Posted Patient Note Sample(s) for this Case


Name: ferchi
Email: soyferchi@hotmail.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 25th of November 2007 01:18:28 PM
 
History

CC:cc: fatigue
HPI: 46yo M, c/o fatigue that started 3 months ago, after failing to save a friends life from a MVA. He feels fatigued throughout the day. He presents problems staying asleep, due to nightmares from the accident, and he wakes up early, which is affecting his job. He experiences loss of energy, difficulty to concentrate, loss of appetite but gained 6 lbs and he had suicidal ideation but no attempt and no plans. He also experiences hair loss, cold intolerance but no constipation. He feels helpless and scared. Denies guilt.
ROS: negative except as above
PMH urethritis (possible chlamydia) treated with antibiotics for 7 days.
PSH: none
Allergies: NKDA
Meds: none
sh: 1ppd/day for 25 years. no etoh, no illicit drugs. Not interested in sex, h/o unprotected sex with multiple partners.

Physical Examination

 patient in no acute distress, flat affect and talks and moves slowly.
HEENT. mouth and throat wnl, thyroid gland normal size
CV: RRR, normal S1/S2, no murmurs, gallops or rubs
Chest: clear breaths sounds bilaterally
Abd: soft, nondistended, nontender, +bs, no heaptomegaly
Extremities. DTRs intact and symmentric

Differential Diagnosis
1.Depression
2.adjustmend disorder with depressed mood
3.ptsd
4.hypothyroidism
5.obstructive sleep apnea
Diagnostic Workup
1.CBC
2.TSH
3.MRI brain
4.polysomnography
5.HIV antibody
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Posted Patient Note Sample(s) for this Case


Name: hhh
Email: hh@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Tuesday 30th of October 2007 06:12:34 PM
 
History

CC: abdominal pain
HPI:

ROS:
PMH:
Allergies:
Meds:
SH:
FH:

Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:
Neuro:hhhhhhhhh

Differential Diagnosis
1.hhhhhhhhh
2.
3.
4.
5.
Diagnostic Workup
1.
2.vvvvvvvvvvvv
3.
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: tutan
Email: mariola_00@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 28th of October 2007 08:16:32 AM
 
History

CC:hemoptysis
HPI:

ROS:
PMH:
Allergies:
Meds:
SH:
FH:

Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:
Neuro:

Differential Diagnosis
1.lung cancer
2.TB
3.lung abcess
4.pneumonia
5.wegener disease
Diagnostic Workup
1.CBC with diferencial
2.sputum gram stain
3.chest x ray
4.urinalysis
5.blood urea nitrogen
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Posted Patient Note Sample(s) for this Case


Name: ak
Email: anika94@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 23rd of September 2007 03:13:43 PM
 
History

CC:Pain in Rt. arm
HPI: Developed pain in Rt. Arm 3 days ago after falling on outstretched right arm while playing with grandchildren.. Pain gradually got worse.. Can\'t move arm because of pain. Rates pain 6-7/10.. Moving it around exacerbated pain while resting arm and tylenol improves pain. Denies abuse, denies weakness/numbess, denies diziness

ROS: Negative except for above
PMH: Asthma (well controlled with Albuterol)
Allergies: Asprin (develops rash)
Meds: Albuterol, Tyelenol
SH:
FH:

Physical Examination

 Gen: Alert & oriented
Vitals: WNL
HEENT:
Neck: no bruises, normal movment
LUNGS: clear breath sounds bilaterally
CVS: Apex beat not displaced RRR, normal S1 + S2, no murmurs, rubs, or rales
ABD:
Ext: DTRs +2
Neuro: Muscle strength couldn\'t be assessed in right exteremity couldn\'t be assessed because of pain,

Differential Diagnosis
1. Fracture of humerous
2. Osteoporosis
3. Dislocation shoulder
4.
5.
Diagnostic Workup
1. XR Right arm
2. DEXA (Bone density)
3. MRI Rt. Shoulder
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: ak
Email: anika94@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Wednesday 19th of September 2007 03:57:06 PM
 
History

CC:hypertension follow up
HPI: 54 Male with hypertension which was diagnosed a year ago. Patient compliant with HCTZ but hypertension not well controlled so 6 mo ago placed on propanolol. After propanolol added experiencing impotence. Rated erection as 4/10, denies anxiety, stress, depression, or marital problems. Not experiencing any other problems

ROS: negative except for above
PMH: Hypercholesterolemia, hypertension
Allergies: NKDA
Meds: HCTZ, Propanolol, Lovastatin
SH:
FH:

Physical Examination

 Gen: Alert & Oriented
Vitals: Normal
HEENT: PERRLA, no carotid murmur
Neck: supple,
LUNGS: symmetric clear breath sounds bilaterally
CVS: RRR, Normal S1 + S2, no murmurs, rubs, or gallops
ABD: Soft and nontender, non distended, BS+, no bruits
Ext: peripheral pulses
Neuro: no focal neurology

Differential Diagnosis
1. Erectile dysfunction due to medication
2. ED due to vascular dysfunction
3.ED due to depression
4.
5.
Diagnostic Workup
1. Genital exam
2. rectal exam
3. CBC
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: Bhuwan
Email: drbh_poudel@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Tuesday 18th of September 2007 03:01:51 PM
 
History

CC:shortness of breath
HPI:was alright till 2 weeks back when started to become short of breath,it was sudden in onset developed while running.its getting worse since than.does occurs every 3-4 days.severity is in ascale of 7,limiting the patient from carrying out activities of daily living.precipated by exercise,releived with rest.no associated complain.

ROS:no cough,no chest pain,no ankle swelling,no wheezes,no history of travel,no other symptom of urti.exercise tolerance is decreased,co orthopones or paroxysymal dysponea
PMH:no any
Allergies:not any
Meds:inhalers prescribed by family physician
SH:smoker 20 per day social drinker,not sexually active,does not use recreational drug
FH:not significant

Physical Examination

 Gen: male
Vitals:120/80,72 bpm,afebrile,r/r 14/min
HEENT:not significant
Neck:jvp not raised
LUNGS:vesicular breath sounds
CVS:1 2 nd sound,no murmer
ABD:no organo megaly
Ext:normal
Neuro:intact

Differential Diagnosis
1.copd
2.asthama
3.
4.
5.
Diagnostic Workup
1.peak flow metry
2.
3.
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: OO
Email: oo@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 15th of September 2007 01:16:58 PM
 
History

CC:chest pain
HPI: 60 y/o AAM c/o chest pain. Started 2 hrs ago. sharp in nature. Radiates to jaw and L shoulder. Relieved by Notroglycerine. Worsended by exertion. Associated with cough and SOB. No Ranked 7/8 on pain scale.
ROS: No wheezing or palpitation or syncope; No diaphoresis
PMH: Heart attack 2 yrs ago No Diabetes. Hypertension since 5 yrs
Allergies: No allergies. No hospitalization since 2 yrs ago
Meds: Aspirin dly since 2 yrs
SH: Retired teacher. Lives with wife. Etoh (-); Cig(-); Illit drugs(-)
FH: dad, hypertensive; mom, Diabetic

Physical Examination

 Gen:A&O x3: In distress
Vitals:WNL except for BP 138/85
HEENT: Eyes: PERRLA. No lateralizing signs
Neck: Supple. No JVD, No carotid bruit, No thyromegaly or adenomegaly
CVS: NRRR. PMI not displaced. No murmurs, gallops, rubs, clicks, or heaves.
LUNGS: Symetrical. N breath sounda B/L. No wheezes, rales or dulllness. Normal vocal and tactile fremitus.

Differential Diagnosis
1. Acute MI
2. Unstable Angina
3. Pericarditis
4. PE
5. Costochondiritis/Plueresy
Diagnostic Workup
1.EKG/ECHO
2.CK-MB/ProponinMyoglobin
3.CXR PA & Lat
4.PFT/VQ Scan
5.Pulse Oximeter
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Posted Patient Note Sample(s) for this Case


Name: OO
Email: oo@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 06th of September 2007 10:39:46 PM
 
History

CC:52 y/o female c/o headache.

HPI: Wakes up with morning L frontoparietal headache since 2 days. Dull, continuous non-radiating headache alleviated by tylenol and worsened by light and noise.
ROS:Associted photophobia since 2 days ago.
PMH: Hospitalized 3 yrs ago for hepatitis
Allergies:Rashes with penicillins
Meds:Tylenol
SH:Lives with husband and 2 children. Post menopausal. Sexually active with husband.
FH: None significant

Physical Examination

 Gen: AAA x3. Sitting up with eyes closed and holding head in the hands
Vitals:WNL
HEENT:Nil of note
Neck:WNL
LUNGS:CLear bilaterally with good air entry
CVS: Normal S1 and S2 without murmurs or heaves
ABD: Soft and benign. No organomegaly
Ext: Normal pulses and no edema
Neuro:Normal DTR, tone, power and muscle musce mass.

Differential Diagnosis
1. Migraine
2. Cluster Headache
3. Meningitis
4. Sinusitis
5. Temporal ateritis
Diagnostic Workup
1.CSF analysis and C&C
2. CT Scan of the head
3. CBC with differentials
4. Xray of the Sinus
5. ESR
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Posted Patient Note Sample(s) for this Case


Name: Fateh
Email: fateh.b@hotmail.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 12th of August 2007 03:18:22 PM
 
History


30 yo W F c/o sharp,MLQ abdominal pain that increased slowly over the past 12hrs. pain is generalized in all lower abdomen. 7/10 in severity. began after eating a large meal. Worsens with movement. no alleviating factors. No vomiting but patient feels nauseated. appetite/weight without changes. associated with fever/chills/rigors and increased ing frequency with burning pain while passing . No GI problems.LMP 3wks ago. No l bleeding/discharge. PMH: 1 episode of UTI.Allergies:NKDA. PSH: Once for evaluation of UTI. Social hx: no tobacco/alcohol/drugs use.works as a receptionist.sexually active with multiple partners ,uses OCP. Family Hx: None.

Physical Examination

 Patient is no actute distress
Vs: WNL
Chest: Nontender,Clear breath sounds bilaterally.
Heart:RRR, Normal S1/S2. No gallops/rubs/murmurs.
Abdomen: No Surgical Scars/Skin abnormalities.Soft,Nondistended,No palpable masses,No heptospelnomegaly, tenderness in lower abdomen.- rebound/murphy/psoas/obturator/mcburny. + CVA.Tympanitic to auscultation in all quadrants. + Bowel sounds.

Differential Diagnosis
1.Pelvic Inflammatory Disease
2.Pelvic Abscess
3.Ovarian cyst torsion
4.Appendicits
5.
Diagnostic Workup
1.Rectal+Pelvic+Genital Exam. Stool for occulut
2.CBS/Electrolytes/AST/ALT/Bilirubin
3.UA and Culture
4.U/S Abdomen
5.hCG Test
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Posted Patient Note Sample(s) for this Case


Name: Quresh
Email: qureshmuhammad@hotmail.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 26th of July 2007 10:40:45 AM
 
History

CC:60 y/o M c/o chest pain
HPI:Got pain in middle of chest 12 hours ago which is excruciating in character and stands 9/10 on a scale of 1-10. The pain is radiating to the neck and associated with nausea nand swating. The pain is constant and is aggravated by movements. There is no releiving factors. There is shortness of braatha as well as palpitation. No similar pain in the past. pt is hypetensive and diabetic.

ROS:Negative exept aboe
PMH:Hypertensive and diabetic
Allergies:NKDA
Meds:Aspirin, proprnolol and glyburide
SH:Appendectomy at age 20
FH:Father died at 80 of hear attack, mother alive and ok

Physical Examination

 Gen: Pt is in acute distess and pain
Vitals:Normal expet tachycardia
HEENT:Normocephalic atramatic, PERRLA, nose and throat are not congested
Neck:Supple and no carotid buit and no lympadenopath.
LUNGS:Lungs are clear bilatrlly on auscultation. no rhonchi added sounds or rubs.
CVS:RRR normal S1/S2 no rubs murmurs or gallops. pulses 2+ BL
ABD:Soft, nontender. + BS no organomegaly no reboud tenderness or scar.
Ext:R Knee joint is erythemic and tender to touch. range of motion resticted and DTR intact.
Neuro:pt oriented to x3. cranial nerves intant from 2--12.

Differential Diagnosis
1.Myocardial Infarction
2.Angina
3.Pneumothorax
4.Pneumonia
5.Pericarditis
Diagnostic Workup
1.CPK,CPK-MB Toponin ECG CXR
2.Electrolytes
3.CBC
4.BUN/Cr
5.Echcardiography
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Posted Patient Note Sample(s) for this Case


Name: kangoo
Email: kango @yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 19th of July 2007 04:23:00 AM
 
History

CC:21 yo f losing wt since 6 months
HPI:no change in diet .no change in activity level. she is not depressed.is sexually active .happy with body image .no feeling of racing heart .no hot intolerance or anxiety .no intential wt loss.no diarrhea .

ROS:looks healthy .
PMH:,none
Allergies:nkda
Meds:none
SH:
FH:

Physical Examination

 Gen: looks happy and active
Vitals:wnl
HEENT:normal thyroid,no proptosis.no adenopathy .no icterus
Neck:no adenopathy
LUNGS:clear bilaterally .
CVS:nor.s1,s2. rrr.pmi not displaced.no rubs or gallops
ABD:nor bowel sounds.no tenderness. no organomegaly
Ext:no lesions
Neuro:aaax3.

