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Write a clinical note about a patient with the following chief complaint: Urinary retention. | CHIEF COMPLAINT: Urinary retention. HISTORY OF PRESENT ILLNESS: This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time. Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably secon... | |
Write a clinical note about a patient with the following chief complaint: Right distal ureteral calculus. | CHIEF COMPLAINT: Right distal ureteral calculus. HISTORY OF PRESENT ILLNESS: The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter. H... | |
Write a clinical note about a patient with the following chief complaint: Testicular pain. | CHIEF COMPLAINT: Testicular pain. HISTORY OF PRESENT ILLNESS: The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning. He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it. Because... | |
Write a clinical note about a patient with the following chief complaint: "Bloody bump on penis.", | CHIEF COMPLAINT: "Bloody bump on penis.",HISTORY OF PRESENT ILLNESS: This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis. The patient states that he has had a large bump on the end of his penis for approximately a year and a half. H... | |
Write a clinical note about a patient with the following chief complaint: Penile discharge, infected-looking glans. | CHIEF COMPLAINT: Penile discharge, infected-looking glans. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for wet ... | |
Write a clinical note about a patient with the following chief complaint: Penile cellulitis status post circumcision. | CHIEF COMPLAINT: Penile cellulitis status post circumcision. HISTORY OF PRESENT ILLNESS: The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge. The child initially had a newborn circumcision at about 1 week of life and then ... | |
Write a clinical note about a patient with the following chief complaint: Foul-smelling urine and stomach pain after meals. | CHIEF COMPLAINT: Foul-smelling urine and stomach pain after meals. HISTORY OF PRESENT ILLNESS: Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time. She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI. This visit was in ... | |
Write a clinical note about a patient with the following chief complaint: Left flank pain and unable to urinate. | CHIEF COMPLAINT: Left flank pain and unable to urinate. HISTORY: The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels... | |
Write a clinical note about a patient with the following history of present illness: This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy... | CHIEF COMPLAINT: This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. Timing (onset/frequency): Onset was 6 mont... | |
Write a clinical note about a patient with the following chief complaint: Recurrent bladder tumor. | CHIEF COMPLAINT: Recurrent bladder tumor. HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient unde... | |
Write a clinical note about a patient with the following chief complaint: Blood in urine. | CHIEF COMPLAINT: Blood in urine. HISTORY OF PRESENT ILLNESS: This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past, but the patient noted... | |
Write a clinical note about a patient with the following chief complaint: The patient comes for bladder instillation for chronic interstitial cystitis. | CHIEF COMPLAINT: The patient comes for bladder instillation for chronic interstitial cystitis. SUBJECTIVE: The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not think ... | |
Write a clinical note about a patient with the following chief complaint: Bladder cancer. | CHIEF COMPLAINT: Bladder cancer. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. CT scan was performed, which demonstrated no hydronephrosis o... | |
Write a clinical note about a patient with the following chief complaint: Non-healing surgical wound to the left posterior thigh. | CHIEF COMPLAINT: Non-healing surgical wound to the left posterior thigh. HISTORY OF PRESENT ILLNESS: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted ac... | |
Write a clinical note about a patient with the following chief complaint: The patient comes for three-week postpartum checkup, complaining of allergies. | CHIEF COMPLAINT: The patient comes for three-week postpartum checkup, complaining of allergies. HISTORY OF PRESENT ILLNESS: She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not a... | |
Write a clinical note about a patient with the following chief complaint: Essential thrombocytosis. | CHIEF COMPLAINT: Essential thrombocytosis. HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis. He was first diagnosed when he first saw a hematologist on 07/09/07. At that time, his platelet count was 1,240,000. He was initially started on ... | |
Write a clinical note about a patient with the following chief complaint: Polycythemia rubra vera. | CHIEF COMPLAINT: Polycythemia rubra vera. HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied. CURRENT MEDICATIONS: Levothyroxin... | |
