Best Links to
everything about:
Doe, Jane
DATE OF SERVICE 10/09/___
DOB:
CC: Wheezing and
cough productive of yellowish sputum for the last several days.
S:
The
patient has had a rough last couple of weeks. She saw Dr. Schaeffer on the
Allergies: Sulfa.
Medications: Paxil, Lo-Ovral, Protonix, and phentermine.
O:
Weight 188½ lb. BP 130/80, T 98.4°, P 76, R 14. The patient is a well-developed,
well-nourished, pleasant, obese, and alert young white female who is in no
acute distress. She has no
tachypnea, stridor, grunting, use of accessory muscles with respiration, or
retractions. She has course
sonorous rales bilaterally, especially in the right base with expiratory
wheezing bilaterally. She has no grunting or tripoding. Nasal mucosa is swollen and pale with
no active discharge. Oropharynx,
lymph nodes, eyes, and ears are normal.
Abdomen is benign and unremarkable, except for obesity.
Lab: Chest x-ray is
normal.
A:
1.Asthmatic bronchitis.
P: Put her on Avelox q.d. x seven days. Serevent inhaler p.r.n. Tessalon Perls 100 mg up one to two perls q6-8h. Recheck p.r.n.
________________,D.O./ht:___
Dictated Date:
10/09/___
Transcribed Date: 10/10/___
Doe, Jane
DATE OF SERVICE 10/09/__
DOB:
CC: The patient
states that she has had congestion, sinus pressure, cough, and headaches for
the last several days.
S: The patient saw my associate Dr. Schaeffer on 09/26/__ with a diagnosis of sinusitis. She states that she does not feel like she is getting any better, and now a cough has developed. No chest pain or shortness of breath. No gastrointestinal or genitourinary symptoms. No other family members have been ill. The patient is a nonsmoker.
Allergies: No known
allergies.
Medications: Generic Septra and Femhrt.
O:
Weight 199 lb. BP 120/70, T 98.0°, P 68, R 18. The patient is a well-developed,
well-nourished, pleasant, and alert young white female who is in no acute
distress. Nasal mucosa is swollen
and pale with no active discharge.
There is green postnasal drip, however. The patient has tenderness to
percussion over both maxillary sinuses.
Eyes and ears are normal. Heart reveals a regular sinus rhythm with no
murmur. The patient has some
scattered coarse rales bilaterally, but no wheezing or signs of
consolidation.
A: 1. Sinusitis.
2.
Cough.
P: I put her on some Aquatab p.r.n. for the congestion. Avelox q.d. x 10 days. Symptomatic measures. Recheck p.r.n.
_______________,
D.O./ht:_____
Dictated Date:
10/09/___
Transcribed Date: 10/10/___
Doe, Jane
DATE OF SERVICE 10/09/__
DOB: 11/24/__
CC: Poison ivy on
her leg and mouth.
S: Started on her right lower leg and worked its way up to her abdomen, back, and right thigh. Now she has some around her mouth. She denies any chest pain or shortness of breath. No tightness in her throat. She is doing fairly well overall. Depressive symptoms have not been bothersome recently. Doing well on the Ortho-Tricyclen. No side effects either volunteered or elicited.
Allergies: Sulfa.
Medications: Effexor and Ortho-Tricyclen.
O:
Weight 147 lb. BP 112/72,
T 98.4°, P 70, R 16. The patient is a well-developed,
well-nourished, pleasant, and alert young white female who is in no acute
distress. She has contact
dermatitis in the aforementioned areas with no evidence of airway
compromise. Chest is clear to
auscultation. No signs of
impetiginization or other complications.
A:
1.Contact dermatitis.
P: A
t her request we gave her a "shot." Kenalog 80 mg IM. Prednisone initial dosage of 60 mg
q.d. to be tapered by 20 mg q3d.
Atarax p.r.n. for the itching.
Recheck p.r.n.
_____________,
D.O./ht:___
Dictated Date: 10/09/__
Transcribed Date: 10/10/___
Doe, Jane
DATE OF SERVICE 10/09/___
DOB:
CC: The patient's mother
states that the child is fighting a cold.
S: The
patient has had a runny nose, low-grade fever, and eyes have been red for the
last three weeks. The patient was seen by Dr. Schaeffer on
Allergies: No known
allergies.
Medications: None.
A:
1.Upper respiratory infection.
2.
Subacute bronchitis.
P: Put her on Zithromax 200/5 cc to take one tsp today and then ½ tsp q.d. for the next four days. Tussi-12 p.r.n. for cough and
congestion. Watchful waiting and reassurance. Recheck p.r.n.
