal. His pulse rate is in the low 90s. His respiratory rate is 16.
GENERAL APPEARANCE: His mood and affect are normal. He is alert and oriented x 3. He is an excellent historian.
HEAD, EYES, EARS, NOSE, AND THROAT: Examination reveals he is normocephalic, atraumatic. Extraocular movements are intact.
NECK: Supple without jugular venous distention or thyromegaly.
CHEST: Grossly clear.
HEART: Rate is regular. Peripheral pulses appear to be normal.
LYMPHATICS: He has no abnormal adenopathy in the axillary, supraclavicular, cervical, or inguinal lymph node regions.
ABDOMINAL EXAMINATION: Soft, nontender, slightly protuberant. No evidence of inguinal, umbilical, or other fascial hernias are noted.
GENITOURINARY: The testes and phallus are normal. Prostate is about 20 g in size and significantly tender on the right hand side.

LABORATORY DATA: Indicative of a white blood cell count of 13.7. Hemoglobin and platelet count are well within normal limits. Comprehensive metabolic panel reveals a normal creatinine. Urinalysis reveals white cells present. Urine culture has been sent.

 DIAGNOSTIC IMPRESSION:
1. Probable prostatitis.
2. Urinary tract infection.

PLAN: Admission. Will do non-contrast CT scan to evaluate him for possible stone. No apparent prostate abscess is present and he will be treated with intravenous antibiotics.

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