Write a clinical note about a patient with the following diagnosis: Polycythemia vera with secondary myelofibrosis. | DIAGNOSIS: Polycythemia vera with secondary myelofibrosis. REASON FOR VISIT: Followup of the above condition. CHIEF COMPLAINT: Left shin pain. HISTORY OF PRESENT ILLNESS: A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. I... | |
Write a clinical note about a patient with the following chief complaint: The patient is here for followup visit and chemotherapy. | CHIEF COMPLAINT: The patient is here for followup visit and chemotherapy. DIAGNOSES: 1. Posttransplant lymphoproliferative disorder. 2. Chronic renal insufficiency. 3. Squamous cell carcinoma of the skin. 4. Anemia secondary to chronic renal insufficiency and chemotherapy. 5. Hypertension. HISTORY OF PRESENT ILLNESS: ... | |
Write a clinical note about a patient with the following chief complaint: Right knee. , | CHIEF COMPLAINT: Right knee. ,HISTORY OF THE PRESENT ILLNESS: The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Pain: Localized to the bilate... | |
Write a clinical note about a patient with the following chief complaint: MGUS. | CHIEF COMPLAINT: MGUS. HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS. I initially saw him for thrombocytopenia when his ANC was 1300. A bone marrow biopsy was obtained. Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 an... | |
Write a clinical note about a patient with the following chief complaint: Follicular non-Hodgkin's lymphoma. | CHIEF COMPLAINT: Follicular non-Hodgkin's lymphoma. HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's... | |
Write a clinical note about a patient with the following chief complaint: 1. Extensive stage small cell lung cancer. 2. Chemotherapy with carboplatin and etoposide. 3. Left scapular pain status post CT scan of the thorax. | CHIEF COMPLAINT: 1. Extensive stage small cell lung cancer. 2. Chemotherapy with carboplatin and etoposide. 3. Left scapular pain status post CT scan of the thorax. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment with car... | |
Write a clinical note about a patient with the following chief complaint: Leg pain. | CHIEF COMPLAINT: Leg pain. HISTORY OF PRESENT ILLNESS: This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasio... | |
Write a clinical note about a patient with the following problem list: 1. HIV stable. 2. Hepatitis C chronic. 3. History of depression, stable off meds. 4. Hypertension, moderately controlled. | PROBLEM LIST: 1. HIV stable. 2. Hepatitis C chronic. 3. History of depression, stable off meds. 4. Hypertension, moderately controlled. CHIEF COMPLAINT: The patient comes for a routine followup appointment. HISTORY OF PRESENTING ILLNESS: This is a 34-year-old African American female who comes today for routine follow... | |
Write a clinical note about a patient with the following chief complaint: One-month followup. | CHIEF COMPLAINT: One-month followup. HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I think the... | |
Write a clinical note about a patient with the following chief complaint: Followup on hypertension and hypercholesterolemia. | CHIEF COMPLAINT: Followup on hypertension and hypercholesterolemia. SUBJECTIVE: This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he... | |
Write a clinical note about a patient with the following chief complaint: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. , | CHIEF COMPLAINT: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE: A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days.... | |
Write a clinical note about a patient with the following chief complaint: The patient is here for two-month followup. | CHIEF COMPLAINT: The patient is here for two-month followup. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old Caucasian female. She has hypertension. She has had no difficulties with chest pain. She has some shortness of breath only at walking up the stairs. She has occasional lightheadedness only if she be... | |
Write a clinical note about a patient with the following chief complaint: Followup on diabetes mellitus, status post cerebrovascular accident. | CHIEF COMPLAINT: Followup on diabetes mellitus, status post cerebrovascular accident. SUBJECTIVE: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a n... | |
Write a clinical note about a patient with the following chief complaint: 1. Stage IIIC endometrial cancer. 2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. | CHIEF COMPLAINT: 1. Stage IIIC endometrial cancer. 2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thick... | |
Write a clinical note about a patient with the following chief complaint: Followup diabetes mellitus, type 1. , | CHIEF COMPLAINT: Followup diabetes mellitus, type 1. ,SUBJECTIVE: Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar due to ... | |
Write a clinical note about a patient with the following chief complaint: Septal irritation. | CHIEF COMPLAINT: Septal irritation. HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation. The patient has been using saline nasal wash 2-3 times daily, however, she states that she st... | |
Write a clinical note about a patient with the following chief complaint: Hip pain. | CHIEF COMPLAINT: Hip pain. HISTORY OF PRESENTING ILLNESS: The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management... | |