_______________, D.O./ht:____
Dictated Date: 10/09/___
Transcribed Date: 10/10/____
Doe, Jane
DATE OF SERVICE 10/09/
DOB:
CC: The patient states
she has had a states for the last couple of weeks with a little bit of postnasal
drip, sneezing, and itchy eyes.
S: The patient denies any fevers, chills, chest pain, or shortness of breath. No gastrointestinal or genitourinary symptoms. No other family members have been ill. She does not have a history of diagnosed allergies this time of the year otherwise.
Allergies: No known
allergies.
Medications: Oral contraceptives.
O: Weight
157 lb. BP
122/76, T 97.2°, P 66,
R 16. The
patient is a well-developed, well-nourished, pleasant, and alert middle-aged
white female who is in no acute distress. Anterior cervical nodes are tender but not
enlarged.
Oropharynx is benign. Nasal mucosa is swollen and pale with no
active discharge.
There is some clear postnasal drip. Eyes and ears are normal. Chest is clear to
auscultation.
Lab:
Strep screen is negative.
A:
1.Nonstreptococcal pharyngitis.
P: Antibiotics are deferred. I am going to empirically try her on some Allegra 180 mg q.d. Watchful waiting and reassurance. Symptomatic and avoidance measures were advised. Recheck p.r.n.
_______________, D.O./ht:___
Dictated Date: 10/09/___
Transcribed Date: 10/10/____
Jane Doe
DATE OF SERVICE 01/12/__
DOB:
Allergies:
No known allergies.
Medications:
Lipitor 40 mg daily, aspirin 81 mg daily, ibuprofen 800 mg p.r.n.
S:
This pleasant, 50-year-old patient of mine presents with complaints of
renewed onset within the past two weeks of nasal congestion, discharge, pain,
and pressure.
Now both ears feel plugged with ringing sensation and has a productive
morning cough of thickened phlegm. His second complaint is of a painful left
second toe after he had trimmed the nail back a little too much. He is concerned
that it is "ingrown".
It bled a little at first. Otherwise denies any severe amount of
swelling, redness, oozing, crusts, or drainage from the area. Thirdly, he
requests a flu shot.
O: Pleasant, 50-year-old male in no acute distress. He has a quite prominent nasal tinge to speech. Vitals: Weight 186 lbs, BP 124/72, T 98.3°, P 70, R 20. EENT with no conjunctival redness, mattering, or drainage. Right TM with moderate level of clear effusion. No inflammation noted. Left TM is already dark pink in color and inflamed convex with effusion level. No signs of rupture. 2+ nasal edema with inflamed mucosa and thickened yellow discharge emanating from both nostrils. Oropharynx with thickened PND and mild erythema. Neck is supple with lymphadenopathy. Heart regular rate and rhythm without murmur. Lungs clear. Inspection of his left second toe reveals a moderate sized area of the distal nail that has been completely clipped out at an oblique angle exposing a small amount of the nailbed. At this point, it has dried up and is starting to form an epidermis here. There are no signs of secondary infection. The remaining untrimmed nail is quite long and now is very sharp, and I am certain it is catching on his socks and shoes.
A: 1.Acute left otitis media.
2. Acute
sinusitis.
3.
Dermatitis of the left second toe secondary to overzealous nail clipping.
4.
Request for flu shot.
P: 1.Amoxicillin 500 mg 2 p.o. b.i.d. for 10 days.
2.
Pan-Mist DM samples 1 p.o. q. 12 hours for cough and sinus congestion symptoms.
3. The
patient was instructed how to properly trim his nails and encouraged to go ahead
and trim off the
sharper
edge sticking out on this toe. Otherwise allow the nail to grow back evenly
before trimming it again.
Recheck
symptomatically for that.
4. Flu shot given.
________________ D.O./ht:___
Dictated
Date:
01/__/___
Transcribed Date: __/23/__
Doe,
Jane
DATE OF SERVICE 00/22/____
DOB: 10/__/__
Allergies:
Penicillin.
Medications: None.
S:
This pleasant, 16-year-old female presents with onset within the past 2.5
days of constant, moderate nausea making her stomach feel constantly upset and
sore and achy, although she denies any severe abdominal pain per se. Denies radiation of
the pain to her flank area. Denies any associated cough or ENT-related
symptoms.
Denies sore throat. She has noticed some chills and sweats since
onset of the nausea.
So far she has not vomited but feels constantly like she could. She is avoiding
eating very many solids because of this. She denies any lower abdominal cramps or
diarrhea so far.
