| 1 |
HPI: 25 yo M c/o left chest pain and LUQ pain |
| 2 |
- Started last night after MVA, constant severity |
| 3 |
- 8/10 sharp left chest and LUQ pain, no radiation |
| 4 |
- Allev - nothing, accompanied by SOB |
| 5 |
- Cough 2 days with 1 teaspoon yellow sputum, no blood or odor |
| 6 |
- Few scratches on arms |
| 7 |
- No head trauma, LOC, vomiting, wheezing, discharges from ears, nose, mouth, numbness or visual changes |
| 8 |
ROS: No change in appetite, bowel/urinary habits, no fever |
| 9 |
Meds: No Rx or OTC. All: NKDA. FH: Mother and Father healthy, alive |
| 10 |
PMH: Infectious Mononucleosis 2 months ago |
| 11 |
PSH: No traumas, surgeries or hospital |
| 12 |
SxH: With girlfriend 2 years, use condoms, no STI |
| 13 |
SH: No cigs/drugs, occasional EtOH. Works as banker |
| 14 |
Pt is in NAD |
| 15 |
VS: fever 38^C, HR 85/minute, SOB |
| 16 |
HEENT: NC/AT |
| 17 |
CV: Chest wall tenderness on left, RRR, N S1/S2, no MRG |
| 18 |
Abd: Tenderness in LUQ, +BS in all 4Q, tympanic in 4Q |
| 19 |
Neuro: CN 2-12 intact. Muscle strength 5/5 in UE LE b/l |
| 20 |
Lungs: clear BS b/l |
| 21 |
Ext: few scratches on both arms, radial pulses 2+ b/l DP and PT pulses 2+ b/l. |
| 22 |
Pt is in acute distress |
| 23 |
VS: BP: 90/60 mm Hg, HR: 90/minute, RR: 35/minute |
| 24 |
HEENT: Bruises on face, mild tenderness to palpation on L side of the face. EOMI, PEERLA, no Vision change |
| 25 |
Neck: NL Thyroid, no LAD |
| 26 |
CV: Tachycardia, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 27 |
Lungs: Clear BS b/l, no abnormal dullness under lungs due to tapping |
| 28 |
Abd: Diffuse tenderness to palpation, no bruises, no rebound or guarding. +BS in all 4Q, tympanic in 4Q. |
| 29 |
Ext: Bruises in R groin and hip, pain in R hip to palpation and moving. Sensation on both legs intact, pedal pulses 2+ b/l |
| 30 |
HPI: 56 yo F c/o numbness and tingling |
| 31 |
- Started 5 months ago, constant, getting worse |
| 32 |
- Involves right thumb, index finger and middle finger |
| 33 |
- Aggrav. by typing text on the keyboard. Allev. by rest |
| 34 |
- No nausea/vomiting, headache or h/o head trauma or hand trauma |
| 35 |
- 20 lbs wt gain x 5 months, h/o fatigue x 5 months |
| 36 |
- G1P1, LMP 2 years ago, PAP smear 3 years ago was normal, no STD |
| 37 |
ROS: No fever, no change in bowel/urinary habits |
| 38 |
Meds: No Rx or OTC. ALL: NKDA |
| 39 |
FH: noncontributory. PMH: none. PSH: none. |
| 40 |
SxH: with husband. SH: no cig/EtOH/drugs. Works as a secretary |
| 41 |
Pt is in NAD |
| 42 |
VS: WNL |
| 43 |
HEENT: NC/AT, EOMI, PEERLA |
| 44 |
Neck: NL thyroid gland, no carotid bruits |
| 45 |
Lungs: Clear BS b/l |
| 46 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 47 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 48 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation to |
| 49 |
soft and pinprick decreased in right thumb, index finger and middle finger |
| 50 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 51 |
Pt is distressed |
| 52 |
VS: Fever 101F |
| 53 |
HEENT: No oral or pharynx lesions. NC/AT, EOMI, PEERLA |
| 54 |
Neck: NL Thyroid, no LAD |
| 55 |
Lungs: Clear BS b/l |
| 56 |
CV: RRR, N S1/S2, PMI nondisplaced, no MRG |
| 57 |
Abd: Tenderness in left CVA, rebound, no guarding. +BS in all4Q, tympanic in 4Q, ND, no masses |
| 58 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. |
| 59 |
Muscle strength 5/5 throughout. |
| 60 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 61 |
HPI: |
| 62 |
21 yo F c/o abdominal pain |
| 63 |
- Started this morning, getting worse |
| 64 |
- Constant, 7/10, cramping, nonradiating pain in RLQ of abdomen |
| 65 |
- Aggrav by movement, Allev - nothing |
| 66 |
- Accompanied by fever, nausea, vomiting, loose stools |
| 67 |
- Patient notes some brownish spotting this morning |
| 68 |
- LMP 5 weeks ago, used to have regular cycles 7d/1month. Menarche age |
| 69 |
13. Uncomplicated NSVD at full term 3 years ago |
| 70 |
ROS: negative except as above |
| 71 |
Meds: Ibuprofen, OCP. ALL: NKDA. FH: Noncontributory. |
| 72 |
PMH: STD 6 months ago, treated with AB. PSH: none. SxH: Unprotected sex with multiple males during last year. |
| 73 |
SH: 1 ppd * 6 years, 2-3 beers/week, no illicit drugs. Works as waitress |
| 74 |
Pt is in pain |
| 75 |
VS: WNL except for fever of 38.1^C |
| 76 |
HEENT: no pallor, no excessive hair on face, EOMI, visual fields intact |
| 77 |
Neck: NL thyroid gland |
| 78 |
CV: RRR, N S1/S2, no MRG |
| 79 |
Lungs: Clear BS b/l |
| 80 |
Abd: Hypoactive BS, tympanic in 4Q, ND, no masses. Direct and rebound RLQ tenderness, RLQ guarding, +Psoas sign, +Rovsing sign, -Obturator sign, no CVA tenderness |
| 81 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 82 |
HPI: |
| 83 |
26 yo M c/o sore throat |
| 84 |
- Started 2 weeks ago, constant, getting worse |
| 85 |
- Pain in throat - severity 5/10, dull, no radiation |
| 86 |
- No Allev. or Aggrav. factors |
| 87 |
- Fatigue, poor sleep and appetite, lost 5 lbs x 1 month |
| 88 |
- Abdominal discomfort, watery diarrhea x 1 week without blood |
| 89 |
ROS: Fever, no change in urinary habits |
| 90 |
Meds: No Rx or OTC. ALL: NKDA |
| 91 |
FH: Noncontributory. PMH: Gonorrhea 6 months ago, treated with AB |
| 92 |
PSH: none, no trauma or hospital. SxH: Multiple F partners x 1 year, condoms - inconsistently. SH: No cig/EtOH. IV Heroin with sharing needles x 1 year. Works as Constructor |
| 93 |
Pt is in NAD |
| 94 |
VS: Fever 37.5C |
| 95 |
HEENT: Gray pharyngeal exudates, NC/AT, EOMI, PEERLA |
| 96 |
Neck: Cervical lymphadenopathy, NL thyroid gland |
| 97 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 98 |
Lungs: Clear BS b/l |
| 99 |
Abd: Non-blanching rash on abdomen and chest. Hepatosplenomegaly, tenderness to palpation in RUQ and LUQ, +BS in all 4Q, ND, no masses. Negative Murphy sign |
| 100 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact. Sensation to soft and pinprick intact. Muscle strength 5/5 throughout. Gait normal |
| 101 |
Ext: Needle marks on both arms. Radial pulse 2+ b/l |
| 102 |
HPI: |
| 103 |
30yo F c/o wrist pain and black eye |
| 104 |
- Started 2 days ago, after tripping, falling and hitting her had on the edge of a table |
| 105 |
- 5/10, dull pain in L wrist, no radiation |
| 106 |
- Allev. by L limb rest, Aggrav by moving of L hand |
| 107 |
- She gives inconsistent story. |
| 108 |
- She lives with husband(alcoholic) and 5yo son |
| 109 |
- No vision change, no headache, no nausea/vomiting |
| 110 |
Ob/Gyn: G1P1, LMP 14 days ago, last PAP smear - 2 years ago was normal |
| 111 |
ROS: No fever, no change in bowel/urinary habits |
| 112 |
Meds: Ibuprofen. ALL: NKDA. FH: none. PMH: Rib fractures 1 year ago |
| 113 |
PSH: none. SxH: Monogamous with husband, they use condoms, no h/o STD. |
| 114 |
SH: Drinks vodka every day(CAGE 4/4), smoke 1 ppd*10 years, no illicit drugs. Works as waitress |
| 115 |
Pt is anxious and in acute distress |
| 116 |
VS: WNL |
| 117 |
HEENT: Bruise under L eye. No vision changes. EOMI. PEERLA |
| 118 |
Ext: Swelling and bruises on L wrist. Decreased passive and active range of motion in L wrist and hand. Sensation intact. |
| 119 |
Neck: NL Thyroid, no LAD |
| 120 |
Back: Bruises on L side of the back, tenderness to palpation |
| 121 |
CV: RRR, N S1/S2, no MRG |
| 122 |
Lungs: Clear BS b/l |
| 123 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 124 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 125 |
Mental exam: AAO in person and place, disoriented in time. Can't spell backwards, can't register and recall 3 objects Thought process irrational. Judgment intact |
| 126 |
HPI: 70 yo F c/o anxiety |
| 127 |
- Started 6wks ago w/o ppt events, getting worse |
| 128 |
- Almost all day long, no stress relation |
| 129 |
- Worse in the morning and when skips meal, better with Valeriana |
| 130 |
- Palpitations, hot flashes, hair loss x 1 month |
| 131 |
- Difficulty falling asleep and early morning awaking, sleeps 4hrs instead of 8hrs before |
| 132 |
- No excessive thirstiness or skin changes |
| 133 |
ROS: 10lb wt loss x 1 month, no change in bowel/urinary habits |
| 134 |
Ob/Gyn: LMP 20y ago, G1P1. Monogamous with husband |
| 135 |
Meds: no Rx, Advil for occasional headache. All: NKDA |
| 136 |
FH: noncontributory. PSH: none. No trauma or hospital. |
| 137 |
PMH: no similar problems before. No h/o HTN, DM or heart problem |
| 138 |
SH: no cig/EtOH/drugs. Biochemistry professor. Good family support |
| 139 |
Pt is in NAD, anxious |
| 140 |
VS: WNL except for HR 106/min |
| 141 |
HEENT: no lid lag, no exophthalmos. EOMI |
| 142 |
Neck: NL thyroid gland |
| 143 |
CV: RRR, N S1/S2, no MRG |
| 144 |
Ext: tremor of outstretched hands. DTRs 3+ b/l |
| 145 |
HPI: 53 yo M c/o weakness |
| 146 |
- Started 5 hours ago, lasts 20 min, totally resolved at this time |
| 147 |
- He had right-sided arm and face numbness |
| 148 |
- Started suddenly, no ppt events or head trauma |
| 149 |
- No change in vision, palpitations, dizziness or LOC |
| 150 |
- No nausea/vomiting or balance problems |
| 151 |
ROS: No fever, no change in bowel/urinary habits |
| 152 |
Meds: Captopril, HCTZ, Atorvastatin, Insulin - noncompliant. |
| 153 |
ALL: NKDA |
| 154 |
FH: father - died of CVA age 60 yo, mother - DM. |
| 155 |
PMH: DM, HTN x 15y, poor control, Migraines. No h/o CVA or MI. |
| 156 |
PSH: none. No traumas or hospital. SxH: with wife |
| 157 |
SH: 2 PPD*30 years, 2-3 beers/weekend, no illicit drugs. Works as engineer |
| 158 |
Pt is in NAD |
| 159 |
VS: WNL except for BP 160/90 |
| 160 |
HEENT: NC/AT, EOMI, PEERLA |
| 161 |
Neck: NL thyroid gland, no carotid bruits |
| 162 |
Lungs: clear BS b/l |
| 163 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 164 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 165 |
Neuro: CN 2-12 grossly intact. DTRs 2+ symmetric, intact. Muscle strength 5/5 throughout. Sensation intact b/l. Romberg, finger-to-nose |
| 166 |
WNL. Gait normal. |
| 167 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 168 |
HPI: The of information is the mother of 10yo F who c/o her daughter was diagnosed with DM |
| 169 |
- Diagnosed 1 months ago, unknown type |
| 170 |
- She is active, play in tennis, follow prescribed diet, is not depressed, but concerned, normal bowel habits |
| 171 |
- Lost 9lbs, thirst, frequent urination before Insulin started, now normal |
| 172 |
- She on Insulin - basal-bolus regimen, compliant, checks her blood Glc regularly, fasting Glc 80-100mg/dL, prandial - high 100s |
| 173 |
- No vision problems |
| 174 |
- No sick contacts at home or school |
| 175 |
Meds: Insulin. PMH: none. PSH: no traumas or surgeries |
| 176 |
Birth: no complications during pregnancy, term vaginal delivery |
| 177 |
Development: wt.:180lbs, height:5'1'', not yet menstruating |
| 178 |
HPI: |
| 179 |
61 yo M c/o fatigue and weakness |
| 180 |
- Started 7 months ago, he feels tired all day |
| 181 |
- Poor appetite, lost 8 lbs x 6 months, occasional nausea |
| 182 |
- Epigastric discomfort: started 4 months ago, severity 4/10, vague, radiates to the back, allev by leaning forward, no related to food |
| 183 |
- Recently notice foul-smelling, greasy-looking stool, no blood |
| 184 |
- Feels sad, lost interest to things, low energy, poor concentration, no suicidal ideations, no feelings of guilt or worthlessness |
| 185 |
ROS: Negative except as above. Meds: Tylenol. ALL: NKDA |
| 186 |
FH: father has DM, died accidentally, mother died of breast cancer |
| 187 |
PMH: None. PSH: Appendectomy at 16 yo. SxH: monogamous with wife |
| 188 |
SH: Smoked 1 ppd*30 years, quite 6 months ago. Drinks 2 beers daily |
| 189 |
and 3-4 beers on weekends. Retired police officer |
| 190 |
Pt is in NAD, looks sad |
| 191 |
VS: WNL |
| 192 |
HEENT: No conjunctival pallor, no oral or pharynx lesions |
| 193 |
Neck: NL thyroid gland, no carotid bruits, JVD or LAD |
| 194 |
CV: no chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 195 |
Lungs: clear BS b/l |
| 196 |
Abd: Mild epigastric tenderness, no rebound tenderness, +BS in all 4Q, tympanic in 4Q, ND, no masses or Murphy sign |
| 197 |
Ext: no skin changes, DTRs 2+ symmetric intact |
| 198 |
HPI: |
| 199 |
35 yo F c/o headache |
| 200 |
- Started 3 weeks ago, intermittent at least 1 episode/day 1-2 hours |
| 201 |
- At right hemisphere, 9/10, sharp and pounding, no radiate, sometimes feel nausea during pain and yesterday 1-st time vomiting. |
| 202 |
- Allev: resting in quiet, dark room, Aspirin. Aggrav: stress, light, noise |
| 203 |
- No related to menses, no visual changes, no weakness, numbness, no speech difficiences, no head trauma |
| 204 |
ROS: no change in wt/appetite, bowel and urinary habits, no fever |
| 205 |
Meds: Ibuprofen. All: NKDA. FH: father - died of Brain Cancer at age 65yo, mother - Migraines. PMH: Had similiar episodes headache and vomiting in college. Sinusitis 4 months ago. PSH: tubal ligation 8 years ago. |
| 206 |
SxH: with husband. SH: no cigs/EtOH/drugs. Works as Engineer, has alot of stress at work. Live with husband and 3 children |
| 207 |
Pt is in NAD |
| 208 |
VS: WNL |
| 209 |
HEENT: NC/AT, EOMI, PEERLA, no papilledema |
| 210 |
Neck: Supple, no carotid bruits, no LAD |
| 211 |
CV: no chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 212 |
Lungs: Clear b/s bl |
| 213 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 214 |
Neuro: CN 2-12 intact, DTRs 2+ intact, symmetric. Muscle strength 5/5 throughout. Sensation: intact b/l |
| 215 |
Mental exam: AAO in person, time, place. Good concentration, judgement intact |
| 216 |
HPI: 60yo M c/o urinary urgency |
| 217 |
- Started 3 years ago, getting worse |
| 218 |
- Nocturia, weak stream and terminal dribbling |
| 219 |
- He had 2 episodes of urinary retention, that required catheterization |
| 220 |
- No bone pain, weight changes, fatigue, night sweating |
| 221 |
ROS: No fever, no changes in bowel habits |
| 222 |
Meds: Captopril. ALL: NKDA. FH: father - BPH. PMH: HTN x 20 years |
| 223 |
PSH: h/o 2 hospitalizations due to urinary retention 2 and 3 years ago |
| 224 |
SxH: With wife. SH: No cig/EtOH/drugs. Works as Engineer |
| 225 |
Pt is in NAD |
| 226 |
VS: BP 160/90 mm Hg |
| 227 |
HEENT: NC/AT. EOMI. PEERLA |
| 228 |
Neck: NL Thyroid, no LAD |
| 229 |
Lungs: Clear BS b/l |
| 230 |
CV: RRR, N S1/S2, PMI nondisplaced, no MRG |
| 231 |
Abd: +BS in all 4Q, ND, NT, no masses |
| 232 |
HPI: The source of the information - mother 3yo M child, who c/o her child has constipation |
| 233 |
- Started since birth, 1 bowel movement per week, constant |
| 234 |
- No improve despite using stool softeners |
| 235 |
- Hard stool consistency without blood |
| 236 |
- Normal vaginal delivery, but he did not pass meconium for 48 hours |
| 237 |
- Day care attending. No sick contact |
| 238 |
ROS: No fever, change in urinary habits |
| 239 |
Meds: Different stool softeners. ALL: NKDA |
| 240 |
FH: mother - constipation, father- Hirschprung disease |
| 241 |
PMH: Negative except as above. PSH: none. |
| 242 |
Immuniz: UTD. Diet: low fiber, high fat diet. |
| 243 |
Development: He has poor weight gain. Last checkup - 2 months ago. |
| 244 |
HPI: |
| 245 |
32yo F c/o vaginal bleeding |
| 246 |
- Started 4 hours ago, getting worse |
| 247 |
- She changed 2 pads x 4 hours - blood on pads, without odor |
| 248 |
- 9/10, sharp, pain in LLQ of the abdomen, radiates to the back and scapula |
| 249 |
- No nausea/vomiting, no vision or skin changes |
| 250 |
Ob/Gyn: G0P0, LMP 8 weeks ago. Menarche at 15yo. |
| 251 |
ROS: No fever, no change in bowel/urinary habits |
| 252 |
Meds: No Rx or OTC. ALL: NKDA. |
| 253 |
FH: noncontributory. PMH: Gonorrhea 1 year ago, treated with AB |
| 254 |
PSH: None, no trauma or hospital. Sx: Sex. active with 3 M partners x 1 |
| 255 |
year, they use condoms inconsistently. HIV test - never. PAP smear 1 year ago was normal. |
| 256 |
SH: Smoke 1 ppd*10 years, drinks 3-4 beers/weekend(CAGE 0/4), no illicit |
| 257 |
drugs. Works as waitress |
| 258 |
Pt is anxious |
| 259 |
VS: BP 90/60 mm Hg, HR 100/minute |
| 260 |
HEENT: Conjunctival pallor. NC/AT, EOMI, PEERLA |
| 261 |
Neck: NL Thyroid, no LAD |
| 262 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 263 |
Lungs: Clear BS b/l |
| 264 |
Abd: Tenderness in LLQ with rebound and guarding. +BS in all 4Q, tympanic in 4Q |
| 265 |
Neuro: CN 2-12 grossly intact. Sensation intact. DTRs2+ symmetric, intact. Muscle strength 5/5 throughout |
| 266 |
Mental exam: AAO x 3, skips, spell backward, recall 3 items, obey 3 commands. Judgment and thought process intact |
| 267 |
HPI: 75 yo M c/o hearing loss |
| 268 |
- Started 1 year ago, bilateral, for all sounds, gradually worsening |
| 269 |
- Occasional tinnitus, rare headaches |
| 270 |
- No ear pain, discharge, nausea, spinning, imbalance, no ear traumas |
| 271 |
- Cerumen removal 1 month ago - moderate improvement |
| 272 |
ROS: No change in bowel/urinary habits |
| 273 |
Meds: Hydrochlorothiazide x 25 years, Aspirin daily |
| 274 |
All: Penicillin(rash). FH: no history of hearing loss. |
| 275 |
PMH: Hypertension x 25 years, UTI 1 year ago, treated with antibiotics. No traumas or hospital PSH: none. SxH: with wife |
| 276 |
SH: No cigs, EtOH, drugs. Retired veteran |
| 277 |
Pt is in NAD |
| 278 |
VS: WNL |
| 279 |
HEENT: NC/AT, EOMI, PEERLA, no nystagmus, papilledema, no cerumen. TMs with lite reflex, no infection, no redness of ear canal, no LAD. Weber |
| 280 |
test without lateralization, normal Rinne test(air>bone b/l) |
| 281 |
Neck: NL Thyroid gland, no carotid bruits |
| 282 |
Neuro: CN 2-12 intact except for decreased hearing. Motor strength 5/5 throughout, DTRs 2+ intact, symmetric. Sensation: intact, Gait - normal |
| 283 |
CV: No chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 284 |
Lungs: clear BS b/l |
| 285 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 286 |
Pt is in NAD |
| 287 |
VS: WNL |
| 288 |
HEENT: Conjunctival pallor, NC/AT, EOMI, PEERLA |
| 289 |
Neck: NL Thyroid, no LAD |
| 290 |
Lungs: Clear BS b/l |
| 291 |
CV: RRR, N S1/S2, PMI nondisplaced, no MRG |
| 292 |
Abd: Tenderness in lower part of the abdomen, no rebound or guarding. +BS in all 4Q, tympanic in 4Q, distended, no masses |