Write a clinical note about a patient with the following chief complaint: 1. Metastatic breast cancer. 2. Enrolled is clinical trial C40502. 3. Sinus pain. | CHIEF COMPLAINT: 1. Metastatic breast cancer. 2. Enrolled is clinical trial C40502. 3. Sinus pain. HISTORY OF PRESENT ILLNESS: She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa, Faslodex, and Aromasin. She was fou... | |
Write a clinical note about a patient with the following chief complaint: Stage IIA right breast cancer. | CHIEF COMPLAINT: Stage IIA right breast cancer. HISTORY OF PRESENT ILLNESS: This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer. She noticed a lump in the breast in November of 2007. A mammogram was obtained dated 01/28/08, which showed a mass in the right breast.... | |
Write a clinical note about a patient with the following chief complaint: Aplastic anemia. | CHIEF COMPLAINT: Aplastic anemia. HISTORY OF PRESENT ILLNESS: This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospital fro... | |
Write a clinical note about a patient with the following chief complaint: 1. Chronic lymphocytic leukemia (CLL). 2. Autoimmune hemolytic anemia. 3. Oral ulcer. | CHIEF COMPLAINT: 1. Chronic lymphocytic leukemia (CLL). 2. Autoimmune hemolytic anemia. 3. Oral ulcer. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. H... | |
Write a clinical note about a patient with the following history of present illness: Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of lo... | CHIEF COMPLAINT: Rule out obstructive sleep apnea syndrome. Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the ... | |
Write a clinical note about a patient with the following history of present illness: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related t... | CHIEF COMPLAINT: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has existe... | |
Write a clinical note about a patient with the following identification of patient: The patient is a 34-year-old Caucasian female. | IDENTIFICATION OF PATIENT: The patient is a 34-year-old Caucasian female. CHIEF COMPLAINT: Depression. HISTORY OF PRESENT ILLNESS: The patient's depression began in her teenage years. Sleep has been poor, for multiple reasons. She has obstructive sleep apnea, and has difficulties with a child who has insomnia rela... | |
Write a clinical note about a patient with the following referral data: This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister. She also has a stepsister that is 8 years old. The patient was brought in by h... | ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA: This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister. She also has a stepsister that is 8 years old. The patient was brought in by he... | |
Write a clinical note about a patient with the following identifying data: The patient is a 36-year-old Caucasian male. | IDENTIFYING DATA: The patient is a 36-year-old Caucasian male. CHIEF COMPLAINT: The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted. HISTORY OF PRESENT ILLNESS: The patient has been receiving servi... | |
Write a clinical note about a patient with the following identification of patient: This is a 31-year-old female who was referred by herself. She was formerly seen at Counseling Center. She is a reliable historian. | IDENTIFICATION OF PATIENT: This is a 31-year-old female who was referred by herself. She was formerly seen at Counseling Center. She is a reliable historian. CHIEF COMPLAINT: "I'm bipolar and I have severe anxiety disorder. I have posttraumatic stress syndrome." ,HISTORY OF PRESENT ILLNESS: At age 19, Ms. Abc had a... | |
Write a clinical note about a patient with the following identifying data: The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. | IDENTIFYING DATA: The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. CHIEF COMPLAINT: "I am not sure." The patient has poor insight into hospitalization and need for treatment. HISTORY OF PRESENT ILLNESS: The ... | |
Write a clinical note about a patient with the following identifying data: The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner. | IDENTIFYING DATA: The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner. CHIEF COMPLAINT: "I'm in jail because I was wrongly arrested." The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability. HISTORY OF PRESENT ILLNESS: The patien... | |
Write a clinical note about a patient with the following reason for consult: Anxiety. | REASON FOR CONSULT: Anxiety. CHIEF COMPLAINT: "I felt anxious yesterday.",HPI: A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.... | |
Write a clinical note about a patient with the following chief complaint: Mental status changes after a fall. | CHIEF COMPLAINT: Mental status changes after a fall. HISTORY: Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had alt... | |
Write a clinical note about a patient with the following identifying data: Mr. T is a 45-year-old white male. | IDENTIFYING DATA: Mr. T is a 45-year-old white male. CHIEF COMPLAINT: Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence, his energy level i... | |
