Breast: Patient denies any pain, lump, nipple discharge, rash, history of breast disease, or any surgery on breasts. Patient denies performing breast self-examination.
Respiratory: Patient denies having history of lung diseases such as asthma, emphysema, bronchitis, pneumonia, or tuberculosis. She also denies having chest pain with breathing, wheezing or noise breathing, shortness of breath, hemoptysis, sputum, toxin or pollution exposure. Patient states that she had common cold with some productive cough for about a week last month. Also, patient states that occasionally she experiences shortness of breath when she runs for more than 40 minutes. Patient states that her last chest x-ray was 1 years ago, and the results were negative.
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Patient denies any straining or discomfort on defecation. Patient denies having any recent change of bowel movements as, constipation, diarrhea, black stools, or rectal bleeding. She denies hemorrhoids, or fistula. Patient also denies using laxatives or antacids.
Urinary System: Patient states that she urinates about 4 times a day without urgency. She denies having nocturia, dysuria, polyuria or oliguria, hesitancy or straining, narrowed stream, inconsistence, or pain in flank groin, suprapubic region, or low back. She states that her urine is clear, and it does not present hematuria. In order to avoid urinary tract infections, she states that she drinks about three liters of water every day. She had a UTI at age 18.
Male Genital System: N/A
Female Genital System: No discharge, itching, sores, lumps. Patient had her menstruation was 2 weeks ago normal menstruation.
Peripheral Vascular: Patient denies any coldness, numbness or tingling, swelling of legs or arms, discoloration in hands or feet, varicose veins or complications, intermittent claudication, thrombophlebitis, or ulcers. She states that she crosses legs at the knees occasionally when long term sitting, and she does not wear support hose in these circumstances.
Musculoskeletal System: Patient denies having history of arthritis or gout. She also denies the presence of pain, stiffness, swelling, deformity, limitation of motion,
According to the provider, the claimant's cough has been improved. His review of systems was positive for fatigue, malaise, sleep difficulty, shortness of breath, wheezes, and a cough. His blood pressure was 115/71 mmHg and his BMI was 30.35 kg/m2. The physical examination revealed wheezes. Clonazepam was prescribed for agitation. Atorvastatin, Nystatin, Citalopram, and a probiotic were prescribed. Continued use of Aspirin and a regular inhaler were suggested. Further, a follow-up visit with Endocrinology, Cardiology, and Pulmonology. As it relates to a spot in his lung, a repeat CT scan was recommended. The bronchial washes were negative for
History of Present Illness: Ms. Noseworthy is a 76-year-old woman who I had seen at the end of July for the evaluation of ILD. She is here today for followup of those results. She has stable cough and shortness of breath. She states that she is exercising on a treadmill on a daily basis and bought an oxygen saturation monitor, which consistently has shown her oxygen levels to be in the low to mid 90's. She denies any chest pain. She has no other complaints today.
This is 51 year old AAF. Patient is here complaining of several issues as listed. Patietn reports for the past several days she had increased SOB at rest, non-productive cough, adiouble wheezes. Patient denies chest pain, N/V/ D. Patient is a current tobacco user wit 20 pack year hisotyr. Denies use of alcohol or illicit drug use. Denies depressive moods, current pain 3/10.
History of Present Illness: I last evaluated Ms. Dall at the end of June for a chronic cough. She had previously been given the diagnosis of COPD, as she is a 240 pack-year smoker who continues to smoke. She states that her cough is similar to when she has last seen me as previously believed she had an acute viral illness that led to her persistent cough She does have some shortness of breath which is stable, but worse on hot, humid days like today. Once again, she is smoking up to a pack to two packs a day and she does not have any interest, at this point, in quitting.