| 293 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 294 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 295 |
HPI: |
| 296 |
55 yo F c/o altered mental status |
| 297 |
- Started 2 weeks ago after she falls and hit her head and LOC for 2 minutes. Gradually progress |
| 298 |
- Associated with headache, nausea and occasionally vomiting |
| 299 |
- Headache in L temporal and parietal areas, severity 6/10, intermittent, dull, no radiation. Aggrav by physical work. |
| 300 |
- No palpitations, diaphoresis, weakness |
| 301 |
ROS: no change in bowel/urinary habits, no fever |
| 302 |
Meds: Captopril, Ibuprofen. ALL: NKDA. FH: father died of a stroke at |
| 303 |
60yo. PMH: HTN x 20 years. PSH: none. SxH: with husband, no STD |
| 304 |
SH: 1ppd*25 years. No EtOH/drugs. Work as engineer. |
| 305 |
Pt is confused |
| 306 |
VS: WNL, except for BP 150/90 |
| 307 |
HEENT: R pupil dilated, visual acuity worse in R eye. Bruise in R temporal area |
| 308 |
Neck: Supple, no LAD, NL thyroid gland |
| 309 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 310 |
Lungs: clear BS b/l |
| 311 |
Abd: +BS in all 4Q, tympanic in 4Q, NT, ND, no masses |
| 312 |
Mental exam: AAO in person and place, disoriented in time. Can't spell backwards, can't register and recall 3 objects, obeys 3 commands. |
| 313 |
Judgment and thoughts process intact |
| 314 |
Neuro: CN 2-12 grossly intact. Muscle strength 5/5 in R UE/LE and |
| 315 |
3/5 in L UE/LE. DTRs 2+ in R side and 3+ in L side. |
| 316 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 317 |
HPI: The source of the information - mother of 5 yo M child, who c/o her child has temper tantrums |
| 318 |
- Started 6 months ago, no progression |
| 319 |
- 5-10 minutes episodes immediately follow a disappointment or a discipline |
| 320 |
- Not display these behaviors at day care |
| 321 |
- No trouble sleeping, no change in wt/appetite |
| 322 |
- No sick contacts at home or day care |
| 323 |
ROS: No fever, no change in bowel/urinary habits |
| 324 |
Meds: No Rx or OTC. ALL: NKDA |
| 325 |
Birth: term vaginal delivery, no complications during pregnancy |
| 326 |
Immuniz: UTD. Diet: Balanced food. |
| 327 |
Development: Wt/height gain appropriate to age, walking, talking |
| 328 |
Last checkup: was normal 1 month ago except of behavioral problems |
| 329 |
FH: older brother - ADHD. PMH: URI 2 weeks ago, none |
| 330 |
HPI: 34yo M c/o cough |
| 331 |
- Started 6 days ago, getting worse |
| 332 |
- cap full, green, blood-steaked sputum, no odor |
| 333 |
- Fever 100.1F x 2 days |
| 334 |
- Sick contact: sister had similar symptoms |
| 335 |
- No contact with TBC-peoples, no night sweating, no weight loss |
| 336 |
- No travel recently. PPD - never |
| 337 |
ROS: No change in bowel/urinary habits |
| 338 |
Meds: Tylenol. ALL: NKDA. FH: noncontributory |
| 339 |
PMH: none. PSH: Cholecystectomy at 21yo |
| 340 |
SxH: No sex. active now, no h/o STD |
| 341 |
SH: No cig/EtOH/drugs. Works as Accountant |
| 342 |
Pt is in NAD |
| 343 |
VS: Fever 100.1F |
| 344 |
HEENT: NC/AT, EOMI, PEERLA. No pharynx or oral lessions |
| 345 |
Neck: NL Thyroid, no LAD |
| 346 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 347 |
Lungs: BS, no wheezing and rhonchi b/l. Positive tactile fremitus and egophony at lower lobes b/l |
| 348 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 349 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 350 |
Ext: No edema, clubbing, or cyanosis. radial pulses 2_ b/l |
| 351 |
HPI: 53 yo M c/o dizziness |
| 352 |
- Started 2 days ago, getting worse, episodes last 20-30 min |
| 353 |
- Sensation of room spinning around him |
| 354 |
- Isn't specific to time, usually occurs when getting up or lying down |
| 355 |
- Nausea, vomited several times. |
| 356 |
- Left-sided hearing loss episodes since yesterday. |
| 357 |
- No tinnitus, fullness in ear, ear discharge, headache or head trauma. No recent URI |
| 358 |
ROS: He had watery, nonbloody diarrhea x3 days. Normal urination. |
| 359 |
Meds: Furosemide, captopril. ALL: NKDA. FH: Noncontributory |
| 360 |
PMH: Hypertension x 7 years. PSH: Appendectomy 3 months ago |
| 361 |
SxH: monogamous with wife. SH: No smoking/drugs, drinks 2-3 beers/week |
| 362 |
Pt is in NAD |
| 363 |
VS: WNL, no orthostatic changes |
| 364 |
HEENT: NC/AT, PEERLA, EOMI without nystagmus, no papilledema, no cerumen, TMs normal, mouth and oropharynx normal |
| 365 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 366 |
Neuro: CN 2-12 intact except for decreased hearing acuity in the left ear. Normal Rinne(Air>Bone conduction b/l). Weber right lateralization. Negative Dix-Hallpike maneuver. Motor: strength 5/5 throughout. DTRs intact, symmetric. Negative Babinski b/l. |
| 367 |
Cerebellar: Negative Romberg, finger to nose normal. Gait: normal |
| 368 |
HPI: 27 yo M c/o seeing strange writing on we wall |
| 369 |
- Started yesterday, intermittent, 3-4 times since yesterday |
| 370 |
- Writing is not clear, he can't read them but thinks he might be getting instructions from them |
| 371 |
- He mentions hearing strange voices, associated with the writing, but he can't understand them either |
| 372 |
- No visual changes, headache, seizures, head trauma or prev episodes |
| 373 |
- No feeling of being controlled, no suicidal/homicidal ideation |
| 374 |
- No changes in wt/appetite, no fever or sleep problems |
| 375 |
ROS: No change in bowel/urinary habits. |
| 376 |
Meds: No Rx or OTC. ALL:NKDA. PMH: None. PSH: None. No traumas or hospital. SxH: with girlfriend, use condoms, no h/o STD. |
| 377 |
SH: 1 ppd*6 years,uses PCP(Angel dust) and MDMA(Ecstasy) occasionally, no EtOH. Works as a bartender |
| 378 |
Pt seems anxious and in mild distress |
| 379 |
VS: HR 110/min, BP 140/80 mm Hg |
| 380 |
HEENT: EOMI, PEERLA, no oral or pharynx lesions |
| 381 |
Neck: NL thyroid gland |
| 382 |
CV: Tachycardic, N S1/S2, no MRG, PMI nondisplaced |
| 383 |
Lungs: clear BS b/l |
| 384 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 385 |
Neuro: CN 2-12 intact. Muscle strength 5/5 throughout. DTRs 2+ symmetric, intact |
| 386 |
Mental exam: AAO x 3, spells backward, recall 3 items, obeys 3 commands, judgment and thought process intact |
| 387 |
Ext: no tremor |
| 388 |
HPI: 34yo M c/o weight loss |
| 389 |
- Unintentional loss 30 lbs x 5 months |
| 390 |
- weakness, palpitations and perspires a lot |
| 391 |
- no night sweats, chills, chest pain or SOB |
| 392 |
- no nausea, vomiting, diarrhea or constipation |
| 393 |
- no travel recently |
| 394 |
ROS: No fever, no change in bowel/urinary habits |
| 395 |
Meds: No Rx or OTC. ALL: NKDA |
| 396 |
FH: Noncontributory. PMH: STD treated with AB 2 years ago |
| 397 |
PSH: None. SxH: Sex. active with multiple F and M partners, use condoms inconsistently. |
| 398 |
SH: Drinks 3 vodka/day(CAGE: 0/4), smokes marijuana, injects heroin IV once a week x 1 year. No cigs. Works as bartender |
| 399 |
Pt is in NAD |
| 400 |
VS: WNL |
| 401 |
HEENT: NC/AT, EOMI, PEERLA, no oral or pharynx lesions |
| 402 |
Neck: NL Thyroid, no LAD |
| 403 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 404 |
Lungs: Clear BS b/l |
| 405 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 406 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Muscle strength 5/5 throughout. Sensation intact |
| 407 |
Ext: Needle marks on his arms b/l. No edema or cyanosis, radial pulses 2+ b/l |
| 408 |
HPI: 35 yo F c/o pain in right calf pain |
| 409 |
- Started few day's ago |
| 410 |
- Constant, 8/10, pressure pain, no radiate, associated with swelling, redness and warmth |
| 411 |
- Aggrav by walking and extending right knee, allev by ibuprofen and elevating R LE |
| 412 |
- No weakness, numbling or tingling |
| 413 |
ROS: Fever, no nausea/vomiting, no change in bowel/urinary habits, gain 50 lbs for 3 years |
| 414 |
Meds: OCP 2 years. ALL: NKDA. FH: father has DVT. PMH: none |
| 415 |
PSH: no. No traumas or hospital. SxH: monogamous with husband. |
| 416 |
SH: no cig/EtOH/drugs. Work as Executive consultant, 15-hour flight 1 week ago |
| 417 |
Pt is in NAD |
| 418 |
VS: fever 37.7^C, SOB |
| 419 |
HEENT: no pallor, EOMI, visual fields intact |
| 420 |
Neck: NL thyroid gland, no JVD |
| 421 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 422 |
CV: RRR, N S1/S2, no MRG |
| 423 |
Lungs: clear b/s b/l, no rales or rhonchi |
| 424 |
Neuro: DTR's 2+, Muscle strength 5/5, intact sensation in LE b/l. |
| 425 |
Ext: Right calf red and swollen, warmer compared to the left calf. |
| 426 |
Pitting pedal edema in R LE. Positive Homans sign on R LE. DP and PT pulses 2+ b/l |
| 427 |
Pt is anxious |
| 428 |
VS: BP 90/60 mm Hg. HR 90/minute |
| 429 |
HEENT: Conjunctival pallor. NC/AT, EOMI, PEERLA |
| 430 |
Neck: NL Thyroid, no LAD |
| 431 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 432 |
Lungs: Clear BS b/l |
| 433 |
Abd: Lower abdominal pain with rebound and guarding. +BS in all 4Q, tympanic in 4Q, distended |
| 434 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. |
| 435 |
Muscle strength 5/5 throughout |
| 436 |
Mental exam: AAO x 3, skips, spells backward, recall 3 objects, obey 3 commands. Judgment and thought process intact |
| 437 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 438 |
HPI: 52 yo F c/o yellow skin and eyes |
| 439 |
- Onset 3 weeks ago, persistent |
| 440 |
- Pain in RUQ: dull, intermittent, unrelated to meals, 3/10 severity, relieved by Tylenol |
| 441 |
- Pruritus - 7/10 severity, light-colored stool, dark urine |
| 442 |
- Fatigue, anorexia, nausea.No diarrhea,constipation or weight loss |
| 443 |
- Recently traveled to Mexico, had blood transfusion 20 years ago |
| 444 |
ROS: Negative, except as above |
| 445 |
Meds: Tylenol 4 pills/day, Synthroid. ALL: Penicillin(rash) |
| 446 |
FH: father - died of Pancreatic cancer at 55yo. PMH: Hypothyroidism |
| 447 |
PSH: 2 C-sections, tubal ligation. SxH: monogamous with husband |
| 448 |
SH: Drink 1-2 glasses wine/day for 35 years, CAGE 0/4. No cigs/drugs |
| 449 |
Pt is in NAD |
| 450 |
VS: WNL |
| 451 |
HEENT: Sclerae icteric |
| 452 |
Neck no LAD, no JVD, no carotid bruits |
| 453 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 454 |
Lungs: clear BS b/l |
| 455 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, no masses. Mild RUQ tenderness without rebound or guarding, no Murphy sign. No ascites, C-section scar. |
| 456 |
Skin: Jaundice, excoriations due to scratching, no spider teleangiectasias or palmar erythema |
| 457 |
Ext: no edema or cyanosis, no asterixis, radial pulses 2+ b/l |
| 458 |
Pt is in NAD |
| 459 |
VS: BP 160/90 mm Hg |
| 460 |
HEENT: Conjunctival pallor. NC/AT. EOMI. PEERLA |
| 461 |
Neck: NL Thyroid. No LAD |
| 462 |
Lungs: Bronchial sounds with rhonchi b/l |
| 463 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 464 |
Abd: +BS in all 4q, tympanic in 4Q, ND, NT, no masses, no Murphy sign. |
| 465 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 466 |
HPI: 62 yo M c/o hoarseness |
| 467 |
- Persistent hoarseness x 3 months, gradually progress, getting worse |
| 468 |
- Allev or Aggrav - nothing |
| 469 |
- Fatigue, poor appetite, lost 10lbs in 3 months |
| 470 |
- Feel "lump in his throat" |
| 471 |
- No exposure to dust or cold weather |
| 472 |
ROS: Mild fever, no change in bowel/urinary habits |
| 473 |
Meds: No Rx or OTC. All: NKDA. |
| 474 |
FH: father - Lung cancer, mother - Thyroid disease |
| 475 |
PMH: Flu 4 weeks ago, constant heartburn, hypercholesterolemia |
| 476 |
PSH: none. No traumas or hospital. SxH: monogamous with wife |
| 477 |
SH: Etoh:3 glasses of wine/day/30 years(CAGE: 0/4), smoke |
| 478 |
1 ppd x 30 years. Retired school teacher |
| 479 |
Pt is in NAD |
| 480 |
VS: Fever 37.7^C |
| 481 |
HEENT: No conjunctival pallor, scleral icterus, oral, pharynx erythema |
| 482 |
Neck: Right anterior cervical LAD, no Left LAD |
| 483 |
CV: RRR, N S1/S2, no MRG |
| 484 |
Lungs: Clear BS b/l |
| 485 |
Neuro: CN 2-12 intact, DTRs 2+ in LE and UE 2+ b/l. Muscle strength 5/5 in LE and UE b/l |
| 486 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 487 |
Ext: No edema or cyanosis. DP and PT pulses 2+ b/l |
| 488 |
HPI: 23yo M c/o seizures |
| 489 |
- 1 episode 2 days ago, last 30 seconds, witnessed by his family |
| 490 |
- Jerking movements of the limbs, lost control of his bladder |
| 491 |
- He bit his tongue and felt weak after the episode |
| 492 |
- No similar events in the past |
| 493 |
- No tingling, numbness, weakness, chest pain, palpitations or SOB |
| 494 |
- Nausea x 2 days, vomited 4 times, non-bloody, non-bilious |
| 495 |
ROS: No fever, no change in bowel/urinary habits |
| 496 |
Meds: No Rx or OTC. ALL: NKDA. |
| 497 |
FH: father - seizure disorder. PMH: None. PSH: None. No trauma or hospital |
| 498 |
SxH: Multiple F partners x 1 year, use condoms all time, no h/o STD |
| 499 |
SH: No cigs. Drins beer(not count how many), CAGE: 0/4. Smokes marijuana once a week x 1 year. College student. |
| 500 |
Pt is in NAD |
| 501 |
VS: WNL |
| 502 |
HEENT: NC/AT, EOMI, PEERLA, no oral or pharynx lesions |
| 503 |
Neck: NL Thyroid, no LAD |
| 504 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 505 |
Lungs: Clear BS b/l |
| 506 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 507 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 508 |
Mental exam: AAOx3, skips, spell backward, recall 3 items, obey 3 commands, judgmenth and thought process intact |
| 509 |
HPI: |
| 510 |
The source of the is the mother of 11 mo F child who c/o her child has seizure |
| 511 |
- Started this morning at 11 a.m. - tonic-clonic seizure, witnessed by parents. It lasted 1 minute. She denies any tongue or head trauma |
| 512 |
- Postictal drowsiness after the seizure, no h/o prior seizures |
| 513 |
- Rhinorrhea for past 2 days. Fever, T=102.9F, measured rectally. |
| 514 |
- Decreased PO intake, difficulty sleeping, fewer wet diapers |
| 515 |
- No rash, nausea/vomiting, lethargy, inconsolability |
| 516 |
- No day care. No h/o sick contacts |
| 517 |
ROS: none. Meds: Tylenol. ALL: NKDA. FH: none. PMH: none. PSH: none |
| 518 |
Birth: Term uncomplicated vaginal delivery. Immuniz: UTD |
| 519 |
Diet: Breast milk, table foods, supplemental vitamins |
| 520 |
Development: wt/height gain appropriate to age. Last checkup 2 months ago none |
| 521 |
HPI: 18yo F c/o amenorrhea |
| 522 |
- Started 4 months ago |
| 523 |
- No vaginal discharge, no spotting |
| 524 |
- No hot flashes, night sweats, headache, breast discharge |
| 525 |
- G0P0, Menarche at 15yo, last PAP smear 1 year ago was normal |
| 526 |
- Sex. active with boyfriend x 3 months, no OCP, they use condoms, no h/o STD |
| 527 |
- Vigorous exercise at gym |
| 528 |
- Heat intolerance, no hair loss or skin changes |
| 529 |
ROS: No fever, no change in bowel/urinary habits |
| 530 |
Meds: laxatives. ALL: NKDA |
| 531 |
FH: mother has thyroid disease. PMH: noncontributory |
| 532 |
PSH: none, no traumas or hospital. |
| 533 |
SH: Smoke 1ppd*5 years, no EtOH, drugs. College student |
| 534 |
Pt is in NAD |
| 535 |
VS: BMI - 14.5 kg/m2, HR - 80/minute |
| 536 |
HEENT: NC/AT, EOMI, PEERLA |
| 537 |
Neck: NL Thyroid, no LAD |
| 538 |
CV: RRR, N S1/S2, PMI nondisplaced, no MRG |
| 539 |
Lungs: Clear BS b/l |
| 540 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 541 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact, Sensation intact. Muscle strength 5/5 throughout |
| 542 |
Ext: No tremor, no edema or cyanosis, radial pulses 2+ b/l |
| 543 |
Pt is in NAD |
| 544 |
VS: WNL |
| 545 |
HEENT: NC/AT. EOMI. PEERLA |
| 546 |
Neck: NL Thyroid, no LAD |
| 547 |
CV: RRR, N S1/S2, PMI nondisplaced, no MRG |
| 548 |
Lungs: Clear BS b/l |
| 549 |
Abd: +BS in all 4Q, tympanic in 4Q, NT, ND, no masses |
| 550 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. |
| 551 |
Muscle strength 5/5 throughout |
| 552 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 553 |
HPI: |
| 554 |
The source of information is the mother of 2 yo F child who c/o her child suddenly developing noisy breathing |
| 555 |
- Started 1 hour ago and getting progressively worse |
| 556 |
- Was playing with toys when she developed noisy breathing |
| 557 |
- The sound is consistent, best heard on inhalation and similar to that of a washing machine. No related to posture |
| 558 |
- Associated with a nonproductive cough without hemoptysis, tachypnea, drooling or bluish discoloration of the skin |
| 559 |
- No sick contacts at home or day care |
| 560 |
Meds: No Rx or OTC.ALL: NKDA.FH: Noncontributory.PMH: None. PSH:None. |
| 561 |
Birth: no complications during pregnancy, term vaginal delivery |
| 562 |
Immuniz: UTD. Diet: milk, solid foods. |
| 563 |
Development: wt/height gain appropriate to age, walking, talking |
| 564 |
None |
| 565 |
HPI: 30yo F c/o vaginal discharge |
| 566 |
- Started 1 week ago, no progression |
| 567 |
- 1 tablespoon, white, cottage sheese-like discharge, no blood |
| 568 |
- Vaginal itching |
| 569 |
Ob/Gyn: Menarche - 15yo, G1P1(normal vaginal delivery 10 years ago) |
| 570 |
LMP - 14 days ago, regular periods 3-4days/month, no OCP use |
| 571 |
ROS: No fever, no change in bowel/urinary habits |
| 572 |
Meds: No Rx or OTC. ALL: NKDA |
| 573 |
FH: noncontributory. PMH: none. PSH: none. No trauma, 1 hospitalization 10 years ago due to delivery |
| 574 |
SxH: Monogamous with husband, no h/o STD |
| 575 |
SH: Smoke 1ppd*10 years, no EtOH/drugs, works as Accountant |
| 576 |
Pt is in NAD |
| 577 |
VS: WNL |
| 578 |
HEENT: NC/AT, EOMI, PEERLA |
| 579 |
Neck: NL Thyroid, no LAD |
| 580 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 581 |
Lungs: Clear BS b/l |
| 582 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 583 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact, Sensation intact. Muscle strength 5/5 throughout |
| 584 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 585 |
HPI: 45 yo M c/o R knee pain |
| 586 |
- Started 3 days ago, getting worse |
| 587 |
- 7/10, throbbing, intermittent R knee pain, no radiation |
| 588 |
- Fever, redness of R knee area |
| 589 |
- Recently traveled to New England |
| 590 |
