WS Sample
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Andy Chang (Urgent Care, Family Medicine) PAMF Samples <BODY> SUBJECTIVE: Patient presents for following issues: 1. Suture removal. Patient had suture placed previously at Washington Hospital after he was hit on the side of the face, and kicked by his brother-in-law. Previously the suture did not appear to be ready to be removed. Patient denies having any redness, pus, discharge, or any other symptoms associated with the wound. 2. Head and neck pain. Overall, getting better. He did develop some tingling over the left occipital parietal area, and there is still some pain of the neck; however it is not as bad as before. 3. Positive PPD. Patient here to discuss chest x-ray report. Other historical information is typed. OBJECTIVE: Other than typed, scalp reveals ecchymosis with decreasing intensity of color over the left occipital area. The swelling there also decreased in size as well. No vertebral tenderness, however, there is paravertebral tenderness much more on the left paravertebral C-spine area, and also shoulder tenderness, as well as tenderness over the bruise. Wound site shows suture to be intact, in place, and wound is dry with a scab over the wound. No erythema. No foul smell. ASSESSMENT AND PLAN: 1. Head and neck pain. Improved compared to before, likely related to the contusion ecchymosis. Recommended p.r.n. ibuprofen, Tylenol, continuation of the cool compression which helped. RTC if worsening or development of any new symptoms, or if the tingling does not improve. 2. PPD. Positive PPD status. Discussed the risks, benefits of isoniazid with patient. After discussion, patient declined. Patient would like to just keep an eye on it. 3. Suture removal. After discussion of options, we went ahead and removed the sutures. After removal of the 4 sutures, the 5th one appeared to be buried inside a scab. Touching the scab resulted in pus expression from the wound. The pus was cultured. The last suture appeared was in the dehisced granulation tissue. The sutures were removed. Advised patient to apply topical antibiotics. I have given a sample of Polysporin, and use p.o. antibiotics if there are any signs of infection as discussed in detail, and as per PI. </BODY> <BODY> SUBJECTIVE: 12-year-old female presents with being “sick” for the last 2 days. Initially, fever up to 100 degrees. Subsequently, up to 101 degrees yesterday and then development of a dry cough. Last night, the temperature was 99 and it was 100 this morning. Other symptoms include, chills, nausea before meals, as well as right before she came to urgent care, anorexia, some abdominal pain diffusely around the umbilicus before she ate last night. She thought the abdominal pain might be from hunger pain. No recent travel outside the immediate area. Other historical information as typed. ROS: Reveals no runny nose, stuffy nose, sore throat, ear pain, chest pain, shortness of breath, wheezing, vomiting, diarrhea, dizziness, headache, sinus pain and pressure. OBJECTIVE: As typed. ASSESSMENT AND PLAN: Fever, cough, nausea, likely from viral gastroenteritis. Currently, no evidence of bacterial infection. Gave the patient’s dad recommendations for symptomatic measures, as discussed and as per p.r.n. Will have the patient use a prescription Rx only if the OTC medications are ineffective. The patient can definitely be brought back on a p.r.n. basis if not better by the end of next week or sooner if worsening. </BODY> <BODY> SUBJECTIVE: 77-year-old presents with the following issues: 1. Bilateral lower extremity edema, more on the LLE than the RLE for last 10 years. He has not used any compression stockings ever for this. He does not elevate his feet while he is sitting; however he does elevate them when sleeping. It tends to get worse after he sits in front of the computer for more than 2 hours. It has been worse over the last few months, and there is some shortness of breath associated with this. 2. Bilateral knee pain for many years. He went to an alternative medicine specialist who found he had high antimony (3.2 mcg/g of CR, normal less than 0.6). He hurts in bilateral knees. He used to play squash every day for the last 20 years, and he has been having this pain at least for the last 10 or 15 years. Now, he is not able to play squash, and he wishes to play squash again. He went to Rush Medical Center, saw Dr. Richard Burger who told him about arthroscopic surgery for knee replacement. The knees do feel very stiff in the morning, a little bit better after walking. He had an x-ray done and it showed that bone was pushing on bone. He tried Vioxx in the past, which was ineffective. He tried 02 as well as ozone injections into the knee by the outside physician, who requested quite a few lab tests, and it did not help after 3 therapies. He underwent Hyalgan injection previously, which did alleviate the symptoms. 