Abdominal Aortogram Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Infrarenal abdominal aortic aneurysm.

POSTOPERATIVE DIAGNOSES:
1.  Infrarenal abdominal aortic aneurysm.
2.  Left common iliac artery stenosis.
3.  Bilateral superficial femoral artery occlusions.
4.  Single-vessel runoff bilaterally consisting of peroneal artery.

OPERATION PERFORMED:  Abdominal aortogram with bilateral lower extremity runoff.

SURGEON:  John Doe, MD

ANESTHESIA:  Lidocaine 1% along with 1 mg of Versed and 100 mcg of fentanyl.

ADJUSTED CONTRAST:  Visipaque 70 mL

INDICATION FOR PROCEDURE:  The patient is a (XX)-year-old female who is a renal dialysis patient as well as hypertensive, with known peripheral vascular disease.  The patient was found to have a 5 cm infrarenal abdominal aortic aneurysm.  At this time, we discussed the possibility of an endovascular repair secondary to her multiple comorbidities.  We discussed with the patient the risks, benefits, and alternatives to an arteriogram.  She understood and agreed to proceed.

ESTIMATED BLOOD LOSS:  Minimal.

SHEATH:  A 5-French sheath.

DESCRIPTION OF OPERATION:  After the patient was taken to the operating room and adequate anesthesia was induced, the groins were prepped and draped in the usual fashion.  The right common femoral artery was easily accessed using a 19 gauge introducer needle, and a guidewire was fluoroscopically guided to the level of the diaphragm.  This was then followed by placing a 5 French sheath and then a pigtail catheter with 1 cm markings.

Sequential views were obtained from the level of the celiac artery down to the pelvis, followed by runoff of bilateral lower extremities.  This showed bilaterally occluded renal arteries, a patent SMA and celiac artery, and an infrarenal abdominal aortic aneurysm that involved the bifurcation.  The right common iliac artery was mildly dilated and calcified.  The right external iliac artery was patent, but small, with no evidence of focal stenosis.  The right hypogastric artery was patent.

On the left, the common iliac artery showed a 40% stenosis 1 cm distal to the ostium, associated also to severe calcification.  The external iliac was also, overall, small and calcified.  The left hypogastric artery was patent.  Bilateral common femoral arteries were patent and not diseased.  Both profunda femoral arteries were patent.

Actually, both superficial femoral arteries occlude after takeoff, with some collateralization around the geniculate, into an occluded segment of popliteal artery, with highly diseased tibioperoneal trunks, completely occluded anterior tibial arteries, and single vessel runoffs via the peroneal artery.

At this time, we went ahead and removed the patient's sheaths and catheters from the right groin and held pressure for 10 minutes, obtaining good hemostasis.

At the end of the procedure, all counts were correct.

IMPRESSION:
1.  Infrarenal abdominal aortic aneurysm, bilateral occluded renal arteries.
2.  Occluded superficial femoral arteries bilaterally.
3.  Moderate stenosis of the left common iliac artery.
4.  Single vessel runoff on the right consisting of peroneal artery.
5.  Single vessel runoff on the left consisting of peroneal artery.

The patient tolerated the procedure well without any complication.

Lab Data Medical Transcription Format Samples

LABORATORY STUDIES:  White count of 4.6, hemoglobin 12.8, platelet count 320.  Sodium 142, potassium 3.8, chloride 108, carbon dioxide 28, BUN 11, creatinine 0.9, glucose 82, calcium 9.4, magnesium 1.8.  Total bilirubin 1.4, AST 20, ALT 15.  Total protein 6.4, albumin 3.6.  TSH 2.14.  Alkaline phosphatase 60.  Triglycerides 36, cholesterol 143, LDL 57, HDL 69.  The patient had three sets of cardiac enzymes with a peak CK of 78, troponin less than 0.06 x4.  PT of 12.8, INR 1.0, PTT 25.  D-dimer 0.79.  The patient had an MRI of the T-spine which was a normal exam.