Denies burning or pain with urination.
She is attributing the symptoms to eating some relatively under cooked
ground beef just prior to onset of the symptoms. Is not aware of anyone else who has developed
the symptoms from eating that. Medical history otherwise negative.
O:
Alert, 16-year-old female in no acute distress. Vitals: Weight 136 lbs, BP
120/52, T 98.1°, P 68, R
20. EENT with
no scleral icterus.
Oral exam normal. No difficulty swallowing. Neck is supple
without lymphadenopathy. Heart regular rate and rhythm without
murmur. Lungs
clear. Abdomen
is soft, scaphoid, and generally nontender to palpation throughout the entire
abdomen, although the patient localizes her soreness to the midepigastric
region. No
rebound, rigidity, guarding, organomegaly, discrete masses, or hernias
noted. No
flank pain elicited.
A: 1.
Acute gastroenteritis of new onset with no other concerning symptoms. I suspect more
likely a viral
etiology than food poisoning.
2. Intractable nausea.
P: 1.
Explained my findings to patient. Reassurance given. I do suspect this
is self-limited and will
probably resolve within another few days. We discussed
continuing with clear liquids and slowly
advancing the diet as tolerated.
2. We prescribed Phenergan 25 mg p.o. up to q. 8 hours p.r.n. for
nausea.
3. Encouraged recheck or call back if symptoms worsen.
John D.
Doe, D.O./ht:slh
Dictated
Date:
00/22/____
Transcribed Date: 0/23/___
John Doe
DOB:
Allergies:
No known allergies.
Medications:
None.
S:
This pleasant, 47-year-old patient of mine presents with onset about six
days ago of URI symptoms. At this point, he is complaining of
unresolved symptoms of nasal congestion and constant postnasal drip that causes
a tickle deep in his throat and causes a tickly cough frequently during the day
and worse at night.
NyQuil has helped but left him feeling hungover. He is a salesman
for Phillip Morris, and he does report daily encounters at the office as well as
meetings of constant exposure to a lot of cigarette smoke. He usually only
uses chewing tobacco himself. Denies purulent nasal discharge, productive
cough, wheezing, or dyspnea. Denies vomiting or other concerning
symptoms.
O:
Pleasant, 47-year-old male in no acute distress. Frequent, dry,
hacky cough and nasal congestion are noted. Vitals: Weight 211 lbs, BP 118/72, T
98.5°, P 64, R
20. EENT with
no conjunctival redness, mattering, or drainage. Both TMs normal gray color without
effusions. 2+
nasal edema with pale and swollen turbinates and clear rhinorrhea observed. Posterior pharynx
without significant erythema. Neck is supple without lymphadenopathy. Lungs clear to
auscultation and percussion.
A: 1.
Acute viral upper respiratory infection.
2.
Cough.
P: 1.
Reassurance given.
I still suspect a self-limited illness, and antibiotics are not
indicated.
2. We provided samples of Tussi-12 for symptoms during the day and
Histussin HC p.r.n. for nocturnal
symptoms. Encouraged recheck if symptoms persist or worsen.
John D.
Doe, D.O./ht:slh
Dictated
Date:
00/22/____
Transcribed Date: 00/23/______
Jane
Doe
DATE OF SERVICE 00/22/____
DOB:
Allergies:
Oxsoralen.
Medications: Premarin, Duratuss.
S:
This 44-year-old patient of Dr. Jones presents today on my schedule for
"adjustment".
She was seen just yesterday for pharyngitis, nasal congestion, and
eustachian tube dysfunction. She is complaining of that within the past
two days all of the congestion and postnasal drainage has caused her to have
several episodes of vomiting. While retching, she feels that she really
cranked on her neck and caused it to be sore. She is complaining of bitemporal aching
headaches and pain down into her neck and is requesting an adjustment for
it. She has
received adjustments to her neck and back in the past for various reasons. Previous notes were
reviewed per chart.
She denies any self-treatment for the above complaint nor does she do any
regular home exercises.
O:
Alert, 44-year-old woman who appears to be in no acute distress
today.
Vitals:
Weight 151 lbs, BP 124/76, T 98.6°, P 70, R
20. She
demonstrates full active and passive range of motion of the cervical spine
without significant restriction. She localizes her symptoms mostly to the base
of the C-spine as well as the bitemporal headache. Palpatory exam
suggests C3 rotated to the right. Otherwise no other gross abnormalities are
noted by osteopathic exam.
A: 1.
Acute cervical spine strain secondary to a recent episode of illness per history
above.