- No headache, nausea, vomiting |
| 591 |
- Low-fiber, high fat diet |
| 592 |
- Allev. by lying quitly. Aggrav. by moving R leg |
| 593 |
ROS: No changes in bowel/urinary habits |
| 594 |
Meds: Ibuprofen. ALL: NKDA |
| 595 |
FH: father - gout. PMH: none. PSH: none, no trauma or hospital |
| 596 |
SxH: Monogamous with wife, no h/o STD |
| 597 |
SH: smoke 1 ppd*10 years, drinks 2-3 beers/day(CAGE 0/4), no drugs. |
| 598 |
Works as Accountant |
| 599 |
Pt is in NAD |
| 600 |
VS: Fever 101F |
| 601 |
HEENT: NC/AT, EOMI , PEERLA |
| 602 |
Neck: NL thyroid, no LAD |
| 603 |
CV: RRR, N S1/S2, no MRG |
| 604 |
Lungs: Clear BS b/l |
| 605 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 606 |
Ext: Swelling, redness of R knee. Pain in R knee due to palpation and |
| 607 |
movements. No discharges or fistulas in R knee region. Pedal pulses 2+ b/l |
| 608 |
HPI: 28 yo M c/o hearing voices |
| 609 |
- Started 2 weeks ago, intermittent, 5 times/day, last 15-30 sec |
| 610 |
- Voices tell him that is intra of universe |
| 611 |
- No feeling of being controlled, no suicidal/homicidal ideation |
| 612 |
- No visual hallucinations, no problems with hearing, no headache |
| 613 |
- Increased energy, euphoric mood, less need for sleep |
| 614 |
- Episode of depressed mood 6 months ago after he lost job |
| 615 |
- No change in wt/appetite, no change in hair/voice, skin |
| 616 |
ROS: no change in bowel/urinary habits |
| 617 |
Meds: no Rx or OTC. All: NKDA. FH: mother - schizophrenia |
| 618 |
PMH: asthma, good control. No surgeries, trauma or hospital. |
| 619 |
SxH: sex. active with multiple F and M partners, inconsistent use of condoms, no h/o STDs |
| 620 |
SH: No cig/EtOH. Uses PCP and ecstasy x 1y, once/week, last intake yesterday. College student. |
| 621 |
Pt is in NAD. Speech fluent, talkative, mood euphoric, affect c/w mood, behavior inappropriate. Cooperative. Appearence disheveled. |
| 622 |
HEENT: EOMI, PERRLA. |
| 623 |
Neck: NL thyroid gland |
| 624 |
Ext: no tremor |
| 625 |
Mental exam: AAO in person and place, disoriented in time. Can't spell backwards, can't register and recall 3 objects, obeys 3 commands, |
| 626 |
judgement intact. Thought process irrational |
| 627 |
HPI: |
| 628 |
42 yo F c/o weight loss |
| 629 |
- 15.5 lbs weight loss x 2 months |
| 630 |
- Has a good appetite and no change in diet |
| 631 |
- Palpitations, hot flashes, hair loss x 2 months |
| 632 |
- Difficulty falling asleep and early morning awakening |
| 633 |
- Diarrhea x 2 months - 3-4 bowel movements per day, no blood in stool |
| 634 |
Ob/Gyn: G1P1, LMP 14 days ago, last PAP smear 1 year ago was normal |
| 635 |
ROS: No fever, no change in urinary habits |
| 636 |
Meds: No Rx or OTC. ALL: NKDA. |
| 637 |
FH: father - died of colon cancer age 60 years. PMH: none. |
| 638 |
PSH C-section at 25 yo. SxH: multiple M partners x 1 year, condoms - inconsistently. SH: Smoke 1 ppd*20 years, drinks 2-3 beers/weekend, no |
| 639 |
illicit drugs. Works as Accountant |
| 640 |
Pt is in NAD |
| 641 |
VS: HR 106/min |
| 642 |
HEENT: lid lag, mild exophthalmos b/l. EOMI. PEERLA |
| 643 |
Neck: Enlarged Thyroid gland, no carotid bruits |
| 644 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 645 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses. |
| 646 |
CN: 2-12 grossly intact, DTRs3+ symmetric. Sensation to soft and pinprick intact. Muscle strength 5/5 throughout. |
| 647 |
Ext: tremor of outstretched hands, no edema, pallor or cyanosis, radial pulses 2+ b/l |
| 648 |
67 yo M c/o Alternating diarrhea and constipation |
| 649 |
- Started 8 months ago, getting worse |
| 650 |
- Decreased stool caliber and blood in the stool x 8 months |
| 651 |
- Unintentionally lost 20 lbs x 8 months, poor appetite and sleep |
| 652 |
- Last colonoscopy was normal 12 years ago |
| 653 |
- He consumes low-fiber diet |
| 654 |
ROS: No fever, no change in urinary habits |
| 655 |
Meds: Captopril, HCTZ. ALL: NKDA. |
| 656 |
FH: father - died of colon cancer at age 60 yo. PMH: HTN x 10 years |
| 657 |
PSH: none. No trauma or hospital. SxH: monogamous with wife |
| 658 |
SH: Smoke 1 ppd*35 years, drinks 2-3 beers/day(CAGE: 0/4), no illicit drugs use. Works as Engineer |
| 659 |
Pt looks tired |
| 660 |
VS: BP 160/90 mm Hg |
| 661 |
HEENT: Conjunctival pallor, NC/AT, EOMI, PEERLA |
| 662 |
Neck: NL Thyroid gland |
| 663 |
Abd: Mild tenderness in LUQ of abdomen, no rebound or guarding. +BS in all 4Q, tympanic in 4Q |
| 664 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation: intact. Muscle strength 5/5 throughout |
| 665 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 666 |
HPI: 35 yo F c/o amenorrhea |
| 667 |
- LMP 3 months ago, decrease flow from 2/3 pads/day to 1 pads/day during last year |
| 668 |
- Used to have regular cycles 4-5d/1month, now 7d/5-6 weeks |
| 669 |
- No vaginal discharge, no spotting or pain during periods |
| 670 |
- Menarche age 14, G1P1, normal vaginal delivery 10 years ago, last Pap smear 10 months ago - normal |
| 671 |
- Milky discharge from left breast |
| 672 |
- No headache, vision changes, change in skin, voice, cold intolerance |
| 673 |
- Excessive hair on chin, 15 lbs wt gain x 1 year |
| 674 |
ROS: no nausea/vomiting, no change in bowel/urinary habits, vegetarian x 10 years |
| 675 |
Meds: OCP x 8 years. All: NKDA. FH: mother-menopause at 55 yo |
| 676 |
PMH: no similar problems before. PSH: none.No hospital or traumas |
| 677 |
SxH: monogamous with husband. SH: No cigs/EtOH/drugs |
| 678 |
Pt is in NAD |
| 679 |
VS: WNL |
| 680 |
CV: no chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 681 |
HEENT: no pallor, excessive hair on chin, EOMI, visual fields intact |
| 682 |
Neck: NL thyroid gland |
| 683 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 684 |
Ext: no skin changes, DTRs 2+ intact, symmetric |
| 685 |
HPI: |
| 686 |
28 yo F c/o seeing bugs crawling on her bad |
| 687 |
- Started 2 days ago, intermittent, 5-6 times/day, last 15-30 sec |
| 688 |
- Also she hearing loud voices when she is alone in her room |
| 689 |
- No feeling of being controlled, no suicidal or homicidal ideation |
| 690 |
- No problems with hearing, no headache |
| 691 |
- No change in wt/appetite, no change in hair/voice, skin |
| 692 |
ROS: No fever, no change in bowel/urinary habits |
| 693 |
Meds: No Rx or OTC. ALL: NKDA |
| 694 |
FH: mother - schizophrenia. PMH: none. No surgeries, trauma or hospital. |
| 695 |
SxH: sex. active with multiple M partners, inconsistent use of condoms, |
| 696 |
no h/o STDs. SH: No cig/EtOH. Recently ingested unknown substance. |
| 697 |
Works as waitress |
| 698 |
Pt is in NAD. Speech fluent, talkative, mood euphoric, affect c/w mood, behavior inappropriate |
| 699 |
VS: WNL |
| 700 |
HEENT: EOMI, PEERLA |
| 701 |
Neck: NL thyroid gland |
| 702 |
Mental exam: AAO in person and place, disoriented in time. Can't spell backwards, can't register and recall 3 objects, obeys 3 commands, judgement intact. Thought process irrational |
| 703 |
Ext: No tremor |
| 704 |
HPI: 23yo F c/o amenorrhea |
| 705 |
- LMP was 6 months ago, and during last year cycles was irregular |
| 706 |
- No vaginal discharge, no spotting |
| 707 |
- Menarche at 14yo, G0P0, last PAP smear 3 years ago was normal |
| 708 |
- No headache, vision problems, |
| 709 |
- No skin/voice changes or cold/heat intolerance |
| 710 |
- Excessive hair on the face, 15 lbs wt gain x 6 months |
| 711 |
- Infertility x 3 years, regular sex. activity with husband, no OCP or condoms using, no h/o STD |
| 712 |
ROS: No fever, no changes in bowel/urinary habits |
| 713 |
Meds: No Rx or OTC. All: NKDA. FH: noncontributory. PMH: none |
| 714 |
PSH: none. No traumas or hospital. |
| 715 |
SH: No cig/EtOH/drugs. Works as Accountant |
| 716 |
Pt is in NAD, obese. |
| 717 |
VS: WNL |
| 718 |
HEENT: NC/AT, EOMI, PEERLA. Excessive hairs on the face |
| 719 |
Neck: NL Thyroid, no LAD |
| 720 |
CV: RRR, N S1/S2, PMI nondisplaced, no MRG |
| 721 |
Lungs: Clear BS b/l |
| 722 |
Abd: Excessive hairs on abdomen. +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 723 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 724 |
Pt is in NAD |
| 725 |
VS: WNL |
| 726 |
HEENT: no oral or pharynx lesions. NC/AT, EOMI, PEERLA |
| 727 |
Neck: NL Thyroid, no LAD |
| 728 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 729 |
Lungs: Clear BS b/l |
| 730 |
Abd: mild lower abdominal tenderness, no rebound or guarding. |
| 731 |
+BS in all 4Q, tympanic in 4Q, ND, no masses |
| 732 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 733 |
HPI: |
| 734 |
46 yo M c/o chest pain |
| 735 |
- Started 40 minutes ago, constant severity, start during sleep, |
| 736 |
- 7/10, pressure, mid chest pain, radiation to neck, upper back, left arm, |
| 737 |
- Allev - nothing, accompanied by SOB, nausea, and sweating |
| 738 |
- No vomiting, cough, wheezing, stomach pain during this episode |
| 739 |
ROS: no change in appetite, bowel/urinary habits, no fever |
| 740 |
Meds: Maalox, diuretic. All: NKDA |
| 741 |
FH: father - died of Lung Cancer at age 72, mother - Peptic Ulcer |
| 742 |
PMH: HTN for 5 years, high cholesterol, GERD 10 years ago, no traumas |
| 743 |
PSH: none. No traumas or hospital |
| 744 |
SH: Monogamous with wife, avoids sex 3 months due to chest pain. Cocain use - 10 years, no EtOH. 1 ppd*25 year, quite 3 months ago. Works as |
| 745 |
accountant |
| 746 |
Pt is in NAD |
| 747 |
VS: WNL except for BP 165/85 mm Hg, HR 90/minute |
| 748 |
CV: no chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced in upright or lying position. |
| 749 |
Lungs: clear BS b/l |
| 750 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 751 |
HPI: 68yo F c/o neck pain |
| 752 |
- Started 2 days ago, without eliciting event |
| 753 |
- 7/10, constant, sharp pain, radiate to L arm |
| 754 |
- Aggrav. by head movement. Allev. - nothing |
| 755 |
- Tingling and numbing in L arm |
| 756 |
- No joint stiffness, weakness |
| 757 |
- Unintentional wt loss - 8 lb x 3 months |
| 758 |
Ob/Gyn: G1P1, LMP - 18 years ago, PAP smear 10yr ago normal, no HRROS:T |
| 759 |
ROS: No fever, no change in bowel/urinary habits |
| 760 |
Meds: Multivitamins. ALL: NKDA |
| 761 |
FH: father - osteoarthritis. PMH: None PSH: none, no traumas or hospital |
| 762 |
SxH: Monogamous with husband, no h/o STD |
| 763 |
SH: No cig/EtOH/drugs. Retired engineer |
| 764 |
Pt is in NAD |
| 765 |
VS: WNL |
| 766 |
HEENT: NC/AT, EOMI, PEERLA no oral or pharynx lesions |
| 767 |
Neck: NL Thyroid, no LAD |
| 768 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 769 |
Lungs: CTAB/L |
| 770 |
MSK: Neck is tender and warm to touch. Decreased active and passive ROM |
| 771 |
in neck. Pain is elicited by flexion, extension, abduction and |
| 772 |
adduction of the neck. Pain is radiating in the L arm. Muscle strength 5/5 throughout |
| 773 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact(except in L arm) |
| 774 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 775 |
HPI: 65yo F c/o inability to use left leg or bear weight |
| 776 |
- Started 1 day ago after tripping on a carpet, getting worse |
| 777 |
- 9/10, sharp, constant pain in L groin, radiate to L knee |
| 778 |
- inability to use of left leg or stay on it |
| 779 |
- Allev. by lying quietly, Aggrav. by moving L leg |
| 780 |
Ob/Gyn: LMP 20 years ago, she didn't receive HRT or calcium and Vit. D supplements. Last PAP smear 10 years ago was normal. G1P1 |
| 781 |
ROS: Constipation(2 bowel movements/week), no change in urinary habits, no fever |
| 782 |
Meds: Captopril, HCTZ, Ibuprophen. ALL: NKDA |
| 783 |
FH: noncontributory. PMH: HTN x 15 years. PSH: none. |
| 784 |
SxH: no sexually active since dead of her husband 3 years ago, no h/o STD. SH: No cig/EtOH/drugs. Works as a School Teacher |
| 785 |
Pt is in acute distress |
| 786 |
VS: BP 160/90 mm Hg, HR 80/minute |
| 787 |
HEENT: EOMI, PEERLA, no pharynx or oral lesions |
| 788 |
Neck: NL Thyroid, no LAD |
| 789 |
CV: RRR, N S1/S2, no MRG |
| 790 |
Lungs: Clear BS b/l |
| 791 |
Abd: +BS in all 4Q, ND, NT, no masses |
| 792 |
Neuro: CN 2-12 grossly intact. Sensation intact. DTRs2+ symmetric, |
| 793 |
intact. Muscle strength 5/5 throughout |
| 794 |
Ext: L leg externally rotated, pain in L groin during palpation and |
| 795 |
moving in L leg, deformation in L groin area. Radial and pedal pulses 2+ b/l |
| 796 |
HPI: |
| 797 |
60 yo M c/o abdominal pain |
| 798 |
- Started 2 months ago, getting worse |
| 799 |
- Severity 6/10, dull, epigastric pain, radiate in the back |
| 800 |
- Clay-colored stool, dark urine, poor sleep, and appetite, lost 20 lbs for 2 months |
| 801 |
ROS: No Fever. |
| 802 |
Meds: No Rx or OTC. ALL: NKDA. |
| 803 |
FH: father - died of pancreatic cancer at 60 yo. PMH: none |
| 804 |
PSH: none. No trauma or hospital. SxH: monogamous with wife, no h/o STD, HIV, HBV, HCV. |
| 805 |
SH: Smoke 1 ppd*40 years. Drinks 3-4 beers/day x 15 years. |
| 806 |
Works as Constructor |
| 807 |
Pt is in NAD |
| 808 |
NEENT: Yellow sclerae. Conjunctival pallor. NC/AT, EOMI, PEERLA |
| 809 |
Neck: NL Thyroid gland, no carotid bruits |
| 810 |
Lungs: BS, wheezing and rhonchi b/l, VTF intact |
| 811 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 812 |
Abd: Epigastric mass and tenderness without rebound and guarding, signs of ascites, "caput medusae" over anterior abdomen wall. Hepatosplenomegaly, no Murphy sign. +BS in all 4Q, tympanic in 4Q |
| 813 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact, Sensation intact. Muscle strength 5/5 throughout |
| 814 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 815 |
HPI: |
| 816 |
28yo F c/o pain during sex |
| 817 |
- Started 3 months ago every time she tries to have sex |
| 818 |
- Aching and burning pain located externally and internally |
| 819 |
- Vaginal discharge - scant, white with fishy odor, accompanied by mild pruritus, no postcoital or intermenstrual vaginal bleeding |
| 820 |
- LMP - 2weeks/ago. Regular cycles 3d/1month, using 3pads/day, starting to have abdominal pain during periods over the past year |
| 821 |
- Menarche at age 14 G0P0. Recent Pap-smear 6 months ago - normal |
| 822 |
- No change in skin, voice, no cold intolerance |
| 823 |
ROS: no nausea/vomiting, no change in bowel/urinary habits, wt/appetite. |
| 824 |
Meds: no Rx or OTC. All: NKDA. FH: none. PMH: Raped 10 years ago, contracted gonorrhea. PSH: none, no traumas or hospital. |
| 825 |
SxH: with boyfriend x 1 year, normal desire, no abuse. SH: no cig/drugs, EtOH occasionally. Work as Editor for a fashion magazine |
| 826 |
Pt in NAD |
| 827 |
VS: WNL |
| 828 |
HEENT: No pallor, no excessive hair on the face, EOMI, visual fields intact |
| 829 |
Neck: NL Thyroid gland |
| 830 |
CV: RRR, N S1/S1, no MRG |
| 831 |
Lungs BS b/l |
| 832 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 833 |
Ext: No skin changes, DTRs 2+ intact, symmetric |
| 834 |
HPI: The source of the information - mother of 3yo F child, who c/o her child has red eye |
| 835 |
- Started 3 days ago from the R eye, now involves both eyes |
| 836 |
- Mucoid discharges from both eyes without blood |
| 837 |
- Itching, difficulty opening her eyes in the morning |
| 838 |
- No change in wt/appt, no vomiting |
| 839 |
- Sick contact - mother had URI last week |
| 840 |
ROS: No fever, no change in bowel/urinary habits |
| 841 |
Meds: None. ALL: MKDA. FH: No major diseases. |
| 842 |
PMH: Asthma, atopic dermatitis. |
| 843 |
Birth: No complications during pregnancy, term vaginal delivery |
| 844 |
Diet: Balanced food. Immuniz: UTD |
| 845 |
Development: Normal wt/height gain, walking, talking |
| 846 |
Last checkup: 2 weeks ago was normal |
| 847 |
none |
| 848 |
HPI: 18yo M c/o burning urination |
| 849 |
- Started 2 days ago, getting worse |
| 850 |
- 2-3 drips, cloudy urethral discharge without blood or odor |
| 851 |
- No abdominal pain, no h/o recent travel, no fatigue or night sweating |
| 852 |
ROS: No fever, no change in bowel habits |
| 853 |
Meds: No Rx or OTC. ALL: NKDA |
| 854 |
FH: Noncontributory. PMH: Gonorrhea 1 year ago, treated with AB |
| 855 |
SxH: Sex. active with multiple F partners, use condoms inconsistently. |
| 856 |
No HIV tested before. SH: Smoke 1 ppd*3 years, no EtOH/drugs. |
| 857 |
College student |
| 858 |
Pt is in NAD |
| 859 |
VS: WNL |
| 860 |
HEENT: No oral lesions. NC/AT, EOMI, PEERLA |
| 861 |
Neck: NL Thyroid, no LAD |
| 862 |
Lungs: Clear BS b/l |
| 863 |
CV: RRR, N S1/S2, PMI nondisplaced, no MRG |
| 864 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 865 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 866 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 867 |
HPI: |
| 868 |
45 yo M c/o abdominal pain |
| 869 |
- Started 4 hours ago, w/o ppt events |
| 870 |
- Constant, 10/10, colicky, right flank pain, radiates to the testicles |
| 871 |
- Accompanied by nausea, vomiting, hematuria(approx. 1 teaspoon blood in 1 liter urine) |
| 872 |
- Aggrav by walking, jumping. Allev - nothing |
| 873 |
ROS: no fever, no change in bowel/urinary habits |
| 874 |
Meds: Ibuprofen. ALL: NKDA. FH: father - died of renal cancer at 60 yo |
| 875 |
PMH: none. PSH: none. No traumas or hospital. |
| 876 |
SxH: monogamous with wife, no h/o STD. |
| 877 |
SH: Smoke 1 ppd*15 years, no EtOH/drugs. |
| 878 |
Works as a Truck driver |
| 879 |
Pt is anxious |
| 880 |
VS: WNL |
| 881 |
HEENT: NC/AT, EOMI, PEERLA, no conjunctival pallor |
| 882 |
Neck: NL Thyroid gland |
| 883 |
Lungs: clear BS b/l |
| 884 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 885 |
Abd: Right CVA tenderness to palpation. +BS in all 4Q, tympanic in 4Q, ND, no masses |
| 886 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 887 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 888 |
HPI: 50yo M c/o pain in the R shoulder |
| 889 |
- Started 2 hours ago after falling onto his outstretched hand |
| 890 |
- 9/10, sharp, constant pain in R shoulder, no radiation |
| 891 |
- He noticed deformity of his R shoulder and had to hold his R hand |
| 892 |
- No headache, nausea, vomiting. |
| 893 |
ROS: No fever, no change in bowel/urinary habits |
| 894 |
Meds: Ibuprofen, captopril. ALL: NKDA |