Differential Diagnosis
1.bleeding disorder
2.malignancy
3.new onset diabetes
4.hiv
5.grave disease
Diagnostic Workup
1.cbc,facbor viii assay ,protien c&s.
2.hct.mcv
3.fasting glucose
4.elisa,pcr for hiv
5.tsh
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Posted Patient Note Sample(s) for this Case


Name: sler
Email: ayazalikhan01md@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 15th of July 2007 02:44:01 AM
 
History

CC:loss of concious
HPI:loss concious while working on production line 1 hour ago ,no head trauma,body injuries,chest pain ,nausea ,vomiting ,shortness of breath,weight change ,appetite change ,constipation,diarrhea,numbness,weakness,headache,hallucination.Does have palpitations,viosion change,diaphrosis,seizure,

ROS:wnl
PMH:htn
Allergies:nkda
Meds:furosimide
SH:smoking 2ppdx25 yrs.heavy drinker.production line worker
FH:mother and father a/w

Physical Examination

 Gen:no acute distress ,obess

Vitals:wnl
HEENT:no adenopahty.mouth lesions.perrla.no ear discharge.
Neck:normal thyroid.no carotid bruits.
LUNGS:clear ,bilateral clear breath sounds.no wheezing .no rales and crackles
CVS:rrr.pmi not displaced.no murmurs.gallops.normal s1 and s2
ABD:soft ,nondistanded.nontender.
Ext:normal pulses.no edema,
Neuro:aaax3.dtr wnl.muscle strength 5/5

Differential Diagnosis
1.convulsive syncope
2.vasovagal syncope
3.cardiogenic shock
4.tia
5.brain tumor
Diagnostic Workup
1.ekg
2.cbc.electrolytes.bun/cr.
3.ct head ,mri brain
4.holter monitor
5.fobt.dre
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Posted Patient Note Sample(s) for this Case


Name: sndhu
Email: gottipatisindhu@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 14th of July 2007 08:21:24 PM
 
History

CC:headahes-8 months
HPI:28 y/o f with throbbing,one sided headaches,increasing severity,2-3/ month,12 hours without relief with OTC pain killers,trigered by light & noise,stress,with n/v,no fever,vision problems.
ROS:negative
PMH:previous similar episodes.No DM,HTN.No surgery,hospitalization
Allergies:NKA
Meds:OTC pain killers-no relief,none
SH:nonsmoker,social drinker(red wine),no iv drugs,banker,single sexual partner,regular menses
FH:mother & sister migraine

Physical Examination

 Gen: not in distress
Vitals:BP-120/80
HEENT:PERRLA,fundus normal,No temporal A. tenderness,PNS tenderness -, oral cavity normal
Neck:stiffness absent
LUNGS:clear PA b/l
CVS:s1s2,no murmurs
ABD:soft,nontender
Ext:no edema,pulses normal
Neuro:motor strength 5/5,tone sensory,reflexes normal

Differential Diagnosis
1.migraine
2.sinusitis
3.tension headaches
4.cluster headaches
5.meningitis,SAH
Diagnostic Workup
1.CBC with differential,
2.ESR
3.x ray PNS
4.CT head
5.
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Posted Patient Note Sample(s) for this Case


Name: gaurav
Email: anaghya82@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 30th of June 2007 08:29:22 AM
 
History

CC:21y patient came to ER with complaint of sudden onset of crushing chest pain which started 1 hour back,7/10 in intensity. associted with nausea and 2 episodes of vomiting , and SOB.
HPI:

ROS:negative except as above
PMH:had 1 episode of MI 1 year back
Allergies:NDAK
Meds:on asprin 75mg,PO , daily
SH:smokes 1 pack/ day/13 years,do not want to quit, EToH ,2 beers /day; CAGE: 0/4
FH:Non -cantributary

Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:
Neuro:

Differential Diagnosis
1.Angina
2.Pneumothorax
3.Pericarditis
4.pulmonary thrombo-embolism
5.
Diagnostic Workup
1.CBC
2.CArdiac enzymens, CK_MB< Tropinin,
3.ECG
4.throcaic ecocardiography
5.
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Posted Patient Note Sample(s) for this Case


Name: bbbb
Email: none
Case Number: 01
Case Title: 01

Date Posted:

Thursday 14th of June 2007 05:41:50 AM
 
History

CC:
HPI:57yomale c/o 1 episode of painless hematuria yesterday morning ,. he has no fever, no abdominal or flank pain, and no dysuria. no history of renal stones.he has a 2yr history of staraining on urination, polyuria, nocturia,weak stream and dribbling .no nausea . no vomitying diarrhoea or constipation. no change in appetite or wt los. no previous similar episode

ROS:negative except as above
PMH:gout, genital herpes that recurred several months ago
Allergies:nkda
Meds:allopurinol
SH:one ppd for 30yrs, 2beers2;3toimes aday, noillicirt drug. work as apainnterhererosexual haas a new partner, and uses condom occasionaly
FH:father died at age og 80 due to kidney problem

Physical Examination

 Gen: pt is on no acute distress
Vitals:wnl
HEENT:
Neck:
LUNGS:clear breath sounds bilaterally
CVS RRR, normal s1 s2.nomurmurs, rub or gallops
ABD:soft normal, nondistended.bs,nohepatosplenomegaly,mild right cva tenderness
Ext:no edema
Neuro:

Differential Diagnosis
1.bladder cancer
2.urolithiasis
3.bph
4.renal cell cancer
5.uti
Diagnostic Workup
1.genital exam
2.rectal exam
3.ua
4.urine cytology
5.psa
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Posted Patient Note Sample(s) for this Case


Name: xxx
Email: xx@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 24th of May 2007 02:45:23 PM
 
History

CC: 42 yo f with chest pain
HPI: Constant, sharp pain across the chest for the last 10 hours. No radiadion or change with exercise, food or deep inspiration. Denies any associated symptoms like SOB, palpitations, fever, chills. Denies any previous history of chest pain.
PMH: No HTN, heart disease, diabetes, asthma. Doesn\'t take any medications. NKDA
FH: noncontributory
SH: no smoke, no ETOH, no recreational drugs.
Sexual hx: one sexual partner, married for 15 years
No hx of STD, LMP 2 weeks ago

Physical Examination

 Vital signs WNL except BP 150/90
Heath appearing patient, calm, no distress
Chest: tenderness to palpation of the sternum
Heart: Normal S1/S2, regular rhythm. no JVP
Lungs: Clear to auscultation, normal tactile fremitus, no dullness to percussion, no clubbing or cyanosis.
Abd: normal bowel sounds, non tender abd

Differential Diagnosis
1.angina
2.MI
3.Costochondritis
4.PUD
5.atypical pneumonia
Diagnostic Workup
1.Serial CKMB, troponin, CBC with diff
2.EKG
3.Chest xray
4.Repeat BP next visit
5.Upper endoscopy
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Posted Patient Note Sample(s) for this Case


Name: asdf
Email: dse@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 18th of May 2007 09:41:30 PM
 
History

CC:
HPI:

ROS:
PMH:dfhgagnszdgxcb bxb c
Allergies:
Meds:
SH:
FH:

Physical Examination

 Gen:
Vitals:
HEENT:bahaeht
Neck:
LUNGS:
CVS:
ABD:
Ext:
Neuro:

Differential Diagnosis
1.
2.
3.
4.rehwhwrtjwrjwryjwryyjwryjwryjeryjeryrjwryw
5.
Diagnostic Workup
1.
2.
3.ewrgqerhqerhqehqerhqerhrdfggnwafeb
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: Navid
Email: Amir@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 11th of May 2007 01:24:51 PM
 
History

CC:57 year-old male comlpaining of bloody urine.
HPI:57 yo male complanning of painless hematuria since two days ago.Patients denies any flank pain, fever, dsuria. Patient noted strainingon urination since five months ago. Patient reports polyuria, nocturia, ewak urinary steam. patient reports no change in appetite or weight loss,nausea, vomiting, diarrhea.

ROS:Negative except as above.
PMH:Asthma sine 4 years ago
Allergies:dogs and cats.
Meds:Tylenol.
SH:one PPD since 10 years ago,no alcohol, no illicit drugs
FH:Mother alive and healthy. Fathe passed away 10 years ago old age.

Physical Examination

 Gen: Patient isn\'t acute stress.
Vitals: WNL
HEENT:Atraumatic,Normocephalic,PERRLA,EOMI, No tonsillar erythema.
Neck:Supple, No JVD. Normal thyroid, no cervicakl LAD.
LUNGS:Clear to percuccion biaterally.no rubs, wheezing.
CVS:RRR, Normal S1 and S2. No murmurs, rubs or gallops.
ABD:Soft, nontender, nondistended, BS +, no hepatoslenomegaly.
Ext:No clubbing, Cyanosis, or edema.
Neuro:Alert orinted X3, good concentation.

Differential Diagnosis
1.BPH
2.renal cell carcinima
3.UTI
4.Urolithiasis
5.Bladder cancer
Diagnostic Workup
1.Genital and rectal exam
2.UA
3.urine culture
4.Ct abdomen
5.PSA
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Posted Patient Note Sample(s) for this Case


Name: o9ook
Email: none
Case Number: 01
Case Title: 01

Date Posted:

Tuesday 08th of May 2007 05:22:07 PM
 
History

CC:
HPI:

ROS:
PMH:
Allergies:
Meds:i9098u087u8088-908897766ty7yhjiujoi8u86r5e645re575675867y9u8yhiu
SH:
FH:

Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:
Neuro:

Differential Diagnosis
5r655iuyyypiuhyigygyghjhkjpkpjhpnjnkjm1.
2.
3.
4.
5.
Diagnostic Workup
1.
2.
3.
4.yo8u-98887765756r6ue4433w54e765y08
5.
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Posted Patient Note Sample(s) for this Case


Name: sammu
Email: sangtar@rediffmail.com
Case Number: 01
Case Title: 01

Date Posted:

Wednesday 02nd of May 2007 11:57:49 PM
 
History

CC:28y/o f c/o throbing headaches which starts gradually on one side of head & then become sever and pounding the head on both sides which lasts about 12hours ,she is having these headaches from last eight months ,lying in bed & avoidin bright light & noice gives relief to these headaches,these headaches are accompanied by nausea
HPI:same as in CC

ROS:NEGATIVE EXCEPT WRITTEN ABOVE
PMH:HE IS HAVING THESE HEADACHES FROM COLLEGE TIME
Allergies:NO, TAKING ANALGESICS
Meds:
SH:
FH:

Physical Examination

 Gen: HE LOOKS ANXIOUS
Vitals:WNL
HEENT:WNL
Neck:SUPPLE,WNL
LUNGS:NOT CONTRIBUTORY
CVS:NOT CONTRIBUTORY
ABD:NON DITENDED ,BS +,NO MASSES FOUND ON PALPATION
Ext:MUSCLE STRENGTH5/5,CONTACT SENES TO DULL& SHARP BOTH ARE INTACT
Neuro:DTR+,GAIT NORMAL ,NO PARESIS,WEAKNESS,BABINSKY SIGN-

Differential Diagnosis
1.MIGRAINE
2.CLUSTER HEADACHES
3.TENSION HEADACHES
4.SUBACHNIOD HAEMORRAGE
5.BRAIN TUMER
Diagnostic Workup
1.BMP
2.ESR
3.CT SCAN-BRAIN
4.MRI-BRAIN
5.CBC
< Back

 

Posted Patient Note Sample(s) for this Case


Name: hsuehni
Email: none
Case Number: 01
Case Title: 01

Date Posted:

Sunday 22nd of April 2007 04:53:12 AM
 
History

CC:
HPI: The 30 yo woman c/o lower abdominal pain that started 12 hours ago, occured after meals, 7-8/10 in severity, sharp in charater, no radiation. There was also nausea and She also states that she got fever yesterday, associated with chills and rigor. No alleviating factors. Moving around makes the pain better.
ROS:All negative except for above
PMH:once hosptialized for evaluation of UTI
Allergies:NKDA
Meds:No
SH:No smoking, no drinking alcohol, no use of recreational drugs, works as a receptionist
FH:No hereditary disorder
Sex History: sexually active with her husband only, use oral contracepative pills

Physical Examination

 Gen: in no acute distress
Vitals: BP TPR
HEENT:
Neck:supple, no JVE, no thyromegaly
LUNGS:clear to auscultation
CVS:PMI no-displacedS1/S2 +, no murmur
ABD:no operation scar, +BS, no tenderness
Ext: no deformity
Neuro:

Differential Diagnosis
1. Pelvic inflammatory disease
2. Torsion of ovarian cyst
3.
4.
5.
Diagnostic Workup
1.CBC and diff
2.
3.
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: nm
Email: nmjyoti76@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Tuesday 10th of April 2007 02:59:16 AM
 
History

CC: c/o headaches
HPI: 28 y/o female comes with c/o severe headaches which are throbbing in nature get aggrevated by bright light and noise, gets better on lying down in quite room.typical episode lasts for 12 hr if untreated accompanied by nausea and sometimes vomiting. no radiation, no neck stiffness.

ROS:no fever , cough , SOB, urinary / bowel complains. no weakness/ tingling numbness in extemities.
PMH: similar episodes in past of and on
Allergies: NKA
Meds: taken tylenol for headches
SH: alcohol occasionaly, no smoking, single sexual partner,works as banker, normal sleep and appetite
FH:mother and sister - miagrane

Physical Examination

 Gen: normal
Vitals:normal
HEENT: noo local tenderness, oral cavity normal
Neck: no tenderness rigidity.
LUNGS:CTAP
CVS: S1 S2 normal no murmurs
ABD: soft no organomegaly
Ext: no weakness. no pedal odema
Neuro: tone, reflex, power, reflexes- normal

Differential Diagnosis
1.migrane
2.tension headaches
3.cluster headaches
4.sinusities
5.
Diagnostic Workup
1.CBC ESR with diffrential
2. CT scan head
3. U/A
4.x ray PNS
5.
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Posted Patient Note Sample(s) for this Case


Name: XX
Email: none
Case Number: 01
Case Title: 01

Date Posted:

Monday 09th of April 2007 07:23:09 PM
 
History

CC:
HPI:33 YOWF PRESENTS WITH INTERMITTENT PAIN FOR 4 WEEKS WITH OUT ANY TRIGGER POINT. PAIN IS SHARP, RADIATE AROUND NECK AND HEAD. 7/10 IN SEVERITY, WORSEN BY MOVMENT AND . LESSEN BY TYLENOL, REST AND SILENCE

ROS: NON CONTRIBUTORY
PMH: NO SIMILER EPISODE IN THE PAST
Allergies:NKDA
Meds:TYLENOL
SH:NO ETOH, NO CIG. LIVES WITH HUISBAND AND TWO KIDS AND WORKS AS ASECTRETARY. NO OTHER STRESSORS.
FH:

Physical Examination

 Gen: APPERAS COMFORTABLE
Vitals:WNL
HEENT:SUPPLE, NO PAIN ON MOVING, NO GLAND, THUYROIDS
Neck: PERLA, FUNDOSCOPY- UNREMARKAB;E NO KERNIGS OR BRUDZINSKI NEGATIVE
LUNGS:
CVS:
ABD:
Ext:
Neuro: AXOX3, CNII-XII INTACT, MOTOR -5/5 THROUGHOUT, SENSORY ANDDTR INTACT,

Differential Diagnosis
1.MIGRAINE
2.TENSION HEADACHE
3.INTRACRANIAL PROCESS
4.
5.
Diagnostic Workup
1.BMP
CBC WITH DIFF
CT HEAD CONTRAST
lp THERAFTER
2.
3.
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: shantaveer
Email: gangushantaveer@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 05th of April 2007 03:32:30 AM
 
History

cc;urinary incontinence hopi;urinapatients mother is the informer .she is the mother of a 8 yr old male child who c/o her child havind urinary incontinece .pt never attained continence and never had been dry for more than few days .however she denies any h/o fever,pain ,dysuria,gematuria,abd pain,orconstipaion.no h/o night time awakenings or excess of water or food or beverages at sleep..

ROS:n
PMH:none
Allergies:nkda
Meds:
SH:
FH:

Physical Examination

 Gen: patients mother is the informer .she is the mother of a 8 yr old male child who c/o her child havind urinary incontinece .pt never attained continence and never had been dry for more than few days .however she denies any h/o fever,pain ,dysuria,gematuria,abd pain,orconstipaion.no h/o night time awakenings or excess of water or food or beverages at sleep..