3. Followup abnormal lab tests. Previously, the patient had an abnormal chemistry and would like to follow up on it. 4. A bump on the top of the lip which he has had for 1 year. It is not changing size or character. Does not itch or hurt. 5. High blood pressure, for which he was previously getting lisinopril. He thought he did not need it, so he stopped it and his blood pressure went to the 160s. Subsequently, he started back on lisinopril, currently taking 20 mg every other day, and his blood pressure is less 130 at home systolic, and he feels it is under well control at this regimen. Other historical information as typed. OBJECTIVE: Other than typed, BLE examination reveals no hip pain with abduction or adduction. Bilateral feet are purplish in color, cool to touch, 2+ bilateral pedal pulses. Motor 5/5, sensory intact to gross touch. No superficial skin erythema or ecchymosis; however, there are atrophic changes at the leg. Capillary refill less than 2 seconds. The patient does have varicosities at the lower legs, as well as around the ankle and at the upper leg on the left more so than the right. ASSESSMENT AND PLAN: 1. Peripheral edema, possibly from venous insufficiency, unlikely to be from CHF based on the history and current physical findings. With patient's history of abnormal creatinine, cannot rule out renal dysfunction or liver dysfunction contributing to this. At this time, will go ahead and give patient a trial of compression stockings, as well as checking the appropriate lab tests. Also recommend elevation when sitting and sleeping, as well as avoidance of prolonged sitting. RTC should the compression stockings not be effective. 2. Pain in the knees. Discussed the various treatment options available. Offered patient orthopedics as well as physical medicine for possible repeat Hyalgan versus steroid injections. Patient will probably go for the Hyalgan injection since it worked well for him. Discussed options for medication, including Celebrex. However, after discussion of the risks and benefits, patient declined. 3. For the abnormal chemistry, will go ahead and follow up on the lab tests. Will also order lab tests as requested by the outside physician. 4. Screening for osteoporosis since the patient is at risk. 5. Upper lip swelling concerning for malignancy since it came out of nowhere a year ago. Will go ahead and refer to Dermatology for consultation and if necessary, excisional biopsy. 6. Need for pneumonia and shingles vaccine. Gave to patient after discussion of risks and benefits. 7. High blood pressure, currently under well control on current medication regimen. Will go ahead and continue. </BODY> <BODY> SUBJECTIVE: 9-year-old female brought in by parents with 2-day history of knee pain. This started while patient was in gymnastics. They were jumping onto a soft mat, and after she jumped, someone else jumped on her. Subsequently, she has been feeling like her knee will "give out," and while she described that as though the patella will go from the front to the back on the left side. She was quite uncomfortable in the last 2 days, even as late as this morning where she complained of uneasiness, as well as discomfort. Patient at this moment does not have any pain. Pain is located over on the left knee and does not radiate anywhere else. Previously, it was exacerbated with full extension of the knee, but now she can tolerate so without problem. No other symptoms associated with this. Other historical information as typed. ROS: No fevers, chills, nausea, vomiting, diarrhea, blood in the urine or stool, loss of urine or stool, melena, numbness, weakness, tingling. OBJECTIVE: As typed. ASSESSMENT AND PLAN: Left knee discomfort, uncertain if this may be contusion or if this is muscular sprain/strain. Current examination is inconsistent with fracture, nor is it consistent with problems with the ACL, PCL, MCL, LCL. Reassured patient's parents of the normal finding in regard to those structures. The only abnormality is possible patellofemoral syndrome, but it is most likely a separate issue from this. At this time, recommend p.r.n. ibuprofen and Tylenol, symptomatic measures, and will have patient RTC to see our peds orthopedist in 2 weeks if not better, sooner if worse. </BODY> <BODY> SUBJECTIVE: 