Write a clinical note about a patient with the following chief complaint: "A lot has been thrown at me.",The patient is interviewed with husband in room. | CHIEF COMPLAINT: "A lot has been thrown at me.",The patient is interviewed with husband in room. HISTORY OF PRESENT ILLNESS: This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325... | |
Write a clinical note about a patient with the following chief complaint: Falls at home. | CHIEF COMPLAINT: Falls at home. HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They n... | |
Write a clinical note about a patient with the following identifying data: The patient is a 35-year-old Caucasian female who speaks English. | IDENTIFYING DATA: The patient is a 35-year-old Caucasian female who speaks English. CHIEF COMPLAINT: The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. Last night, she tried to turn on the garb... | |
Write a clinical note about a patient with the following identifying data: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approxima... | IDENTIFYING DATA: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he... | |
Write a clinical note about a patient with the following chief complaint: Foot pain. | CHIEF COMPLAINT: Foot pain. HISTORY OF PRESENT ILLNESS: This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an hour p... | |
Write a clinical note about a patient with the following chief complaint: Ankle pain. | CHIEF COMPLAINT: Ankle pain. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym. Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now. It hurts to mo... | |
Write a clinical note about a patient with the following admission diagnosis: Left hip fracture. | ADMISSION DIAGNOSIS: Left hip fracture. CHIEF COMPLAINT: Diminished function, secondary to the above. HISTORY: This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture iden... | |
Write a clinical note about a patient with the following admitting diagnosis: Encephalopathy related to normal-pressure hydrocephalus. | ADMITTING DIAGNOSIS: Encephalopathy related to normal-pressure hydrocephalus. CHIEF COMPLAINT: Diminished function secondary to above. HISTORY: This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagno... | |
Write a clinical note about a patient with the following chief complaint: Well-child check. | CHIEF COMPLAINT: Well-child check. HISTORY OF PRESENT ILLNESS: This is a 12-month-old female here with her mother for a well-child check. Mother states she has been doing well. She is concerned about drainage from her left eye. Mother states she was diagnosed with a blocked tear duct on that side shortly after birt... | |
Write a clinical note about a patient with the following chief complaint: Well-child check and school physical. | CHIEF COMPLAINT: Well-child check and school physical. HISTORY OF PRESENT ILLNESS: This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues, especially wri... | |
Write a clinical note about a patient with the following chief complaint: Well-child check sports physical. | CHIEF COMPLAINT: Well-child check sports physical. HISTORY OF PRESENT ILLNESS: This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. He is here with his mother for a well-child check. Mother states he has been doing well with regard to his asthma and allergies. He is currently on immunoth... | |
Write a clinical note about a patient with the following chief complaint: This 3-year-old female presents today for evaluation of chronic ear infections bilateral. | CHIEF COMPLAINT: This 3-year-old female presents today for evaluation of chronic ear infections bilateral. ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: Associated signs and symptoms include: cough, fever, irritability and speech and language delay. Duration (ENT): Duration of symptom: 12 rounds of antibiotics for... | |
Write a clinical note about a patient with the following chief complaint: Not gaining weight. | CHIEF COMPLAINT: Not gaining weight. HISTORY OF PRESENT ILLNESS: The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. The patient appeared to have failure-to-th... | |
Write a clinical note about a patient with the following chief complaint: Arm and leg jerking. | CHIEF COMPLAINT: Arm and leg jerking. HISTORY OF PRESENT ILLNESS: The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These moveme... | |
Write a clinical note about a patient with the following chief complaint: Head injury. | CHIEF COMPLAINT: Head injury. HISTORY: This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizzy. S... | |
Write a clinical note about a patient with the following chief complaint: Questionable foreign body, right nose. Belly and back pain. , | CHIEF COMPLAINT: Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. The... | |
Write a clinical note about a patient with the following chief complaint: Irritable baby with fever for approximately 24 hours. | CHIEF COMPLAINT: Irritable baby with fever for approximately 24 hours. HISTORY OF PRESENT ILLNESS: This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room... | |