LABORATORY STUDIES:  Normal hemoglobin, normal white cells.  White count of 9, hemoglobin 13.1.  Sodium 138, potassium 3.6, chloride 98, bicarbonate 26.  CK initially was elevated to 914, then 640, and normalized to 70.  CPK and MB fraction negative.  Triglycerides 84, cholesterol 156, LDL 102, and HDL 39.  Albumin 3.4.  Dilantin level on the day of admission was 3.6, subsequently raised up to 4.2, and when the dose was increased, to 11.1, 13.9, and 16.1 on the day of discharge.

LAB AND DIAGNOSTIC STUDIES:  White count was 12.3, hemoglobin 10.6, platelets 196.  Sodium 132, potassium 5.2, chloride 98, bicarb 28.  BUN and creatinine 24 and 1.8.  Alkaline phosphatase 154, total protein 5.2.  BNP 540.  Troponins were positive at 0.9 and CPK is 48.

EKG showed no acute changes.  The patient was in sinus rhythm.  A chest x-ray showed underlying chronic interstitial fibrosis, stable in appearance, slightly improved aeration, left base.  No evidence of development or recurrence of consolidation or new infiltrate.  On the CAT scan of her chest, the patient had pulmonary fibrotic changes and central lobar emphysema, hazy, ground glass opacities within the mid lung zone, perihilar region, bilaterally.  Essentially unchanged in appearance from the prior study.  There was no evidence of bronchiectasis or new focal consolidation or atelectasis.  There was no pleural effusion.  A 14 mm nodule in the left costophrenic angle, previously described mildly enlarged anteromedial mediastinal nodes were stable.

LABORATORY STUDIES:  Showed hemoglobin 7.8, hematocrit 23.6, which remained stable during this hospitalization.  White count of 6.4, 5.2, 7.2.  Normal platelets from 286,000 to 350,000.  There was no symptom of acute decompensation.  Anemia was asymptomatic.  His INR initially was 9.2 and then he received vitamin K x3 and subsequently INR came to 9.7, 7.5, 5.1 and 2.1.  Microbiology data showed urine cultures with contamination as well as wound culture was VRE, which was sensitive to ampicillin, ceftriaxone, cefepime, imipenem, Levaquin as well as tobramycin.  VRE was sensitive to ampicillin, but the patient has allergy to penicillin as well as cephalosporin, but most exclusively to Keflex.

LABORATORY STUDIES:  White count 8.4, hemoglobin 12.2, hematocrit 36.2, platelet count 266,000.  On admission, white count was 9.2 with a peak of 11.  The patient's hemoglobin on admission was 15.2.  The patient's sodium was 135, potassium 3.8, chloride 100, carbon dioxide 28, BUN 20, creatinine 1.1, glucose 120, calcium 8.6.  Magnesium level pending.  Total bilirubin 12.8, was 14.2 on admission, peaking at 15.8 two days after ERCP.  Direct bilirubin 7.3, down from 8.6 on admission.  Indirect bilirubin 5.4, down from peak of 6.8 after ERCP.  AST 41, down from 142 on admission.  ALT 48, down from 204 on admission.  Total protein 4.6, albumin 2.2, alkaline phosphatase 274, down from 360 on admission.  Amylase 34, lipase 22.  CA 19-9 antigen 534, which was markedly elevated.  The patient's sodium on admission was 131.  PT 13.6, INR 1.1, PTT 24.  D-dimer 0.74.  The patient's urine was amber in appearance, 25 mg estimated protein, large amount of bilirubin, negative leukocyte esterase, 2-4 white cells, 10-14 granular casts, and 3-4 white cell casts.