5-year-old female brought in by Mom with the following issues: 3-day history of fever up to 100.5, alleviated with ibuprofen, associated with dry cough, which started today. Patient had 1 episode of nonbloody emesis after lunch on Tuesday after she was given Motrin. Patient's father is concerned because they are flying to India in 4 days' duration. No recent travel outside the immediate area and patient's mom was recently diagnosed with bronchitis, with symptoms consisting of postnasal drip and was started on antibiotics. One-week history of very itchy eyes not associated with any discharge or erythema. They used OTC HypoTears 2-3 times a day and that does decrease her itchiness. They were wondering what may be the source of the eye problem. ASSESSMENT/PLAN: 1. Fever, cough, likely viral URI, likely also the source of the vomiting. No findings suggestive of bacterial infection or suggestive of need for a specialist consultation or surgical management or radiological studies at this time. Gave patient recommendations for symptomatic measures, as discussed and as per PI, in addition to Cheratussin with codeine for symptoms not controlled by OTC medications. RTC if not better by next week or sooner if worsening. 2. Itchy eyes, likely allergic conjunctivitis. Based on her current normal examination, reassured patients. Recommend OTC treatments. </BODY> <BODY> SUBJECTIVE: The patient presents for the following issues: Abscess in the right lower quadrant of the abdomen for which he would like it rechecked. He has been applying topical antibiotics. For the few last few days a small amount of pus came out. Minimal amount of pain. No other symptoms. Right foot pain. Yesterday he was stepping in the backyard when he misstepped. He does not recall the mechanism of the injury, however, now he is experiencing pain in the joint space distal to right lateral malleolus as well as the right lateral midfoot. This is worse on weight bearing, alleviated by nonweightbearing. No other symptoms associated with this as reviewed in ROS. Other historical information as typed. OBJECTIVE: Other than typed, the right lower quadrant of the abdomen reveals the open wound with granulation tissue. No foul smell. No pus upon expression. Minimal erythema. No underlying crepitation. RLE examination reveals no knee pain on palpation over the patella, infrapatellar ligament, menisci, collateral ligament, or posterior fossa. No calf tenderness on palpation. Negative Homans sign. 2+ pedal pulse. No tenderness over medial malleolus, Achilles tendon, or calcaneus. Positive tenderness over the lateral malleolus, joint space distal to it, as well as the lateral midfoot bones and proximal 5th MT. No other MT tenderness. No phalanx tenderness. Cap refill less than 2 seconds. ASSESSMENT AND PLAN: 1. Wound on the right lower quadrant that is possibly an abscess that ruptured. Currently does not appear infected. Recommended that the patient keep the area clean and if there is any sign of infection to go ahead and use the antibiotic as prescribed. 2. Right foot pain. No fracture. Likely is a sprain/strain or contusion. Recommend p.r.n. ibuprofen. Incidentally an x-ray found a possible osteochondritis dissecans. Explained to the patient what this may mean. Discussed the options available. After discussion the patient elected to go ahead and get an MRI. </BODY> <BODY> SUBJECTIVE: A 56-year-old male here for CPE. In addition, he also has the following issues 1. Palpitations. The patient reports that mostly in the nighttime when he is sitting on the sofa after dinner, he will feel that his heart will beat really fast. This occurs 1-2 times a week. Sometimes, after the heart beats fast, he will feel that his heart is going to stop. This has been going on for the last few months, up to 6 months. He has never seen a physician for this. He denies any other symptoms associated with this. 2. Hearing loss. The patient reports that sometimes he is not able to hear things that other family members are able to hear. He was wondering whether or not he may have hearing loss. 3. Fatigue. The patient reports that he feels fatigued throughout the day. Frequently, he will need to drink caffeinated products that keep him up. He believes he does snore. He does not know whether or not he gasps for air in the middle of the night or whether or not he stops breathing in the middle night. 4. Nausea, going on for the last 6 months, usually after lunch or dinner. At first, he thought it was related to stomach discomfort from taking the 7 or 8 vitamins that his wife gets him. He stopped taking those vitamins. Unfortunately he still feels the nausea. He denies any reflux sensation. He has not taken any medication yet for this nausea sensation. 