Vitals:WNL
ROS;none
vitals;wnl
PMH;none
PSH;none
FH; isolated male incontinece is +
SH;none.

Differential Diagnosis
1.monoymptomatic primary incontinence
2.secondary incontinence
3.UTI
4.sleep apnea
5.constipation
Diagnostic Workup
1.genital exam
2.UA
3.UC
4.S.gravity of early morning urine
5.u/s renal.
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Posted Patient Note Sample(s) for this Case


Name: dog
Email: dog@dog.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 30th of March 2007 01:42:21 PM
 
History

CC: This 33 yr old white female presents with a 4 week history of intermittent headache, Dull in nature radiate around back of head and neck, 5/10 in severity, relieved by tylenol and silence, worse by noise and movement. Nothing in particular brings these on. Associated nausea, flashing lights. No loss of consciousness, no seizures, no weakness
ROS: Remaining review of systems unremarkable
PMH: 2 vaginal deliveries at term, appendicectomy
Allergies: NKDA
Meds: Tylenol 1g 4 times daily
SH: Non smoker, no alcohol, lives with husband and children works as receptionist
FH: Father dies of stroke aged 60

Physical Examination

 Gen: Appears comfortable at rest
Vitals: 22 140/70 60 23
HEENT: PERLA, fundoscopy unremarkable
Neck: supple, no pain on movement, kernigs brudzinski negative

LUNGS: clear
CVS: hs normal no added sounds
ABD: unremarkablr
Ext:
Neuro: cranial nerves normal, plantars flexor, tone power sensation all normal in all 4 limbs

Differential Diagnosis
1. Migraine
2. tENSION HEADACHE
3. INTRACRANIAL LESION
4.
5.
Diagnostic Workup
1. CBC
2. METABOLIC PROFILE
3. CT head
4. Consider LP thereafter
5.
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Posted Patient Note Sample(s) for this Case


Name: mazinger
Email: tumadrenbolas@hotmail.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 25th of March 2007 04:00:08 PM
 
History

HPI:46 yo male comes to the clinic with a cc of fatigue with an onset of 1 month ago. the patient doesnt refer what might be the apparent cause of this problem and explains that his problem has been getting worse since it started. He has had similar symptoms in the past which were milder and lasted for a few days. He describes that he feels tired, and sleepy during the day and has been having sleep problems. He snores when he sleeps, he also wakes up early in the dawn without being able to fall back to sleep. He also refers that has been having difficulty to concentrate and constantly forgets things which are affecting his performance in his job. He denies cold intolerance, feelings of depression, changes in his weight, hair and skin.

ROS:normal except as above
PMH:Hypertensio for 5 years
Allergies:NKDA
Meds:HCTZ
SH:works as a lawyer, denies the use of tobacco and drugs, alcohol one pint a day CAGE 1/4
FH:Father died of ACV, mother has unespecified heart disease.

Physical Examination

 Gen: Male patient under no stress.
Vitals:
HEENT:neck supple, no lymphadenopathies, thyroid gland of normal size.
Neck:
LUNGS:
CVS: PMI non displaced, s1s2 rythmic no rubs no murmurs
ABD:Soft depressible, no organomegaly, no masses.
Ext:
Neuro:

Differential Diagnosis
1.Sleep apnea
2.Depression
3.Hypothyroidsm
4.Chronic fatigue syndrome
5.Bipolar disorder
Diagnostic Workup
1.CBC
2.CXR
3.TSH
4.DRE & Fecal occult blood
5.head ct
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Posted Patient Note Sample(s) for this Case


Name: mazinger
Email: latuyaenpatrulla@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 25th of March 2007 02:14:34 PM
 
History

HPI: 53 yo male comes to the clinic with a cc of dizziness with an onset of 1 week ago. According to the patients statement he refers that the dizziness is episodic and is described as the subjective feeling of spining and it often lasts for a period no longer than 10 minutes. Episodes can be provoked by head movement and relieved by rest. The patient also refers the presence of tinnitus, hypoacusia, and the history of having cold symptoms in the recent past which have already solved at this moment. He refers loss of balance and difficulty walking, tends to fall to the left but doesnt refer any episode of loss of conciosuness nor head injury.

ROS:Normal except as above
PMH:NA
Allergies:NKDA
Meds:NA
SH:works as a lawyer
FH: Father died of an MI, mother alive DM.

Physical Examination

 Gen:
Vitals:
HEENT:Head nontraumatic, normocephalic. Eyes EOM intact, PERRLA. Ears no abnormalities in the canals and tympanic membrane is clear. Nose no congestion. Throat no erythema or exudate
Neck:
LUNGS:
CVS:MPI is normal. No cyanosis or clubbing, S1S2 rythmic no rubs no murmurs.
ABD:
Ext:
Neuro:

Differential Diagnosis
1.Peripheral vertigo
2.Cerebellar ataxia
3.vasovagal Syncope
4.Epilepsy
5.
Diagnostic Workup
1.tympanometry
2.audiometry
3.CBC
4.MRI of the head
5.
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Posted Patient Note Sample(s) for this Case


Name: mazinger
Email: tumadrenbolas@hotmail.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 25th of March 2007 11:18:35 AM
 
History

HPI: 65 yo female that come to the clinic with a cc of forgetfulness and confusion. According to the patients statement she has not noticed her problems and that she came because her daughter insisted. She refers that she is not able to bathe, dress, feed by herself anymore. And has been having urinary accidents for 2 months. She has had difficulty walking and recurrently loses her balance and also describes a head injury from which she cannot recall any detail of it. She finds difficult to remember things such as turning the stoffe off, close the windows in her house, turned off the lights. And she is not able to manage her own accounts, prepare her own meals, taking her own medications and she gets lost in the way to her house. She doesnt. refer any changes in her mood.

ROS: Normal except as above
PMH:DM type 2
Allergies:NKDA
Meds:metformin
SH:Smoke na, no alcohol, no drugs. Retired school teacher 15 years ago.
FH:daughter is healthy. cannot remember the reason of her parents\' deaths.

Physical Examination

 Gen:
Vitals:wnl
HEENT:wnl
Neck:
LUNGS:
CVS:
ABD:wnl
Ext:wnl
Neuro:no palsies of the cranial nerves, muscle strength and general sensitivity within normal limits.

Differential Diagnosis
1.alzheimer\'s dementia
2.multi infarct dementia
3.hypothiroidism
4.pseudodementia
5.vit b12 deficiency
Diagnostic Workup
1.CBC
2.CT of the head
3.CXR
4.TSH, vit b12 levels
5.VDRL, RPR
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Posted Patient Note Sample(s) for this Case


Name: mazinger
Email: tumadrenbolas@hotmail.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 24th of March 2007 08:09:54 AM
 
History

HPI: 30 yo male patient that comes to the clinic with a chief complaint of fatigue with an onset of 2 years. According to the patients statement he refers his problem occurrs in a daily basis and refered as being worse in the morning. The patient also refres that he has problem maintaining his sleep, there\'s no snoring, no restless sleep, doesnt urinate in the night and has no pain that might be causing this. He also refers depression symptoms as difficulty concentrating, mild memory problems.

ROS:Normal except as above
PMH:Depression for which he was hospitalized
Allergies: NKDA
Meds:Valproate
SH:Doesnt smoke, no drugs, no alcohol. Works as a doctor. Hasnt had any sexual actvity in the last 6 months, because of a decrease in the libido.
FH:Parent are still alive

Physical Examination

 Gen: Male in no acute distress.
Vitals: WNL.
HEENT:
Neck:
LUNGS: Clear to percussion and auscultation
No cyanosis no clubbing
no tenderness to palpation
No rales, no rubs, no wheezes, no ronchi in any lung field.
CVS:
ABD:
Ext:
Neuro:

Differential Diagnosis
1.Depression
2.Bipolar disroder
3.Hypothyroidism
4.Anemia
5.Chronic fatigue syndrome
Diagnostic Workup
1.CBC
2.CXR
3.TSH
4.Vit b12 levels
5.VDRL, RPR
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Posted Patient Note Sample(s) for this Case


Name: sheba mohsin
Email: smohsin13@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 19th of March 2007 11:26:51 AM
 
History

CC:
HPI:28 yo female c/o headache since yesterday.The pain is10/10 in intensity is throbbing,associated with nausea,vomiting sensitivity to light and noise.Aggravated with light and noise and alleviated with lying down and tylenol.
Negative Symptoms:Denies any change in vision,numbness or tingling,SOB,palpitations,fevr or chills

ROS:
PMH:
Allergies:
Meds:
SH:
FH:

Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:Clear bilateral brea
CVS:
ABD:
Ext:
Neuro:

Differential Diagnosis
1.Migraine
2.cluster headache
3.tension headache
4.
5.
Diagnostic Workup
1.CBC
2.Head CT /MRI
3.
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: arr
Email: allradoslavova@yahoo.com
Case Number: 008
Case Title: 01

Date Posted:

Monday 12th of March 2007 10:19:13 AM
 
History

CC:A 45 y/o M c/o Rt lower abdominal pain
HPI:This is a 45 Y/o M with sudden,sharp abdomonal pain since 2 hrs.Began after large meal.Pain is localised in lower abdomen,shifting to right,9-10 severity.Had 2episodes of vomiting and sweating,vomit contains yesterday food ,no blood.No defecation since 20 hrs.

ROS:WNL,no urinary problems,no SOB
PMH:peptic ulcer 10 years ago
Allergies:NKDA
Meds:no
SH:bus driver, 1 PPD for 20 yrs, # beera dayly since 15 yrs,NIDI
FH:normal

Physical Examination

 Gen: AAOx3
Vitals:WNL
HEENT:WNL
Neck:WNL
LUNGS:CTA B/L
CVS:WNL
ABD:BS -,tender,+ rebound and +guarding in RLQ,psoas +,obturator +,no mases
Ext:WNL
Neuro:WNL

Differential Diagnosis
1.Appendicitis
2.Intestinal obstruction
3.Diverticulitis (Meckel\'s)
4.Perforated peptic ulcer
5.Urolithiasis
Diagnostic Workup
1.CBC
2.Abdomen X-ray
3.Abdominal US
4.Upper GI endoscopy
5.
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Posted Patient Note Sample(s) for this Case


Name: arr
Email: allradoslavova@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 12th of March 2007 09:40:14 AM
 
History

CC:A 30 y/o F c/o abdominal pain
HPI:This is a 30 y/o F with complains of progressive sharp abdominal pain (8/10 severity)right below the umbillicus since 12 hrs.Started after large meal.Not associated vomitus,but has nausea,no bowel problems.Has a fever and chills since yeaterday.has burning urination and passed urine more number of times

ROS:WNL,No SOB,no vaginal discharge
PMH:Once hospitalised for evaluation of UTI,no hystory of STD
Allergies:NKDA
Meds:no
SH:no smoking or ETOH consumption,NIDI,Working as a receptionist,multiple sexual partners,useing OCP,no condoms LMP -3 weeks ago,
FH:normal

Physical Examination

 Gen: AAO X3
Vitals:WNL
HEENT:WNL
Neck:WNL
LUNGS:CTA B/L
CVS:S1,S2- present and normal,no murmurs,clics,gallops,rubs
ABD:S,BS +,NT,ND,mild discomfort in suprapubic area,no guardingor rebound,McMurphy -,Psoas -,Obturator -,CVA tendernes -
Ext:WNL
Neuro:WNL

Differential Diagnosis
1.PID
2.Pelvic abscess
3.rupture/torsion of ovarian cyst
4.UTI
5.Appendicitis
Diagnostic Workup
1.Rectal and vaginal exam
2.CBC
3.UA
4.Pregnancy test
5.US abdomen
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Posted Patient Note Sample(s) for this Case


Name: arr
Email: allradoslavova@yahoo.com
Case Number: 06
Case Title: 01

Date Posted:

Monday 12th of March 2007 09:25:53 AM
 
History

CC: A 35 y/o F with acute onset diarrhea
HPI:A 35 Y/o F with acute anset diarrhea since yesterday.Started after eating seafood and salad in a local restaurant.Bowel movements are 6-7 times a day,loose ,watery,no blood or mucus,associates with tenesmus,abdominal cramps,vomiting and fever.

ROS:WNL,no changes in urination,no SOB
PMH:Sinusitis,treated with amoxicillin 10 days till 2 days ago
Allergies:NKDA
Meds:no
SH:denies smoking ,couple of beers every week
FH:no family histiry if diarrheal disease

Physical Examination

 Gen: AAO X 3
Vitals:
HEENT:Dry mucus membranes,no oral rashes or ulcers
Neck:supple,no lymphadenopathy
LUNGS:CTA B/L
CVS:RRR,no murmurs
ABD:S,NT,ND,no organomegaly,hyperactive BS
Ext:no pedal edema
Neuro:

Differential Diagnosis
1.Viral gastroenterlitis
2.Bacterial Gastroenteritis
3.Clostridium Difficile diarrhea
4.
5.
Diagnostic Workup
1.Rectal exam and FOBT
2.CBC with differential count
3.Basic metabolic panel ( Na,K,Cl,Co2,BUN,Cr,Glu )
4.Stool for clostridium difficile toxin
5.Stool for fecal leucocytes
5.
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Posted Patient Note Sample(s) for this Case


Name: arr
Email: allradoslavova@yahoo.com
Case Number: 05
Case Title: 01

Date Posted:

Monday 12th of March 2007 08:47:58 AM
 
History

CC:A 50 y/o M c/o Fatigue and loss of weight
HPI:This is a 50 Y/o M c/o fatigue and weakness foe the past 5 months.
Has complains of reduced appetite and 30 pounds weight loss.Stomach feels full after a few bites,no nausea,vomiting,fever,no jaundice.
Denies changes of bowel habits,but had black stools couple of times,no blood.After death of his wife feels sad,tought that life is not worth living,decreased energy,feeling of guilt present ,decreased concetration,denies suicidal ideations.Secteased sleep with morning insomnia.