The patient is a 64-year-old female who has had recurrent admissions to the hospital and recently discharged after being treated for a ESBL Ecoli urinary tract infection. She presents again to the ER complaining of abdominal pain and abdominal distention. Her medical history is significant for schizophrenia, knee replacements, diabetes mellitus, hypertension, past CVA, COPD and dyslipidemia. Workup in the ED reveals her to be anemic and hemoglobin on admission is approximately 9.6 with hydration dropped to 8.5. She is also thrombocytopenic. Her labs reflect chronic kidney disease and her urinalysis reveals large amount of blood in the urine. In the ED she undergoes a CT of the abdomen and pelvis which reveals her to have ascites and
Ellen, a 19 year old college student, has been experiencing some abdominal pain and a burning sensation when urinating when coming home from spring break. Later that week, she observed a small amount of abnormal yellowish vaginal discharge. Ellen remembered, during sexual activity she forgot to urinate afterwards; she had always been told to urinate after having sex, so she believed it to be a Urinary Tract Infection. Ellen, once before had a UTI, so she went to her local pharmacy, and obtain some over-the-counter medicine. Once she started an AZO Urinary Pain Relief the pain during urinating was gone, but the discharge started to get worse and she began to itch around her vagina. After talking to her sorority sister, she began to worry that
The patient would usually seek consult to his doctor complaining of cough, chest wall pain, fever, fatigue, difficulty of
MK is a 45 years old female, with a BMI of 37, 4. She has a medical history of hypertension and diabetes mellitus II. In addition, MK has been a smoker for the las 22 years. Currently she is complaining of chronic cough with sputum that is more severe in the morning, light-headedness, and an increase urination at night. During assessment it was observed distended neck veins and peripheral edema. Her prescribed medications include an ACE inhibitor Lotensin (Benazepril) and Lasix (Furosemide) a diuretic. MK has recently diagnose with chronic bronchitis. She presented with the following lab values: Blood pressure: 158/98 mmHG, Hematocrit 57%, HbA1c 7.3%, Cholesterol
Upon assessment patient denies any nausea, vomiting, diarrhea, dysuria, abdominal pain. Patient denies any medical history, medications and allergies.
A three year old male was admitted to urology (the medical department that treats, diagnoses, and manages, diseases and abnormalities in the male reproductive system) due to anuria (being unable to urinate or produce liquid waste) with a possible (BNO) bladder neck obstruction (a plug at the base of the bladder that will not allow urine to move into the urethra). The patient’s parents explained he has recently been suffering from dysuria (painful or difficulty urinating, often describe a burning feeling) as well as occasional enuresis (producing, or leaking urine involuntarily), urgency (the feeling of needing to release urine immediately), and hematuria (the presence of blood in the urine). Upon birth the patient was diagnosed with (PKD) polycystic kidney disease (a disease passed from the parents characterized by the formation of cysts in the kidneys). I have also noted he is experiencing moderate nephralgia (kidney pain), and an additional case of hydronephrosis (abnormal dilation of the renal pelvis and the calyces of one or both kidneys due to pressure from accumulated urine that cannot flow past an obstruction in the urinary tract) (Gylys, 2013),
Based on the symptoms faced by the individual, the doctor will guide her to take the next necessary action. The doctor might want to provide a verdict after the assessment of what is inside the breast. In that case, the individual might be asked to perform an X-Ray of the breast, commonly known as Mammogram. He might also take a sample of the tissue out off the breast lump and do a biopsy test to know if the lump is malignant or cancerous. Hence, visiting a doctor is always the right thing to do as one would rather be safe than sorry.
○ The patient may be asymptomatic, complain of voiding symptoms (e.g., urinary frequency, urgency, nocturia), recurrent
History of Present Illness- The patient is a 64-year-old female with a 15-pack year smoking history presents to clinic complaining of chest pain for the past two weeks. The chest pain is accompanied by fatigue and weakness. She denies any recent illness, fever, or weight change. She denies any hypertension and shortness of breath?.She was nauseous with hot flashes and sweating 4 days ago with no vomiting. She has a hyperlipidemia history, and her last lipid test was a year ago. She has an episode of chest pain 4 times for 3 minutes since 2 weeks ago. She described her pain like somebody sitting on her chest. Her pain is in the middle of her chest and radiated to her left jaw. Chest pain is relieved by rest and exacerbated by physical activity. She tried Ibuprofen for her pain with no relief. On a scale of 10, she rates the pain as an 8. She denied any major medical history and any hospitalization. She is not using any medication, and she is not allergic to any medication or environmental allergens. She has been married to her husband for 33 years. The Patient is concerned because symptoms have impeded her activities of daily living, including going to work, and she is concerned that it may be a heart attack. She missed her job 2 days last week.
Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications):The patient denies cough or shortness of breath. The patient denies chest pain upon inspiration or expiration. The patient denies lung disease. The patient states he stopped smoking 32 years ago. The patient states he is up to date on his flu vaccination as well as his pneumonia vaccination.