| 895 |
FH: noncontributory. PMH: HTN x 10 years. PSH: none |
| 896 |
SxH: Monogamous with wife, no h/o STD |
| 897 |
SH: Smoke 1 ppd*15 years, drinks 2-3 beers/weekend(CAGE: 0/4), no illicit drugs. |
| 898 |
Works as Accountant |
| 899 |
Pt is distressed |
| 900 |
VS: BP 150/90 mm Hg |
| 901 |
HEENT: EOMI, PEERLA, no oral and pharynx lesions |
| 902 |
Neck: NL Thyroid, no LAD |
| 903 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 904 |
Lungs: Clear BS b/l |
| 905 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 906 |
Neuro: CN 2-12 grossly intact DTRs2+ symmetric, intact. Sensation intact. |
| 907 |
Ext: Hold his R arm near to the body. Deformation and swelling in R shoulder. Pain during palpation and decreased ROM in R shoulder. radial pulses2+ b/l. |
| 908 |
HPI: 48yo F c/o amenorrhea |
| 909 |
- LMP was 6 months ago |
| 910 |
- No vaginal discharge, no spotting |
| 911 |
- Hot flashes, night sweats, emotional lability, pain during sex |
| 912 |
- G1P1(uncomplicated vaginal delivery at 23yo) |
| 913 |
- Menarche at 15yo. Last PAP smear 4 years ago was normal |
| 914 |
- No excessive hair on the face or abdomen. No changes of the skin |
| 915 |
ROS: No fever, no change in bowel/urinary habits |
| 916 |
Meds: No Rx or OTC. ALL: NKDA |
| 917 |
FH: Menopause in mother at 50yo. PMH: none |
| 918 |
PSH: none. 1 hospitalization due to delivery at 23yo, no traumas |
| 919 |
SxH: Avoid sex with husband due to pain during sex, no h/o STD |
| 920 |
SH: no cig/EtOH/drugs. |
| 921 |
Works as Engineer |
| 922 |
Pt is in NAD |
| 923 |
VS: WNL |
| 924 |
HEENT: NC/AT, EOMI, PEERLA |
| 925 |
Neck: NL Thyroid no LAD |
| 926 |
Lings: Clear BS b/l |
| 927 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 928 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 929 |
Ext: NO edema or cyanosis, radial pulses 2+ b/l |
| 930 |
HPI: 28yo F c/o pain in the hands |
| 931 |
- Started 1 month ago, getting worse |
| 932 |
- 4/10, burning, intermittent pain in MCP joints ob both hands and in L knee |
| 933 |
- No nausea, vomiting, no skin changes |
| 934 |
- lost 10 lbs x 3 months, poor appt, poor sleep |
| 935 |
Ob/Gyn: G0P0. LMP 14 days ago. Last PAP smear 1 year ago was normal |
| 936 |
ROS: No fever, no change in bowel/urinary habits |
| 937 |
Meds: Ibuprofen. ALL: NKDA. FH: mother - Crohn disease |
| 938 |
PMH: none. PSH: appendectomy in 2yo. SxH: Sex. active with husband, they use condoms, no h/o STD |
| 939 |
SH: No cig/EtOH/drugs. Works as Accountant |
| 940 |
Pt is in NAD |
| 941 |
VS: WNL |
| 942 |
HEENT: NC/AT, EOMI, PEERLA. No pharynx or oral lesions |
| 943 |
Neck: NL thyroid, no LAD |
| 944 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 945 |
Lungs: Clear BS b/l |
| 946 |
Ext: Edema and inflammation MCP joints on both hands and L knee. Radial pulse 2+ b/l |
| 947 |
HPI: The source of information - mother of 7 mo M child who c/o her child has fever |
| 948 |
- Started x 1 day, measured it once, T=101F rectally, constant |
| 949 |
- No cough, ear pulling, discharge, no rush |
| 950 |
- The child has been tired, irritated, breathing rapidly for past day |
| 951 |
- Mother notes rhinorrhea and refusal of breast and baby food |
| 952 |
- Sick contact - 3 yo brother had URI 1 week ago |
| 953 |
- He attends day care |
| 954 |
ROS: Negative except as above |
| 955 |
Meds: Tylenol. All: NKDA. FH: no major diseases |
| 956 |
PMH: Jaundice in the 1-st week of life. PSH: None |
| 957 |
Birth: No complications during pregnancy, term vaginal delivery |
| 958 |
Immuniz: UTD. Diet: Breastfeeding and baby food |
| 959 |
Development: Last checkup was 2 weeks ago and showed normal wt/height and developmental milestones |
| 960 |
none |
| 961 |
HPI: 72 yo F c/o memory loss |
| 962 |
- Started 6 months ago, no progression |
| 963 |
- Accompanied by gait disturbance and urinary incontinence |
| 964 |
- She is upset due to memory difficulty |
| 965 |
- No headache, visual changes, difficulty sleeping |
| 966 |
ROS: unintentional wt loss, no appetite. No changes in bowel habits |
| 967 |
Meds: HCTZ, Captopril, Aspirin. ALL: NKDA |
| 968 |
PMH: Hypertension x 40 years, frequent falls, no bone fractures |
| 969 |
PSH: none. FH: mother - Alzheimer disease |
| 970 |
SH: No cigs/drugs/EtOH. |
| 971 |
Retired school teacher |
| 972 |
Pt is in NAD |
| 973 |
WS: WNL, except for BP 150/85 mm Hg |
| 974 |
HEENT: NC/AT, EOMI, PEERLA. No fundoscopic abnormalities |
| 975 |
Neck: NL thyroid gland, no carotid bruits |
| 976 |
Lungs: clear BS b/l |
| 977 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 978 |
Abd: +BS in all 4Q, tympanic in 4Q, NT, ND, no masses |
| 979 |
Mental exam: AAO x 3, spells backward, but can't recall 3 items, obeys 3 commands, judgment and thought process intact |
| 980 |
Neuro: CN 2-12 intact. Muscle strength 5/5 in both UE and 3/5 in both |
| 981 |
LE. DTRs 2+ in UE and 3+ in LE. +Babinski in LE. Sensation to pinprick and soft touch decreased in LE. Gait unsteady. |
| 982 |
Ext: no edema, cyanosis or bruisings, radial pulses 2+ b/l |
| 983 |
HPI: 70 yo M c/o loss of vision in L eye |
| 984 |
- Started 3 hours ago suddenly, getting worse, constant |
| 985 |
- Associated with palpitations and SOB |
| 986 |
- No eye pain, headache, photophobia. No redness or discharges from eyes. No headache, weakness or numbness |
| 987 |
- No allev or aggrav factors. No speech difficiences, no head trauma |
| 988 |
ROS: No fever. No change in bowel/urinary habits |
| 989 |
Meds: Coumadin, Atorvastatin, Captopril. ALL: NKDA |
| 990 |
FH: father died of stroke age 65. PMH: H/o atrial fibrillation, cataracts in R eye. Hypertension x 40 years |
| 991 |
SH: Live with wife. No cigs/drugs/EtOH. |
| 992 |
Retired engineer |
| 993 |
Pt is anxious |
| 994 |
VS: WNL, except for BP 150/90 mm Hg and HR 85/min |
| 995 |
HEENT: NC/AT. EOMI. Retinal whitening and cherry red macula on fundoscopy. Loss of vision in L eye |
| 996 |
Neck: NL thyroid gland. No LAD. No carotid bruits |
| 997 |
CV: Tachycardia, N S1/S2, no MRG, PMI nondisplaced |
| 998 |
Lungs: Clear BS b/l |
| 999 |
Abd: +BS in all 4Q, tympanic in 4Q, NT, ND, no masses |
| 1000 |
Neuro: CN 2-12 grossly intact, except for loss of vision in L eye, |
| 1001 |
Muscle strength 5/5 throughout. DTRs2+ symmetric, intact. |
| 1002 |
Ext: No edema or cyanosis, radial pulses 2+ |
| 1003 |
HPI: 33 yo M c/o diarrhea |
| 1004 |
- Started 3 weeks ago, no progression |
| 1005 |
- He has 3 watery bowel movements per day without blood |
| 1006 |
- 4/10, diffuse, cramping abdominal pain, no radiation |
| 1007 |
- Allev/Aggrav - nothing |
| 1008 |
- Lost 15 lbs x 3 months. No changes in appetite or diet |
| 1009 |
ROS: No fever, no change in urinary habits |
| 1010 |
Meds: Was treated with Antibiotics, but not responded to them. ALL: NKDA |
| 1011 |
PMH: h/o aphthous ulcers x 6 months. FH: mother - Ulcerative colitis |
| 1012 |
PSH: none. No traumas or hospital. SxH: Monogamous with wife, they use condoms. No h/o STD |
| 1013 |
SH: Smoke 1 ppd&10 years, no EtOH/drugs. Works as Engineer |
| 1014 |
Pt is in NAD |
| 1015 |
VS: WNL |
| 1016 |
HEENT: Aphthous ulcers on posterior 1/3 tongue and palate. NC/AT, EOMI, PEERLA |
| 1017 |
Neck: NL Thyroid. No LAD |
| 1018 |
Lungs: Clear BS b/l |
| 1019 |
CV: RRR, N S1/S2, PMI nondisplaced. No MRG |
| 1020 |
Abd: diffuse abdominal tenderness, no rebound or guarding. Abdomen is distended, tympanic in 4Q. +BS in 4Q. No masses |
| 1021 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact |
| 1022 |
Muscle strength 5/5 throughout |
| 1023 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1024 |
HPI: 51 yo M c/o back pain |
| 1025 |
- Started 1 week ago after lifting heavy boxes, no progression |
| 1026 |
- Constant, 8/10, sharp lower back pain, radiate in left thigh and foot |
| 1027 |
- Aggrav by walking, long sitting, coughing, allev by lying in bed |
| 1028 |
- No weakness, numbness or tingling |
| 1029 |
- No fatigue or fever |
| 1030 |
ROS: urination difficulty - need strain to urinate, |
| 1031 |
no change in wt/appetite, bowel habits |
| 1032 |
Meds: no Rx or OTC. All: Penicillin |
| 1033 |
FH: mother - RA, father - died from heart attack at 65 yo |
| 1034 |
PMH: had short episode of back pain 2 y ago, accompanied by leg pain |
| 1035 |
PSH: no. No traumas or hospital. |
| 1036 |
SxH: monogamous with wife. SH: works as constructor, lifts heavy objects. 1 PPD*18 years, no drugs/EtOH |
| 1037 |
Pt is in NAD |
| 1038 |
VS: WNL |
| 1039 |
Back: paraspinal lower back tenderness, no skin changes. ROM full x 6. |
| 1040 |
Ext: no skin changes in LE b/l. DP and PT pulses 2+ b/l |
| 1041 |
Neuro: DTRs 2+ in LE b/l. Muscle strength 5/5 in LE b/l. Sensation: intact in right LE, decreased in L LE. Straight leg raise negative b/l |
| 1042 |
Pt is distressed |
| 1043 |
VS: BP 160/85 mm Hg, HR 90/minute |
| 1044 |
HEENT: NC/AT, EOMI, PEERLA |
| 1045 |
Neck: NL Thyroid, no carotid bruits |
| 1046 |
Lungs: CTAB/L |
| 1047 |
Chest: No chest tenderness due to palpation |
| 1048 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1049 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1050 |
Pt is in NAD |
| 1051 |
VS: WNL |
| 1052 |
HEENT: NC/AT, EOMI, PEERLA |
| 1053 |
Neck: NL Thyroid, no LAD |
| 1054 |
Lungs: Clear BS b/l |
| 1055 |
CV: RRR, N S1/S2, PMI nondisplaced, no MRG |
| 1056 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1057 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1058 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1059 |
HPI: 26yo M c/o abdominal pain |
| 1060 |
- Started 2 weeks ago, getting worse |
| 1061 |
- 5/10 sharp, episodic pain in lower abdomen, radiate in L groin and L testicle |
| 1062 |
- Dysuria x 2 weeks, no hematuria, pyuria, hesitancy, straining or week stream |
| 1063 |
ROS: Fever 99.8F from yesterday, no change in bowel habits |
| 1064 |
Meds: Multivitamins. ALL: NKDA |
| 1065 |
PMH: noncontributory. FH: none PSH: Appendectomy at 14yo |
| 1066 |
SxH: Monogamous with wife, no h/o STD, they use condoms |
| 1067 |
SH: No cig/EtOH/drugs. he is a small business owner |
| 1068 |
Pt is in NAD |
| 1069 |
VS: Fever 99.8F |
| 1070 |
HEENT: NC/AT, EOMI, PEERLA |
| 1071 |
Neck: NL Thyroid, no LAD |
| 1072 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1073 |
Lungs: Clear BS b/l |
| 1074 |
Abd: +BS in all4Q, tympanic in 4Q, ND, NT, no masses. Negative Rovsing and Murphy's signs |
| 1075 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1076 |
HPI: 25 yo M c/o diarrhea |
| 1077 |
- Started 3 days ago, getting worse |
| 1078 |
- 3-4 bowel movements per day with watery stool without blood |
| 1079 |
- 4/10, diffuse abdominal cramps, no radiation |
| 1080 |
- Allev/Aggrav - nothing |
| 1081 |
- He was recently traveled to Mexico |
| 1082 |
ROS: No fever, no change in urinary habits |
| 1083 |
Meds: No Rx or OTC. ALL: NKDA |
| 1084 |
FH: noncontributory. PMH: none. PSH: None. No traumas or hospital |
| 1085 |
SxH: Sex with girlfriend x 6 months, they use condoms, no h/o STD |
| 1086 |
SH: Smoke 1 ppd*5 years, no EtOH/drugs. Works as Engineer |
| 1087 |
Pt is in NAD |
| 1088 |
VSL: WNL |
| 1089 |
Neck: NL Thyroid, no LAD |
| 1090 |
Lungs: Clear BS b/l |
| 1091 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1092 |
Abd: Diffuse abdominal tenderness, no rebound or guarding. +BS in all 4Q, |
| 1093 |
distended, tympanic. No Murphy sign |
| 1094 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1095 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1096 |
Pt is in NAD, obese |
| 1097 |
VS: BP: 160/90 mm Hg |
| 1098 |
HEENT: NC/AT. EOMI. PEERLA. No oral or pharynx lesions |
| 1099 |
Neck: NL Thyroid, no carotid bruits. No LAD |
| 1100 |
CV: RRR. N S1/S2, no MRG, PMI nondisplaced |
| 1101 |
Lungs: Clear BS b/l |
| 1102 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1103 |
Ext: Pain during palpation in both thighs and calves. Muscle strength 3/5 in LE b/l and 5/5 in UE b/l. Pedal pulse and radial pulse 2+ b/l. No rash. ROM x 6 normal in all extremities |
| 1104 |
HPI: 28 yo F c/o positive pregnancy test |
| 1105 |
- Positive pregnancy test - 2 days ago, LMP was 6 weeks ago, lightly whan usual(1-2 days vs regular 3-4 days/1month usual) |
| 1106 |
- No vaginal discharge, no spotting or pain during periods |
| 1107 |
- Menarche age 14, G0P0, PAP smear normal 6 months ago |
| 1108 |
- Fullness in breasts, no discharge |
| 1109 |
- No vision problems |
| 1110 |
- No change in skin, voice, no cold intolerance, no wt gain |
| 1111 |
ROS: mild nausea 2 days, no vomiting, no change in bowel habits, increased urination frequency |
| 1112 |
Meds: Multivitamins. All: NKDA. FH: father - DM, mother - thyroid |
| 1113 |
disease and obesity. PSH: appendectomy at 20 yo, no traumas |
| 1114 |
SxH: Sex with boyfriend, contraception - withdrawal method, no STD |
| 1115 |
SH: Graduate Student. Pregnancy is no planned, unknown desirable |
| 1116 |
Pt is in NAD |
| 1117 |
VS: WNL |
| 1118 |
HEENT: no pallor, no excessive hair on face, EOMI, visual fields intact |
| 1119 |
Neck: NL thyroid gland |
| 1120 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1121 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1122 |
Est: no skin changes, DTRs 2+ b/l in LE |
| 1123 |
HPI: 69yo M c/o weakness |
| 1124 |
- Started 1 hour ago suddenly w/o ppt events, constant |
| 1125 |
- involves only L UE and LE |
| 1126 |
- no association with any other symptoms |
| 1127 |
- he had similar episodes in the past but lasted only about 1 minute |
| 1128 |
- No trauma, LOC, numbness or tingling, speech changes |
| 1129 |
- No visual/voice changes, headache, chest pain, palpitations, leg swelling |
| 1130 |
ROS: No fever, no recent travel, no change in wt or bowel/urinary habits |
| 1131 |
Meds: Statin drug(not remember the name), atenolol. ALL: NKDA |
| 1132 |
FH: mother - HTN. PMH: HTN x 20 years. PSH: none |
| 1133 |
SxH: Monogamous with wife. SH: No cig/EtOH/drugs. He is retired |
| 1134 |
Pt is in NAD |
| 1135 |
VS: BP 160/110 mm Hg |
| 1136 |
HEENT: NC/AT, EOMI, PEERLA, no oral or pharynx lesions |
| 1137 |
Neck: NL Thyroid, no carotid bruits |
| 1138 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1139 |
Lungs: CTAB/L |
| 1140 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1141 |
Neuro: CN 2-12 grossly intact. DTRs 3+ on left side and 2+ on the right |
| 1142 |
side. Muscle strength 2/5 on his L UE and LE and 5/5 throughout. |
| 1143 |
Sensation to soft and pinprick intact. Patient can't walk due to hip left side weakness - could not assess his gait |
| 1144 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1145 |
HPI: |
| 1146 |
17yo F c/o irregular prolonged cycles |
| 1147 |
- irregular prolonged menstrual bleeding, started 6 months ago, getting worse |
| 1148 |
- Use 4-5 pads per day, cycles 7-10days/3-7weeks |
| 1149 |
- No headache, weight changes, breast discharges |
| 1150 |
- No changes in skin, voice, no cold/heat intolerance |
| 1151 |
Ob/Gyn: Menarche at 14yo, G0P0, PAP smear - never, HIV test - never. |
| 1152 |
Sex. active with boyfriend x 3 months, they use condoms, no h/o STD |
| 1153 |
ROS: No fever, no changes in bowel/urinary habits |
| 1154 |
Meds: No Rx or OTC. ALL: NKDA. |
| 1155 |
FH: mother - died of Cervical cancer at 60yo. |
| 1156 |
PMH: none. PSH: none, no trauma or hospital |
| 1157 |
SH: no cig/EtOH/drugs. |
| 1158 |
College student |
| 1159 |
Pt is in NAD |
| 1160 |
VS: WNL |
| 1161 |
HEENT: NC/AT, EOMI, PEERLA |
| 1162 |
Neck: NL Thyroid, no LAD |
| 1163 |
CV: RRR, N S1/S2, no MRG, PPAP smear - never MI nondisplaced |
| 1164 |
Lungs: Clear BS b/l |
| 1165 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1166 |
Neuro: CN 2-12 grossly intact, DTRs2+, symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1167 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1168 |
HPI: |
| 1169 |
54 yo M c/o hypertension follow-up |
| 1170 |
- Hypertension was diagnosed last year |
| 1171 |
- Was initially started on HCTZ, propranolol was added 6 months ago |
| 1172 |
- Fairly compliant with medications. Does not monitor BP in home |
| 1173 |
- Last BP checkup was 4 months ago. |
| 1174 |
- Complains of erectile dysfunction and decreased libido x 4 months |
| 1175 |
- No leg claudication or history of heart problems, stroke, TIA, DM |
| 1176 |
- No marital or work problems, no depression or anxiety |
| 1177 |
ROS: no change in appetite, bowel/urinary habits, no fever. |
| 1178 |
Meds: HCTZ, propranolol, lovastatin. ALL: NKDA. |
| 1179 |
FH: father-died of heart attack at 50yo, mother-Alzheimer disease |
| 1180 |
PMH: Hypertension, hypercholesterolemia diagnosed 1 year ago |
| 1181 |
PSH: none. No traumas or hospital. |
| 1182 |
SxH: with wife 2 times/week, has erectile dysfunction. |
| 1183 |
SH: Drinks 3-4 beers/week(CAGE 0/4), no smoking or illicit drugs. |
| 1184 |
Work as a schoolteacher |
| 1185 |
Pt is in NAD |
| 1186 |
VS: WNL |
| 1187 |
HEENT: No fundoscopic abnormalities |
| 1188 |
Neck: No carotid bruits, no JVD |
| 1189 |
CV: No chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1190 |
Lungs: Clear BS b/l |
| 1191 |
Abd: + BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1192 |
Ext: No edema or cyanosis, radial, DP and PT pulses 2+ |
| 1193 |
Neuro: CN 2-12 intact. DTRs 2+ in LE b/l. Muscle strength 5/5 throughout. Sensation: intact to pinprick and soft touch in LE b/l |
| 1194 |
HPI: 47 yo M c/o hypertension follow-up |
| 1195 |
- HTN was diagnosed 10 years ago |
| 1196 |
- He does not check his BP regularly |
| 1197 |
- Noncompliant with medications |
| 1198 |
- SOB x 8 months, Aggrav. by walking. Allev by rest |
| 1199 |
- Unintentionally gained 4 lbs x 2 months |
| 1200 |
- Bilateral leg swelling x 8 months |
| 1201 |
- No headache, dizziness, confusion, LOC or bloody nose |
| 1202 |
ROS: Fever 99.9F, no change in bowel/urinary habits |
| 1203 |
Meds: Metoprolol, furosemide(noncompliant). ALL: NKDA |
| 1204 |
FH: father - hypertension. PMH: HTN x 10 years |
| 1205 |
PSH: None. SxH: Monogamous with wife, use condoms, no h/o STD |
| 1206 |
SH: No cig/EtOH/drugs. |
| 1207 |
Works as sales representative |
| 1208 |
Pt is in NAD |
| 1209 |
VS: Fever 99.9F |
| 1210 |
