Henry Villegas, MD # 2532
Date of Visit: 10/10/2005
TIME OF SERVICE: 2020
CHIEF COMPLAINT: Vomiting.
HISTORY OF PRESENT ILLNESS: The patient is a 1 ½-year-old Hispanic male who
has had 20 episodes of clear emesis during the day today. They denies diarrhea. The
patient had diminished urine output during the day.
REVIEW OF SYSTEMS: ENT: Unremarkable. NEUROLOGIC: Unremarkable.
PULMONARY: The patient has no cough, rhinorrhea, no difficulty breathing, chest pain,
or wheezing. CARDIOVASCULAR: Unremarkable. GASTROINTESTINAL: Vomiting
but no diarrhea. No abdominal pain. GENITOURINARY: Diminished urine output.
SKIN: Unremarkable.
ALLERGIES: None.
PAST MEDICAL HISTORY: Unremarkable.
SOCIAL HISTORY: The parents do not smoke. The patient does not go to daycare.
Immunizations are up-to-date.
MEDICATIONS: None.
FAMILY HISTORY: Maternal grandmother has hypothyroidism currently with
medications well controlled. Maternal grandfather has diabetes. A 10-year-old cousin
also has a history of diabetes.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101.3, heart rate 160,
respiratory rate 24. O2 saturations 99%. Weight 11.8 kg. GENERAL: The patient is
alert, he is cooperative. He looks real good considering the history of 20 episodes of
vomiting. HEENT: Tympanic membranes were clear. Nose is clear. The patient has
slight erythematous pharynx with no exudates or tonsillar enlargement or petechia of the
soft pallet. NECK: Supple, no meningismus. He has clear bilateral breath sounds to
auscultation. HEART: Regular rate and rhythm. No murmurs. ABDOMEN: Soft, no
masses. No organomegaly. SKIN: The skin appears to be normal. The skin turgor is
slightly diminished and the oral mucosa is slightly dry.
EMERGENCY DEPARTMENT COURSE: The patient had a bolus of normal saline of
250 (20 cc/kg). Also he had Zofran 1.8 mg IV. During the stay the patient had
electrolytes remarkable for potassium 5.8, CO2 20, and glucose 91. BUN 10, creatinine
0.4. Sodium 139, calcium 9.9. The total white count was elevated at 15.4. Hemoglobin
and hematocrit 13 and 38.3 respectively. Platelets were 532,000, neutrophils 76%,
lymphocytes 17%.
The patient tolerated the p.o. fluids and ice chips after the bolus of fluids and Zofran. He
is going to be discharged.
DIAGNOSES:
1.
Dehydration.
2.
Viral syndrome.
DISCHARGE INSTRUCTIONS: Tylenol 1 tsp every 4 hours as needed for fever. He is
going to have Pedialyte and BRAT diet.
Sample 2
Date of Visit: 10/10/2005
TIME OF SERVICE: 1515.
CHIEF COMPLAINT: Coughing.
HISTORY OF PRESENT ILLNESS: This is a 2-month-old Hispanic male who has one
week history of coughing spells with stuffy nose but no nasal discharge. No history of
fevers, no history of emesis; however, the patient has been having these choking spells
associated with a cough and also gagging spells but no vomiting. The patient has
progressed and now he is worse than he was a week ago.
REVIEW OF SYSTEMS: Unremarkable for the respiratory system. No pulling of the
ears, no ear discharge. The patient has not had any discharged from the eyes or
redness. No rhinorrhea. No difficulty breathing, tachypnea, retractions, or wheezing.
CARDIOVASCULAR: Appears to be normal. The patient is active and vigorous.
GASTROINTESTINAL: No history of vomiting or diarrhea. SKIN: Appears to be normal
with no rash.
PAST MEDICAL HISTORY: Unremarkable. No previous hospitalizations. No previous
surgeries. Immunizations are up to date.
FAMILY HISTORY: No history of asthma. There is paternal history of diabetes and also
MI at an older age.
SOCIAL HISTORY: The patient lives with mom and dad and there is a 14-month-old
healthy sibling and both parents are healthy. No smoking around the house or outside
of the house. No ETOH habits.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature was 99.2 and the heart rate
146, respiratory rate 36. The O2 saturation was 100% on room air. The weight is 5.58
kilograms. GENERAL: The patient is alert, active, playful, and vigorous in no acute
distress. He does not appear toxic. HEENT: Tympanic membranes were clear.