ROS:WNL,no SOB,no urinary complains
PMH:no hystory of past illneses,no surgeries
Allergies:NKDA
Meds:NO
SH:restaurant manager,no stress,no smoking.Couple of beers every day for past 30 years
FH:mother died from pancreatic cancer at the age of 60

Physical Examination

 Gen: AAO X 3
Vitals:
HEENT:pale mucus membranes, no oral rashes or ulcers
Neck:supple,no limphadenopathy
LUNGS:CTA B/L
CVS:RRR,no gallops,rubs,murmurs
ABD:S,ND,no organomegaly.mild tendernes on epigastric region
Ext:no pedal edema,
Neuro:CN II-XII-intact.Motor: Tone WNL B/l.Power 5/5 LUE,RUE,LLE,RLE

Differential Diagnosis
1.GI malignancy
2.Depression
3.Hyperthyroidism
4.
5.
Diagnostic Workup
1.Rectal sxam and FOBT
2.CBC
3.TSH
4.LFT
5.abdominal USG
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Posted Patient Note Sample(s) for this Case


Name: arr
Email: allradoslavova@yahoo.com
Case Number: 04
Case Title: 01

Date Posted:

Monday 12th of March 2007 08:18:51 AM
 
History

CC:A 35 y/o M with recent onset cough
HPI:This is a 35 Y/o M c/o of cough for the past 3 days.The cough began as dry ang progress to productive with yellowish sputum,no blood.Associated complains of cold,sore throat,sinus pressure,mild headache and fever.Denies SOB,wheezing and chest pain

ROS:WNL.No urinary and GI complains
PMH:Sinusitis and asthma,well comtrolled with albuterol
Allergies:Cats
Meds:Tylenol and cough suppressants.
SH:paramedic,Smokes 1 pack /day for 15 years.ETOH-occasionally
FH:father with bronchial asthma.His 8-year old son is also sick

Physical Examination

 Gen: AAO X 3
Vitals:PR- 98 /min,BP 120/75 ,RR- 20/min, T 101 F
HEENT:mild pharyngeal erytema and exudate,mild tendernes over maxillar and frontal sinuses
Neck:supple,no lumphadenopathy
LUNGS:CTA B/L
CVS:RRR,no murmurs,clicks,gallops,rubs
ABD:S,NT,ND,no organomegaly
Ext:
Neuro:

Differential Diagnosis
1.Common cold
2.Acute sinusitis
3.Acute bronchitis
4.Pneumonia
5.
Diagnostic Workup
1.CBC with differential count
2.Sputum gram stain and culture /sensitivity
3.Chest X-ray,PA and Lateral view
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: arr
Email: allradoslavova@yahoo.com
Case Number: 03
Case Title: 01

Date Posted:

Monday 12th of March 2007 07:54:29 AM
 
History

CC:A 50 y/o M with difficulty swallowing
HPI:A 50 y/o M c/o of difficulty swallowing of 3 months duration. Started with difficulty with solids and slowly progress for liquids. Has a feeling of food getting stuck behind the sternum,used to push food with gulp of water-not able to do that anymore. no problem with passing food from mouth to esophagusHeart burns for 2-3 years,taking antiacids.Recet loss of appetite and weight (10 Pounds ).No nausea,vomiting,change in bowel habits and color of stools

ROS:WNL
PMH:Heartburns for 3 years,no surgery
Allergies:NKDA
Meds:Antiacids
SH:Stock broker,a lot of stress,Smokes 1 pack/day for past 30 years,glass of wine occasionaly
FH:no hystiry of cancers or neurological diseases

Physical Examination

 Gen: AAO X 3
Vitals:BP 130 /90,PR 85/min,RR- 16/min,T 98 F
HEENT:Mild throat erytema,no rashes or ulcers
Neck:supple,no lymphadenopathy,thyroid- normal,no JVD
LUNGS:CTA B/L
CVS:normal S1 and S2,no murmurs,gallops,rubs
ABD:soft,nondistended,no guatding,tenderness,rebound,no organomegaly
Ext:no pedal edema
Neuro:CN II -XII -intact

Differential Diagnosis
1.Carcinoma esophagus
2.Achalasia cardia
3.Reflux esophagitis
4.Stricture
5.
Diagnostic Workup
1.CBC
2.Barium swallow
3.Esophagoscopy
4.Chest X-ray
5.
< Back

 

Posted Patient Note Sample(s) for this Case


Name: arr
Email: allradoslavova@yahoo.com
Case Number: 02
Case Title: 01

Date Posted:

Monday 12th of March 2007 07:32:56 AM
 
History

CC:A 22 y/o WF c/o of burning urination
HPI:A 22 y/o WF C/o of burning urination for the past 4 days, associated with fever 101 F.Additional complaints of increased urination up to 10 times/day,urge,constant dul pain in suprapubic area and tinge of blood in urine.No nausea and vomiting,no SOB,no back pain.Greenish vaginal discharge foe couple of days

ROS:WNL
PMH:Chlamidia infection 1 yar ago,threated with doxycycline as an autpatient
Allergies:NKDA
Meds:NO
SH:Student,no smocking hystory,Etoh-occasionaly
FH:Parents alive and well

Physical Examination

 Gen:AAO X 3
Vitals:PR 82/min,BP 11/80,RR 16/min,T 101 F
HEENT:no oral rashes,PERRLA,EOM WNL
Neck:neck supple,no lumphadenopathy
LUNGS:CTA B/L
CVS:normal S1,S2,no murmurs,gallops,rubs
ABD:soft,nondistended,BD -present,no organomegali,mild dyscomfort in suprapubic area,no rebound or guarding,CVA -
Ext:
Neuro:

Differential Diagnosis
1.Cystitis
2.Pyelonephritis
3.PID
4.Uretritis
5.Vulvovaginitis
Diagnostic Workup
1.Pelvic exam
2.CBC with differential
3.Urinanalisis
4.Culture of urine
5.PAP smear
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Posted Patient Note Sample(s) for this Case


Name: arr
Email: allradoslavova@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 12th of March 2007 07:17:03 AM
 
History

CC:A 56 y/o WM evaluation of HTN
HPI:A 56 y/o WM present for evaluation of HTN of 10 yars duration.Treatet with Propranolol 20 mg po BID with good control of symptoms.No chest pain,palpitations,dyspnea,ortopnea,peripheral edema

ROS:WNL
PMH:1.Hipercholesterolemia 2.HTN
Allergies:NKDA
Meds:Propranolol 20 mg po BID , Simvastatin 40 mg at bed time
SH:works in food industry,no stress
FH:father has HTN

Physical Examination

 Gen: AAO X 3
Vitals:BP 122/80 mm Hg,PR 98/min ,RR 16/min, T 38.3 C
HEENT:WNL ,Fundi- no hemorrhages ar exudates and no AV crossing changes
Neck:supple,no masses,no JVD,no bruits and thyroid normal
LUNGS:CTA B/L
CVS:PMI narmal,normal S1 and S2,no murmurs,gallops,heaves,rubs
ABD:no bruits,no tendernes,organomegaly,guarding and rebound
Ext:normal and full peripheral pulses:radial=2/4,femoral=2/4,popliteal=2/4,post tib= 2/4,dorsalis pedis=2/4
Neuro:CN II-XII- intact

Differential Diagnosis
1.essential hypertension follow -up
2.
3.
4.
5.
Diagnostic Workup
1.Urinanalysis
2.Lipid panel
3.LFT
4.
5.
< Back

 

Posted Patient Note Sample(s) for this Case


Name: sree
Email: msrdr007@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Tuesday 06th of March 2007 08:45:07 PM
 
History

CC:headache for the past 8 months comes and goes
HPI:comes and goes suddenly, starts with flashes of light right side, 5/10 intensity, throbbing, no radiation, aggravated by light and noise, relieved by rest, nausea and vomiting, no fever, no trauma

ROS: no vision problems,
PMH:similar complaints few years back, no htn, bp, diabetes
Allergies:no known allergies to drugs , food
Meds: no medications
SH:drinks 10 cigarretes per day, no alcohol consumption, no illegal drugs, is a teacher in school,
FH: sister has migraine
sexually active with husband. LMP 2wks ago.

Physical Examination

 Gen: aaox3 sitting holding her head
Vitals: wnl
HEENT:normocephalic. atraumatic
Neck:no distended viens, supple
LUNGS:cta B/L vesicular BS. no rhonchi, rales, wheezes
CVS: PMI undisplaced, s1s2+ RRR, no murmurs/gallops/clicks
ABD:soft not distended no pulsations no peristalisis BS+ no hepatosplenomegaly, no tenderness, percussion tympanic, no cva tenderness
Ext: pulse present in all extremities
Neuro: cranial nerves grossly intact, mental status normal, sensations present for touch, pain and vibration
strength 5/5 in all groups
DTR\'s 2+ , gait normal, no abnormal movements.

Differential Diagnosis
1.migraine
2.tension headache
3.cluster headache
4.sinusitis
5.intra cranial tumor
Diagnostic Workup
1.cbc esr
2.ct scan head
3.mri brain
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: @gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 01st of March 2007 03:04:01 PM
 
History

CC:chest pain
HPI:pt is a 25 yo m c/o cp following an accident last night.it is sharp in lt chest and 8/10 in severity,it increases with cough,deep bretah,no pain radiation.he had prodeuctive cough since 2 d ago,no blood in spytum,he had a fever but no chills,and has shortness of breath.no heart problem,pain in extrimities,head trauma,LOC,weakness,confusion,vision change
or urinary problems.
he has a sharp LUQ pain too.he had Infec Mono 2 w ago.

ROS:
PMH:Infection mOno,
Allergies:nkda
Meds:none
SH:he\'s a banker,no smoking or recretaional dtugs,alcohol occasionally.
FH:nothing related

Physical Examination

 Gen: breathing deifficultly,seems to be in acute distress
Vitals:wnl
HEENT:
Neck:no lymphadenopathy,thyromegaly
LUNGS:breath sounds decreases lt side,hyperresonance lt chest on precussion.
CVS:rrr,s1,s2 heard,no g,m,r
ABD:soft,tenderness in LUG,no organomegaly,nondistended

Differential Diagnosis
1.pneumothorax
2.hemothorax
3.Rib FX
4.pneumonia
5.splenic rupture
Diagnostic Workup
1.chest X R
2.sputum gr stain and culture
3.EKG
4.pulse oximetry/ABG
5.XR,CT abdomen
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: @gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 01st of March 2007 02:52:11 PM
 
History

CC:hearing loss
HPI:pt is a 75 yo m c/o hearing loss started 1 y ago and was progressive,problem is in both ears,he has tinnitus,and headache occasionally.no vertigo,weakness,nausea or vomit,no trauma to ears,no insertion of foreign body,ear discharg e or feeling of imbalance.he was exposed to the loud noise as a military veteran.he had used antibiotic to treat UTI last year.no problem in appetite,weight.

ROS:
PMH:UTI,HTN,no hospitalization,surgery
Allergies:penicillin causes rash
Meds:HCTZ,Aspirin for 25 y
SH:sexually active with wife,no smoking,alcohol,recreational drugs.
FH:

Physical Examination

 Gen: no acute distress
Vitals:wnl
HEENT:perrla,at/nc,eomi,nop tenderness,redness over the ears,npo no nystagmus,no papilledema,discharge,Weber test negative no lateralization,Rhinne test+,no lateralization.
Neck:no thyromegaly
LUNGS:clear sounds bilaterally
CVS:rrr,s1,s2 heard,no r,g,m
ABD:soft,nt,nd,no organomegaly
Ext:
Neuro:cranial n 2-12 intact,except decreaded hearing,motor strength 5/5,DTR 2+,sensation intact,gaint normal.

Differential Diagnosis
1.prebyscosis
2.Menierre\'s disease
3.Acoustic neuroma
4.Labyrinthits
5.Antibiotc-induced ototoxicity
Diagnostic Workup
1.audiometry
2.CT-head
3.MRI-brain
4.CBC
5.VDRL
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Posted Patient Note Sample(s) for this Case


Name: IK
Email: @msn.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 26th of February 2007 06:10:20 PM
 
History

CC:31 y o f c/o severe abdom pain
HPI:10/10 upper abd pain x 5 hours, band-like, rad to pack, leaning forward alleviates it, aggravated bu alcohol intake(pt/ tried to sekf medicate with vadka and ASA), pt. vomited x3 p alcohol ing, pt can\'t describe vomit

ROS:no fever, chills, drak stools or dirhea, + mild SOB, no chest pain, -diaphoresis, palitations, deniaes sick contacts
PMH: similar episede of severe abdom pain, pt was in ICU, does\'t knoa her Dx or deatails; h/o alcoholism, gallstones, UTI(no recent). LMP 2 w. ago, regular
Allergies:nkma
Meds:ASa prn
SH:-smok, no illicit drugs. EToh daily to relief stress of unempoyment. monogaoumos with 1 m partner, condmo use 100%, no h/ STD
FH:mother-Dm, father-MI

Physical Examination

 Gen: anxoius, uncomfortable to sit
Vitals:febrile, tachycardia, tachypnea
HEENT:
Neck:no JVD
LUNGS:clear b/l
CVS:s1/s1, no m/r/g/, no cynosis, clubbig, edem
ABD:+bs; no discoloration of abd flanks; tender on palp in mmidepigastrium +RUQ, voluntary guarding, - rebound tender, no organomegaly - Murphy, -rovsing\'s, no psoas, no obturator
Ext:
Neuro:

Differential Diagnosis
1.Alcohol vs. biliary pancreatitis
2.cholecystitis
3.appendicitis
4.alcohol gastritis
5.PID, ectopic pregnancy
Diagnostic Workup
1.ct abdom
2.usd abd
3.wbc with diff, amylasa, lipasa, bilirubin, total protein, AST, ALT, PTT/Pt, creatinin, BUN
4.endoscopy
5.pel/ectal eam; pregnancy blood test
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Posted Patient Note Sample(s) for this Case


Name: IK
Email: @msn.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 26th of February 2007 05:41:03 PM
 
History

CC:29 y o m c/o severe HA
HPI:10/10 severe diffuse HA woke up pt. from sleep, ass. with nausea, no vomit, radiates to neck and back, aggrav, by movement and coughing, - alleviat. factors, no fever, no chills, no blurry VA, no recent sick contacts. Had much less pain 6/10 day before. Denies trauma, -cough, -UR sx\'s

ROS:
PMH:never had such bad HA in his life, no hospit., no sugeries
Allergies:nkma
Meds:none, declines use of weight loss products, cough supressants
SH:10pack -year cigg, drinks daily ETOH, intranasal cocaine recreational, denies Iv drug, last used cocaine 1 d. before
FH:uncle on dialysis for polycystic kidney dis

Physical Examination

 Gen: confused, in a lot of pain
Vitals:hypertensive, bradycardia, bradytachya,low grade fever
HEENT:atraumatic, EOM-full, photophobic on fudoscopic exam:no gross lesions of optic n, no optic disc edema
Neck:no lympoadenopathy
LUNGS:clear b/l
CVS:s1/s2, no M/R/g.
ABD:soft +bs, no oraganomegaly
Ext:
Neuro:2-12 cranila nerves grossly-wnl
+nuchal rigidity, +Kerning\'s
-Romberg, _finger-nose, heel-to shin
2+DTR, 5/5 full muscle strengh, shrap/dull sens. intact b/l
no Babinski

Differential Diagnosis
1.meningitis
2.SAH-ruptured berry aneurysm
3.intraparenchimal hem-coaine-induced
4.
5.
Diagnostic Workup
1.ct head, mri brain, mra brain vessels
2.LP
3.WBC with diff
4.blood cultures
5.csf cultures, protein.glucose/cells, gram,
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: @gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 26th of February 2007 05:06:18 PM
 
History

CC:passing out
HPI:pt is a 49 yo m c/o passing out while he was bringing the groceries to the car.he lost his conciousness before falling and had heart racing before the attack.he had seizure for 30 seconds with shaking arms and legs w/o tongue bite,urinary incontinence.he deines any unusual sense before the fall,headache,numbeness,weakness or confusion after regaining conciousness,appetite or weight change.