HEENT: NC/AT, EOMI, PEERLA, normal eye fundus |
| 1211 |
Neck: NL Thyroid, no LAD |
| 1212 |
Lungs: CTAB/L |
| 1213 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1214 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1215 |
Ext: Bilateral leg swelling, radial, and pedal pules 2+ b/l |
| 1216 |
HPI: The source of information - mother of 9 yo M, cho c/o her child has angry outbursts in the school and in the home |
| 1217 |
- Started 2 years ago, getting worse |
| 1218 |
- Mother complains, that he runs around "as if driven by a motor" |
| 1219 |
- His teacher reports that he can't sit still in the class regularly interrupts his classmates and has trouble making friends |
| 1220 |
- No change in wt/appetite |
| 1221 |
- No headache or vision changes |
| 1222 |
ROS: No fever, no change in bowel/urinary habits |
| 1223 |
Meds: No Rx or OTC ALL: NKDA PMH: URI 3 months ago |
| 1224 |
Birth: Term vaginal delivery, no complications during pregnancy |
| 1225 |
FH: father - conduct disorder |
| 1226 |
Diet: Balanced food. Immuniz: UTD |
| 1227 |
Development: Normal wt/height gain, walking, talking |
| 1228 |
Last checkup 1 month ago was normal except behavior problems |
| 1229 |
none |
| 1230 |
HPI: |
| 1231 |
65 yo F c/o memory impairment |
| 1232 |
- Started 1 year ago after death husband, progressively worsening |
| 1233 |
- Affects daily activities(bathing, feeding, toileting, dressing, |
| 1234 |
shopping, cooking and managing money) |
| 1235 |
- Transient orthostatic lightheadedness, frequent falls, 1 head injury |
| 1236 |
- She is upset due to memory difficulty. |
| 1237 |
- No headache, visual changes, gait problems, difficulty sleeping |
| 1238 |
ROS: unintentional wt loss, no appetite. No change in bowel/urinary habits. No fever. Residual weakness in left arm after a stroke. |
| 1239 |
Meds: HCTZ, aspirin, transdermal nitroglycerin. ALL: NKDA. |
| 1240 |
FH: Noncontributory. PMH: Hypertension, stroke, MI. Can't remember when she had them. PSH: Partial bowel resection due to obstruction |
| 1241 |
SH: No smoking/EtOH/drugs. |
| 1242 |
Widow, lives with daughter and has good support(daughter, friends) |
| 1243 |
Pt is in NAD |
| 1244 |
VS: WNL, no orthostatic changes |
| 1245 |
HEENT: NC/AT, EOMI, PEERLA, no fundoscopic abnormalities |
| 1246 |
Neck: NL thyroid gland, no carotid bruits |
| 1247 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1248 |
Lungs: Clear BS b/l |
| 1249 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1250 |
Mental exam: AAO x 3, spells backward, but can't recall 3 items, obeys 3 commands, judgment and thought process intact. |
| 1251 |
Neuro: CN 2-12 intact. Muscle strength 5/5 in all muscle groups, except 3/5 in left arm. |
| 1252 |
DTRs: Asymmetric 3+ in LE and LL extremities, 1+ in the |
| 1253 |
right, +Babinski b/l. Gait normal. Sensation intact to pinprick and |
| 1254 |
soft touch |
| 1255 |
HPI: |
| 1256 |
46 yo M c/o fatigue |
| 1257 |
- Started 3 months ago after unsuccessful attempt to save his friend after a car accident |
| 1258 |
-Constant fatigue, low energy, decreased concentration affect his job |
| 1259 |
- Decreased appetite, but gained 6 lbs x 3months |
| 1260 |
- Multiple awakenings and difficulty staying asleep due to nightmares about accident. Feelings of beed depressed and helpless. |
| 1261 |
- Passive suicidal ideation, no suicide plan/attempts |
| 1262 |
- Sleepy throughout all day. Cold intolerance. Hair loss. |
| 1263 |
ROS: no change in bowel/urinary habits. No fever |
| 1264 |
Meds: No Rx or OTC. ALL: NKDA. FH: Noncontributory |
| 1265 |
PMH: Urethritis(possibly chlamydia), treated 5 months ago |
| 1266 |
PSH: none. No traumas or hospital. |
| 1267 |
SxH: History of unprotected sex with multiple female partners. SH: 1 PPD*25 years, 2-3 beers/month, no illicit drugs. |
| 1268 |
Works as accountant |
| 1269 |
Pt is in NAD. Looks tired. Flat affect. Speaks and moves slowly |
| 1270 |
VS: WNL |
| 1271 |
HEENT: NC/AT, EOMI, PEERLA, no conjunctival pallor |
| 1272 |
Neck: NL thyroid gland, no LAD |
| 1273 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1274 |
Lungs: Clear BS b/l |
| 1275 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1276 |
Neuro: CN 2-12 intact. DTRs2+ symmetric, intact. Muscle strength 5/5 throughout |
| 1277 |
Mental exam: AAO x 3, spells backward, recall 3 items, obeys 3 commands, judgment and thought process intact |
| 1278 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 1279 |
Pt is in NAD, obese |
| 1280 |
VS: BP 150/90 mm Hg |
| 1281 |
HEENT: NC/AT, EOMI, PEERLA |
| 1282 |
Neck: NL Thyroid, no LAD |
| 1283 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1284 |
Lungs: Clear BS b/l |
| 1285 |
Abd: +BS in all 4Q, ND, NT. no masses |
| 1286 |
Ext: Skin changes on both LE, pain during palpation in both LE. Muscle strength 3/5 in both LE and 55 in both UE. Radial pulses 2+ in UE and 1+ |
| 1287 |
jn LE b/l |
| 1288 |
HPI: 74yo M c/o pain in right arm |
| 1289 |
- Started 3 days ago, when he play with child and fell on R UE |
| 1290 |
- 7/10, throbbing, constant pain in upper and middle parts R arm, no radiation |
| 1291 |
- Allev - no moving R UE, Tylenol, aggrav - moving R UE |
| 1292 |
- No LOC, weakness, numbling or tingling |
| 1293 |
- Not seeking medical attention since trauma because his son didn't have time to take him in hospital |
| 1294 |
ROS: no change in bowel/urinary habits, no fever |
| 1295 |
Meds: Tylenol, albuterol inhaler. All: Aspirin(rush). FH: none |
| 1296 |
PMH: Asthma, BPH. PSH: prostatectomy 2 years ago |
| 1297 |
SH: No cigs/drugs/EtOH, live with son's family. |
| 1298 |
Retired teacher |
| 1299 |
Pt is NAD, appears anxious |
| 1300 |
VS: WNL |
| 1301 |
HEENT: NC/AT, EOMI, PEERLA, no bruises |
| 1302 |
Neck: subtle, no bruises, no carotid bruits, ROM full x 6 |
| 1303 |
CV: no chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1304 |
Neuro: CN 2-12 intact, sensation intact in UE and LE |
| 1305 |
Ext: R UE closely against chest wall, tenderness in middle and upper R arm and R shoulder. Restricted ROM x 6 due to pain, no crepitus. Unable |
| 1306 |
to assess muscle strength in R UE due to pain, 5/5 in L UE. Radial pulses 2+ b/l. DTRs 2+ in LE and UE b/l. |
| 1307 |
HPI: |
| 1308 |
32 yo F c/o fatigue and weakness |
| 1309 |
- Started 5 months ago, increase throughout a day, loss of energy, concentration |
| 1310 |
- Patient admits, what husband(alcoholic) has beaten her. At least 1 episode of physical abuse directed at youngest son. Patient attempts to defend husband's actions. Feels guilty. Has not reported abuse |
| 1311 |
- No head trauma or accidents due to husband. No emergency plan |
| 1312 |
- Feels sad, but denies suicidal ideation. |
| 1313 |
- Polyuria,polydipsia,nocturia x5 months,no dysuria,no color change |
| 1314 |
- LMP 2 weeks ago, regular cycles 7d/1month, heavy flow |
| 1315 |
ROS: No constipation, wt/appetite changes, no cold intolerance or sleep problems. |
| 1316 |
Meds: No Rx or OTC. ALL: NKDA. |
| 1317 |
FH: father - had DM, died of a heart attack, mother in nursing home - Alzheimer disease |
| 1318 |
SH: No cigs/Etoh/drugs. Sexually active with husband, decreased sexual desire. |
| 1319 |
Pt is obese, in NAD, looks anxious |
| 1320 |
VS: WNL |
| 1321 |
HEENT: Pale conjunctivae. NC/AT, EOMI, PEERLA |
| 1322 |
Neck: NL thyroid gland, no LAD |
| 1323 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1324 |
Lungs: Clear BS b/l |
| 1325 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1326 |
Neuro: CN 2-12 intact. DTRs2+ symmetric, intact. Muscle strength 5/5 throughout |
| 1327 |
Ext: Bruises on both arms, radial pulses 2+ b/l |
| 1328 |
HPI: |
| 1329 |
25 yo M c/o abdominal pain |
| 1330 |
- Started 2 days ago, getting worse |
| 1331 |
- Severity 7/10, dull pain in RUQ of abdomen, no radiation |
| 1332 |
- Nausea, vomiting(2 rimes, yellow color, no blood), no appetite |
| 1333 |
- Clay-colored stool, dark colored urine(without blood) |
| 1334 |
ROS: Fever 101F |
| 1335 |
Meds: No Rx or OTC. ALL: NKDA. |
| 1336 |
FH: noncontributory. PMH: Gonorrhea 1 year ago, treated witn AB. |
| 1337 |
PSH: none. No trauma or hospital. |
| 1338 |
SxH: Sex. active with multiple female partners x 1 year, condoms - inconsistently. SH: Smoke 1 ppd*5 years, no EtOH/drugs. |
| 1339 |
Works as Engineer |
| 1340 |
Pt is in NAD |
| 1341 |
VS: Fever 101F |
| 1342 |
HEENT: Sclerae is icteric. NC/AT, EOMI, PEERLA |
| 1343 |
Neck: NL Thyroid, no LAD |
| 1344 |
Lungs: Clear BS b/l |
| 1345 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1346 |
Abd: Positive Murphy sign in RUQ, tenderness in RUQ without rebound or guarding. +BS in all 4Q, tympanic in 4Q |
| 1347 |
Neuro: CN 2-12 grossly intact, DTRs2+ b/l. Sensation intact. Muscle strength 5/5 throughout |
| 1348 |
Skin: Jaundice, no spider telangiectasias or palmar erythema |
| 1349 |
HPI: 54yo F c/o vaginal bleeding |
| 1350 |
- Started 2 weeks ago |
| 1351 |
- Bright red blood spotting in underwear, no odor, no clots or vaginal discharges |
| 1352 |
- G1P1, Menarche at 15yo, LMP 4 years ago, PAP smear 2 years ago was normal |
| 1353 |
- Unintentionally loss 10 lbs x 1 month |
| 1354 |
- No HRT |
| 1355 |
- No warm/cold intolerance, no skin/voice changes |
| 1356 |
- No abdominal pain, mo headache, dizziness, nausea, vomiting or LOC |
| 1357 |
ROS: No fever, no change in bowel/urinary habits |
| 1358 |
Meds: No Rx or OTC. ALL: NKDA. FH: Noncontributory. PMH: None |
| 1359 |
PSH: None. No traumas or hospital. SxH: With husband, stop sex. activity since vaginal spotting began |
| 1360 |
SH: No cig/EtOH/drugs. Works as High school teacher |
| 1361 |
Pt is in NAD |
| 1362 |
VS: WNL |
| 1363 |
HEENT: Conjunctival pallor, NC/AT, EOMI, PEERLA. No excessive hair on face |
| 1364 |
Neck: NL Thyroid, no LAD |
| 1365 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1366 |
Lungs: CTAB/L |
| 1367 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1368 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1369 |
HPI: 24 yo F c/o abdominal pain |
| 1370 |
- Started 14 days ago(with the first day of her LMP), no progression |
| 1371 |
- Severity 5/10, dull, bilateral abdominal pain, no radiation |
| 1372 |
- Associated with fever 100.5F and greenish-yellow tablespoon vaginal discharge without blood |
| 1373 |
OB/Gyn: LMP - 14 days ago, menarche at 13 yo, G0P0 |
| 1374 |
ROS: Fever 100.5F, no nausea/vomiting, no change in bowel/urinary habits |
| 1375 |
Meds: No Rx or OTC. All: NKDA |
| 1376 |
FH: mother - endometriosis. PMH: Gonorrhea 1 year ago, treated with AB |
| 1377 |
PSH: none. No trauma or hospital. SxH: Sex. active with multiple M partners, inconsistently use condoms |
| 1378 |
SH: Smoke 1ppd*5 years. No EtOH/drugs. Works as Waitress |
| 1379 |
Pt is in NAD |
| 1380 |
VS: Fever 100.5F |
| 1381 |
HEENT: NC/AT, EOMI, PEERLA |
| 1382 |
Neck: NL Thyroid, no LAD |
| 1383 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1384 |
Lungs: Clear BS b/l |
| 1385 |
Abd: Tenderness in LLQ and RLQ, no rebound or guarding. +BS in all 4Q, tympanic in 4Q |
| 1386 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1387 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1388 |
HPI: |
| 1389 |
56 yo M c/o diabetes follow-up |
| 1390 |
- 25 years history of DM, treated with insulin, compliant with meds |
| 1391 |
- Monitors blood Glc 2/week(range 120-145mg/dL), last HbA1C 7% 6 months ago per patient report |
| 1392 |
- Occasional palpitation and diaphoresis after missing meals and resolves after orange juice. Tingling and numbness in feets, especially at night, worse in past 2 months. Loss of erections x 2 years, absence of early morning erections |
| 1393 |
- No wt/appetite changes, no special diet or exercise |
| 1394 |
ROS: Negative, except as above |
| 1395 |
Meds: Lovastatin, NPH insulin, aspirin, atenolol. All: NKDA |
| 1396 |
PMH: Hypercholesterolemia 2 years ago, MI 1 year ago. PSH: none |
| 1397 |
FH: Father died of a stroke at 60 yo. |
| 1398 |
SH: No smoking, drink whiskey on weekends, live with wife. |
| 1399 |
Work as a clerk |
| 1400 |
Pt is in NAD |
| 1401 |
VS: WNL |
| 1402 |
HEENT: PERRLA, fundoscopic exam normal - no AV nicking, hemorrhages, exudates |
| 1403 |
Neck: No carotid bruits, no JVD |
| 1404 |
CV: RRR, N S1/S2, no MRG |
| 1405 |
Lungs: clear B/S b/l |
| 1406 |
Ext: no edema or cyanosis. DP and PT pulses 2+ b/l |
| 1407 |
Neuro: Muscle strength 5/5 in LE b/l. |
| 1408 |
DTRs: symmetric 2+ knee, absent ankle and Babinski reflexes b/l. Diminished pinprick sensation on plantar surfaces b/l |
| 1409 |
Pt is in NAD |
| 1410 |
VS: WNL |
| 1411 |
HEENT: NC/AT, EOMI, PEERLA |
| 1412 |
Neck: NL Thyroid, no LAD |
| 1413 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1414 |
Lungs: Clear BS b/l |
| 1415 |
Abd: +BS in all 4Q, tympanic in 4Q, nondistended, NT no masses |
| 1416 |
Neuro: Bitemporal decreased visual fields. CN 3-12 grossly intact, |
| 1417 |
DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1418 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1419 |
HPI: |
| 1420 |
35yo F c/o vaginal discharge |
| 1421 |
- Started 4 days ago, getting worse |
| 1422 |
- 4 tablespoon/day, frothy, greenish malodorous discharge, no blood |
| 1423 |
- Vaginal itching |
| 1424 |
Ob/Gyn: Menarche at 14yo, G1P1, LMP 14 days ago, regular periods 3-4days/month, no OCP use. Last PAP smear 3 years ago was normal. |
| 1425 |
ROS: No fever, no change in bowel/urinary habits |
| 1426 |
Meds: No Rx or OTC. ALL: NKDA |
| 1427 |
FH: noncontributory. PMH: Gonorrhea 1 year ago, treated with AB |
| 1428 |
PSH: none. No trauma. 1 hospitalization 5 years ago due to delivery |
| 1429 |
SxH: Sex. active with 3 M partners pharynx x 1 year, they use condoms inconsistently. HIV test - never. |
| 1430 |
SH: Smoke 1 ppd*10 years, no EtOH/drugs. Works as Waitress |
| 1431 |
Pt is in NAD |
| 1432 |
VS: WNL |
| 1433 |
HEENT: NC/AT, EOMI, PEERLA, no oral or pharynx lesions |
| 1434 |
Neck: NL Thyroid, no LAD |
| 1435 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1436 |
Lungs: Clear BS b/l |
| 1437 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, no masses. Mild tenderness in lower part of the abdomen, no rebound or guarding |
| 1438 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1439 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1440 |
HPI: |
| 1441 |
39 yo F c/o neck mass |
| 1442 |
- Noticed mass 1 month ago - single 2 cm mass on right side of her neck, painless, no change in size |
| 1443 |
- Fever, night sweats, lost 10 lbs x 1 month, loss of appetite, early satiety |
| 1444 |
- No heat intolerance, skin changes, tremor, palpitations, hoarseness, cough, difficulty breathing, difficulty swallowing or abdominal pain |
| 1445 |
Ob/Gyn: G1P1, LMP 14 days ago, last PAP smear 1 year ago was normal |
| 1446 |
ROS: No change in bowel/urinary habits. Meds: no RX or OTC. |
| 1447 |
ALL: NKDA. PMH: none. FH: husband - recently discharged from prison, mother - h/o gastric cancer. PSH: none, no traumas or hospital. |
| 1448 |
SxH: Monogamous with husband, no h/o STD. |
| 1449 |
SH: smoke 1 ppd*15 years, no EtOH/drugs. Works as engineer. |
| 1450 |
Pt is in NAD |
| 1451 |
VS: Fever 37.5C |
| 1452 |
HEENT: NC/AT, EOMI, PEERLA, no lid lag, no conjunctival pallor |
| 1453 |
Neck: Single, mobile, painless 2 cm mass on the right side of her neck. No LAD. NL Thyroid gland, no carotid bruits |
| 1454 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1455 |
Lungs: Clear BS b/l |
| 1456 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1457 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact, Sensation intact. Muscle strength 5/5 throughout |
| 1458 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1459 |
HPI: |
| 1460 |
33 yo F c/o left knee pain |
| 1461 |
- Started 2 days ago, causing difficulty in walking |
| 1462 |
- Constant, 7/10, dull pain, no radiation |
| 1463 |
- Aggrav by moving L knee and walking, Allev by rest and Tylenol |
| 1464 |
- She has swelling and redness in L knee, mild fever, no traumas |
| 1465 |
- History of fatigue, painful wrists, and fingers, 1-hour morning stiffness in past 6 months. Multiple oral ulcers, resolved last month |
| 1466 |
- She describes Raynaud phenomenon but denies rash, photosensitivity, hair loss or recent tick bites |
| 1467 |
ROS: no change in bowel/urinary habits, 10lbs wt loss x 6 months |
| 1468 |
Meds: Tylenol. ALL: NKDA. FH: mother - rheumatoid arthritis |
| 1469 |
PMH: Gout 5 years ago, Gonorrhea 1 year ago. |
| 1470 |
PSH: 2 C-sections, 2 spontaneus abortions. |
| 1471 |
SxH: Sex active with 4 males x 1 year, inconsistent condom use. |
| 1472 |
SH: 1 ppd*10 years, drinks 2-4 beers/week, CAGE 0/4, no illicit drugs. |
| 1473 |
Works as waitress |
| 1474 |
Pt is in NAD |
| 1475 |
VS: WNL except fever 37.7^C |
| 1476 |
HEENT: NC/AT, EOMI, PEERLA, no oral lesions |
| 1477 |
Neck: NL thyroid, no carotid bruits |
| 1478 |
Neuro: CN 2-12 intact, DTRs 2+ intact, symmetric. Muscle strength 5/5 throughout |
| 1479 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1480 |
Lungs: clear BS b/l |
| 1481 |
Abd: +4BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1482 |
Ext: Erythema, tenderness, pain, swelling, restricted ROM of L knee |
| 1483 |
Fingers and hands with stiffness b/l |
| 1484 |
HPI: 18yo M c/o pain in the hands |
| 1485 |
- Started 2 months ago, getting worse |
| 1486 |
- 4/10, intermittent, burning pain in the interphalangeal joints of both hands, no radiation |
| 1487 |
- Allev. y Ibuprofen, Arrgav. when he moves his fingers |
| 1488 |
- Scaly lesions on the elbows and knees |
| 1489 |
- No headache, no wt/appt change, no night sweats |
| 1490 |
ROS: No fever, no change in bowel/urinary habits |
| 1491 |
Meds: Ibuprofen. ALL: NKDA. |
| 1492 |
FH: mother - SLE. PMH: had similar episode 1 year ago |
| 1493 |
PSH: None, no trauma or surgery. SxH: Sex. active with girlfriend x 1 year, they use condoms, no h/o STD |
| 1494 |
SH: smoke 1 ppd*2 years, no EtOH/drugs. College student |
| 1495 |
Pt is in NAD |
| 1496 |
VS: WNL |
| 1497 |
HEENT: NC/AT. EOMI. PEERLA. No oral or pharynx lesions |
| 1498 |
Neck: NL Thyroid, no LAD |
| 1499 |
CV: RRR, N S1/S2, no MRG |
| 1500 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1501 |