5. Fungal foot infection for which he has been using beclomethasone on an infrequent basis. It is still there and has been there for more than a few months. He has never seen a physician for treatment for this, and he was wondering whether or not he can get a refill of beclomethasone which he actually believes is a prescription for his wife. OTHER HISTORICAL INFORMATION: OBJECTIVE: As typed. ASSESSMENT AND PLAN: 1. Palpitations with a current normal EKG. There is definitely concern about irregular heartbeat, possibly intermittent atrial fibrillation versus premature beats. Will go ahead and refer to our cardiac electrophysiologist for consultation and to determine what type of cardiac monitoring is indicated. 2. Hearing loss. Abnormal audiology screening. Will go ahead and refer to audiology for formal complete audiology testing. 3. Fatigue with a history of snoring. Based on patient's history, there is a high concern that this may be sleep apnea. As such, we will go ahead and refer to ENT for consultation, and if indicated, sleep studies. 4. Nausea, uncertain etiology. Possibly acid reflux or gastritis. Will go ahead and give the patient a trial of Protonix. If effective, the patient is go ahead and finish a 1month course of a PPI. If ineffective, the patient will go ahead and contact our gastrointestinal for consultation and possible EGD. 5. Tinea pedis, found on examination, unlikely to improve on the beclomethasone since it does not contain any antifungals. Recommended Mycolog-II as a trial b.i.d. until resolution. If ineffective RTC. </BODY> <BODY> SUBJECTIVE: The patient presents for a bite in the right shoulder area. The patient was bitten by a child with developmental disorder at a preschool. The child was 3-1/2 years old. The patient was trying to remove the child from a disruptive situation when the child got upset and bit her on the right shoulder. The patient’s mom does not recall when patient's last tetanus shot was. The shoulder is painful. Otherwise there are no symptoms. The patient has not taken any medication yet for this. Other historical information as typed. OBJECTIVE: Other than typed, right shoulder region reveals an ecchymosis corresponding to the upper and lower lip as well as the central portion where the teeth are. The central portion measures 1.9 cm at the widest, and the upper and lower portion measures approximately 3.1 cm at its widest. ASSESSMENT AND PLAN: Ecchymosis in the right shoulder status post human bite. Does not appear to have any breaks in the skin. As such, will hold off on needing antibiotics. Instead, recommended cleaning with soap and water as well as using p.o. Tylenol, ibuprofen, and symptomatic measures to the alleviate pain. Discussed at least 2 occasions of warning signs of infection. Advised patient's mom to fill the Rx for antibiotic should the patient develop signs of infection. She can definitely be brought back at any time should there be any concerns. </BODY> <BODY> SUBJECTIVE: The patient presents for the following issues: 1. Diabetes, for which he changed his exercise regimen. Previously, he was exercising 3 to 4 times a week, 45 minutes each time. Now is exercising 5 times a week, 30 minutes each time. He has not seen an ophthalmologist the last 1 year. He has been watching his diet while in the United States; however, he went back to Taiwan recently and while there, he did not watch his diet and was eating quite a bit of carbs. Incidentally, he reports that he likes to eat yam, and has been eating a lot of that. 2. GI bleed, for which he previously underwent EGD. He does not really understand the note that Dr. Mary Hu sent him, because it was in English. He took the omeprazole 20 mg OTC x12 days, and afterwards he stopped. He reports that he continues to have some epigastric discomfort sometimes after he eats. Sometimes it occurs every 2 or 3 days, other times it occurs once a week. Usually only lasts for a minute and it does not radiate anywhere else. Pain described as "sharp", and he has not noticed any specific food making the pain better or worse. Anemia, for which he underwent the EGD. The patient denies feeling tremendously fatigued, nor having any other symptoms of anemia as reviewed on ROS. OTHER HISTORICAL INFORMATION/OBJECTIVE: As typed. ASSESSMENT AND PLAN: 1. Diabetes. Control worsened compared to before. Discussed options available. The patient will try to exercise every single day, and will cut down on the melon or solid type of vegetable and try to eat more leafy vegetables. Repeat all testing 3 months duration. In the meanwhile, patient is due for urine albumin. Will go ahead and order that per the patient. 