Pharynx was slightly erythematous with stuffy nose with no rhinorrhea at this point in
time. Eyes were normal. The anterior fontanel is soft. NECK: Supple. No
meningismus. RESPIRATORY/LUNGS: The patient has course bilateral breath sounds
but no retractions, no respiratory distress at this point. No wheezing and normal breath
sounds to both lung fields. HEART: Regular rate and rhythm. No murmurs.
ABDOMEN: Soft. No masses and no organomegaly. SKIN: Appears to be normal on
inspection and examination.
IMPRESSION: Bronchiolitis.
DISCHARGE INSTRUCTIONS: Chest physiotherapy every four hours and bronchiolitis
instruction sheet, Tylenol 80 mg every four hours as needed for fever. I advised mom to
increase the amount of fluids such as Pedialyte, also elevate the head of the bed and
use a humidifier as he lies down. Follow up with his pediatrician, Dr. Susan McCullum
as needed in two days.
Carrie S. Dunn, MD # 2529
Date of Visit: 10/11/2005
CHIEF COMPLAINT: Weakness.
HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old female with significant
past medical history for chronic anemia, hypothyroidism, and upper GI bleed who
presents to the emergency department with weakness and shaking. Per the patient she
was transfused blood roughly six weeks ago when her hemoglobin was 6.5. Her
hemoglobin last week was 8.9 per the patient. The patient states that she felt shaky and
that she was about to pass out. She did not have a syncopal episode. She has been
feeling short of breath with exertion. She denies chest pain, double vision, blurry vision,
or any syncopal episodes. She denies abdominal pain, pain or burning with urination,
blood in urine or stool. The patient denies difficulty ambulating and uses a cane at
home. She does live alone. She says that this is the exact same symptom that she has
had when her hemoglobin has gotten low. She denies any dark tarry stool or bright red
blood per rectum. She denies any pain or burning with urination or blood in urine.
REVIEW OF SYSTEMS: As per History of Present Illness, the remaining systems are
negative.
PAST MEDICAL HISTORY: Significant for arthritis, anemia, and ulcers.
PAST SURGICAL HISTORY: Hysterectomy, C-section, bladder repair, right hip
replacement x2, left knee replacement x2.
ALLERGIES: SULFA, VICODIN.
MEDICATIONS: Include metoprolol, Protonix, Darvocet, Procrit, and Synthroid.
SOCIAL HISTORY: The patient smokes, uses alcohol occasionally, and denies drug
use. She lives alone.
PRIMARY CARE PHYSICIAN: Dr. Burdzy.
PHYSICAL EXAMINATION: GENERAL: The patient is alert and oriented in no acute
distress, non-labored breathing, and appears as stated age. VITAL SIGNS:
Temperature 98.4, pulse 115 rechecked at 105, respirations 14, blood pressure 175/86
satting 98% on room air. HEENT: Extraocular movements are intact. Pupils are equal
and reactive to light. Head: Normocephalic, atraumatic. NECK: Supple. No
adenopathy. Trachea midline. CARDIOVASCULAR: Increased rate, regular rhythm.
LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender with positive
bowel sounds in all four quadrants. MUSCULOSKELETAL: There is 5/5 muscle strength
in all four extremities, 2+ pulses in all four extremities. No clubbing, cyanosis, or edema
noted. NEUROLOGIC: Cranial nerves II-XII intact. Gait not assessed secondary to the
patient's weakness. RECTAL: Heme negative, good rectal tone.
EMERGENCY DEPARTMENT COURSE/MEDICAL DECISION
MAKING/DIFFERENTIAL DIAGNOSES:
1. Anemia secondary to upper or lower GI bleed.
2. Occult infection.
3. Chronic anemia.
4. Coronary artery disease.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined
immediately upon arrival. IV had been established by EMS and blood work drawn. The
patient was placed on a monitor and EKG was obtained. This showed a rate of 90, a
QDC of 424, no ST changes, no Q waves noted. QRS interval was normal. No T wave
inversion noted. This was a normal sinus rhythm. Chest x-ray was also obtained
looking for occult pneumonia which was negative for infiltrate or pneumothorax.
Laboratory work was also obtained on this patient which showed a urinalysis showing a
white count of 16-20 and bacteria moderate with moderate nitrites. Laboratory work also
revealed a WBC of 8.3 and hemoglobin and hematocrit of 9.0 and 27.4, a platelet count
of 318, sodium 139, potassium 4.1, chloride 107, cO2 of 23, BUN of 14, creatinine of
1.1, and glucose of 139. Troponin of 0.04, CPK-MB of 3.4, an INR of 1.13. The patient
remained stable throughout her time in the emergency department with stable vital signs
and a repeat heart rate of 100. She received IV fluids and felt symptomatically better.