ROS:
PMH:heart attack 1 y ago,hypertension
Allergies:nkda
Meds:HCTZ,atenolol,aspirin,captoril
SH:clerck,quitted smoking after 25ppd,EtOH+,CAGE0/4,no recretaional drugs
FH:father died of heart attack

Physical Examination

 Gen: no acute distress
Vitals:wnl
HEENT:no bruise,thyrois is normal.
Neck:no carotid bruit
LUNGS:clear bretah sounds are heard bilaterally.
CVS:rrr,s2,s2 heard,no rucs,gallops,murmurs,no orthostatic change.
ABD:soft,nt,nd,no organomegaly.
Ext:pulses are 2+ pal[able bilaterally.
Neuro:alert and oriented,DTR 2+,muscle strength 5/5 bilaterally and symmetric.cerebellar tests are intact

Differential Diagnosis
1.convulsive syncope
2.vasovagal syncope
3.seizure
4.arrythmia
5.orthostatic hypotension
Diagnostic Workup
1.EEG
2.holter monitoring
3.blood glucose
4.CT-head
5.MRI-brain
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: @gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 26th of February 2007 04:54:11 PM
 
History

CC:tremor
HPI:the pt is a 66 yo m c/o tremor in his rt hand since 6 m ago which has become worse.it\'s incresed when he\'s tired.he has tremor in rest the most and decreases when he does something.he feels slowing down,denies any change in handwriting,adl,IADL,drooling,headche,or previous TIA/stroke,cp,appetite or weight change or head trauma.he had similar episode of tremor in collegue after coffee ingestion or sleep deprivation.now he uses one cup of coffee per day but used 3 untill a few months ago.

ROS:
PMH:asthma,high blood cholestrol
Allergies:nkda
Meds:albuterol inhaler
SH:he\'s a retired chemical professor ,no smoking or alcohol drinking,no recreational drugs.no excercise.
FH:nr

Physical Examination

 Gen: no acute distress,seems slowed down.
Vitals:wnl
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:no gait abnormality,oriented*3,cranial nerves 2-12 intact,cerebellar tests:rhomberg,alternate hand movement,hell-to-shin normal.sensory exam intact to needle and pinprick.DTR 2+.rt hand tremor with freq of 6 Hz,
Neuro:

Differential Diagnosis
1.Parkinson\'s disease
2.essential tremor
3.physiologic tremor(hyperthyroidism)
4.substance-induced tremor
5.brain tumor
Diagnostic Workup
1.CT-head
2.MRI-brain
3.urine toxicology
4.TSH
5.heavymetals
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Posted Patient Note Sample(s) for this Case


Name: IK
Email: @msn.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 26th of February 2007 04:29:21 PM
 
History

CC:48 y o w f c/o chest pain
HPI:shrap substernal pain 6/10 x 4 hour post lifting haevy luggage post prolonged airplane trip, no relief with rest or acetominophen, worse on deep breath, associated with SOB, not associated with diaphoresis or nausea, no radiateion

ROS:no nausea, vomit, change in bowel mov, dysuria, fever, chills, recent sick contacts, shange in sleeping pattern, lower extr swelling, ortopnea
PMH:no h/o chest pain; diet control HTN; appendectomy as a child, hspital X2 for normal vag delivery
Allergies:nkma
Meds:BCP to control menstrual cycle, mVI, acetominophen prn
SH:10-12 pack-year cigg, social ETOH, no illicit drugs; sex acitve with the spouse only,
FH:no haert dis, hyperlipidemia, DM

Physical Examination

 Gen: anxious, uncomfortable,
Vitals:increased RR-25-30.min
HEENT:
Neck:no JVD
LUNGS:clear to auscult b/l, poor cooperation with deep breathing d.t pain
CVS:s1/s2 RRR, no M/R/G/, PMI not displaced.
ABD:faint scar RLX. + bs. tynpani in 4 Q, no liver enlarg on percus. soft to palp. in 4 Q
Ext:no varicose, no tendeness, no palpabale cord, no clubbing, cyanosis, edema
Neuro:

Differential Diagnosis
1.PE
2.MI
3.Spont. pneumothorax
4.Pneumonia
5.Muscle strain
Diagnostic Workup
1.V/Q scan
2.CXR
3.ABG, CBC with diff
4.EKG
5.CK_MB< trpponin
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Posted Patient Note Sample(s) for this Case


Name: dariush
Email: dariushekabir@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 25th of February 2007 11:43:32 PM
 
History

CC: chest pain
HPI: pt, came in with the complaint of chest pain since yesterday

ROS: same as above
PMH: appendectomy
Allergies: none
Meds:ASA
SH:
FH:

Physical Examination

 Gen: WNL
Vitals: WNL
HEENT:WNL
Neck:WNL
LUNGS:WNL
CVS:WNL
ABD:WNL
Ext:WNL
Neuro:WNL

Differential Diagnosis
1.acute MI
2.aortic dissection
3.GERD
4.Pericarditis
5.Pnemonia
Diagnostic Workup
1.EKG
2.CXR
3.endoscopy
4.
5.
< Back

 

Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: @gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 25th of February 2007 01:32:32 PM
 
History

CC:lt knee pain
HPI:the pt is 32 yo f c/o knee pain,swelling,redness since 2 d ago,it she feels better by rest and Tylenol and has more pain with move or walking.she has painful wrist and fingers since 6 m ago along with morning stiffness which lasts about one hour.she had some oral ulcer one month ago which has been resloved.she denies any rash,photosensitivity,chest pain,dyspnea,cough,constipation,abdominal pain,diarrhea,tick bite,seizure hair loss or vision problem.she has fatigue,fever,weight loss of 10 pounds in 6 mo and a poor appetite.

ROS:negative except as mentined above
PMH:none
Allergies:nkda
Meds:Tylenol
SH:she\'s a waitress lives with 2 children,had two spontaneous abortions,had 4 sexual partners last year and occasionally uses condomes.smoking+20ppd,alcolhol+,CAGE 0/4,she has a history of gonorrehal STD one y ago treated with antibiotics.

FH:RA+in mother

Physical Examination

 Gen: in no acute distress
Vitals:wnl except a high temperature
HEENT:no lymphadenopathy,no oral ulcer,no skin rash
Neck:no thyromegaly or lemphadenopathy
LUNGS:breath sounds are clear bilaterally
CVS:rrr,s1,s2 heard,no rub,gallop,murmur
ABD:non tender,non distended,bs are heard,no organomegaly
Ext:pulses 2+,decrease ROM in the lt knee,swelling,redness and tenderness in both wrists and all hand fingers.
Neuro:

Differential Diagnosis
1.SLE
2.rheumatoid arthritis
3.gonococcal arthritis
4.HIV
5.psoriatic arthritis
Diagnostic Workup
1.CBC
2.ESR
3.ANA,anti ds DNA,RF
4.XR-knee
5.CT-knee
6.HIV attibody test
7.pelvic exam and cervical culture
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Posted Patient Note Sample(s) for this Case


Name: Ik
Email: @msn.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 24th of February 2007 02:38:24 PM
 
History

CC:72 yo f c/o rectal bleeding
HPI:sibce this afternoon 4 bowel movements mixed with bright red blood, also blood on paper and in a toilet bowl, no pain or cramps associated with defecation. some dizziness and weakness.

ROS:-chills, fever, nausea, vomiting, melena, hamatomesis
PMH:pt. never had this problem before. HTN-controlled, pre Rx=in 160 systol BP, diverticulitis, h/o cholecystektomy at 40\'s. Denies recent travel, or sick contacts
Allergies:NKMA
Meds:HCTZ, MVI, acetominophen prn
SH:-smok, ETHOH, illicit drugs; health diet
FH:denis any GI problems or cancer

Physical Examination

 Gen: no distress, comfortable
Vitals:hypotension, tachycardia
HEENT:
Neck:-JVD
LUNGS:clear b/l to auscult
CVS:s1/s2, RRR, -M/R/G
ABD:scar in RUQ, +bs, tympanic on percussion in 4 Q, soft, nonteder to palpation, no hepatosplenomegaly
Ext:no periph edem, no cyanosis, no clubbing
Neuro:

Differential Diagnosis
1.colon CA2. diverticulosis.3. inf diarhea
4.Hemorrhoids
5.PUD
Diagnostic Workup
1.rectal exam
2.stool fo blood, culture
3.cbc with diff, hematocrit, electrolites
4.colonoscpy
5.abd usd,
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Posted Patient Note Sample(s) for this Case


Name: IK
Email: @msn.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 24th of February 2007 02:12:05 PM
 
History

CC:63 y o f c/o fever and back pain
HPI:sx\'s of nausea and fatigue x 3 days, frequent urination x 3 days, no blood i urine
dull 4/10 pain in R lower back, also milder pain in R lower abd.
chills and fever x1 day, some rlief with acetominophen

ROS:+ nausea, - vomiting, _dizziness, +chills, increase urination, no change in bowel movements, can toperate food
PMH:Had recurrent epizodes of urinary infection, NIDDM-good control, HTN, diabetic foot ulcer, no surgeries
Allergies:NKMA
Meds:lisinopril, metformin
SH:-smok, - ETHOH,- illicit drug
FH:mother-NIDDM

Physical Examination

 Gen: in mild distress, skin flushed, warm to touch, anxious, after exam felt dizzy getting p the exam table
Vitals:fever, tachycardia, slightly hypotensive, omparing to usual numbers in 140 range
HEENT:no lymphodenopathy
Neck:
LUNGS:clear to percussion, auscult b/l
CVS:s1/s2, -M/G/R, _JVD, no clubbing, cyanosis, periph. edema
ABD:+BS, tympany on percussion in 4 quadrants, hepatosplenomegaly on percussion, mild tenderness in RLQ to palpation. -Murphy. + R CV tenderness
Ext:
Neuro:

Differential Diagnosis
1.sepsis
2.Pyelonephritis
3.Kidney stones
4.Glomelunephritis
5.cholecystitis
Diagnostic Workup
1.Blood cultures
2.CBC with diff: electrolytes, AST, ALT, bilirubun, total protein
3.KUB
4.CT abd, USD abd
5.u/a, urine cultures
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Posted Patient Note Sample(s) for this Case


Name: IK
Email: @msn.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 23rd of February 2007 06:23:29 PM
 
History

CC:56 yo w m c/o cough, fatigue, chest pain
HPI:dry hacking cough x 6 m, slowly geting worse, occaionally couhgs up rusty blood tinged small amount of sputu,. Right sided chest pain, 3-4/10, no adiation, wirse on inspiration. Some relief of cough and chest pain with ORC coughg supressent and tylenol. 2 episodes of night chills.sweating in last 2 m. period. Pt. feels veryt tired, no appetite, lost 10 lbs over 1-2 y perid. No nausea, vomiting, palpitations, acute SOB.

ROS:
PMH:NO same episode in episode, though 2 y ago had \"pneumonia\" x 2 weeeks, resolved on it\'s own. Denies traveling abroud, sick contacts. Though recently released from jail, where his cellmate had nasty copugh x 1 y.
Allergies:NKMA
Meds:None
SH:In jail used to be sex. active with man, no condom use. No ETOH. 35-70 pack -y. cigg. h.o heroin use
FH:wnl

Physical Examination

 Gen: Greyish color skin, looks cachectic. on L shin 2 small red raised blotches. Poor tatoo L chest
Vitals:
HEENT:Claer oropharynx, no ulcers, no thrush
Neck:No lymph nodes
LUNGS:clear to peercussion, auscult. tactile fremitus-wnl
CVS:no JVD, no perip edema. Clear s2/s1, no murmors, no gallops
ABD:soft 4 q, +bowel sounds, liver wnl on percussion
Ext:
Neuro:

Differential Diagnosis
1.TB
2.Pneumocistic cariniii pneumonia with HIV
3.Lung CA
4.Pneumonia
5.chronic bronchitis
Diagnostic Workup
1.ppd
2.CXR, CT chest
3.HIV test
4.Sputum culture, cytology
5.Blood culture, CBC with diff
< Back

 

Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: @gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 23rd of February 2007 05:14:26 PM
 
History

CC:headachee
HPI:pt is a35 yo f c/o a progressive sharp and pounding headache on her right side of the head since 2 w ago,she has the pain 2-3 times a day,increases with light and stress,decreases with sleep,dark room,aspirin.it\'s 9/10 in severity.with no radiation.she has nausea and vomit once.she deines aura,weakness,numbness,head trauma,red eye,tearing,nasal congestion,post nasal dribbling recently.
she was understress recently,no depression sympotoms.pain never waked her up at night,

ROS:
PMH:sinusitis 2 months ago treated with amoxicilin,similar episode at collegue accompanied with nausea
Allergies:nkda
Meds:ibuprofen
SH:an engineer,no smikng,alcohl drink or recreational drug use.
FH:migraine in mother+,father died of brain tumor

Physical Examination

 Gen: pt is in severe pain
Vitals:wnl
HEENT:no red eye or tearing,no bruise or swelling,no sinus tenderness
Neck:no carotid bruit,no thyromegaly
LUNGS:breath sound are clear bilaterally
CVS:rrr,s1,s2 are heard.no gallop,murmur or rub
ABD:non tender,non distended,bs+,no organomegaly
Ext:pulses 2+,muscle strength 5/5 bilaterally,dtr 2+ bilaterally and symmetric
neuro:cranial nerves 2-12 are intact

Differential Diagnosis
1.migraine headache
2.tension h
3.cluster h
4.brain Tumor
5.Sinusitis
Diagnostic Workup
1.cbc
2.head ct/brain MRI
3.sinus CT
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 23rd of February 2007 04:38:33 PM
 
History

CC:
HPI:pt is a 54 yo m coming for BP follow-up which was diagnosed 1 y ago.he\'s under treatment with Hydrochlorothiazide and propranolo which staretd 6 m ago.he has erectile dysfunction and decreased libido since 4 m ago,he doesn\'t have nocturnal or early morning erections.he has hypercholestrolemia since 6 m ago.he denies chest pain,shortness of breath,leg claudication.headache,fatigue,edema,visual problem.he doesn\'t have an y constipation/diarreha,weight change or appetite change,depression
or anxiety fatigue or night sweats recently.