Write a clinical note about a patient with the following chief complaint: A 2-month-old female with 1-week history of congestion and fever x2 days. | CHIEF COMPLAINT: A 2-month-old female with 1-week history of congestion and fever x2 days. HISTORY OF PRESENT ILLNESS: The patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. The mother has also reported irregular breathing, which she describes as being rapid br... | |
Write a clinical note about a patient with the following chief complaint: Congestion, tactile temperature. | CHIEF COMPLAINT: Congestion, tactile temperature. HISTORY OF PRESENT ILLNESS: The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any pe... | |
Write a clinical note about a patient with the following chief complaint: Congestion and cough. | CHIEF COMPLAINT: Congestion and cough. HISTORY OF PRESENT ILLNESS: The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was des... | |
Write a clinical note about a patient with the following chief complaint: Chronic otitis media. | CHIEF COMPLAINT: Chronic otitis media. HISTORY OF PRESENT ILLNESS: This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane perf... | |
Write a clinical note about a patient with the following history of present illness: This 1-year-old female presents today for a health maintenance exam. Patient was accompanied by mother. The child eats 3 meals a day plus 2 snacks and is off the bottle. She sleeps through the night. She takes morning and afternoon ... | CHIEF COMPLAINT: This 1-year-old female presents today for a health maintenance exam. Patient was accompanied by mother. The child eats 3 meals a day plus 2 snacks and is off the bottle. She sleeps through the night. She takes morning and afternoon naps. Mother is concerned about child's red, matted eye and not walki... | |
Write a clinical note about a patient with the following chief complaint: A 5-month-old boy with cough. | CHIEF COMPLAINT: A 5-month-old boy with cough. HISTORY OF PRESENT ILLNESS: A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he... | |
Write a clinical note about a patient with the following history of present illness: This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, give... | CHIEF COMPLAINT: This 5-year-old male presents to Children's Hospital Emergency Department by the mother with "have asthma." Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma,... | |
Write a clinical note about a patient with the following chief complaint: Right shoulder pain. | CHIEF COMPLAINT: Right shoulder pain. HISTORY OF PRESENT PROBLEM: | |
Write a clinical note about a patient with the following reason for referral: Evaluation for right L4 selective nerve root block. | REASON FOR REFERRAL: Evaluation for right L4 selective nerve root block. CHIEF COMPLAINT: | |
Write a clinical note about a patient with the following chief complaint: Left wrist pain. | CHIEF COMPLAINT: Left wrist pain. HISTORY OF PRESENT PROBLEM: | |
Write a clinical note about a patient with the following chief complaint: Right shoulder pain. | CHIEF COMPLAINT: Right shoulder pain. HISTORY OF PRESENT PROBLEM: | |
Write a clinical note about a patient with the following history of present illness: This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. P... | CHIEF COMPLAINT: This 18 year old male presents today with shoulder pain right. Location: He indicates the problem location is the right shoulder diffusely. Quality: Quality of the pain is described by the patient as aching, throbbing and tolerable. Patient relates pain on a scale from 0 to 10 as 5/10. Severity: The se... | |
Write a clinical note about a patient with the following chief complaint: Right knee. , | CHIEF COMPLAINT: Right knee. ,HISTORY OF THE PRESENT ILLNESS: The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Pain: Localized to the bilate... | |
Write a clinical note about a patient with the following chief complaint: Chronic low back, left buttock and leg pain. | CHIEF COMPLAINT: Chronic low back, left buttock and leg pain. HISTORY OF PRESENT ILLNESS: This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005. Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. He has also tried acupuncture, TENS... | |
Write a clinical note about a patient with the following chief complaint: Back pain and right leg pain. The patient has a three-year history of small cell lung cancer with metastases. | CHIEF COMPLAINT: Back pain and right leg pain. The patient has a three-year history of small cell lung cancer with metastases. HISTORY OF PRESENT ILLNESS: The patient is on my schedule today to explore treatment of the above complaints. She has a two-year history of small cell lung cancer, which she says has spread... | |
Write a clinical note about a patient with the following chief complaint: Neck pain, thoracalgia, low back pain, bilateral lower extremity pain. | CHIEF COMPLAINT: Neck pain, thoracalgia, low back pain, bilateral lower extremity pain. HISTORY OF PRESENT ILLNESS: Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse. She has previou... | |
Write a clinical note about a patient with the following chief complaint: Neck and lower back pain. | CHIEF COMPLAINT: Neck and lower back pain. VEHICULAR TRAUMA HISTORY: Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off th... | |
