Consultation report samples:
Consultation Report Sample #1
| RE: | Debra Jones |
| DATE: | 12/01/10 |
| MR: | 240804 |
| DOB: | 12/01/65 |
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a 55-year-old white female referred today for chest pain. She was recently evaluated for a typical chest pain and had exercise stress testing. She exercised for 9 minutes and 26 seconds and the test was clinically negative. She continues to have atypical chest pain complaints. She has no orthopnea, no lower extremity edema, no palpations, or dyspnea on exertion.
PAST MEDICAL HISTORY: Hypothyroidism.
PAST SURGICAL HISTORY: Partial hysterectomy, lumbar laminectomy, and benign bony tumor removed from sinus cavity.
SOCIAL HISTORY: She is married and has a 28-year-old son. She is self-employed. She makes custom draperies.
FAMILY HISTORY: Father is deceased from congestive heart failure and mother is still living at age 86 with history of hypertension and CVA. She has three sisters who are healthy. She smokes cigarettes one-half pack per day for 25 years. She quit 10-15 years ago. She drinks on a social basis, one to two mixed drinks per week. Caffeine intake, two to three diet Rite Cola’s per day. Three to five eight-ounce glasses of water per day. She exercises regularly and walks one to one-and-one-half miles per day, five day a week. She follows a regular diet with no restrictions.
REVIEW OF SYSTEMS: She has lost 16 pounds since January. She is positive for easy bruising. She does experience occasional seasonal allergies symptoms, occasional nocturia, urinary urgency, and hyperkeratosis.
CURRENT MEDICATIONS: Premarin everyday, Synthroid everyday, and oxybutnin p.r.n.
ALLERGIES: SULFA DRUGS CAUSE RASH.
PHYSICAL EXAMINATION: Weight 169 pounds, height 5’8” tall.
VITAL SIGNS: In the right arm blood pressure 140/80 and in the left arm 130/80. She has an applicable respiratory rate at 16.
GENERAL: A 56-year-old white female in no acute distress.
SKIN: Warm and dry.
PHYSICAL EXAM: Unremarkable.
EKG: Normal sinus rhythm.
IMPRESSION:
1. A typical chest pain with negative exercise stress testing on 09/11/02.
2. Reform smoker.
3. Unknown lipid status.
4. Hypertension.
DISCUSSION: At this time, chest pain appears to be caustic chondritis, will treat with Motrin. Check fasting lipids. I will see the patient back in the office in four weeks and reevaluate blood pressure readings at that time, as to whether or not medical therapy will be necessary.
Consultation Report Sample #2
| PATIENT NAME: | David Jones |
| ID NUMBER: | 240804 |
| DATE OF SERVICE: | 12/01/10 |
| D.O.B.: |
CHIEF COMPLAINT: Low back pain, bilateral lower extremity pain of 4-5 weeks duration.
HISTORY OF PRESENT ILLNESS: This is a 70-year-old male with chief complaint of low back pain and bilateral lower extremity pain. The patient denies any recent trauma to the low back. He states that he has been a body builder for the past 30 years and has worked out at the gym on a regular basis. He has entered in one multiple body building contests. He states that approximately 3 years ago, he was a using a machine at the gym doing crunches and felt a pop in his low back. He states that his back has not been the same since then. However, he was able to continue working out until about 4-5 weeks ago when he states he was unable to get out of bed due to bilateral lower extremity burning in his legs. He went to see a chiropractor and had some manipulation, which helped somewhat. He has taken multiple pain medications, NSAID’s and narcotics. At present, he is taking Percocet. He states that this has not helped much at all. He has not been able to return to the gym. The patient also gives a history of taking a growth hormone that was a black market product from China for an entire year, approximately 4-5 years ago. He denies any change in bladder or bowel movements.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PAST MEDICAL HISTORY: Significant for depression and anxiety.
PAST SURGICAL HISTORY: The patient had a right knee arthroscopy in January of 2002.
SOCIAL HISTORY: The patient denies any alcohol use, denies any smoking history. He is presently retired. Prior to retiring, he worked as a massage therapist. He does this occasionally for friends at the present time. He is married. He lives with his wife. There is no litigation involved in this pain management case.
FAMILY HISTORY: Parents are deceased. Mother died of cancer in 2001. Father died of cardiac disease.