2. Screening for prostate cancer. Will go ahead and order PSA for next lab test. 3. Gastritis, with the patient continuing to be symptomatic. Recommended a higher dose of omeprazole x1 month, and the patient will call me back should that not be effective. 4. Anemia, uncertain etiology. Will go ahead and recheck CBC to ensure clearance. If not, then we may consider further workup. </BODY> <BODY> SUBJECTIVE: 34-year-old male presents for CPE; in addition, also has the following issues: 1. Numbness extending from bilateral shoulders starting at deltoid all the way down to the hands. This occurs at night when he goes to sleep. Pain described as “sharp.” This has been going on for more than 3 years. Prior to that time he was doing lot of home remodeling himself, and also he does not recall any specific trauma, injury that preceded the pain. He did do a lot of heavy lifting and repetitive motions. 2. Soreness over the bilateral shoulders along the area of the trapezius as well as the interscapular area. It occurs every night after sleep, and 2 hours after falling asleep it will wake him up. After it wakes him up, he will turn to one side, and after it gets a little bit better, he will turn to the other side. As such, his sleep is interrupted. He has not seen a physician for this. 3. Lower back pain for at least 10 years. It is worse when lies down for a prolonged period or goes from a lying to a sitting position. Usually it lasts only for a few minutes and it goes away spontaneously. Pain is located over the lumbar spine and does not radiate anywhere else. Pain described as “sharp.” Other historical information, objective as typed. ASSESSMENT AND PLAN: 1. Paresthesia of the bilateral upper extremities, definitely concerning, possibly spinal cord abnormality. Will go ahead and x-ray the C-spine. In addition, will refer to Physical Medicine. 2. Back pain located along the distribution of the trapezius muscle. Uncertain whether or not this may be muscle sprain/strain. Will go ahead and give the patient a trial of muscle relaxants. Advised the patient to RTC in 2 days’ duration. However, due to patient's work schedule, he is not able to do so. Instead, he will return in August after I return from my sabbatical. If the pain gets worse prior to that time, he can see anyone in family medicine. Will also have the patient see Physical Medicine for this as well. 3. Lower back pain, suspect muscular sprain/strain. Again, will try the muscle relaxant, and will have the patient see Physical Medicine to see whether or not the patient may benefit from traction device and also to determine whether or not patient would benefit from injection or if he needs further radiographic studies. </BODY> <BODY> SUBJECTIVE: Patient here for following issues: 1. Hernia. Patient recently went to see the general surgeon and he was wondering whether or not the fact that he had a hydrocele that underwent drainage when he was younger made any difference in his diagnosis. He was also wondering why it is that he needs to have a hole made in the epigastric area rather than 1 big cut in the right groin area. 2. Gastritis for which he underwent EGD lately. He was wondering what the EGD showed and what he should do at this point. 3. Follow up lab tests with an abnormal white blood cell. 4. Tobacco use for which he is currently tried to quit. ASSESSMENT AND PLAN: 1. Hernia on the right side. Explained to patient that having a hydrocele in the past does not necessarily complicate his case and does not necessarily mean that his hernia may be a misdiagnosis. Advised patient that I would suggest he discuss this surgery with Dr. Koransky more but I would recommend the surgery due to potential complications if he were to need an emergency surgery for the hernia. Also explained to patient that most surgeons performing laparoscopic surgeries that is why they make 3 small cuts rather than 1 large cut. Again defer all questions to Dr. Koransky and I have recommended for surgery at this point. 2. Gastritis. Explained to patient the findings by Dr. Bi recommend omeprazole 40 mg p.o. daily x30 days. RTC if persistent symptoms despite taking the omeprazole. 3. Elevated white blood cell resolved. 4. Decreased tobacco use. Highly commended patient on his effort at quitting smoking. Recommend that the patient try to quit completely. </BODY>