Write a clinical note about a patient with the following history of present illness: Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms. HPI - | CHIEF COMPLAINT: Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms. HPI - LUMBAR SPINE: The patient is a male and 39 years old. The current problem began on or about 3 months ago. The sy... | |
Write a clinical note about a patient with the following reason for referral: Evaluation for right L4 selective nerve root block. | REASON FOR REFERRAL: Evaluation for right L4 selective nerve root block. CHIEF COMPLAINT: | |
Write a clinical note about a patient with the following chief complaint: Decreased ability to perform daily living activities secondary to right knee surgery. | CHIEF COMPLAINT: Decreased ability to perform daily living activities secondary to right knee surgery. HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patient ... | |
Write a clinical note about a patient with the following chief complaint: Left knee pain and stiffness. | CHIEF COMPLAINT: Left knee pain and stiffness. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are nego... | |
Write a clinical note about a patient with the following chief complaint: Non-healing surgical wound to the left posterior thigh. | CHIEF COMPLAINT: Non-healing surgical wound to the left posterior thigh. HISTORY OF PRESENT ILLNESS: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted ac... | |
Write a clinical note about a patient with the following chief complaint: Decreased ability to perform daily living activity secondary to recent right hip surgery. | CHIEF COMPLAINT: Decreased ability to perform daily living activity secondary to recent right hip surgery. HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoperati... | |
Write a clinical note about a patient with the following admission diagnosis: Left hip fracture. | ADMISSION DIAGNOSIS: Left hip fracture. CHIEF COMPLAINT: Diminished function, secondary to the above. HISTORY: This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture iden... | |
Write a clinical note about a patient with the following chief complaint: Left foot pain. | CHIEF COMPLAINT: Left foot pain. HISTORY: XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to contin... | |
Write a clinical note about a patient with the following chief complaint: Right middle finger triggering and locking, as well as right index finger soreness at the PIP joint. | CHIEF COMPLAINT: Right middle finger triggering and locking, as well as right index finger soreness at the PIP joint. HISTORY OF OCCUPATIONAL INJURY OR ILLNESS: The patient has been followed elsewhere, and we reviewed his records. Essentially, he has had a trigger finger and a mucocyst, and he has had injections. T... | |
Write a clinical note about a patient with the following chief complaint: Left elbow pain. | CHIEF COMPLAINT: Left elbow pain. HISTORY OF PRESENT ILLNESS: This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies... | |
Write a clinical note about a patient with the following chief complaint: Left knee pain. | CHIEF COMPLAINT: Left knee pain. SUBJECTIVE: This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she ... | |
Write a clinical note about a patient with the following chief complaint: Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain. | CHIEF COMPLAINT: Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years, b... | |
Write a clinical note about a patient with the following past medical condition: None. | PAST MEDICAL CONDITION: None. ALLERGIES: None. CURRENT MEDICATION: Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain. CHIEF COMPLAINT: Back injury with RLE radicular symptoms. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male who is here for independent medical evaluation. The pa... | |
Write a clinical note about a patient with the following chief complaint: Right ankle sprain. | CHIEF COMPLAINT: Right ankle sprain. HISTORY OF PRESENT ILLNESS: This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other ... | |
Write a clinical note about a patient with the following identification: The patient is a 15-year-old female. | IDENTIFICATION: The patient is a 15-year-old female. CHIEF COMPLAINT: Right ankle pain. HISTORY OF PRESENT ILLNESS: The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician ... | |
Write a clinical note about a patient with the following chief complaint: Achilles ruptured tendon. | CHIEF COMPLAINT: Achilles ruptured tendon. HISTORY: Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola. He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg. He was seen locally and diagnosed with an Ach... | |
Write a clinical note about a patient with the following chief complaint: This 26-year-old male presents today for a complete eye examination. | CHIEF COMPLAINT: This 26-year-old male presents today for a complete eye examination. ALLERGIES: Patient admits allergies to aspirin resulting in disorientation, GI upset. MEDICATION HISTORY: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. Gener... |
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