The patient states that her feeling of weakness and dizziness was similar to the time
when she needed a blood transfusion. She states that she has had transfusions before
in the past and has been taking her Procrit injections. The patient did have signs of a
UTI and therefore was given Levaquin 500 mg IV while in the emergency department.
At this point I spoke with Dr. Burdzy, the patient's primary care physician, who agreed to
admit this patient for further evaluation and treatment of her UTI. The patient does live
alone and I did not feel comfortable sending this patient home with her current bouts of
weakness. She was heme negative on exam. The patient will be admitted to Dr.
Burdzy's service.
ADMITTING DIAGNOSES:
1. Weakness and fatigue.
2. Urinary tract infection.
3. Anemia.
Sample 2
Date of Visit: 10/01/2005
CHIEF COMPLAINT: Chest pain, fever, headache.
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male with significant
past medical history for emphysema, several abdominal surgeries, hepatitis, who
presents to the emergency department with a one-week history of worsening chest pain
and chest pressure, as well as a low-grade fever and decrease in p.o. intake. According
to the wife, this patient does not like hospitals and has been not feeling well for over
three months but has refused to come to the hospital until today. This patient does see
Dr. Conrado for his emphysema. The patient is complaining of some mild chest
pressure which is intermittent in nature. He denies any swelling in his legs. He also has
had a low-grade fever according to the wife which is treated with Tylenol. The patient
has had a decrease of p.o. intake but has no difficulty urinating but does suffer from
constipation occasionally. The patient has no past medical history of coronary artery
disease but has not been evaluated for his heart. Currently the patient is rating his pain
a 2/10. He did not take aspirin, therefore was given some on arrival. The patient denies
nausea or vomiting, double vision, blurry vision, lightheadedness or syncopal episodes.
He does state he has occasional palpitations, as well as chest tightness. He has no
radiation of the pain into his neck or down his arm. The patient denies blood in his stool,
difficulty urinating or difficulty ambulating.
REVIEW OF SYSTEMS: As per history of present illness. The remaining systems are
negative.
PAST MEDICAL HISTORY: Significant for:
1. Hepatitis.
2. Emphysema.
3. Multiple abdominal surgeries.
4. Past history of substance abuse.
ALLERGIES: None.
MEDICATIONS:
1. Flovent.
2. Albuterol nebulizer.
3. Tylenol.
SOCIAL HISTORY: The patient denies smoking, alcohol or drug use. He lives with his
wife.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: GENERAL: The patient is alert and oriented, in no acute
distress, non-labored breathing. VITAL SIGNS: Temperature 98.3, pulse 94,
respirations 22, blood pressure 104/65, oxygen saturation 93% on room air. HEENT:
Extraocular movements are intact. The pupils are equal and reactive to light. HEAD:
Normocephalic and atraumatic. NECK: Supple, no adenopathy, no jugular venous
distention noted. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to
auscultation bilaterally. ABDOMEN: Multiple old scars noted, soft, nontender with
positive bowel sounds in all four quadrants. MUSCULOSKELETAL: 5/5 muscle
strength in all four extremities. 2+ pulses in all four extremities. No clubbing, no
cyanosis, no edema noted. NEURO: Cranial nerves II-XII are intact.
EMERGENCY ROOM COURSE/MEDICAL DECISION MAKING/DIFFERENTIAL:
1. Unstable angina.
2. Gastritis.
3. Pneumonia.
EMERGENCY ROOM COURSE: The patient was placed on a monitor. IV was
established. Oxygen was given via nasal cannula. Due to the patient's blood pressure,
nitroglycerin paste was not given. The patient was given Toradol for a headache, as
well as his mild chest pain. Electrocardiogram was obtained which showed a normal
QRS interval, normal and upright P waves, no ST changes or Q waves noted, normal
sinus rhythm. Due to the patient's multiple complaints, an extensive workup was done
which included cardiac enzymes, as well as an abdominal series and LFTs to the
patient's history of hepatitis. According to the wife he has had his gallbladder, as well as
appendix removed.