ROS:negative except as mentioned above
PMH:hyperchol
Allergies:nkda
Meds:hctz,lovastatin,propranolol
SH:a schoolteacher,no smoking,drinks 2-3 beers a week,eats lots of junk food,no exercies
FH:father died of hear attack,mother had alzheimer\'s

Physical Examination

 Gen: pt is in no acute distress
Vitals:wnl except bp=135/90
HEENT:no carotid bruit,fundoscopic exam normal,no lymphadenopathy
Neck:
LUNGS:breath sounds are clear bilaterally
CVS:rrr,s1,s2 are heard.no rub,gallop or murmur
ABD:non tender,non distended,bs heard
Ext:pulses are 2+ bilaterally
Neuro:DTR 2+,muscle strength 5/5 bilaterally,babinski-

Differential Diagnosis
1.b-blocker induced sexual dysfunction
2.diabetic neuropathy
3.hypogonadism
4.HTN-induced erectile dysfunction
5.hypothalamic dysfunction
Diagnostic Workup
1.rectal and genital exam
2.serum testosterone

3.serum blood glucose
4.penis doppler ultrasound
5.serum TSH/Prl
5.
< Back

 

Posted Patient Note Sample(s) for this Case


Name: IK
Email: @msn.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 22nd of February 2007 04:34:33 PM
 
History

CC:48 yo w f with c/o confusion, blurry VA, SOB
HPI:\"difficulty thinking\" , blurry VA, SOB acote onset x3 hours, while at work, progresively worsening over last hour, never had such an episode in a past, also worsennig of headache, dizziness, palpitations

ROS:no nausea, vomiting, diaphoresis
PMH:no h/o MI, H/o HTN x 10 y., good control until now on RX
Allergies:NKMA,
meds:thizide diuretic
SH:healthy diet - smoking, 1glass wine.month, no illicit drugs; not sex active, 2 adult children in teir 20
FH:no MI, haert dis, CVA, DM, both parents alive in good health

Physical Examination

 Gen: confused, distress
Vitals:wnl, exept high BP-230/150
HEENT:Perla, CF-full EOM-wnl, om ophthalmoscopy, shrap disc margin, vessels-wnl with limits of view
Neck:
LUNGS:
CVS:no JVD, no periph. edema; s1/s2, no murmors, no gallops
ABD:+bowel sounds, tympanic in 4 quadrants
Ext:
Neuro:2-12 cranila grossly intact, 2-dtr, sensation, reflexes, muscle strength-intact b/l

Differential Diagnosis
1.Hypertensive crisis
2.Hemorrhagic CVA
3.MI
4.dissecting aneurysm og aorta
5.
Diagnostic Workup
1.VA on Snellen chart, dfe
2.mRI brain
3.BUN, creatinine
4.CPK_MB, troponin
5.EKG+Cxr
< Back

 

Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 22nd of February 2007 02:59:41 PM
 
History

CC:bloody urine
HPI:pt is a 63 yo m c/o bloody urine once yesterday,that hasn\'t ever happened,it was bright blood in the urine which changed to the clot afterwards.he has dribbling,weak urine stream,frequency,urgency and nocturia for 2 y.he denies any abdominal pain,flank pain,dysuria.he denies any change in appetite,weight,fatigue,or night sweats.

ROS:
PMH:gout
Allergies:nkda
Meds:allopurinol
SH:he\'s a painter,smoking +35ppd,alcohol 2-3 beers 2-3 times a week,cage0/4
FH:father died of kidney disease,mother alzheimer\'s

Physical Examination

 Gen: no acute distress,no pale,no icteric
Vitals:wnl
HEENT:no lymphadenopathy
Neck:supple,no carotid bruit,no thyromegaly
LUNGS:breath sounds are symmetrically clear
CVS:s1,s2,rrr,no murmur,no gallop,or rub
ABD:non tender,non distended,no roganomegaly,rt cva tenderness+
Ext:pulse
Neuro:

Differential Diagnosis
1.bladder cancer
2.cystitis
3.glumerulonephritis
4.pyelonephritis
5.renal cell carcinoma
Diagnostic Workup
1.rectal exam,pelvic exam
u/a ,u/c
2.kub
3.abdominopelvic u/s
4.cbc
5.cystoscopy
6.hiv testing
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 22nd of February 2007 02:45:36 PM
 
History

CC:fatigue
HPI:the pt is a 46 yo accountant m c/o of fatigue since 3 m ago,after an accident which he lost his friend and couldn\'t help him be saved.he has lost energy,interest,lost performance,appetite.he has a weight gain of 6lb.decreased peformance at job,has dry skin and hair and cold intolernace and loss of concentration.he denies any injuries in the accident chest pain,shortness of breath,abdominal pain,nausea,vomit or bowel movement change.he has early waking ups recently and has snoring at night.he thinks about death most the times but he doesn\'t have any plans or previous commit.

ROS:nothing except as mentioned above
PMH:cystitis treated with antibiotics
Allergies:nkda
Meds:nothing
SH:smoking 25 ppd,alcohol 2-3 beers a week
FH:decreased sexual desire,not useing condoms

Physical Examination

 Gen: looks sad and slow.no plae or icteric
Vitals:wnl
HEENT:no thyromegaly,no lymphadenopathy
Neck:supple,no carotid bruit
LUNGS:breath sounds are clear bilaterally
CVS:s1,s2 are heard,rrr,no gallop,murmur or rub
ABD:non tender,non distended,no organomegaly
Ext:pulses are 2+
Neuro:

Differential Diagnosis
1.mdd
2.hypothyroidism
3.anemia
4.sleep apnea syndrome
5.unknown cancer
Diagnostic Workup
1.serum tsh
2.cbc
3.polysomnography
4.nocturnal pulse oximetry
5.
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Posted Patient Note Sample(s) for this Case


Name: IK
Email: irenakokot@msn.com
Case Number: 01
Case Title: 01

Date Posted:

Wednesday 21st of February 2007 07:29:28 PM
 
History

CC:%^ y.o w m with c.o sharp chest pain
HPI:substernal sharp 7/10 pain X 1 hour, after helping his son move furniture, does.\'t radite, not relieved with rest, no aggravating factors, associated with palpitations, not associated with diaphoresis or nausea

ROS:no shortness of breath, no nausea , no vomiting
PMH: no same episode in a past, no hospital, no haert dis, no HTn, no DM
Allergies:NKMA
Meds:MVI
SH:no smoking, ETHOH-socailly, occasionally, no illicit drugs
FH:Father died at age 65 d/t \"heart problem\"

Physical Examination

 Gen: in min distrees
Vitals:wnl, exept tachycardia and tachypnea
HEENT:
Neck:
LUNGS:claer b/l. no dulnees on percussion, no tactile fremitus, no bone tenderness
CVS:strong PMI, not displacedS1/s2 no murmors, regular rythm, no JVD, no periph edema,
ABD:+ bowel sounds, soft all 4 quadrants on palp, liver wnl size to percussion
Ext:
Neuro:

Differential Diagnosis
1.MI
2.Unstable angina
3.pneumothorax
4.dissecting aortic aneurysm
5.GERD
Diagnostic Workup
1.CPK-MB, troponin
2.EKG
3.AP CXR
4.EGd
5.
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Posted Patient Note Sample(s) for this Case


Name: IK
Email: Irenakokot@msn.com
Case Number: 01
Case Title: 01

Date Posted:

Wednesday 21st of February 2007 07:18:26 PM
 
History

CC:56 y.o w m presents with c/o L knee + l great toe pain
HPI:Pt. was awakened by pai i L kne + L graet toe in the middle of the night, 9/10 in intesity, doesn\'t radiate, even bedsheet seemed to be to heavy and painfull, few hours later, L knee + l geart toe swelled up i red; pt. took ibuprfen X2- some relief in pain 5/10 and swelling

ROS:no fevr, no mgrating joint pain,no arthritis, no trauma
PMH:4 y. ago episode of L great toe pain after te wdding, relieved with ibuprofen X2; no h/o arthriris, DM, HTN, haert dis., trauma to extermeties
Allergies:NKMA
Meds:ibuprofen prn
SH:quit smoking 10 y. ago. Occasionally beer. Occasionaly pt. has binges of junk food(chiken wings, pizza), like he ad last night, before pain.
FH:
no arthritis

Physical Examination

 Gen: slightly obese
Vitals:subfebrile tepm, otherwise-wnl
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:no lesions, scars on L lower exteremity.L knee + L graet toe tender to palpation, red, no edema, limited/painful flexion/ eztension.
2+ [eadal pulses B/l: sensation, muscle strength intact B/l. 2+ DTR
Neuro:

Differential Diagnosis
1.Attack of acute gout
2.Rhematoid arthritis
3.Ostearthritis
4.trauma
5.
Diagnostic Workup
1.L knee = graet toe X ray
2.uric acid, creatinine, BUN
3.uric acid in urine
4.Rhematoid factor
5.Aspiration osf synovial fluid
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Wednesday 21st of February 2007 12:05:38 PM
 
History

CC:fatigue
HPI:the pt is a 61 yo m c/o fatigue from 6 m ago which is the same during a day,decreased energy level,feeling depressed without any cause,concentration and performance in job.
he has lost his appetite and weight loss in this period.he has avague deep abdominal pain with 4/10 severity radiated to the back which gets better with leaning forward.he has nausea.
he deines change in bowel movement,blood in sttol,fever,chills,night sweats,chest pain or dyspnea.

ROS:nothing as mentioned above
PMH:appendectomy at 16yo
Allergies:nkda
Meds:tylenol
SH:smoking for 40ppd which quit 6 m ago,alcohol 2-3 beers a week,exercise regularly and eats junk food a lot.
FH:

Physical Examination

 Gen: no acute distress,leaning forward,not pale,or icteric.
Vitals:wnl
HEENT:no jaundice in sclera
Neck:no thyromegaly
LUNGS:breath sound are clear bilaterally
CVS:rrr,s1,s1 heard
no rale,gallop or murmur
ABD:soft,non tender,Bs+,tenderness in epigastric area,no organomegaly,no rebound tenderness.
Ext:no edema,no dry skin,pulses are 2+
Neuro:dtr 2+,muscle strength 5/5,

Differential Diagnosis
1.pancreatic cancer
2.pud
3.MDD
4.hypothyroidism
5.anemia
Diagnostic Workup
1.cbc
2.abdominal U/S
3.ERCP
4.serum tsh
5.sleep apnea syndrome
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 19th of February 2007 08:54:01 PM
 
History

CC:dizziness
HPI:pt is a 52 yo m c/o of intermittent progresive vertigo since three d ago and lt ear hearing loss from yesterday,naysea and vomiting for several times.
no hearing pulling/discharge,headach,head trauma,appetite or weight change,URI,falls,recent infectiona,tinnitus,fever,weakness or numbness.
he had watery non-bloody diarrhea for 3 days.

ROS:nothing as mentioned above
PMH:htn,appendectomy
Allergies:nkda
Meds:furosemide,captopril
SH:executive dirctor,no smoking,recreational drugs.2-3 beers a week,sexually active with his wife
FH:nothing related

Physical Examination

 Gen: not in acute distress
wnl except a high bp
Vitals:
HEENT:heraing loss in lt ear
Neck:no thyromegaly,,lymphadenolathy,no carotid bruit
LUNGS:breath sound are heard bilaterally
CVS:rrr,s1,s2 are heard,no gallop,murmur or rub
ABD:soft,non tender,non-distended
Ext:
Neuro:hallpike maneuver:nystagmus+,vertigo,gait normal,ndtr are bilateral 2+,motor strength are 5/5,cranial nerces 2 to 12 are normal and intact

Differential Diagnosis
1.Menneire\'s dis
2.dehydration
3.benign positional vertigo
4.acoustic neuroma
5.anemia
Diagnostic Workup
1.audiometry
2.hallspike manover
3.brain MRI
4.cbc
5.orthostatic BP
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Monday 19th of February 2007 05:53:34 PM
 
History

CC:forgetfullness
HPI:pt is a 65 yo f c/o forgetfullness since one year ago,she needs help shopping,daily activities,cooking,paying bills and bathing and feeding.she denies headache,vision problem,urinary incontinence,passing out or gait problem.
she had a head trauma while back which didn\'t follow up,no seizure,nausea,vomiting,or speech difficulties.

ROS:heart attack and stroke long time ago which now has weakness in left arm.HTN from along time ago.no cp,dyspnea,constipation,diarrhea,weight change.appetite has decreased and she feels upset because of her problem.
PMH:bowel obstruction which had an operation
Allergies:penicilin causes rash
Meds:
SH:retired one year ago after her husband\'s death,lives with her daughter,has many friends as support group.no smoking,alcohol use or recreational drug use.not sexually active after her husband\'s death
FH:

Physical Examination

 Gen: in no acute distress
Vitals:wnl
HEENT:no icteric sclera,skin
Neck:no thyromegaly
LUNGS:bilaterally and symmetric clear
CVS:s1 and s2 and s3 are heard,no murmur,rub
ABD:tender and soft,BS are heard.no organomegaly
Ext:pulses are 2+ and touchable.
Neuro:

Differential Diagnosis
1.alzheimer\'s disease
2.depression induced dementia(mdd)
3.delirium
4.SDH
5.hypothyroidism,vitamin b12 deficiency
6.
Diagnostic Workup
1.b12 level/tsh/rpr
2.head ct
3.brain MRI
4.eeg
5.
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Sunday 18th of February 2007 09:06:58 PM
 
History

CC:yellow eyes and skin
HPI:pt is a 52 yo f c/o of yellow skin and eyes since three weeks ago,itching from two months ago,nausea,fatigue and decreases appetite occasioanl intermittent dull abdomianl pain,which started three weeks ago,it is 3/10 while in pain and in RUQ,decreases with Tylenol.she denies the pain relationship with food or previous episodes,diarrhea or constipation,fever or night sweats.she has light stool color and dark urine color.
she had a blood transfusion 20 y ago,and travel to Mexico two months ago.

ROS:nothing except as described above
PMH:no similar episodes,hypothyroidism
Allergies:to Aspirin,rash
Meds:Tylenol,synthyroid
SH:two c sections and tubal ligation
FH:her mother died of Pancreatic cancer at age of 55
she works in a travel agency,uses two glasses of wine every day,no history of substance dependence.

Physical Examination

 Gen:no acute distress,jaundice+
Vitals:wnl
HEENT:yellow sclera and skin
Neck:
LUNGS:bilateral and symmetrically are clear
CVS:s1 and s2 are heard,no murmur,gallop or rubs
ABD:soft and non tender,BS heard normally.no organomegaly,no spider nevi or plantar erythema.
Ext:no asterixis,no edema
Neuro:

Differential Diagnosis
1.cholecystitis
2.pancreatic cancer
3.alcoholic hepatitis
4.hepatitis c
5.hepatitis A
6.
Diagnostic Workup
1.serum total Br/direct Br
2.hbs ag/hbc ab/hba ab
3.abdominal U/S
4.ERCP
5.Hida scan
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Wednesday 14th of February 2007 07:35:57 PM
 
History

CC:chest pain
HPI:pi is a 45 yo m c/o of severe middle chest pain started 40 min ago,it was 7/10 in severity ,accompanied with nausea,shortness of breath,sweating and radiated to lt arm and neck.
he had less severe pain episodes 2-3 times a week since 3 months ago exacrebating with climbing the stairs,and heavy meals and decreased with antacids.