LABORATORY DATA:  WBC 6.6, hemoglobin 11.6, hematocrit at 32.8, MCV 86.6, and platelet count 109,000.  PT 11.2.  INR 1.0.  Sodium 134, potassium 3.6, chloride 104, carbon dioxide 22, glucose 108, calcium 8.2, total protein 5.8, albumin 2.9, and alkaline phosphatase 64.  SGPT 52, SGOT 56, total bilirubin 1.0.  BUN 48 and creatinine 1.6.

LABORATORY STUDIES:  Urine culture was positive for Proteus mirabilis and Pseudomonas aeruginosa.  UA with large amount of leukocyte esterase, positive for nitrite, trace amount of blood, protein 25, over 50 wbc's, 1-2 rbc's, many bacteria.  PT of 14, INR 1.1, PTT 25.  WBC 11.8, hemoglobin 13.2, hematocrit 39.8, platelets 314,000.  Bedside glucose ranged from 122 up to 320.  Sodium 142, potassium 4.8, chloride 106, carbon dioxide 26, BUN 68, down to 28 by discharge, creatinine 2.1, down to 1.3 by discharge, glucose 184, calcium 9.6.  Magnesium 1.4 and 1.7, day of discharge was 1.4.  Amylase 58, lipase 18, alkaline phosphatase 58, total bilirubin 0.6, AST 16, ALT 15, total protein 5.4, albumin 2.4.

LABORATORY DATA:  Includes a white count of 10.6, hemoglobin 12.4, hematocrit 37.2, and a platelet count 190,000.  Chemistries include a sodium 134, potassium 4.2, chloride 104, CO2 of 28.  BUN 78 and creatinine 3.6; the initial creatinine was 4.2.  Glucose 176.  CPK 2024 today and it was 1880 yesterday with MB of 1.3 and a troponin of less than 0.06 and a troponin yesterday 0.6.  The CPK from his prior admission was reportedly 312.  Protime 11.2, INR 1.0, and PTT 24.  Arterial blood gas shows a pH 7.38, PCO2 of 44, and a PO2 of 46 with an oxygen saturation of 79.  It is unclear whether that was a venous stick as it does not seem to correlate with his clinical status.  The patient had a CAT scan of the brain, which showed chronic periventricular ischemic white matter changes with no acute abnormalities seen.  The chest x-ray from his prior admission showed no evidence of congestive heart failure and again today it shows no congestive heart failure, but evidence of cardiomegaly with a pacemaker defibrillator noted.  A lung scan was done on the prior admission for similar problems and was low probability for pulmonary emboli.

LABORATORY STUDIES:  Still pending are anti-Sjogren's antibody, anti-neutrophil cytoplasmic Ab, anti-single-stranded DNA Ab, anti-double-stranded DNA Ab, angiotensin converting enzyme, rheumatoid factor, Lyme titer, ANA.  RPR nonreactive.  Rheumatoid factor negative.  WBC 8.8, hemoglobin 14.2, hematocrit 42.4, and platelets 234,000.  ESR 5.  Sodium 141, potassium 3.6, chloride 110, carbon dioxide 26, BUN 16, creatinine 1.1, glucose 88, calcium 9.4.  Liver function tests within normal limits.  Vitamin B12 of 440, folate 15.6.  TSH 0.68.

LABORATORY DATA:  Chemistry showed sodium 131, potassium 3.6, chloride 96, CO2 of 29, glucose 134, calcium 9.4, albumin 2, bilirubin 0.3, alkaline phosphatase 144, SGPT 32, SGOT 23, BUN 36, creatinine 1.4, PT 11.4, INR 1.05, and PTT 31.  CBC:  WBC 14.8, hemoglobin 8.2, hematocrit 24.6, and platelet count 178,000.  CT of the brain without contrast was reviewed and shows mild brain atrophy and white matter disease.  Carotid ultrasound showed no stenosis.