Lab work for this patient includes a white count of 14, hemoglobin and hematocrit of 14.8
and 42.9, platelet count of 247. The patient's troponin was 0.03. CPK-MB was 0.9. The
patient had a slight left shift with neutrophils of 78. The patient's sodium was 136,
potassium 3.8, chloride 101, CO2 of 24, BUN of 18, creatinine of 1, calcium of 8.8,
albumin of 3.6, alkaline phosphate 110, AST of 90, ALT of 82, total bilirubin of 1.4. The
patient did not look jaundice on exam. The patient's abdomen was nontender and
nondistended with positive bowel sounds. Acute abdominal series was obtained which
showed a nonspecific bowel pattern. His chest x-ray was clear with no signs of infiltrate
or pneumothorax. The patient did have some stool on his abdominal series. There are
no air fluid levels or signs of obstruction noted. The patient again was given IV fluids, as
well as Toradol and aspirin while in the emergency department and felt better. On
reevaluation the patient's vital signs were stable. He was in no acute distress and was
not complaining of pain.
DISPOSITION: Admission to a telemetry bed for chest pain, rule-out unstable angina. A
call was placed to Dr. Sachs, who agreed to admit this patient.
ADMISSION DIAGNOSIS: Unstable angina.
Erin Ross, PA
Date of Visit: 10/13/2005
CHIEF COMPLAINT: Dizziness.
HISTORY OF PRESENT ILLNESS: This patient states she woke up this morning to use
the restroom and was extremely dizzy upon sitting up. The patient states the dizziness
felt like she was spinning, not the room. The patient states that she had to crawl to the
restroom and felt better when sitting still. The patient states when she begins movement
she feels nauseous and feels like vomiting. The patient states that this occurred to her
once before in the 1980's and she saw a neurologist and her symptoms went away. The
patient denies any chest pain, shortness of breath, hematosis, or blacking out. The
patient states she did not lose consciousness or strike her head. The patient states she
has not had any recent falls. The patient has not had any gait disturbances up until this
dizzy episode. The patient denies diabetes mellitus and denies any recent infection.
ALLERGIES: Prednisone.
MEDICATIONS: Aspirin, Zocor, lisinopril, Nexium and vitamins.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia and acid reflux disease.
PAST SURGICAL HISTORY: Hysterectomy, carpal tunnel release x2.
IMMUNIZATIONS: Up-to-date per patient.
SOCIAL HISTORY: The patient denies tobacco use, states she drinks a glass a wine
occasionally and denies illicit drug abuse.
REVIEW OF SYSTEMS: All other systems are reviewed and are negative.
PHYSICAL EXAMINATION: GENERAL: This is a very pleasant 74-year-old Caucasian
female alert and oriented to person, place and time. VITAL SIGNS: Temperature 97.9
degrees Fahrenheit, pulse 69, respiratory rate 18, blood pressure 170/82, rechecked at
150/80, oxygen saturation is 100% on room air. SKIN: Warm to touch. There is no
diaphoresis or dehydration. There are no masses, rashes or lesions. No signs of
cyanosis, clubbing or jaundice. Capillary refill is less than two seconds to the bilateral
upper and lower extremities. HEENT: The patient had reproducible vertigo with turning
of the head. The head is normocephalic, atraumatic and symmetric. Facial features are
symmetric. There are no focal signs present. There is no facial drooping. Eyes are
symmetric. Sclerae are white without icterus. Conjunctiva are without injection. Pupils
are equal, round, reactive to light and accommodation. Extraocular muscles are intact.
There is no pain upon palpation of the tragus, pinna or auricle. External canals are
without erythema or maceration. Tympanic membranes are pearly gray without
erythema, fluid or bulging bilaterally. Hearing is diminished chronically. Nose is without
deformity. Turbinates are pink without injection or polyps. Mucous membranes are
moist and pink. Lips are without cyanosis, lesions or ulcers. There are no vesicles or
exudates. There is no postnasal drip. NECK: Supple, trachea is midline. There is no
jugular venous distention, no cervical adenopathy, and no nuchal rigidity. LUNGS: No
signs of distress or accessory muscle effort in breathing. Breath sounds are appropriate.
Lungs are clear to auscultation bilaterally. There are no wheezes, rhonchi, crackles or
rubs noted. CARDIAC: Precordium is calm. There are no lifts, heaves or thrills. S1,
S2 regular rate and rhythm, without murmurs, gallops or rubs. Bruits are absent. Pulses
are 2+ throughout. ABDOMEN: Flat without rashes, masses, lesions or ecchymosis.
Normal active bowel sounds in all four quadrants. The abdomen is soft without
organomegaly. There is no CVA tenderness. Stool guaiac is negative. There is no
rebound, guarding or rigidity noted. NEUROLOGIC: The patient is without confusion or
agitation, alert and oriented x3. Speech is clear and appropriate. Sensation is intact.