PHYSICAL EXAM: The patient is a 70-year-old well developed, well nourished male in moderate distress secondary to low back pain, as well as bilateral lower extremity pain. His blood pressure is slightly elevated today at 130/90. The patient’s pulse is 70. He is 5’6” tall and weighs 223 lbs HEENT: Normocephalic. Atraumatic. Extraocular muscles are intact. Pupils are equal and reactive to light and accommodation. Neck: Supple without masses or adenopathy. Lungs: Clear to auscultation and percussion bilaterally. No rales, rhonchi or wheezing is appreciated. Heart: Negative S4, positive S1, positive S2, negative S3. No murmurs or ectopy is appreciated. Abdomen: Soft and non-tender to palpation. Bowel sounds are present in all four quadrants. GU: Deferred. Skin: Clear. Pulses: Bilaterally symmetric in the upper and lower extremities. No clubbing, cyanosis or edema is noted in the lower extremities. Sensory Evaluation: No sensory deficits are noted in the upper or lower extremities. Motor strength function: The patient ambulates with a normal gait. Transfers on and off the exam table are fluid. There is no motor weakness noted in the lower extremities. Motor strength testing is bilaterally symmetric and 5/5. The patient has well defined musculature. Reflexes are bilaterally symmetric in the upper and lower extremities.
Focus examination of the lumbar spine reveals the patient ambulating with a normal gait. Transfers on and off the exam table are fluid. There is no abnormal list or posturing. Lumbar lordosis is maintained. The patient has full range of motion of the lumbar spine in all planes. He is able to toe-heel walk without difficulty. Straight leg raise is negative. Motor strength testing of the lower extremities is 5/5 and symmetric. The lower extremities are without muscle atrophy. Skin is warm and dry to touch. Pulses are intact. Deep tendon reflexes are bilaterally symmetric.
DIAGNOSTIC TESTING: The patient had an MRI done on 07/14/08. MRI findings reveal HNP L4-L5 on the right minimally compressing the thecal sac. There is an HNP at L3-L4, again, mildly flattening the thecal sac. There is degenerative disc disease at multiple levels.
CURRENT MEDICATIONS:Celexa 10 mg one daily, Ativan 2 mg one daily, Ambien 12.5 mg one daily, and Percocet 5 mg t.i.d./q.i.d.
DIAGNOSTIC IMPRESSION:
- Degenerative disc disease.
- Chronic low back pain.
- Lumbar radiculopathy.
- HNP L3-L4 and L4-L5.
PLAN: The patient is in an acute state of pain secondary to a lumbar radiculopathy. After careful review of his medications and disease status, the patient would most likely benefit from a lumbar epidural steroid injection. He was advised no aspirin products or NSAID’s products 3-5 days prior to his injections. At present, he is taking Percocet for pain. He also understands that the injections may or may not relieve any or all of his pain and the risks include, but are not limited to injection site tenderness, redness, infection, nerve damage or injury, exacerbation of his pain, as well as death. He has been advised to remain NPO 8-10 hours prior to the injections and to have a driver available to transport him to and from the facility. He understands the risks and benefits of the procedure and is willing to undergo a lumbar epidural steroid injection tomorrow. He has been advised of conscious sedation and what that entails. His questions regarding the procedures were answered to his satisfaction.
History And Physical Report Sample #3
| RE: | David Jones |
| DATE: | 12/01/10 |
| MR: | 240804 |
| DOB: | 12/01/65 |
HISTORY OF PRESENT ILLNESS: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills, and sweats. He denies cough and diarrhea. He has mild anorexia. Past Medical History: Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.
MEDICATIONS: Advil and Ibuprofen.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He occasionally drinks. He is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982, which he described as “very active.” He denies intravenous drug use. The patient is currently employed.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION:
General: This is a thin, black cachectic man speaking in full sentences with oxygen.
Vital Signs: Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.
HEENT: Funduscopic examination normal. He has oral thrush.
Lymph: He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.
Neck: No goiter, no jugular venous distention.
Chest: Bilateral basilar crackles, and egophony at the right and left middle lung fields.
Heart: Regular rate and rhythm, no murmur, rub or gallop.
Abdomen: Soft and nontender.
Genitourinary: Normal.
Rectal: Unremarkable.
Skin: The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. He has very pale palms.
LABORATORY: Sodium 133, potassium 5.3, BUN 29, creatinine 1.8, hemoglobin 14, white count 7100, platelet count 515, total protein 10, albumin 3.1, AST 131, ALT 31, urinalysis shows 1+ protein, trace blood, total bilirubin 2.4, and direct bilirubin 0.1.
X-RAYS: Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.
IMPRESSION:
1. Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.
2. Thrush.
3. Elevated unconjugated bilirubin.
4. Hepatitis.
5. Elevated globulin fraction.
6. Renal insufficiency.
7. Subcutaneous nodules.
8. Risky sexual behavior in 1982 in Haiti.
PLAN:
1. Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.
2. Begin intravenous Bactrim and erythromycin.
3. Begin prednisone.
4. Oxygen.
5. Nystatin swish and swallow.
6. Dermatologic biopsy of lesions.
7. Check HIV and RPR.
8. Administer Pneumovax, tetanus shot, and Heptavax if indicated.