Ext: Inflammation and pain during palpation and moving in the interphalangeal joints of both hands. Scaly, salmon pink lesions on the extensor surface of his elbows and knees |
| 1502 |
HPI: |
| 1503 |
25 yo F c/o after being sexually and physically assaulted |
| 1504 |
- Event happened 3 hours ago - she was leaving a bar and was beaten and raped by 2 unknown men. No police report. Vaginal intercourse, without |
| 1505 |
condoms, unsure about ejaculation. |
| 1506 |
- LMP 3 weeks ago, no OCP use or other contraception |
| 1507 |
- Sharp right chest pain, no radiation, aggrav by deep breath, allev by sit still |
| 1508 |
- Dull pain in all abdomen. No vaginal bleeding, not urinate or defecate since event |
| 1509 |
ROS: No LOC, headache, dizziness, weakness, nausea, vomiting |
| 1510 |
Meds: No Rx or OTC. All: NKDA. FH: none. PMH: no prev. assaults |
| 1511 |
PSH: none. No hospital. or traumas. SxH: with girlfriend 6 months |
| 1512 |
SH: Full-time student. Etoh occasionally, no cig/drugs |
| 1513 |
Pt is anxious and in acute distress |
| 1514 |
VS: SOB |
| 1515 |
Chest: Tenderness on palpation of right lateral chest wall, tympanic to percussion b/l, BS b/l. No wheezes, rales or rhonchi |
| 1516 |
CV: RRR, N S1/S2, no MRG |
| 1517 |
Abd: +BS in all 4Q, tympanic in all 4Q, ND, NT, no masses |
| 1518 |
Neuro: CN 2-12 intact. Muscule strength 5/5 in UE and LE b/l |
| 1519 |
Mental exam: AAO in person, place, time |
| 1520 |
Ext: Bruises in both wrists, ROM intact. |
| 1521 |
HPI: 40 yo F c/o double vision and droopy eyelids |
| 1522 |
- Started 1 month ago, no progression, 3-4 episodes per week |
| 1523 |
- Episodes starting at night with normalization by morning |
| 1524 |
- No palpitations, dizziness or LOC |
| 1525 |
- No headache or h/o head trauma |
| 1526 |
ROS: No fever, no change in bowel/urinary habits |
| 1527 |
Meds: Synthroid. ALL: NKDA |
| 1528 |
FH: father died of Brain cancer age 60, mother - Multiple sclerosis |
| 1529 |
PMH: Hypothyroidism x 10 years. PSH: none, no traumas or hospital |
| 1530 |
SH: 1 ppd*15 years, no EtOH/drugs. Works as engineer |
| 1531 |
Pt is in NAD |
| 1532 |
VS: WNL |
| 1533 |
HEENT: Ptosis and diplopia b/l, PEERLA, NC/AT |
| 1534 |
Neck: NL thyroid, no carotid bruits |
| 1535 |
Lungs: Clear BS b/l |
| 1536 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1537 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1538 |
Neuro: CN 5, 7-12 grossly intact. Muscle strength 5/5 in all extremities. DTRs 2+ symmetric, intact. Sensation intact |
| 1539 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1540 |
HPI: The source of the information - mother of 4yo M child who c/o her child has fever |
| 1541 |
- Started 2 days ago, T=101F, measured it once(rectally), constant |
| 1542 |
- Diarrhea - 3-4 watery bowel movement per day, no blood |
| 1543 |
- Vomiting - 2 times per day - contains food, no blood |
| 1544 |
- Lethargy, weakness. Dehydration(less urinary frequency than usual). No ear pulling or discharge |
| 1545 |
- Had contacts with 3 children in daycare with similar symptoms |
| 1546 |
ROS: Negative, except as above |
| 1547 |
FH: No major diseases. PMH: URI 3 months ago. PSH: None |
| 1548 |
Birth: Uncomplicated vagina delivery. Immuniz: UTD |
| 1549 |
Diet: Solid foods, vegetables, milk. Development: last checkup 1 month - normal wt/height and developmental milestones |
| 1550 |
none |
| 1551 |
Pt is in NAD |
| 1552 |
VS: BP 160/90 mm Hg |
| 1553 |
HEENT: NC/AT. EOMI. PEERLA |
| 1554 |
Neck: NL Thyroid. No LAD |
| 1555 |
Lungs: Clear BS b/l |
| 1556 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1557 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, no masses |
| 1558 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. |
| 1559 |
Muscle strength 5/5 throughout. Tenderness in the paraspinal area of the lower back. Straight leg raising negative b/l |
| 1560 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1561 |
HPI: |
| 1562 |
67 yo F c/o neck pain |
| 1563 |
- Started 2 days ago after rapid rotation of neck, constant severity |
| 1564 |
- Severity 2/10 at rest and 8/10 during head rotation, in left side of neck most severe, sharp, radiation to left arm |
| 1565 |
- Allev - holding head still, aggrav - turning head in any directions |
| 1566 |
- Tingling in left arm, no headache, nausea, vomiting |
| 1567 |
- No recent trauma or heavy lifting |
| 1568 |
ROS: Lost 10 lbs in past 6 months, decreased appetite, no fever, no change in bowel/urinary habits |
| 1569 |
Meds: Calcium and Vit D supplements. |
| 1570 |
FH: mother - Osteoporosis, father - MI at 68 yo. PMH: Osteopenia. PSH: none. No traumas or hospital. |
| 1571 |
SH: with husband.Etoh - occasionally, no cigs/drugs. |
| 1572 |
Retired magazine editor |
| 1573 |
Pt is in NAD |
| 1574 |
VS: WNL |
| 1575 |
HEENT: NC, EOMI, PERRLA |
| 1576 |
Neck: No scars, deformations. Limited ROM x 6 2/2 pain. Tenderness to palpation on cervical spinous processes. Negative Lhermitte and Spurling |
| 1577 |
tests. |
| 1578 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1579 |
Ext: No skin changes in UE and LE, radial pulses 2+ b/l |
| 1580 |
Neuro: DTRs 2+ in UE and LE b/l, no Babinski b/l. Muscle strength 5/5 in |
| 1581 |
UE and LE b/l. Sensation: Loss of pinprick sensation on dorsum of L hand and posterior of L arm, forearm. No Kernig and Brudzinski signs |
| 1582 |
none |
| 1583 |
HPI: The source of the information - mother 8 mo F child, who c/o her child has abdominal pain |
| 1584 |
- Started suddenly 10 hours ago, getting worse |
| 1585 |
- Severe episodic pain, episodes lasts 20 minutes, child completely well between episodes |
| 1586 |
- Vomiting - 3 times, contains food, no blood |
| 1587 |
- Loose stools before 1-st episode and now stools is bloody |
| 1588 |
- Lethargy, weakness. Decreased urination(1 wet diaper x 10 hours) |
| 1589 |
ROS: Negative, except as above |
| 1590 |
FH: No major diseases. PMW: URI 3 months ago. PSH: None |
| 1591 |
Birth: Uncomplicated vaginel delivery. Immuniz: UTD |
| 1592 |
Diet: Breastfeeding, solid food, milk. |
| 1593 |
Development: Normal wt/height gain before this episode |
| 1594 |
none |
| 1595 |
HPI: 27yo M c/o chest pain |
| 1596 |
- Started 4 hours ago, no illicit event |
| 1597 |
- 9/10, constant, sharp, lower chest pain |
| 1598 |
- Aggrav when he takes deep breath. Allev - nothing |
| 1599 |
- No burning sensation in the chest |
| 1600 |
- He returned from a trip to the Asia 2 days ago |
| 1601 |
ROS: No fever, no change in bowel/urinary habits |
| 1602 |
Meds: None. ALL: NKDA. PMH: noncontributory. FH: none |
| 1603 |
PSH: none. SxH: monogamous with wife |
| 1604 |
SH: No cig/EtOH/drugs. Works as School teacher |
| 1605 |
Pt is distressed |
| 1606 |
VS: BP 115/75 mm Hg, HR 108/min |
| 1607 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1608 |
Lungs: No chest wall tenderness. Clear BS b/l. No signs of consolidation |
| 1609 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1610 |
HPI: |
| 1611 |
68 yo M c/o abdominal pain |
| 1612 |
- Started 3 days ago, intermittent, no progression |
| 1613 |
- Severity 6/10, dull pain in LLQ, no radiation |
| 1614 |
- Recent onset of alternating diarrhea and constipation |
| 1615 |
- He consumes low-fiber, high-fat diet |
| 1616 |
ROS: Fever 101F, no change in urinary habits |
| 1617 |
Meds: Captopril, HCTZ. ALL: NKDA |
| 1618 |
FH: mother - Ulcerative colitis. PMH: HTN x 20 years. |
| 1619 |
PSH: none. No trauma or hospital. SxH: Monogamintermittentous with wife, no h/o STD. |
| 1620 |
SH: Smoke 1 ppd*30 years, no EtOH/drugs. Works as Engineer |
| 1621 |
Pt is in NAD |
| 1622 |
VS: Fever 101F. BP 150/90 mm Hg |
| 1623 |
HEENT: Conjunctival pallor. NC/AT, EOMI, PEERLA |
| 1624 |
Lungs: Clear BS b/l |
| 1625 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1626 |
Abd: Tenderness in LLQ, no rebound or guarding. +BS in all 4Q, tympanic in 4Q. No Murphy sign |
| 1627 |
Neuro: CN 2-12 grossly intact. DTRs2+, symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1628 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1629 |
HPI: The source of information - mother of 12 mo M who c/o her child has fever |
| 1630 |
- Started 2 days ago, measured it once(rectally), T=101F, constant |
| 1631 |
- No cough, ear pulling, discharge |
| 1632 |
- Maculopapular rash on face and body |
| 1633 |
- Child looks tired, irritated, poor sleep/appt |
| 1634 |
- Sick contact - neighbor child with URI 4 days ago |
| 1635 |
- No day care attending |
| 1636 |
- No change in bowel/urinary habits, 5-6 wet diapers/day |
| 1637 |
ROS: Negative except as above. Meds: Tylenol. ALL: NKDA |
| 1638 |
FH: No major diseases. PMH: Jaundice in the 1-st week of life |
| 1639 |
PSH: None. Birth: Uncomplicated vaginal delivery. |
| 1640 |
Immuniz: not yet received MMR vaccine |
| 1641 |
Diet: Breastfeeding and baby food. Development: Last checkup 2 weeks ago - normal wt/height and developmental milestones |
| 1642 |
none |
| 1643 |
Pt is in NAD |
| 1644 |
VS: Fever 101.2F |
| 1645 |
HEENT: NC/AT, EOMI, PEERLA, no oral or pharynx lesions |
| 1646 |
Neck: NL Thyroid, no LAD |
| 1647 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1648 |
Lungs: CTAB/l |
| 1649 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1650 |
Musculoskeletal: R knee in warm, swollen, tender to palpation. ROM decreased(flexion/extension) in R knee. Anterior and Posterior drawer signs are negative. Ballottement test negative |
| 1651 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1652 |
HPI: |
| 1653 |
60 yo M c/o chest pain |
| 1654 |
- Started 30 minutes ago, constant severity, start during sleep |
| 1655 |
- 8/10, pressure, mid chest pain, radiation to left arm |
| 1656 |
- Allev - nothing, accompanied by SOB, nausea and sweating |
| 1657 |
- No vomiting, cough, stomach pain during this episode |
| 1658 |
ROS: no change in appetite, bowel/urinary habits, no fever |
| 1659 |
Meds: Captopril, HCTZ, Atorvastatin, Aspirin. ALL: NKDA |
| 1660 |
FH: father - died of MI at age 60. PMH: Hyperlipidemia, HTN x 15 years. |
| 1661 |
PSH: none, no traumas or hospital. SxH: Monogamous with wife |
| 1662 |
SH: Smoked 1 ppd*35 years, quite 2 months ago, no EtOH, drugs. |
| 1663 |
Works as School Teacher |
| 1664 |
Pt is in NAD, obese |
| 1665 |
VS: BP 165/85 mm Hg, HR 90/minute |
| 1666 |
CV: no chest wall tenderness, RRR, N S1/S2, PMI nondisplaced |
| 1667 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 1668 |
HPI: |
| 1669 |
50 yo F c/o headache |
| 1670 |
- Started 3 weeks ago, intermittent, 3-4 episodes per week x 2-3 hours at the end of workday |
| 1671 |
- Bilateral headache, 8/10, squeezing, no radiate, sometimes feel nausea during pain |
| 1672 |
- Aggrav by stress(she has a lot of stress at work now) |
| 1673 |
- No vomiting, tingling, numbness, visual changes or speech difficiences. No head trauma |
| 1674 |
- Reduces caffeine uptake to from 5-6 cups/day to 1-2 cups/day. |
| 1675 |
ROS: poor appetite and sleep.No changes in wt, bowel/urinary habits |
| 1676 |
Meds: Ibuprofen. ALL: NKDA. FH: mother - migraines. PMH: Migraines during College studying. PSH: C-section at 25yo. |
| 1677 |
SxH: with husband |
| 1678 |
SH: No cigs/EtOH/drugs. |
| 1679 |
Works as Engeneer, has a lot of stress at work. |
| 1680 |
Pt is in NAD |
| 1681 |
VS: WNL |
| 1682 |
HEENT: NC/AT, EOMI, PEERLA, no papilledema |
| 1683 |
Neck: Supple, no carotid bruits, no LAD, NL thyroid gland |
| 1684 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1685 |
Abd: +BS in all 4Q, tympanic in 4Q. NT, ND, no masses |
| 1686 |
Neuro: CN 2-12 intact, DTRs 2+ intact, symmetric. Muscle strength 5/5 throughout |
| 1687 |
HPI: 54 yo F c/o cough |
| 1688 |
- Persistent cough x 4 years, gotten worse in last 1 month |
| 1689 |
- Allev - nothing |
| 1690 |
- Fatigue x 2 months, SOB, lost 6 lbs in 2 months |
| 1691 |
- Decreased appetite, mild fever with sweating |
| 1692 |
- 2 teaspoon blood-steaked thick and viscous mucus |
| 1693 |
- Contacts with peoples with TB during last month |
| 1694 |
- No h/o recent travel |
| 1695 |
- No chest pain, rash, change in voice or LAD |
| 1696 |
ROS: no change in bowel/urinary habits |
| 1697 |
Meds: albuterol inhaler, OTC cough syrup, multivitamins. ALL: NKDA |
| 1698 |
FH: mother - Alzheimer disease |
| 1699 |
PMH: chronic bronchitis. Tonsillectomy and adenoidectomy in 11 yo |
| 1700 |
SxH: monogamous with husband of 20 years |
| 1701 |
SH: Smoked 1 ppd*35 years, quite 2 weeks ago. Work as nurse's aide. |
| 1702 |
Pt is in NAD |
| 1703 |
VS: fever 37.5^C, SOB |
| 1704 |
HEENT: no oral or pharynx lesions |
| 1705 |
Neck: no LAD |
| 1706 |
CV: RRR, N S1/S2, no MRG |
| 1707 |
Lungs: BS, wheezing and rhonchi b/l, VTF intact |
| 1708 |
Ext: clubbing of the fingers and toes with cyanosis of the lips |
| 1709 |
HPI: 70 yo M c/o chest pain |
| 1710 |
- Started 4 hourse ago, getting worse |
| 1711 |
- 7/10, sharp, bilateral chest pain, no radiation |
| 1712 |
- Allev-nothing, accompanied by SOB, sweating |
| 1713 |
- No vomiting, cough, wheezing, stomach pain during this episode |
| 1714 |
ROS: Mild fever, no change in bowel/urinary habits |
| 1715 |
Meds: Captopril, Aspirin, Ibuprophen. ALL: NKDA. |
| 1716 |
FH: Noncontributory. PMH: HTN, Osteoarthritis x 10 years. |
| 1717 |
PSH: Hip replacement surgery 5 days ago. SxH: Monogamous with husband. SH: no cig/EtOH/drugs. Retired school teacher. |
| 1718 |
Pt is anxious |
| 1719 |
VS: BP 90/60 mm Hg, HR 90/minute, RR 35/minute |
| 1720 |
HEENT: no chest wall tenderness,NC/AT, EOMI, PEERLA, no papilledema |
| 1721 |
Neck: NL thyroid gland, no LAD, no carotid bruits |
| 1722 |
CV: Tachycardia, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1723 |
Lungs: Clear BS b/l |
| 1724 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1725 |
Neuro: CN 2-12 grossly intact, DTRs 2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1726 |
Ext: No edema, clubbing or cyanosis, radial pulses 2+ b/l |
| 1727 |
Pt is in NAD |
| 1728 |
VS: BP 150/90 mm Hg |
| 1729 |
HEENT: Malar rash on the face. NC/AT, EOMI, PEERLA. No oral or pharynx lesions |
| 1730 |
Neck: NL Thyroid, no LAD |
| 1731 |
CV: RRR. N S1/S2, no MRG, PMI nondisplaced |
| 1732 |
Lungs: Clear BS b/l |
| 1733 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1734 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1735 |
Ext: Edema and inflammation interphalangeal joints of her hands, pain during palpation and movement |
| 1736 |
Pt is in NAD |
| 1737 |
VS: WNL, except for BP 150/95 mm Hg |
| 1738 |
HEENT: NC/AT, EOMI, PEERLA |
| 1739 |
Neck: NL Thyroid, no JVD, no Carotid bruit |
| 1740 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1741 |
Lungs: CTAB/L |
| 1742 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1743 |
Neuro: CN 2-12 grossly intact. DTRs1+ symmetric. Sensation intact. Muscle strength 5/5 throughout |
| 1744 |
Mental exam: AAO x 3, spells backward, recall 1/3 items, obeys 2/3 commands, judgment and thought process intact |
| 1745 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1746 |
HPI: 23 yo F c/o irregular cycles |
| 1747 |
- Started 6 months ago, LMP 1 month ago, no change in flow |
| 1748 |
- Used to have regular cycles 5d/1month, now 5d/3-6 weeks |
| 1749 |
- No vaginal discharge, no spotting or pain during periods |
| 1750 |
- Menarche age 14, G0P0 |
| 1751 |
- Headache, breast milky discharge b/l |
| 1752 |
- No vision problems |
| 1753 |
- No change in skin, voice, no cold intolerance |
| 1754 |
- Excessive hair on abdomen, 10lbs wt gain x 4months |
| 1755 |
ROS: no nausea/vomiting, no change in bowel/urinary habits |
| 1756 |
Meds: no Rx or OTC. ALL: NKDA.FH: no h/o irregular cycles in mother |
| 1757 |
PMH: no similar problems before. PSH: none. No hospital or traumas |
| 1758 |
SxH: monogamous with husband, can't conceive x 1 year. |
| 1759 |
SH: no cig/EtOH/drugs |
| 1760 |
Pr is in NAD |
| 1761 |
VS: WNL |
| 1762 |
HEENT: no pallor, no excessive hair on face,EOMI,visual fields intact |
| 1763 |
Neck: NL thyroid gland |
| 1764 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1765 |
Est: no skin changes, DTRs 2+ b/l in LE |
| 1766 |
HPI: 55 yo M c/o chest pain |
| 1767 |
- Started 3 months ago, intermittent, episodes duration 2 minutes |
| 1768 |
- 6/10, dull, pressure retrosternal chest pain, no radiation |
| 1769 |
- Allev by rest, occurs and Aggrav by exercise |
| 1770 |
- No related to food intake |
| 1771 |
- No vomiting, cough, wheezing, stomach pain during episode |
| 1772 |
ROS: No fever, no change in bowel/urinary habits |
| 1773 |
Meds: Captopril, HCTZ. ALL: NKDS. PMH: HTN x 10 years |
| 1774 |
FH: father died of MI - age 60. PSH: appendectomy at 25 yo |
| 1775 |
SxH: With wife, avoids sex x 3 month due to chest pain exacerbation |
| 1776 |
SH: 1 ppd*25 years, drinks 2-3 beers/weekend, no illicit drugs |
| 1777 |
Works as Engineer |
| 1778 |
Pt is in NAD |
| 1779 |
VS: BP 160/90 mmHg |
| 1780 |
HEENT: NC/AT, EOMI, PEERLA |
| 1781 |
Neck: NL thyroid, no carotid bruits |
| 1782 |
CV: No chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1783 |
Lungs: Clear BS b/l |
| 1784 |
Abd: + BS in all 4Q, ND, NT, no masses |
| 1785 |
Neuro: CN 2-12 grossly intact, DTRs 2+ symmetric, intact. Sensation to soft and pinprick intact. Muscle strength 5/5 throughout |
| 1786 |
Ext: no clubbing, edema or cyanosis, radial pulses 2+ b/l |
| 1787 |
HPI: 37yo F c/o painful intercourse |
| 1788 |
- Started 2 years ago |
| 1789 |
- 2/10 vaginal pain during penetration, no radiation |
| 1790 |
- Irregular cycles 4-6d/3-6 weeks. Spotting, pain during periods |
| 1791 |
- Inability to conceive x 2 years - regular sex. activity without contraception |
| 1792 |
- Menarche at 14yo, G0P0, LMP 25 days ago, PAP smear 1 year ago was normal |
| 1793 |
- No headache, no nausea/vomiting, no skin changes |
| 1794 |
ROS: No fever, no change in bowel/urinary habits |
| 1795 |
Meds: Multivitamins. ALL: NKDA |
| 1796 |
FH: noncontributory. PMH: none |
| 1797 |
PSH: None, no trauma or hospital. SxH: Monogamous with husband, no h/o STD. SH" no cig/EtOH/drugs, work as Accountant |
| 1798 |
Pt is in NAD |
| 1799 |
VS: WNL |
| 1800 |