2.
Somatic dysfunction of the cervical spine concurrently.
P: 1.
Osteopathic manipulation therapy in the form of soft tissue and high velocity
techniques to the
cervical spine with good results and tolerated well.
2.Encouraged Sandra to embark on a regular exercise program at home to
help keep her muscles
less stiff and prevent further problems. Heat could be applied to the area as well,
and she was given
ibuprofen 800 mg p.o. t.i.d. with meals as needed for pain as she is
presently popping Advil about
every 4 hours. Otherwise advised to follow up with Dr. Kamhawy or myself as needed.
John D.
Doe, D.O./ht:slh
Dictated
Date:
00/22/____
Transcribed Date: 0/23/01
John
Doe
DATE OF SERVICE 00/22/____
DOB:
Allergies:
No known allergies.
Medications:
None.
S:
John presents today with a couple of complaints. The first is of a
rapidly enlarging lesion on his left upper eyelid that has become bothersome
lately. He can
feel it constantly when he is blinking, although it is not interfering with his
field of vision so far. He first noticed it about three months ago,
and it has gotten a lot larger since then and is really starting to bug
him. He
wondered whether it was the same as a couple of other spots he has - one is on
his left upper arm and the other on the left side of his neck that he has been
aware of for a long time. His wife tells him that they are skin tags,
and he does not really feel that they cause any harm. He is
understandably more concerned about the lesion on his left upper eyelid. He has no previous
history of skin malignancy or other skin problems.
His second concern today is of some ongoing problems with presumed
athlete's foot.
He has continued to have redness and a dry, scaly, itchy eruption on the
sides and bottom of both feet and especially in the interdigital areas,
sometimes with open sores developing in these areas. This has been an
ongoing problem with waxing and waning severity for at least a year or
more. Within
the last three months, he has now noticed a thickened, yellow discoloration of
the fifth, fourth, and third toes of his left foot and similar changes on the
fifth and fourth toes of his right foot. He is correctly assuming that the chronic
fungus infection on his feet appears to have spread to his nails now, and he has
appropriately come into have it checked out. He denies any significant problems with his
hands or fingers.
O:
He is a pleasant, 44-year-old male in no acute distress. Vitals: Weight 229 lbs, BP
102/66, T 98.4°, P 60, R
20. Inspection
of his left upper arm and left side of his neck reveal two, small,
benign-appearing skin tags that are both pedunculated and hanging on
stalks. They
could easily be removed, but the patient prefers not to as they are not causing
any trouble for him.
Inspection of his left upper eyelid reveals a rather large, papillomatous
lesion with multiple little villi hanging off the main body of the lesion, which
is up on a stalk and hanging from the middle of the left upper eyelid. The little villous
projections point right into his eyebrow area every time he blinks, and I can
really see how this has been bothering him with normal eye movement. Inside of the
eyelid is normal.
No other acute changes are noted.
Turning our attention to his feet, both of them are showing the same
changes as aforementioned above.
A: 1.
Rapidly
growing but probably benign papillomatous lesion on the left upper eyelid that
is causing
difficulties with discomfort - would like continue to grow
and cause further problems.
2. Two benign-appearing skin tags on the left upper arm and left side of
his neck as described - the
patient does not wish to proceed with any treatment for them and that is
fine.
3. Chronic tinea pedis that now appears to have caused a complication of
onychomycosis.
P: 1.The patient is agreeable to removal of the lesion today
as follows:
The area on his eyelid was
cleansed and anesthetized with a tiny amount of 1%
Xylocaine. We
then removed the papillomatous
lesion from its stalk with a pair of sharp scissors. A small amount of
Monsel's ointment was used to
stop the tiny amount of bleeding from the resulting small defect. The patient
tolerated the procedure
well.
The lesion was submitted for biopsy. He was given home care instructions of this
wound, dab it
lightly as needed, cleanse it once daily with peroxide, and recheck if
any bleeding continues.
Page
2
John
Doe
DATE OF SERVICE 00/22/____
DOB:
2. Lamisil oral antifungal therapy was discussed and initiated at 250 mg once daily for 6 weeks, then
3. In the meantime, we discussed use of Micatin or a similar antifungal
spray as well as preventative
measures such as wearing cotton socks and changing them twice daily and
other moisture avoidance
behavior.
4.Recheck with either problem as needed.
John D.
Doe, D.O./ht:slh
Dictated
Date:
00/22/____
Transcribed Date: __/__/__
Contact for Service and Pricing: haustranscription@haustranscription.com