ROS:GU and Gi normal
PMH:HTN five years,treated with diuretic
high cholestrol no change in diet
GERD 10 y treated with antacids.
Allergies:no
Meds:maalox,diuretic
SH:he\'s an accountant,smoking 24ppd which quit 3 y ago
uses cocaine once a week,the last use was yesterday.no sex activity for 3 months because he has chest pain in intercourse
FH:
father died of lung cancer and mother has PUD

Physical Examination

 Gen: he\'s in pain and distress
Vitals:wnl other than high BP
HEENT:
Neck:no JVD,no carotid bruit
LUNGS:bilateral clear,no wheeze,rhonchi,or crackle
CVS:s1,s2,s4 heard.no murmur,rub or gallp
ABD:no tenderness,no organomegaly
Ext:pulses are bilateral normal and palpable.
Neuro:

Differential Diagnosis
1.unstable angina
2.MI
3.GERD
4.dissection of aorta
5.pneumonia
Diagnostic Workup
1.ecg
2.troponin and cpk-mb
3.TEE
4.CXR
5.upper endoscopy
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Wednesday 14th of February 2007 04:27:28 PM
 
History

CC:blood in stool
HPI:since one month ago,mixed with stool,every time with defectaion,constipation for a long time,diarrhea for the last two days,bloody,watery,no musos,melena,or urgency,but has some tenesmus.
no abdominal pain,nausea,vomiting,feve,chills,appetite.his weight has decreased recently.no recent travel, no contact with diarreha patients.


ROS:
PMH:bronchitis 3 weeks ago,treated with amoxicilin,hemorrhoidectomy 4 years ago.no allergy.
Allergies:no
Meds:bisacodyl,phenolphetalein
SH:he\'s a lawyer,married with 2 children,no smoking,etOL,recreational drugs.
FH:his father died of colon cancer at 55 yo.
sh:sexual activity with his wife

Physical Examination

 Gen: no acute distresss,no pale,icteric.
Vitals:wnl
HEENT:
Neck:
LUNGS:bilatreal clear counds are heard.
CVS:rrr,s1,s2,no murmur,gallop,or rub.
ABD:bs are heard normally.no tenderness,guarding,or organomegaly found.
Ext:
Neuro:

Differential Diagnosis
1.colon cancer
2.Gastroenteritis
3.hemorrhoids
4.fissure
5.diverticulosis
Diagnostic Workup
1.cbc
2.rectal exam
3.anoscopy
4.colonoscopy
5.stool exam
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Posted Patient Note Sample(s) for this Case


Name: drcolom
Email: vladomolano@hotmai.com
Case Number: 01
Case Title: 01

Date Posted:

Wednesday 14th of February 2007 11:41:21 AM
 
History

CC:
HPI:28 yo F C/O headache. began 8 mts ago, frequency 2 times per month last 12 hs without treatment, intensiti 10/10, quality throbbing and poundin, located, aggraviated ligth, noisi, stress. alleviated lid down and sleep in quid place. She had migraine in the college age but less intense. Associated symptoms aura, nauseas and vomits 2 times.
Neg symptoms: fever, chills, changes in vision, numness or tinblin sensation or weakness, ches pain, palpitation, SOB, sweating.

ROS:good appetite, neg changest in weight or bowel movements, normal urination
PMH:see above
Allergies:NKDA
Meds:Tylenol.
SH:works in a bank, married. denied Etoh, tabaco, drugs use
FH:maother and sister with migraine

Physical Examination

 Gen: AOX3, without distress
Vitals:wnl
HEENT:normocephalic, atraumatic, throat no erytema or exudates
Neck:suple, no enlargements
LUNGS:clears, no rales, rubs or rhonchy
CVS:rrr, no rubs, gallops or murmur
ABD:sof, +BS, no tendernes
Ext:motor, reflexes, sensitiviti symmetrically and normal
Neuro:gait normal

Differential Diagnosis
1.migraine
2.tensional headache.
3.cluster headache
4.sisusitis
5.brain tumor
Diagnostic Workup
1.cbc, differential
2.brain CT, MRI
3.glicemia, cholest, tg
4.EEG
5.
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Posted Patient Note Sample(s) for this Case


Name: Maryam
Email: baroon57@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Tuesday 13th of February 2007 12:01:04 PM
 
History

CC:a 21 yo f co of sever steady cramping RLQ abdominal pain started this morning.nausea+,vomit+ sour yellowish fluid,no blood.
diarrhea+brownish,no blood in stool.

HPI:no radiation,exacerbated by movement.lmp=5 weeks ago
brownish vaginal spotting+
one pad used today,usually 2-3 used in a day


ROS:no urinary sx
menarche:13 yo
pregnancy:three years ago,NVD,no complication
PMH:std i month ago treated,partner not treated,no drug allergy
Allergies:no
Meds:ibprofen
SH:waitress,one child,living alone.single partner,three partners in the last year
FH:parents are alive

Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:are clear
CVS:s1,s2 heard,no murmur.no extra sound
ABD:rebound tenderness in RLQ.guarding+,BS not heard
no organomegaly,psoas sign+,Rovsing sign-,no cva tenderness
Ext:
Neuro:

Differential Diagnosis
1.appendicitis
2.ectopic pregnancy
3.pid
sexually transmitted disease
4.hiv
5.
Diagnostic Workup
1.rectal exam
2.pelvic exam
3.abdomiopelvic ultrasound
4.hiv antibody test
5.cbc
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Posted Patient Note Sample(s) for this Case


Name: Cesar Molano
Email: vlado molano@hotmail.com
Case Number: 07
Case Title: 07

Date Posted:

Monday 12th of February 2007 06:41:47 PM
 
History

CC:abdominal pain.
HPI:started 4 wks ago, getting worse the last week, epigastric pain, 6/10, come and go, 1 per day, last 1 hr, pain like burnig sensation, pain locate, aggaviate with food, alleviating fasting, neg symptoms fever, chills, chest pain, SOB, dysuria, melenas.
ROS: appetito good, no changest in weight.






ROS:
PMH:neg
Allergies:nkda
Meds:tylenos
SH:tabaquismo 1 ppd per 7 years, etoh 1 beer day per 7 ys, CAGE neg, cocaine in higt school. sexualy active with a male, always use of proteccion.
FH:father with renal problems

Physical Examination

 Gen: aox3, VS wnl
Vitals:
HEENT:normocephali, atraumatic
Neck:supple, no enlargements
LUNGS:clear, neg rales, rubs or ronchy.
CVS:rrr, s1, s2 normal, neg rubs, murmurs or gallops
ABD:softly, +BS, no rebound pain or rigidity
Ext:normal
Neuro:noraml

Differential Diagnosis
1.peptic ulcera
2.GERD
3.pancreatitis
4.cholelithiasis
5.gastric ca
Diagnostic Workup
1. rectal examination
2. cbc, differential
3. ep antibody

3.upper endoscopy
4.abdominal ct, u/s
5.
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Posted Patient Note Sample(s) for this Case


Name: jim
Email: jimjonhson76@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 09th of February 2007 08:55:53 PM
 
History

A 60-year old white male comes to E.R with a two- hour history of severe central chest pain that began while relaxing on the couch at home. The patient denies any exertional activity prior to the onset of symptoms. The pain is constant, 9/10 in severity, crushing in quality, and radiates to the left side of the jaw and left shoulder. There is associated nausea without vomiting.

Over the past two months he has experienced several episodes of exertional chest pain while at work. The pain is usually relieved with rest. He did not seek any medical attention thinking that the pain was work related muscle spasms. Medical problems include hypertension for which he has been taking hydrochlorothiazide
the past 10 years. He has no known allergies. FH: His father died of MI when he was 55. Mother is 85 yrs old and healthy. SH: He has been married for 34 years and has two sons. He is not sexually active. He has a 30-pack per year smoking history. He drinks moderate amounts of alcohol on weekends, but denies the use of recreational drugs. He is a truck driver. ROS: Denies headaches, vision changes, tinnitus, or vertigo. Denies muscle tenderness, joint pain, stiffness,
or weakness. Rest of ROS is unremarkable.

Physical Examination

 On PE, pt is a WD, WN male who doesn\'t display much emotion. BP 140/85

Neck-no venous distension

Heart - regular rhythm, no murmurs Lungs-clear to auscultation.

Chest- no tenderness on rib cage or over costochondral junctions Abd - no tenderness, bowel sounds present, no organomegaly Extremities - no peripheral edema, periph pulses +2 and equal bilat

Differential Diagnosis
1. Unstable Angina
2. Acute MI
3. PUD
4. Coronary spasm
5. Muskuloskeletal
Diagnostic Workup
1. EKG
2. Cardiac enzymes - CK and Troponins
3. Stress test
4. CXR
5. CBC, BMP
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Posted Patient Note Sample(s) for this Case


Name: joe hardee
Email: joehardee@cornell.edu
Case Number: 01
Case Title: 01

Date Posted:

Friday 09th of February 2007 08:39:16 PM
 
History

A 75-year-old white male presents with forgetfulness. Vitals: Pulse:75/min, B.P:110/75, Temp:98.6 F, R.R:16/min.

HPI: A 75-year-old white male is brought to the outpatient clinic by his son with the complaint of forgetfulness for the last two years. He reports that his forgetfulness was mild initially but it has gradually worsened and now he cannot continue his routine activities of daily life. He has also developed paranoid features and accuses his son of mixing poison in his food. He eats and sleeps well, does not take any recreational drugs, smoke or drink alcohol. He has been sexually inactive since the death of his wife 15 years ago. There is no history of CAD or stroke. An older sister has a history of dementia. He has no known allergies. He takes docusate for constipation. FH: Father died of MI at 68 and mother died of breast cancer at 55. His rest of the ROS are unremarkable.

Physical Examination

 General: The patient is alert but appears poorly groomed.
HEENT Thyroid gland is normal, no other abnormality found.
Abdominal examination WNL
Rectal examination Normal sphincter tone and prostate; brown colored stools
with no evidence of occult blood; no palpable masses.
Chest/lungs WNL
CVS WNL
Lymph node examination No lymphadenopathy
Neuropsychiatric examination On Mini-mental state examination he can’t
spell ‘world’ backwards, calculate, copy designs, recall objects or follow
3-stage commands.

Differential Diagnosis
Alzheimer’s disease

Parkinson’s and Lewy body dementia

vascular dementia

frontal lobe dementia

pseudo-dementia (Depression)

Normal Pressure Hydrocephalus

Syphilis
Diagnostic Workup
non contrast CT/MRI of the head

vitamin B12, folate levels

TSH level

CBC

BMP

VDRL



< Back

 

Posted Patient Note Sample(s) for this Case


Name: img
Email: raj007@hotmail.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 09th of February 2007 08:33:47 PM
 
History

HPI:
A 24-year-old Asian female presents with complaints of nausea and vomiting for the last several days. She feels more nauseated in the morning and also complains of breast pain. Her last menstrual period was 7 weeks ago and before that her menstrual periods have always been regular with a 28-29 day cycle.

She was married 8 months ago, is sexually active with her husband, and has never been pregnant. The patient denies abdominal pain, fever or vaginal discharge. She has been a one pack per day smoker since her teenage years. She is not on any medications, does not drink or use recreational drugs. The patient migrated to the United States 5 years ago and does not recall her vaccination history.
There is no history of sexually transmitted disease, but she has never been tested for STDs. Recently, she has been experiencing some constipation, other wise her bowel and bladder functions are regular. She is doing well at her office where she works as a secretary and has no emotional stresses.
ROS are unremarkable.

Hospitalization/Procedures None
Other Medical Problems None
Allergies None
Current Medications None
Family History Father is healthy at 55; mother is healthy at 45. Maternal grandmother died of breast cancer at 60. She has one older sister who is healthy.
Recreational history: attending social events and watching movies



Physical Examination

 Gen: NAD
Vitals: BP 110/70 T 98.7 PR 82 RR 22
HEENT: PERL
Neck: No JVD or Thyromegaly
LUNGS: CTAB
CVS: S1, S2 heard, No murmurs, rubs or gallops
ABD: Soft, mild lower quadrant distention, no masses
Ext: 1+ edema
Neuro: Non focal

Differential Diagnosis
1. Pregnancy
2. Hyperemesis gravidarum
3. Gastroenteritis
4. Metabolic
5. Pancreatitis
Diagnostic Workup
1. Beta Hcg
2. CBC
3. BMP
4. UA
5. LFT\'s, Amylase, lipase
6. T/C USG abdomen
< Back

 

Posted Patient Note Sample(s) for this Case


Name: md2008
Email: md2008@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 09th of February 2007 07:47:25 PM
 
History

The patient is a 29yr old receptionist who comes with a sudden onset of left sided mid abdominal pain since this morning. The abdominal pain is situated in the left mid quadrant with radiation to the left groin. The pain described as dull, colicky and comes in waves with the intensity of 5/10. The Pain is associated with inability to urinate during the pain. There is nausea nut no vomiting. No fever, no shortness of breath and review of other system are normal.

PMH – She has no past history of similar episodes before and no history of HTN or Diabetes.

Allergies: None

FH – Father has Heart Disease and mother is healthy.

SH:She does not smoke, use drugs and does not exercise. He is sexually active

Physical Examination

 On PE, pt is in distress. BP 120/70 pulse 108/min temp 98.0 degrees Neck: no venous distension Heart: regular rhythm, no murmurs Lungs: clear to auscultation. Abdomen – Severs tenderness over the left mid quadrant with no rebound tenderness, all other quadrant unremarkable. Chest wall: no tenderness on rib cage or over costochondral junctions. Extremities: no peripheral edema, periph pulses +2 and equal bilat.

Differential Diagnosis
Ectopic Pregnancy

Intestinal Obstruction

Appendicitis.

Renal Colic

Volvulus.



Diagnostic Workup
Urine Pregnancy test

Urine Analysis

Abdominal Ultrasound

CBC

BMP
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Posted Patient Note Sample(s) for this Case


Name: md2008
Email: md2008@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 09th of February 2007 07:42:36 PM
 
History

The patient is a 60 yr. old lady who comes in with sudden onset of palpitations for the past 6 months. She had a total of three episode in the last week and it occurs with no prior warning or symptoms. She has associated lightheadedness but no other symptoms. It has been gradual and progressively becoming worst. She does not complain of shortness of breath or chest pain. All other review of systems are unremarkable

PMH: She has an episode of Angina a year ago and diagnosed with hypercholesterolemia no significant problems since then.

Allergies:On Aspirin and Simvas

FH:Mother died of heart attack

SH:She does not smoke, use drugs and does not exercise

Physical Examination

 On PE, pt is in no distress. Blood Pressure 110/70 Neck: no venous distension Heart: regular rhythm, no murmurs Lungs: clear to auscultation. Chest wall: no tenderness on rib cage or over costochondral junctions Abd: no tenderness, bowel sounds present, no organomegaly Extremities: no peripheral edema, periph pulses +2 and equal bilat.

Differential Diagnosis
Atrial Fibrillation

Hyperthyroidism

Episode of hypoglycemia

Panic attack

Substance abuse: Cocaine

Diagnostic Workup
EKG

TSH/T4

CBC

Urine toxicology

BMP


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Posted Patient Note Sample(s) for this Case


Name: md2008
Email: md2008@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Friday 09th of February 2007 07:37:54 PM
 
History

The patient is a 48 yr. old male who comes in with upper chest discomfort for 3 months. The discomfort is primarily brought on by exertion and is worse when the weather is cold. Occasionally, he has had similar discomfort when talking or doing heavy work.