HEENT: NC/AT, EOMI, PEERLA |
| 1801 |
Neck: NL Thyroid, no LAD |
| 1802 |
CV: RRR, N S1/S2, no MRG, PMIO nondisplaced |
| 1803 |
Lungs: Clear BS b/l |
| 1804 |
Abd: Mild tenderness in lower abdomen. +BS in all 4Q, tympanic in 4Q, no masses |
| 1805 |
HPI: 32yo F c/o Headache |
| 1806 |
- Started 5 hours ago, getting worse |
| 1807 |
- 8/10, sharp pain, located throughout entire head, no radiation |
| 1808 |
- Aggrav. by light and some smells. Allev by rest in dark room |
| 1809 |
- Nausea, vomited 1 time, vomitus contains food, no blood |
| 1810 |
- No h/o recent falls, no trauma, no LOC, no Dizziness |
| 1811 |
- No caffeine or energy drinks |
| 1812 |
Ob/Gyn: G1P1, Menarche 15yo, LMP 14 days ago, last PAP smear 1 year ago was normal |
| 1813 |
ROS: No fever, no change in bowel/urinary habits |
| 1814 |
Meds: No Rx or OTC. ALL: NKDA |
| 1815 |
FH: Mother - migraines. PMH: Migraines for 2 years |
| 1816 |
PSH: Tonsillectomy at 9yo. SxH: Sex active with boyfriend, they use condoms, no h/o STD |
| 1817 |
SH: No cig/EtOH/drugs, works as Accountant |
| 1818 |
Pt is in NAD |
| 1819 |
VS: WNL |
| 1820 |
HEENT: NC/AT, EOMI, PEERLA, normal eye fundus |
| 1821 |
Neck: NL Thyroid, no JVD, no LAD |
| 1822 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1823 |
Lungs: Clear BS b/l |
| 1824 |
Abd: +BS in all 4q, tympanic in 4Q, ND, NT, no masses |
| 1825 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 1826 |
Mental exam: AAO x 3, skips, spells backward, recall 3 items, obeys 3 commands. Though process and judgment intact |
| 1827 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1828 |
HPI: |
| 1829 |
47yo M c/o impotence |
| 1830 |
- Started 3 months ago, getting worse |
| 1831 |
- Constant. No morning erections. No decreased libido |
| 1832 |
- No marital or work problems, no depression or anxiety |
| 1833 |
ROS: No fever, no change in bowel/urinary habits |
| 1834 |
Meds: Atenolol x 4 months. Insulin x 5 years. ALL: NKDA |
| 1835 |
FH: mother - DM2. PMH: HTN, DM2 x 10 years |
| 1836 |
PSH: None, no traumas or hospital. SxH: No sexually active x 3 months due to impotence. |
| 1837 |
SH: Smoke 1 ppd*15 years. Drinks 3-4 beers/weekend(CAGE: 0/4). No illicit drugs. Works as Accountant |
| 1838 |
Pt is in NAD |
| 1839 |
VS: BP 150/85 mm Hg |
| 1840 |
HEENT: NC/AT, EOMI, PEERLA |
| 1841 |
Neck: NL Thyroid, no carotid bruits, no JVD |
| 1842 |
CV: RRR, N S1/S2, no MRG, MPI nondisplaced |
| 1843 |
Lungs: Clear BS b/l |
| 1844 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1845 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation to soft and pinprick intact. Muscle strength 5/5 throughout |
| 1846 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1847 |
none |
| 1848 |
HPI: |
| 1849 |
26 yo M c/o cough |
| 1850 |
- Persistent cough x 1 week |
| 1851 |
- Associated with right sided chest pain, sharp, persistent, severity |
| 1852 |
8/10, no radiate, exacerbated by cough and deep breath |
| 1853 |
- 1 teaspoon white sputum, no blood |
| 1854 |
- No chills, night sweats, SOB or wheezing, mild fever |
| 1855 |
- 2 weeks ago he experienced fever rhinorrhea, sore throat |
| 1856 |
- No recent travel or TB exposure. PPD test - never. |
| 1857 |
ROS: No change in bowel/urinary habits |
| 1858 |
Meds: Tylenol. All: NKDA. FH: Noncontributory. PMH: Gonorrhea 2 years |
| 1859 |
ago, treated with antibiotics.PSH:none.No traumas or hospital |
| 1860 |
SxH: Unprotected sex with multiple female partners |
| 1861 |
SH: Smoke 1 ppd*15 years. Drinks heavily, CAGE 0/4 |
| 1862 |
Pt is in NAD |
| 1863 |
VS: Fever 37.7^C |
| 1864 |
HEENT: Nose mouth and pharynx WNL |
| 1865 |
Neck: No LAD, no JVD |
| 1866 |
Lungs: Increase in tactile fremitus and decrease in breath sounds on R side. No rhonchi, rales or wheezing |
| 1867 |
CV: RRR, N S1/S2, no MRG |
| 1868 |
Ext: no edema or cyanosis, radial pulses 2_ b/l |
| 1869 |
HPI: 42yo M c/o pre-employment medical check-up |
| 1870 |
- Cough, started 5 years ago, getting worse |
| 1871 |
- 1/2 teaspoon of mucus, dark color, no blood or odor |
| 1872 |
- Recently immigrated from Africa(2 years ago) |
| 1873 |
- No night sweating, chest pain, wt loss |
| 1874 |
- No contacts with peoples with TBC |
| 1875 |
ROS: No fever, no change in bowel/urinary habits |
| 1876 |
Meds: Calcium, Vitamin D. ALL: NKDA |
| 1877 |
FH: Noncontributory. PMH: None, except as above |
| 1878 |
PSH: None, no trauma or surgeries. |
| 1879 |
SxH: Monogamous with wife, they use condoms, no h/o STD |
| 1880 |
SH: Smoke 1 ppd*10 years, no EtOH/drugs. Worked as a coal miner x 6 years |
| 1881 |
Pt is in NAD |
| 1882 |
VS: WNL |
| 1883 |
HEENT: NC/AT, EOMI, PEERLA, no oral or pharynx lesions |
| 1884 |
Neck: NL Thyroid, no LAD |
| 1885 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 1886 |
Lungs: BS, wheezing and rhonchi b/l. VTF intact, no dullness to percussion. No pain on palpation |
| 1887 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1888 |
Ext: No edema, cyanosis, clubbing or nails deformations. Radial pulses 2+ b/l |
| 1889 |
HPI - 31 yo M c/o heel pain |
| 1890 |
- Started 2 weeks ago, gradual, intermittent, no progression |
| 1891 |
- 7/10, stretching/tearing pain on the plantar surface of R heel, radiation to arch |
| 1892 |
- Allev - massage, applying ice, ibuprofen. Aggrav by walking barefoot or walking after sitting |
| 1893 |
- No weakness, numbness, burning or tingling. No fatigue or fever |
| 1894 |
ROS: no change in wt/appetite, bowel/urinary habits |
| 1895 |
Meds: Ibuprofen. ALL: NKDA. FH: father with arthritis |
| 1896 |
PMH: Noncontributory. PSH: no. No traumas or hospital |
| 1897 |
SxH: Monogamous with wife. SH: Drinks 2 beers/week, no smoking or illicit drugs. Work as an accountant. Marathon runner |
| 1898 |
Pt is in NAD |
| 1899 |
VS: WNL |
| 1900 |
CV: no chest wall tenderness, RRR, N S1/S1, no MRG, PMI nondisplaced |
| 1901 |
Lungs: clear BS b/l |
| 1902 |
Abd: +4BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1903 |
Neuro: CN 2-12 grossly intact. Muscle strength 5/5 throughout. |
| 1904 |
Sensation intact, symmetric. DTRs 2+ in LE b/l |
| 1905 |
Ext: ROM of hip/knee/ankle and foot WNL b/l. DP and PT pulses 2+ b/l. Tender to palpation over medial calcaneal tuberosity and plantar fascia R LE. Plantar heel and arch pain with dorsiflexion of toes of R LE |
| 1906 |
HPI: 30yo M c/o wrist pain |
| 1907 |
- Started 1 month ago, getting worse |
| 1908 |
- 2/10, intermittent, burning pain and numbness in the palm and 1st, 2nd, 3rd fingers of R hand, no radiation |
| 1909 |
- Aggrav. in the night, Allev. by loose shaking of the R hand |
| 1910 |
- No headache, skin changes, vision problems |
| 1911 |
Ob/Gyn: G0P0, LMP 14 days ago, Menarche at 15yo. Use OCP. |
| 1912 |
ROS: No fever, no change in bowel/urinary habits |
| 1913 |
Meds: Ibuprofen, OCP. ALL: NKDA. |
| 1914 |
FH: noncontributory. PMH: none. PSH: none. No traumas or hospital |
| 1915 |
SxH: Monogamous with husband. SH: Smoke 1 ppd*10 years, drinks 2-3 beers/weekend(VAGE: 0/4), no drugs. Works as Secretary |
| 1916 |
Pt is in NAD |
| 1917 |
VS: WNL |
| 1918 |
HEENT: NC/AT, EOMI, PEERLA |
| 1919 |
Neck: NL Thyroid, no LAD |
| 1920 |
CV: RRR, N S1/S2, no MRG |
| 1921 |
Lungs: Clear BS b/l |
| 1922 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1923 |
Neuro: Decreased sensation and muscle strength(3/5) in the 1st, 2nd, 3rd fingers of R hand. DTRs2+ symmetric, intact. Positive Tinel sign on R |
| 1924 |
hand |
| 1925 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 1926 |
HPI: |
| 1927 |
46 yo M c/o chest pain |
| 1928 |
- Started 40 minutes ago, constant severity, start during sleep, |
| 1929 |
- 7/10, pressure, mid chest pain, radiation to neck, upper back, left |
| 1930 |
arm, |
| 1931 |
- Allev - nothing, accompanied by SOB, nausea, and sweating |
| 1932 |
- No vomiting, cough, wheezing, stomach pain during this episode |
| 1933 |
ROS: no change in appetite, bowel/urinary habits, no fever |
| 1934 |
Meds: Maalox, diuretic. All: NKDA |
| 1935 |
FH: father - died of Lung Cancer at age 72, mother - Peptic Ulcer |
| 1936 |
PMH: HTN for 5 years, high cholesterol, GERD 10 years ago, no traumas |
| 1937 |
PSH: none. No traumas or hospital |
| 1938 |
SH: Monogamous with wife, avoids sex 3 months due to chest pain. Cocain use - 10 years, no EtOH. 1 ppd*25 year, quite 3 months ago. |
| 1939 |
Works as accountant |
| 1940 |
Pt is in NAD |
| 1941 |
VS: WNL except for BP 165/85 mm Hg, HR 90/minute |
| 1942 |
CV: no chest wall tenderness, RRR, N S1/S2, no MRG, PMI nondisplaced in upright or lying position. |
| 1943 |
Lungs: clear BS b/l |
| 1944 |
Ext: no edema or cyanosis, radial pulses 2+ b/l |
| 1945 |
Pt is in NAD, obese. |
| 1946 |
VS: BP: 160/90 mm Hg |
| 1947 |
HEENT: NC/AT, EOMI, PEERLA, no oral or pharynx lesions |
| 1948 |
Neck: NL Thyroid, no LAD |
| 1949 |
CV: RRR, N S1/S2, no MRG |
| 1950 |
Lungs: Clear BS b/l |
| 1951 |
Abd: + BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1952 |
Ext: Swelling and deformation of the R knee. Palpation and moving in R knee is painful. No cyanosis. Radial and pedal pulses 2+ b/l |
| 1953 |
HPI: The source of information is the mother of 18mo M child who c/o her child has a fever |
| 1954 |
- Started 2 days ago, measured it once, T=101F rectally, constant |
| 1955 |
- R ear pulling x 2 days, no discharge |
| 1956 |
- Rash started on face 2 days ago, spread to chest and back |
| 1957 |
- No preauricular lymph node swelling, no vomiting or seizures |
| 1958 |
- Refuses to eat x 2 days, still drinks milk and water |
| 1959 |
- No change in bowel/urinary habits, 5-6 wet diapers/day |
| 1960 |
- Child less active, looks tired, poor sleep |
| 1961 |
- No sick contacts at home or day care |
| 1962 |
Meds: Tylenol. All: NKDA. FH: no major diseases |
| 1963 |
PMH: ear infection 3 months ago, treated with AB. PSH: none |
| 1964 |
Birth: no complications during pregnancy, term vaginal delivery |
| 1965 |
Immuniz: UTD. Diet: milk, solid foods, didn't breastfeed him |
| 1966 |
Development: wt/height gain appropriate to age, walking, talking |
| 1967 |
none |
| 1968 |
HPI: |
| 1969 |
20 yo F c/o inability to sleep |
| 1970 |
- Started 6 months ago, worsened over past month |
| 1971 |
- Difficulty falling and staying asleep. Need 8 hours/day sleep, but getting only 4 hours/day. Difficulty getting up after alarm |
| 1972 |
- Tired all day, inability to concentrate during classes or driving |
| 1973 |
- Snoring x 2 months. Drinks 4-5 cups of coffee/day |
| 1974 |
- Stressed about her performance in school |
| 1975 |
- Lost 6 lbs x 1 month, complains on sweaty palms and palpitations |
| 1976 |
ROS: Increased bowel movements from 1/day to the 3-4/day, no blood in stool. No change of urinary habits. No fever. No changes in hair/skin. No heat/cold intolerance. Ob/Gyn: LMP 2 weeks ago, periods is regular. |
| 1977 |
Sex with boyfriend, use OCP and condoms. |
| 1978 |
Meds: OCP, Multivitamins. ALL: NKDA. PMH: None. PSH: Tonsillectomy at 11 yo. FH: None. SH: EtOH occasionally, no cigs/drugs. Student. |
| 1979 |
Pt appers anxious and restless |
| 1980 |
VS: WNL except for HR 102/minute |
| 1981 |
HEENT: no lid lag, no exophthalmos. EOMI |
| 1982 |
Neck: NL thyroid gland |
| 1983 |
CV: Tachycardic, N S1/S2, no MRG, PMI nondisplaced |
| 1984 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 1985 |
Ext: tremor of outstretched hands. DTRs 3+ b/l |
| 1986 |
Skin: Normal, no rashes, palms moist |
| 1987 |
HPI: The source of the information - mother of 15yo M child, who c/o her child falling grades in the school |
| 1988 |
- Started 1 year ago, getting worse |
| 1989 |
- Associated with school absenteeism, legal problems, shoplifting |
| 1990 |
- Spend most of his time alone in his room |
| 1991 |
- Has new set of friends |
| 1992 |
ROS: No fever, no change in bowel/urinary habits |
| 1993 |
Meds: No Rx or OTC ALL: NKDA |
| 1994 |
Birth: Term vaginal delivery, no complication during pregnancy |
| 1995 |
FH: father had conduct disorder. Diet: junk food |
| 1996 |
Immuniz: UTD. Development: Normal weight/height gain, normal gross and fine motor development, normal speech |
| 1997 |
Last checkup: 1 month ago was normal except behavior problems |
| 1998 |
none |
| 1999 |
HPI: 38 yo M c/o dysphagia |
| 2000 |
- Started 2 months ago, getting worse |
| 2001 |
- Pain on swallowing solids Morethan fluids: |
| 2002 |
- Severity 7/10, in throat, burning pain, no radiation |
| 2003 |
- Lost 10 lbs x 2 months |
| 2004 |
ROS: No fever, no change in bowel/urinary habits |
| 2005 |
Meds: No Rx or OTC. ALL: NKDA. FH: noncontributory |
| 2006 |
PMH: Gonorrhea 1 year ago, treated with AB |
| 2007 |
PSH: none. No traumas or hospital. SxH: Sex. active with multiple female partners, condoms - inconsistently. |
| 2008 |
SH: Smoke 1 ppd*18 years, no etoh/drugs. Works as Engineer |
| 2009 |
Pt is in NAD |
| 2010 |
VS: WNL |
| 2011 |
HEENT: Oral thrush. NC/AT, EOMI , PEERLA |
| 2012 |
Neck: Cervical lymphadenopathy, NL thyroid gland |
| 2013 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2014 |
Lungs: Clear BS b/l |
| 2015 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2016 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact, Sensation intact. Muscle strength 5/5 throughout |
| 2017 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2018 |
HPI: 55 yo F c/o dizziness |
| 2019 |
- Started this morning, constant |
| 2020 |
- Sensation of room spinning around her |
| 2021 |
- Nausea, vomited 1 time in past day |
| 2022 |
- No hearing loss, tinnitus, fullness in ear, ear discharge, headache or head trauma |
| 2023 |
ROS: Mild fever. No change in bowel/urinary habits |
| 2024 |
Meds: Tylenol. ALL: NKDA. FH: Noncontributory |
| 2025 |
PMH: URI 2 days ago. SxH: with husband. SH: No cigs/EtOH/drugs. Works as engineer |
| 2026 |
Pt is in NAD |
| 2027 |
VS: Fever 37.5C |
| 2028 |
HEENT: NC/AT, PEERLA, horizontal nystagmus |
| 2029 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2030 |
Lungs: clear BS b/l |
| 2031 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2032 |
Neuro: CN 2-12 grossly intact. Normal Rinne and Weber. Positive |
| 2033 |
Dix-Hallpike Maneuver(reproduce nystagmus). Muscle strength 5/5 throughout. DTRs 2+ b/l. Gait: unsteady |
| 2034 |
Ext: No edema or cyanosis. Radial pulses 2+ b/l |
| 2035 |
HPI: |
| 2036 |
57 yo M c/o blood in urine |
| 2037 |
- Started yesterday in the morning - only 1 time episode, no progression |
| 2038 |
- Increased urinary freq |
| 2039 |
- Urinary difficulty - need strain to urinate, weak urine stream and dribbing |
| 2040 |
- No pain during urination, no abdominal or flank pain |
| 2041 |
ROS: No change in wt/appetite, bowel habits, no nausea/vomit |
| 2042 |
Meds: Allopurinol |
| 2043 |
FH: Mother died at 80 yo from kidney problem |
| 2044 |
PMH: No similar problems before, no traumas. Ghout. |
| 2045 |
PSH: Appendectomy at 23 yo SxH: With girlfriend during 2 years, use condoms |
| 2046 |
SH: Works as Painter. 1 ppd x 30 years, EtOH 2 couples of beer 2-3 times per week |
| 2047 |
Pt is in NAD |
| 2048 |
VS: WNL |
| 2049 |
HEENT: no pallor |
| 2050 |
Back: No skin changes, tenderness or pain during palpation or percussion |
| 2051 |
Abd: +BS an all 4Q, tympanic in all 4Q, ND, NT, no masses |
| 2052 |
Ext: No edema or cyanosis in LE b/l. DP and PD pulses 2+ b/l |
| 2053 |
Neuro DTRs 2+ in LE b/l. Muscle strength 5/5 in LE b/l |
| 2054 |
Sensation: intact in LE b/l. Straight leg test negative b/l |
| 2055 |
HPI: |
| 2056 |
70yo M c/o tremor |
| 2057 |
- Started 6 months ago w/o ppt events, constant, gradually worsening |
| 2058 |
- R hand tremor at rest, present on purposeful movement also |
| 2059 |
- Aggrav by fatigue, stress, no allev factors |
| 2060 |
- Stiffness in all body, feels like "prisoner in own body" |
| 2061 |
- Problems with walking, afraid of falls, no falls yet |
| 2062 |
- Wife c/o his slowness, changes in handwriting |
| 2063 |
- Headache, no weakness/nubmness/tingling, no nausea/vomiting |
| 2064 |
ROS: no change in wt/appetite, sleep, bowel/urinary habits, no changes |
| 2065 |
with hair/skin, no heat intolerance |
| 2066 |
Meds: no Rx or OTC. All: NKDA. FH: father died of brain cr age 60 |
| 2067 |
PMH: no similar problem before. No head traumas, surgeries or hospital |
| 2068 |
SH: lives with wife, monogamous with her, safe at home. No cig/rec drugs, abused EtOH before, stopped 3 months ago. 1 cup coffee/day |
| 2069 |
Pt is in NAD. Face hypomimic |
| 2070 |
VS: WNL |
| 2071 |
HEENT: EOMI, NC |
| 2072 |
Neuro: resting "pill rolling" tremor in R hand, present with movement also. CN 2-12 intact. Muscle strength in UE difficult to access due to rigidity. DTRs 2+ in UE b/l. Gait shuffling, takes small steps. Adiadochokinesia. |
| 2073 |
HPI: 45yo F c/o postcoital bleeding |
| 2074 |
- Started 5 months ago getting worse |
| 2075 |
- 1/2 teacup postcoital blood discharge without odor |
| 2076 |
- Pain during sex - 3/10, dull, intermittent |
| 2077 |
- Lost 15 lbs x 6 months, poor appetite and sleep, night sweats |
| 2078 |
- G5P5, LMP - 14 days ago, last PAP smear 8 years ago was normal |
| 2079 |
- No vision or skin changes, no headache, no nausea/vomiting |
| 2080 |
ROS: No fever, no change in bowel/urinary habits |
| 2081 |
Meds: No rx or OTC. ALL: NKDA |
| 2082 |
FH: mother - died of cervical cancer at 60yo. PMH: none |
| 2083 |
PSH: none. No Traumas. 5 hospitalizations due to deliveries. |
| 2084 |
SxH: monogamous with husband, no h/o STD. No use OCP or condoms |
| 2085 |
SH: Smoke 1 ppd*25 years, no EtOH/drugs. Works as Accountant |
| 2086 |
Pt is in NAD |
| 2087 |
VS: WNL |
| 2088 |
HEENT: Conjunctival pallor. NC/AT, EOMI, PEERLA |
| 2089 |
Neck: NL Thyroid no LAD |
| 2090 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2091 |
Lungs: Clear BS b/l |
| 2092 |
Abd: Tenderness in lower part of the abdomen. +BS in all 4Q, tympanic in 4Q, no masses |
| 2093 |
HPI: 60yo F pain in L arm |
| 2094 |
- Started 2 hours ago, get better, started when she was swimming |
| 2095 |
- 6/10, intermittent, squeezing pain in L arm, no radiation |
| 2096 |
- Allev. by rest. Aggrav by exercising |
| 2097 |
- She had 1-2 episodes of such pain per week x 2 years |
| 2098 |