Cranial nerves II-XII are grossly intact. The patient had a negative Romberg. Gait is
bradykinetic secondary to caution. Muscle strength is 5/5 to the bilateral upper and
lower extremities.
ASSESSMENT: Peripheral vertigo.
PLAN: During the course in the emergency room visit the patient was given Phenergan
25 mg IV and two doses of meclozine, each 25 mg p.o. The patient experienced
symptomatic relief. The patient was ambulating in the hall prior to discharge without
vertigo.
DISCUSSION: Peripheral vertigo versus central vertigo. This patient demonstrated
numerous signs of peripheral vertigo. She had reproducible dizziness, which resolves
when holding still. The patient had no focal signs. The patient had intense nausea and
vomiting with an abrupt onset of the vertigo. The patient is encouraged to follow-up with
Dr. Bonnette, neurologist, and she currently has an appointment with Dr. Stevens, ENT,
which she was encouraged to keep next week. The patient was given a prescription for
meclozine 25 mg p.o. which will be taken three times daily as needed for vertigo. All the
patient's questions were answered. The patient was discharged in stable condition.
Dictated by Erin Ross, PA
Sample 2
Date of Visit: 10/13/2005
CHIEF COMPLAINT: Vaginal bleeding.
HISTORY OF PRESENT ILLNESS: The patient states yesterday she had heavy vaginal
bleeding. She came to the emergency department last evening. The patient states she
did not have any pain yesterday. During her emergency room course on 10/12/2005 the
patient had an ultrasound of the uterus which revealed a viable intrauterine pregnancy
and no evidence of premature rupture of membranes. Today the patient presents
complaining of a gush of fluid this morning. The patient states the fluid was clear and
states she has been leaking ever since. The patient denies any heavy bleeding today.
The patient states she has a mild lower abdominal discomfort that radiates to her back.
The patient states she has not had any fever, chills, nausea, vomiting, or recent
infections. The patient is 19 weeks gravid.
ALLERGIES: Penicillin.
MEDICINES: Prenatal vitamins.
PAST MEDICAL HISTORY: The patient one spontaneous abortion.
PAST SURGICAL HISTORY: D&C.
PRIMARY CARE PHYSICIAN: Dr. Oram for OB/GYN.
SOCIAL HISTORY: The patient denies smoking, denies ETOH and denies recreational
drug use.
IMMUNIZATIONS: Up-to-date per patient.
REVIEW OF SYSTEMS: All other systems are reviewed and are negative.
PHYSICAL EXAMINATION: GENERAL: This is a very pleasant 38-year-old Haitian
female, a G3, P1, A1, in no acute distress, alert and oriented to person, place and time.
VITAL SIGNS: Temperature 98.1 degrees Fahrenheit oral, pulse 97, respiratory rate 24,
blood pressure 110/66, oxygen saturation is 100% on room air. SKIN: Warm to touch.
There is no diaphoresis or dehydration, no signs of cyanosis, clubbing or jaundice.
There are no masses, rashes or lesions. HEENT: The head is normocephalic,
atraumatic and symmetric. Facial features are symmetric. There is no obvious droop.
Eyes are symmetric. Sclerae are white without icterus. Pupils equal, round, reactive to
light and accommodation. Extraocular muscles are intact. NECK: Supple, trachea is
midline. There is no jugular venous distention, no cervical adenopathy, and no nuchal
rigidity. LUNGS: Clear to auscultation bilaterally. There are no wheezes, rhonchi,
crackles or rubs noted. CARDIAC: S1, S2 regular rate and rhythm, without murmurs,
gallops or rubs. Pulses are 2+ throughout and extremities are warm. Capillary refill is
less than two seconds bilateral upper and lower extremities. ABDOMEN: The abdomen
is round with evidence of a 19-week uterus. There are no masses, rashes or lesions
noted. No ecchymosis noted. There are normal active bowel sounds in all four
quadrants. The abdomen is gravid at 19 weeks. No CVA tenderness noted. There is
no tenderness to palpation. GENITOURINARY: The external genitalia is without
masses, rashes or lesions. There is no blood at the introitus. The os is open at 1 cm
with a large amount of clear fluid in the vault.
EMERGENCY ROOM COURSE: Nitrazine paper was utilized to assess vaginal pH
which was 7.
ASSESSMENTS:
1. Probable premature ruptured membranes.
2. Threatened abortion.
PLAN: Dr. Oram was consulted and has decided to admit this patient. The patient will
be admitted to the perinatal floor. The plan was discussed with the patient and all of her
questions were answered. We are transferring service to Dr. Oram.
Dictated by Erin Ross, PA