It has occurred twice when he was upset. He describes the \"discomfort\" as a steady pressure. It is not affected by brel1thing or position, It is relieved by stopping his exertion, He currently gets the \"discomfort\" 2-3 times/week. He does not complain of shortness of breath, dizziness, lightheadedness.

Three days ago, he awoke at 1 AM with a similar pain but it was more severe and radiated to his neck. lie sat up for a few minutes and it went away. This episode precipitated his visit today, Since that event, he has not h1\'ld sex with his wife for fear of pain and wife discovering his \"problem\"
PMH: He has been told that he has \"borderline\" hypertension but never treated.
FH: father died of cancer at age 72 but also had coronary artery disease.
SH: has smoked I ppd. X 20 yrs. He does not know his cholesterol but does not watch his diet. His job is not particularly stressful. He does not exercise.

Physical Examination

 On PE, pt is a WID, WIN male who does not display much emotion. Blood Pressure 140/85
Neck: no venous distension
Heart: regular rhythm, no murmurs Lungs: clear to auscultation.
Chest wall: no tenderness on rib cage or over costochondral junctions
Abd: no tenderness, bowel sounds present, no organomegaly
Extremities: no peripheral edema, periph pulses +2 and equal bilat.

Differential Diagnosis
1. Coronary artery disease
2. Coronary artery spasm
3. Gastritis/PUD
4. Hypertension
5. Substance abuse: smoking



Diagnostic Workup
1. EKG
2. lipid profile
3. fasting blood sugar, CBC
4. cardiac troponins and CK\'s
5. Stress test
6. smoking cessation
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Posted Patient Note Sample(s) for this Case


Name: DRCOLOM
Email: vladomolano@hotmail.com
Case Number: 03
Case Title: 03

Date Posted:

Wednesday 07th of February 2007 02:45:20 PM
 
History

CC:f 28 yo bank worker with headache
HPI:8 month, twice montly, headache in half of head, 8/10, throbbing, aggaviating soun, light,alleviating rest,quit, associated nausea, pain get up at night. neg simptoms loss of counciousness, vomit, convulsion, numness, tingling sensation

ROS:appetit, weigth normal
PMH:first time with symptom, neg htn. DM, cholesterol
Allergies:nkda
Meds:pain killer for headache.
SH:neg etoh, smoke or use of recreational drugs
maother and sister with headache.
FH:

Physical Examination

 Gen: aox3, ithout distress
Vitals:wnl
HEENT:eom grossly intact, fundoscopy neg for papiledema
Neck:supple
LUNGS:clear, neg rhonchy, rubs or rales.
CVS:rrr, neg murmur, gallops or rubs
ABD:softly,+bs, neg rebound.
Ext:motor 5/5 symmetrically, dtrs simmetrically bilateral
Neuro:dtrs 2/2 symmetrically

Differential Diagnosis
1.migraine
2.cluster headache
3.sinusitis
4.brin tumor
5.
Diagnostic Workup
1.CBC, differential
2.MBT
3.CT BRAIN
4.MRI BRAIN
5.
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Posted Patient Note Sample(s) for this Case


Name: DRCOLOM
Email: vladomolano@hotmail.com
Case Number: 03
Case Title: 03

Date Posted:

Wednesday 07th of February 2007 02:20:15 PM
 
History

CC:f 28 yo bank worker with headache
HPI:8 month, twice montly, headache in half of head, 8/10, throbbing, aggaviating soun, light,alleviating rest,quit, associated nausea, pain get up at night. neg simptoms loss of counciousness, vomit, convulsion, numness, tingling sensation

ROS:appetit, weigth normal
PMH:first time with symptom, neg htn. DM, cholesterol
Allergies:nkda
Meds:pain killer for headache.
SH:neg etoh, smoke or use of recreational drugs
maother and sister with headache.
FH:

Physical Examination

 Gen: aox3, ithout distress
Vitals:wnl
HEENT:eom grossly intact, fundoscopy neg for papiledema
Neck:supple
LUNGS:clear, neg rhonchy, rubs or rales.
CVS:rrr, neg murmur, gallops or rubs
ABD:softly,+bs, neg rebound.
Ext:motor 5/5 symmetrically, dtrs simmetrically bilateral
Neuro:dtrs 2/2 symmetrically

Differential Diagnosis
1.migraine
2.cluster headache
3.sinusitis
4.brin tumor
5.
Diagnostic Workup
1.CBC, differential
2.MBT
3.CT BRAIN
4.MRI BRAIN
5.
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Posted Patient Note Sample(s) for this Case


Name: drcolom
Email: vladomolano@hotmail.com
Case Number: 02
Case Title: 02

Date Posted:

Wednesday 07th of February 2007 01:13:59 PM
 
History

CC:rlq pain
HPI:rlq pain, 8/10, progressive,sharp and colic,no radiated, agraviating with movement, improve with rest, associated with fever, anorexia, nausseated, constipation. NEG chills, chest pain, vomits, dysuria, diarrhea or trauma history.


ROS:neg changest in weigh, obygn menarcha 14, c 28x5 regular, LMP 2 wks ago normal, last pap smear 6 moths ago
PMH:1 year with hart problem, neg ht, dm, cholesterol, hosp, tylenol sometimes.
Allergies:nkda
Meds:tylenol sometimes
SH:neg smoke, etoh, or recreational drugs. She is sexually active with her boyfriend, neg anticonceptive.
FH:neg

Physical Examination

 Gen: aoxe, moderate distress.
Vitals:wnl
HEENT:mouth moisi, throat without eritema, or exudates
Neck:supple, no enlargements
LUNGS:clear, neg ronchy, rubs or weezing
CVS:rrr, pmi norml, neg murmur, gallops or rubs
ABD:soft, bs+, no megaly, + rovsing\'s, mck burni, obturador, neg paravertebral tendernes
Ext:normal
Neuro:normal.

Differential Diagnosis
1.appendicitis
2.ectopic pregnancy
3.uti
4.pid
5.renal calculi
Diagnostic Workup
1.vaginal, rectal examination
2.cbc, differential, hcG
3.abdominopelvic u/s. ct scan
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: abby gabr
Email: gabr_md@hotmail.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 27th of January 2007 07:00:54 AM
 
History

CC:chest pain,left side
HPI:chest pain for the 3D.,relief partially by resting,sob,numbness ,referr to lt.side

ROS:
PMH:HTN,over WT,
Allergies:penicillin
Meds:motrin prn for headech
SH:married,hetrosex.,no ETHanol,smoking nor rec.drugsfather HTN,DM ,
FH:Father died age 78,mother malign.melanoma died age66,brother/sister HTN


Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:
Neuro:

Differential Diagnosis
1.angina

2.MI
3.osteochodritis
4.pneumonia
5.
Diagnostic Workup
1.ekg
2.cbc,cardiac enz.
3.electrolyt
4.angiocath.
5.cxr
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Posted Patient Note Sample(s) for this Case


Name: ghazia pervaiz
Email: gpervaiz@gmail.com
Case Number: 01
Case Title: 01

Date Posted:

Thursday 25th of January 2007 02:18:15 AM
 
History

CC:18 month old W F,c/o fever since 2 days.
HPI:The patient herself is not present, and the history is given by her mother. She says her child c/o fever 101 F. Also, she noticed the child pulling at her right ear repeatedly. The child is lethargic and not interested in her daily acitivities. She has decreased appetite and her sleep pattern is disturbed. Also, she ahs no cough, breathing problem, runny nose, and vomiting. Bowel and bladder habits are normal. She has not been eating regularly since these 2 days. Normally eats milk and whole food. She was born after a normal pregnancy of 40 weeks via spontaneous vagnal delivery. She was not breast-fed. She has normal milestones for her age, and up-to date vaccinations.
ROS:normal, except for above
PMH:Had an ear infection 3 months ago, for which she received amoxicillin.

Allergies:none
Meds:Tylenol
SH:goes to a day care center, but no known hisotry of ill contacts
FH:no known ill contacts

Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:
Neuro:keekqkkqq

Differential Diagnosis
1.uRINARY TRACT INFECTION
3.
4.
5.
Diagnostic Workup
1.COMPLETE BLOOD COUNT AND CULTURES
2.
3.
4.
5.
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Posted Patient Note Sample(s) for this Case


Name: vu
Email: a@aol.com
Case Number: 01
Case Title: 01

Date Posted:

Tuesday 23rd of January 2007 10:36:05 AM
 
History

CC:
HPI:Pt was apparently normal when he started noticing headaches in the frontal aspect of his head.

ROS:
PMH:
Allergies:
Meds:
SH:
FH:

Physical Examination

 Gen:
Vitals:
HEENT:
Neck:
LUNGS:
CVS:
ABD:
Ext:
Neuro:

Differential Diagnosis
1.zzzzzzzzzzzzzzzzz
2.s
3.zzzzzzzzzzzzzzz
4.zzzzzzzzzzzzzzzz
5.zzzzzzzzzzzzzzzzzz
Diagnostic Workup
1.MIgraine
2.Tension headaches
3.Cluster headaches
4.Brain Tumour
5.NPH
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Posted Patient Note Sample(s) for this Case


Name: Tamer
Email: none
Case Number: 01
Case Title: 01

Date Posted:

Tuesday 16th of January 2007 08:49:53 AM
 
History

CC:18 y/o m c/o scrotal pain
HPI:acute onset, 4 hours ago , progressive
nothing increase the pain/decreases by holding the testis
at right testis radiates to the groin
associated with 2 times vomiting of non bloody vomit/ + left knee swelling, testicular swellimn and redness
the pain is 10/10, h/o trauma earlyer that cuses transient pain at that time, the pain is dull thrombing

ROSno urinary frequency/bowel change/ dysnea/cough
PMH:no similar attack
NKDA
no current medication
no h/o hospitalization
Allergies:
Meds:
SH:active/3 f/occassionaly use condoms/- h/o std
FH:no known diseases running in the family

Physical Examination

 Gen: moderate distress/ discomfortable
Vitals:tachycardic, other WNL
HEENT:no rash/mouth lesiond/thyroid not palpable
Neck:
LUNGS:clear to auscultation B/L
CVS:normal rate/rythm, no murmurs, gloops/ rubs
ABD:slight diffuse tenderness
no rebound/gaurding/+bs/no hepatosplenomegaly
Ext:no rash
Neuro:left kness swelling / no deformaty/ painfull in passive and active movement

Differential Diagnosis
Henoch scholien purpura1.
2.trauma--hematocele/testicular rupture
3.testicular torsion
4.STD
5.orchitis
Diagnostic Workup
1.GU examination
2.testicular sonar
3.PTT/PT
4.CBC with differential
5.aspiration of the left knee
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Posted Patient Note Sample(s) for this Case


Name: Tamer
Email: ayadtamer@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 13th of January 2007 09:32:42 PM
 
History

CC:52 yo m c/o fatigue, cough and chest pain
HPI:cought started gradually and progressively over the last 6 months and there is occassionally sputum rusty and blood tinged, chest pain in the right chest wall is of few days, sharp increases with deep breath 4/10 in severity and not radiating. no dysnea, change in bowel or urine .
however there is loss of weight 20 ib over the last month with loss of appetite the cough is slightly improved with OTC acetaminophen and ciugh suppressants.the patient is recently released from prison where his cellmate was suffering of sever cough.

ROS:No Dysnea
PMH:no sililar attacks however sel limited sel diagnosed peumonia over the last year, no HTN, Cardiac or other lung problems
Allergies:NKDA to prescription or OTC medications
Meds:No current medication
SH:Smoke 1-2 packs cig/day for 35 years ,heroin user/ homosexual/ not drinking alcohol
FH:NO known family health problems

Physical Examination

 Gen: slightly underweight/ mild distress
Vitals:Tem.38.2 BL.PR 132/90. hr 91/minute r.r 22/min
HEENT:no oral vesicles/ thrush, no throat erythema or exudate not tonsillar enlargment normal ear canal and tympanic membrane
Neck:no palpable Lymph nodes or thyroid
LUNGS:chest move freely withrespiration normal tactile fremitus resonent in percussion bilaterlally in the front and back clear to auscaltaion bilaterally no wheeze / rhonchi/ rubs/ rales
CVS:Normal S1 and S2 not JVD no pedal edema no murmurs/rubs / gallops
ABD:not tender nor organomegally
Ext:
Neuro:

Differential Diagnosis
1.Pulmonary T.B
2.Pneumocystis carinii
3.Bacterial peumonia
4.Pulmonary embolism
5.C.O.P.D
6.Lung carcinoma
Diagnostic Workup
1.Chest x.rar
2.PPD test with control
3.Sputum for culture, gram stain, acid fast, silver stain and cytology
4.HIV test (western blot/ELISA)
5.CBC with differential
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Posted Patient Note Sample(s) for this Case


Name: Tamer
Email: ayadtamer@yahoo.com
Case Number: 01
Case Title: 01

Date Posted:

Saturday 13th of January 2007 08:17:24 PM
 
History

CC:48 y/o F with confusion, blurry vision and shortness of breath of 3 hours durations
HPI:the onset was 3 hours ago, she has nver had this symptoms before, it was worse over the past hour, and she did not know why this symptoms started, she also c/o headache, dizzeness and mild palpitation, she denied fever nausea or vomiting.

ROS:no changes in bowel movement, urine no cough
PMH:she has HTN no h/o cardiac diseasD.M or high cholesterol
Allergies:NKDA
Meds:thiazide for high blood pressure
OBS/GYn:LMP 2 weeks ago, regular, has two healthy children.
SH:non smoker/1 glass of wine amonth no use of recreational drugs
FH:bothparents are alive any healthy with no h/o cardiac , lung or HTN

Physical Examination

 Gen: mild distressed due to tachypnea
Vitals:Blood pressure 230/150 R.R 16/ minutes other WNL
HEENT:atraumatic head PERLA, EOM normal and normal visual field by confrontation
Neck:non palpable thyroid
LUNGS:clear to auscultation in both sides
CVS:normal regular S1 and S2 no murmurs, rubs or gallops no JVD nor pedal edema
ABD:no tender or rebound no organomegally
Ext:normal sensation perception to touch and pain, normal muscle tone and power intact deep reflexes+2 bilateral and symetrical
Neuro:Patient is conscious oriented to time place and persons.
intact C.N 11-X11
normal coordination (finger to nose , rapid alternative movement), normal gait

Differential Diagnosis
1.TIA, Stroke
2.Hypoglycemia
3.Pneumonia
4.substance abuse
5.toxic exposure
6.multiple infarcts dementia
7.Alzheimer\'s disease
8.Electrolytes abnormality
Diagnostic Workup
1.CT / MRI Brain
2.fasting plasma glucose level & HbA1C
3.Na, K, CL, Bicarbonate
4.Urine drug screening
5.CBC withdifferential
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