Ob/Gyn: LMP 5 years ago. G1P1. No HRT. PAP smear 5 years ago was normal |
| 2099 |
ROS: No fever, no change in bowel/urinary habits |
| 2100 |
Meds: Captopril. Ibuprofen. ALL: NKDA |
| 2101 |
PMH: HTN x 15 years. FH: father - MI |
| 2102 |
PSH: None, no trauma or hospital. SxH: Monogamous with husband |
| 2103 |
SH: Smoke 1 ppd*30 years, no EtOH/drugs. Works as Accountant |
| 2104 |
Pt is in NAD |
| 2105 |
VS: BP 160/90 mm Hg, HR 70/minute |
| 2106 |
HEENT: NC/AT, EOMI, PEERLA |
| 2107 |
Neck: NL Thyroid, no carotid bruits |
| 2108 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2109 |
Lungs: Clear BS b/l |
| 2110 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2111 |
Ext: No pain, swelling, redness in R arm at this moment. ROM x 6 is full. Radial pulse 2+ b/l |
| 2112 |
HPI: 75 yo M c/o dysphagia |
| 2113 |
- Started 4 months ago, getting worse - initially for solid, now progressed for liquid food |
| 2114 |
- Unintentional weight loss - 15 lbs for 4 months, fatigue x 3 months |
| 2115 |
- No Allev or Aggrav factors |
| 2116 |
ROS: No Fever, no change in bowel/urinary habits |
| 2117 |
Meds: Captopril. ALL: NKDA. |
| 2118 |
FH: father - died of gastric cancer age 60 yo. PMH: HTN x 25 years |
| 2119 |
PSH: appendectomy at 20 yo. SxH: Monogamous with wife, no h/o STD |
| 2120 |
SH: Smoke 1 ppd*50 years, drinks 3-5 beers per day x 20 years(CAGE: 4/4). Retired constructor |
| 2121 |
Pt is in NAD |
| 2122 |
VS: WNL |
| 2123 |
HEENT: no oral or pharynx lesions. NC/AT, EOMI, PEERLA |
| 2124 |
Neck: NL Thyroid gland, no LAD |
| 2125 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2126 |
Lungs: BS, wheezing and rhonchi b/l, VTF intact |
| 2127 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2128 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 2129 |
Ext: clubbing of the fingers and toes with cyanosis of the lips |
| 2130 |
HPI: |
| 2131 |
The source of information is the mother of 5 do M child who c/o |
| 2132 |
her child having yellow discoloration of the eyes and skin |
| 2133 |
- Started yesterday, not worsened |
| 2134 |
- Child is awake, responsive, playful and active |
| 2135 |
- No preauricular lymph node swelling, no vomiting or seizures |
| 2136 |
- No change in bowel/urinary habits: 2-3 bowel movements/day and 7-8 wet |
| 2137 |
diapers/day. Stool color is yellow |
| 2138 |
- He is breastfed every 4-5 hours, no change in appetite |
| 2139 |
- No sick contacts at home |
| 2140 |
Meds: no Rx or OTC. All: NKDA. FH: his older sister had jaundice and was |
| 2141 |
hospitalized after 1 week of birth. PMH: none. PSH: none |
| 2142 |
Birth: no complications during pregnancy, term vaginal delivery, |
| 2143 |
The mother received antibiotics for a positive culture before delivery. |
| 2144 |
Immuniz: UTD. |
| 2145 |
none |
| 2146 |
Pt is in NAD |
| 2147 |
VS: WNL |
| 2148 |
HEENT: NC/AT,EOMI, PEERLA |
| 2149 |
Neck: NL Thyroid, no LAD |
| 2150 |
CV: RR, N S1/S2, no MRG |
| 2151 |
Lungs: Clear BS b/l |
| 2152 |
Abd: +BS in all 4Q, ND, NT, no masses |
| 2153 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 2154 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2155 |
HPI: 35yo M c/o Painless hematuria |
| 2156 |
- Started 3 weeks ago, no progression |
| 2157 |
- 1/4 teacup blood in urine |
| 2158 |
- No difficulty during urination, no flank or abdominal pain |
| 2159 |
- No travel recently |
| 2160 |
ROS: No fever, no change in bowel habits |
| 2161 |
Meds: No Rx or OTC. ALL: NKDA |
| 2162 |
FH: father has polycystic kidney disease. PMH: none |
| 2163 |
PSH: None. Nop trauma or Hospital. |
| 2164 |
SxH: Monogamous with wife, no h/o STD |
| 2165 |
SH: Smoke 1 ppd*15 years, no EtOH/drugs. Works as Engineer |
| 2166 |
Pt is in NAD |
| 2167 |
VS: WNL |
| 2168 |
HEENT: Conjunctival Pallor. NC/AT, EOMI, PEERLA |
| 2169 |
Neck: NL Thyroid, no LAD |
| 2170 |
Lungs: Clear BS b/l |
| 2171 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2172 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, enlarged kidneys b/l |
| 2173 |
Neuro: CN 2-12 grossly intact, DTRs2+ symmetric, intact. Sensation intact |
| 2174 |
Muscle strength 5/5 throughout |
| 2175 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2176 |
Pt is in NAD |
| 2177 |
VS: BP 160/90 mm Hg |
| 2178 |
HEENT: Conjunctival pallor. NC/AT. EOMI. PEERLA |
| 2179 |
Neck: NL Thyroid, no LAD |
| 2180 |
Lungs: Clear BS b/l |
| 2181 |
CV: RRR, N S1/S2. PMI nondisplaced. No MRG |
| 2182 |
Abd: +BS in all 4Q, tympanic in 4Q, NT, distended, no masses. Negative Murphy sign |
| 2183 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact |
| 2184 |
Muscle strength 5/5 throughout |
| 2185 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2186 |
Pt is in NAD, obese |
| 2187 |
VS: WNL |
| 2188 |
HEENT: NC/AT. EOMI. PEERLA |
| 2189 |
Neck: NL Thyroid, no LAD |
| 2190 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2191 |
Lungs: Clear BS b/l |
| 2192 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2193 |
Neuro: CN 2-12 grossly intact. Sensation intact. DTRs2+ b/l. |
| 2194 |
Ext: R calf is red, swollen, tender to palpation. Positive Homan sign on R leg. Muscle strength in R calf 2/5, in other extremities - 5/5. Decreased ROM in R knee due to pain. Pulse on R leg 1+, on L leg - 2+ |
| 2195 |
HPI: 41yo F c/o feeling down |
| 2196 |
- Started 7 months ago |
| 2197 |
- this is affecting her work, she has taken a leave of absence |
| 2198 |
- experienced divorce 9 months ago |
| 2199 |
- decreased sleep, lack of interest in things, no energy, decreased appt |
| 2200 |
- having suicidal ideations, no plan or attempts |
| 2201 |
- Cold intolerance and hair thinning x 5 months |
| 2202 |
- No palpitations, sweating, SOB |
| 2203 |
Ob/Gyn: G0P0. Menarche - 15yo, LMP - 14 days ago, last PAP smear 1 year ago was normal |
| 2204 |
ROS: No change in bowel/urinary habits |
| 2205 |
Meds: Vitamins. ALL: NKDA. PMH: None. FH: mother - depression |
| 2206 |
PSH: none. SxH: No sexually active x 9 months, no h/o STD |
| 2207 |
SH: No cig/EtOH/drugs. Works as Accountant |
| 2208 |
Pt is NAD. Looks tired. Flat affect. Speaks and moves slowly |
| 2209 |
VS: WNL |
| 2210 |
HEENT: NC/AT, EOMI, PEERLA, no conjunctival pallor |
| 2211 |
Neck: NL Thyroid, no LAD |
| 2212 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2213 |
Lungs: CTABL |
| 2214 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2215 |
Neuro: CN 2-12 grossly intact, DTRs2+ b/l, sensation intact, |
| 2216 |
Muscle strength 5/5 throughout |
| 2217 |
Mental exam: AAO x 3, spell backward, recall 3 items, obeys 3 commands, judgment and thought process intact |
| 2218 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2219 |
HPI: 48 yo F c/o epigastric pain |
| 2220 |
- Started 2 weeks ago, intermittent, getting worse |
| 2221 |
- Severity reaches 7/10 and diminishes to 0/10, no radiation, sometimes accompanied by nausea and last time - by vomiting |
| 2222 |
- Vomiting 1 time yesterday, sour yellowish fluid, no blood |
| 2223 |
- Aggrav by heavy meals(such pizza) and hunger. Allev by other food, antacids, milk |
| 2224 |
ROS: no change in appetite, bowel/urinary habits, no fever |
| 2225 |
Meds: Maalox, Ibuprofen(2 pills x 2-3 times a day) |
| 2226 |
FH: father died of pancreatic cancer at 55 yo |
| 2227 |
PMH: Arthritis in the knees, treated with Ibuprofen, UTI last year. |
| 2228 |
PSH: 2 C-sections. SH: Monogamous with husband. No cigs/EtOH/drugs. Housewife |
| 2229 |
Pt in NAD |
| 2230 |
VS: WNL |
| 2231 |
CV: No chest wall tenderness, RRR, N S1/S2, no MRG, PMN nondisplaced |
| 2232 |
Lungs: clear BS b/l |
| 2233 |
Abd: C-section scar, +BS in all 4Q, tympanic in all 4Q, ND, epigastric tenderness without rebound and guarding, no Murphy sign, no masses, no |
| 2234 |
hepatosplenomegaly |
| 2235 |
HPI: 68 yo M c/o weakness |
| 2236 |
- Started this morning suddenly w/o ppt events, no progression |
| 2237 |
- Involves R UE only |
| 2238 |
- R facial drooping, slurry speech |
| 2239 |
- No tingling or numbness in extremities, no headache |
| 2240 |
- No change in vision, palpitations, dizziness or LOC |
| 2241 |
- No nausea/vomiting or balance problems |
| 2242 |
ROS: no change in bowel/urinary habits |
| 2243 |
Meds: insulin, captopril, atenolol - noncompliant |
| 2244 |
All: NKDA. FH: mother - DM, father - died of CVA age 60 |
| 2245 |
PMH: DM, HTN x 10y, poor control. No h/o CVA or MI |
| 2246 |
No surgeries or hospitals. H/o head trauma 6 months ago, no LOC |
| 2247 |
SH: no drugs/EtOH, 1 PPD x 40y. Lives with wife |
| 2248 |
Pt is in NAD |
| 2249 |
VS: WNL except for BP 160/90 mm Hg |
| 2250 |
HEENT: NC/AT, EOMI, PERRLA |
| 2251 |
Neck: no carotid bruits |
| 2252 |
Neuro: CN 2-6 intact, R facial and glossopharyngeal nerve palsy |
| 2253 |
Muscle strength 5/5 in LE b/l, 5/5 in L UE, 2/5 in R UE. DTRs 2+ in LE and UE b/l. +Babinski on the R side. |
| 2254 |
Pt is in NAD |
| 2255 |
VS: Fever 99.7F |
| 2256 |
HEENT: NC/AT, EOMI, PEERLA, no pharynx and oral lesions |
| 2257 |
Neck: NL Thyroid, no LAD |
| 2258 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2259 |
Lungs: CTAB/L |
| 2260 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2261 |
Musculoskeletal: Swelling and redness in R heel. Tenderness and warm to touch. Decreased active and passive ROM in L foot. There is diminished |
| 2262 |
ankle dorsiflexion, plantar flexion, and great toe extension |
| 2263 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 2264 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2265 |
HPI: 44 YO F c/o dizziness |
| 2266 |
- Started 1 week ago, no progression, 2-3 episodes per day, lasts 10-15 minutes |
| 2267 |
- Sensation of room spinning around her |
| 2268 |
- Episodes provoked by moving her head to the left |
| 2269 |
- No nausea or vomiting |
| 2270 |
- No tinnitus, fullness in ear, ear discharge, headache or head trauma |
| 2271 |
ROS: No fever, no change in bowel/urinary habits |
| 2272 |
Meds: None. ALL: NKDA. FH: Noncontributory. PMH: None |
| 2273 |
SxH: with husband. SH: No cigs/EtOH/drugs. Work as accountant |
| 2274 |
Pt is in NAD |
| 2275 |
VS: WNL |
| 2276 |
HEENT: NC/AT, EOMI without nystagmus, PEERLA |
| 2277 |
CV: RRR, N S1/S2, mo MRG, PMI nondisplaced |
| 2278 |
Lungs: clear BS b/l |
| 2279 |
Neuro: CN 2-12 grossly intact. Normal Rinne and Weber. Positive Dix-Hallpike Maneuver(reproduce nystagmus). Muscle strength 5/5 throughout. DTRs 2+ b/l |
| 2280 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2281 |
HPI: 18 yo M c/o abdominal pain |
| 2282 |
- Started 1 hour ago, getting worse |
| 2283 |
- Severity 10/10, sharp, LUQ of abdomen pain, radiates to the scapula |
| 2284 |
- No nausea, vomiting |
| 2285 |
- Allev./Aggrav. - nothing |
| 2286 |
ROS: No fever, no change in bowel/urinary habits |
| 2287 |
Meds: none. ALL: NKDA. FH: noncontributory |
| 2288 |
PMH: Infectious mononucleosis 3 weeks ago. PSH: none. Received multiple small traumas as a boxer. No h/o hospitalizations |
| 2289 |
SxH: With girlfriend x 6 months, they use condoms, no h/o STD |
| 2290 |
SH: no cig/EtOH/drugs. Works as a Boxer |
| 2291 |
Pt is anxious |
| 2292 |
VS: BP: 90/60 mm Hg, HR: 100/min |
| 2293 |
HEENT: NC/AT, EOMI, PEERLA |
| 2294 |
Neck: Cervical lymphadenopathy. NL Thyroid |
| 2295 |
Lungs: Clear BS b/l |
| 2296 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2297 |
Abd: Swelling in LUQ. Severe tenderness in LUQ with rebound and guarding. No Murphy sign. +BS in all 4Q, tympanic in 4Q |
| 2298 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric/intact. Sensation intact. |
| 2299 |
Muscle strength 5/5 throughout |
| 2300 |
Mental exam: AAO x 3, skips, spells backward, recall 3 items, obeys 3 commands. Judgment and thought process intact |
| 2301 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2302 |
HPI: 65 yo M c/o pain in the R heel |
| 2303 |
- Started 3 days ago, getting worse |
| 2304 |
- 6/10, dull, intermittent R heel pain |
| 2305 |
- Aggrav and most notable after 1-st steps. Allev by rest |
| 2306 |
ROS: No fever, no change in bowel/urinary habits |
| 2307 |
Meds: Ibuprofen, Captopril. All: NKDA |
| 2308 |
PMH: HTN x 10 years. FH: Noncontributory. PSH: none |
| 2309 |
SxH: Monogamous with wife. SH: Smoke 1 ppd*20 years, no cig/EtOH/drugs |
| 2310 |
Works as Engineer |
| 2311 |
Pt is in NAD |
| 2312 |
VS: BP - 160/90 mm Hg |
| 2313 |
HEENT: NC/AT, EOMI ,PEERLA |
| 2314 |
Neck: NL Thyroid |
| 2315 |
CV: RRR, N S1/S2, no MRG |
| 2316 |
Lungs: Clear BS b/l |
| 2317 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2318 |
Ext: Tenderness to palpation in R heel. No bruises. Decreased ROM due to pain. Radial and Pedal pulses 2+ b/l |
| 2319 |
HPI: |
| 2320 |
70 yo M c/o palpitations |
| 2321 |
- Started 1 month ago, no progression |
| 2322 |
- 3-4 episodes per week x 1-2 hours |
| 2323 |
- Precipitated and Aggrav by skipping meal, Allev after drinking fruit juice |
| 2324 |
- Accompanied by diaphoresis |
| 2325 |
ROS: 10 lb wt loss x 3 months, no change in bowel/urinary habits |
| 2326 |
Meds: Insulin NPH, Captopril, HCTZ. ALL: NKDA |
| 2327 |
FH: mother - DM. PMH: HTN, DM x 20 years. PSH: none, no traumas or hospital. SxH: Monogamous with wife. |
| 2328 |
SH: Smoke 1 ppd*40 years, no EtOH, drugs. Retired school teacher |
| 2329 |
Pt is in NAD |
| 2330 |
VS: WNL, except for HR 106/min |
| 2331 |
HEENT: no lid lag, NC/AT, EOMI, PEERLA |
| 2332 |
Neck: NP Thyroid gland |
| 2333 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2334 |
Lungs: Clear BS b/l |
| 2335 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses |
| 2336 |
Neuro: CN 2-12 grossly intact. DTRs 2+ b/l. Sensation to soft and pinprick intact. Muscle strength 5/5 throughout |
| 2337 |
Ext: No tremor, bruises or pallor, radial pulses 2+ b/l |
| 2338 |
HPI: 61yo F c/o profuse vaginal bleeding |
| 2339 |
- Started 1 month ago, getting worse |
| 2340 |
- She using 1-2 pads per day |
| 2341 |
- LMP 10 years ago, G0P0, PAP smear 10 years ago was normal |
| 2342 |
- Sex. active with husband - pain during sex x 6 months, small amount of bloody discharges after sex |
| 2343 |
- No abdominal pain, no vision or skin changes, no cold/heat intolerance |
| 2344 |
- Weight loss - 15 lbs x 6 months, poor appetite, night sweats |
| 2345 |
ROS: No fever, no change in bowel/urinary habits |
| 2346 |
Meds: Captopril, HCTZ, Insulin. ALL: NKDA |
| 2347 |
FH: mother died of cervical cancer at 65yo. PMH: HTN, DM x 10 years |
| 2348 |
PSH: none, no trauma or hospital. |
| 2349 |
SH: Smoke 1ppd*30 years, no EtOH/drugs. Works as Accountant |
| 2350 |
Pt is in NAD |
| 2351 |
VS: BP 160/90 mm Hg |
| 2352 |
HEENT: NC/AT, EOMI, PEERLA |
| 2353 |
Neck: NL Thyroid, no LAD |
| 2354 |
CV: RRR, N S1/S2, no MRG, PMI nondisplaced |
| 2355 |
Lungs: Clear BS b/l |
| 2356 |
Abd: +BS in all 4Q, tympanic in 4Q, mild tenderness in lower part of the abdomen. Nondistended. No masses |
| 2357 |
Ext: No edema or cyanosis, radial pulses 2+ b/l |
| 2358 |
HPI: The source of information is the mother of 11 months F child c/o her child has jerky movements |
| 2359 |
- Started this morning at 11:00 a.m. - jerky movements of limbs, witnessed by parents. It lasted 1 minute |
| 2360 |
- Postictal drowsiness after the seizure, no h/o prior seizures |
| 2361 |
- Mother denies any tongue, head trauma, diarrhea, vomiting, constipation or rashes |
| 2362 |
- Fever 101.5F(rectally) |
| 2363 |
- Decreased PO intake, poor sleep, fewer wet diapers |
| 2364 |
- No daycare, no ill contacts. Immuniz: UTD |
| 2365 |
ROS: Negative, except as above. Meds: Tylenol. ALL: NKDA. FH: none. |
| 2366 |
PMH: none. Birth: no complications during pregnancy, term vaginal delivery |
| 2367 |
Diet: Breast milk, table foods, supplemental vitamins |
| 2368 |
Development: Wt/height appropriate to age. Last checkup: 1 month ago was normal |
| 2369 |
none |
| 2370 |
HPI: 25yo M c/o Chest pain |
| 2371 |
- Started 3 hours ago after MVA - he drives a car and hit a tree |
| 2372 |
- 8/10, sharp, constant pain in L side of the chest and LUQ of the abdomen |
| 2373 |
- Allev. - nothing. Aggrav - take a deep breath |
| 2374 |
- Yellowish sputum - 1 tablespoon, no blood |
| 2375 |
ROS: Fever 100F, no change in bowel/urinary habits |
| 2376 |
Meds: No Rx or OTC. ALL: NKDA. PMH: none. FH: noncontributory |
| 2377 |
PSH: None, no trauma or hospital. SxH: With girlfriend, use condoms, no h/o STD |
| 2378 |
SH: No cig/Drugs, drinks beer occasionally(CAGE: 0/4) |
| 2379 |
Works as banker |
| 2380 |
Pt is distressed |
| 2381 |
VS: Fever 100F, HR 85/minute, SOB |
| 2382 |
HEENT: EOMI, PEERLA |
| 2383 |
Neck: NL Thyroid, no LAD |
| 2384 |
CV: RRR, N S1/S2, no MRG |
| 2385 |
Chest: Bruises on L side of the chest and back, pain to palpation in L side of the chest |
| 2386 |
Lungs: CTAB/L |
| 2387 |
Abd: +BS in all 4Q, tympanic in 4Q, ND, NT, no masses. Pain to palpation in LUQ |
| 2388 |
Ext: bruises on both arms, radial pulses 2+ b/l |
| 2389 |
HPI: 30yo F c/o after being sexually and physically assaulted |
| 2390 |
- Event happened 2 hours ago - she was leaving a bar and was beaten and raped by 2 unknown men. No police report |
| 2391 |
- Vaginal intercourse, without condoms, unsure about ejaculation |
| 2392 |
- LMP 3 weeks ago, no OCP use or other contraception |
| 2393 |
- Dull pain in all abdomen. No vaginal bleeding, not urinate or defecate since event |
| 2394 |
ROS: No LOC, headache, dizziness, nausea or vomiting |
| 2395 |
Meds: No Rx or OTC. All: NKDA. FH: none. PMH: none |
| 2396 |
PSH: None. no traumas or hospital. SxH: with girlfriend x 6 months, no h/o STD. SH: no cig/EtOH/drugs. Works as Accountant |
| 2397 |
Pt is anxious and in acute distress |
| 2398 |
VS: SOB |
| 2399 |
HEENT: Bruises on face. EOMI. PEERLA |
| 2400 |
Chest: Tenderness to palpation of R lateral chest wall, tympanic to percussion b/l. BS b/l. No wheezes, rales or rhonchi Bruises on R side of the back |
| 2401 |
CV: RRR, N S1/S2, no MRG |
| 2402 |
Abd: Tenderness in lower abdomen. +BS in all 4Q, tympanic in 4Q |
| 2403 |
Neuro: CN 2-12 grossly intact. DTRs2+ symmetric, intact. Sensation intact. Muscle strength 5/5 throughout |
| 2404 |
Ext: Bruises on both hands. Radial pulses 2+ b/l |
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