Normal Lab Values                                Common Lab / Diagnostic Words and Phrases

Normal Physical Exam Template Format for Reference

PHYSICAL EXAMINATION:  At the time of admission, alert and looking older than stated age, chronically ill.  Temperature 98.4 degrees, heart rate 78, respiratory rate 20, and blood pressure 128/82.  Poor dentition.  Dry oral mucosa.  Head, ears, nose and throat examination, no significant findings.  Neck is supple.  No JVD.  No carotid bruits.  Lungs with scattered expiratory wheezing, crackles.  Severe shortness of breath with minimal activity.  Pulse oximetry was 95% on 3 liters.  Abdomen was soft and nontender.  Significant abnormality in the area of the right hip where prior hardware was removed.  Significant skin defect there, although it is well healed.  The patient is not weightbearing on the right lower extremity because of removal of the hardware.

PHYSICAL EXAMINATION:  The patient was alert and oriented x3.  Stable vital signs.  Afebrile with respirations 22, temperature 97.6 degrees, blood pressure 132/66, and pulse 90.  Eyes with white sclerae.  Mouth revealed no hemorrhages, very poor dentition.  Neck showed no cervical or supraclavicular lymphadenopathy.  Lungs were clear to auscultation.  Heart revealed regular rate at rest.  Abdomen showed postsurgical excisional healing wound with some exudations from the lower abdomen, status post squamous cell carcinoma which was performed at the other institution.  Extremities:  Large, open, shallow ulcer in lower extremity.  The other extremity with chronic venous stasis.  Neurological examination without significant findings.  On the skin, there are multiple ulcers with granulation tissue consistent with venous stasis ulcer on the lower extremities as well as ulcers present on the right lower extremity.

PHYSICAL EXAMINATION:   Alert and oriented x3 with dusky appearance and short of breath, tachypneic, hypoxic on room air, 88%.  Temperature in the emergency room was 103, heart rate 22, pulse ox 88% and blood pressure 90/60.  The patient had dusky skin, tachypneic, chronically ill appearing at the time of admission.  Oral mucosa is clean.  Mouth is with no pertinent findings.  Lungs showed coarse rhonchi, fine crackles throughout the lungs.  Breath sounds were diminished at the bases.  Heart showed regular rate and rhythm.  No murmurs, rubs or gallops.  Abdomen was soft, bowel sounds present.  Extremities with no cyanosis, clubbing, or edema.  Neurological examination was grossly intact.

PHYSICAL EXAMINATION:
GENERAL:  Examination at admission revealed the patient to be an alert male, in no apparent distress.
VITAL SIGNS:  Showed a blood pressure of 118/66, pulse 74, respirations 18, temperature 97.8.  Height 5 feet 5 inches and weight 172 pounds.
HEENT:  Unremarkable.
NECK:  Supple.
HEART:  Regular rate and rhythm with no murmurs.
LUNGS:  Clear.  No rales, rhonchi or wheezes.
ABDOMEN:  Slightly distended with active bowel sounds and with minimal epigastric tenderness.  No guarding, masses or rigidity.
EXTREMITIES:  Revealed no edema.
NEUROLOGICAL:  He was alert and oriented x3 with no focal, motor or sensory deficits.

PHYSICAL EXAMINATION:
GENERAL:  The patient is an elderly male lying in bed in no significant distress.
VITALS:  Blood pressure 122/68, pulse 72 beats per minute, respirations 18 breaths per minute, and temperature 98.2 degrees Fahrenheit.
HEENT:  No pallor and no icterus.  Extraocular muscles intact.  Pupils are round and reactive to light.  Normocephalic and atraumatic.
NECK:  No JVD.  No cervical lymph nodes.  Bilateral bruits heard.
LUNGS:  Vesicular breath sounds heard in both lung fields.  Decreased breath sounds heard in the right base.  No rhonchi.  No crackles.
HEART:  First and second heart sounds heard, irregularly irregular rhythm.  No S3.
ABDOMEN:  Bowel sounds heard in all four quadrants.  No hepatosplenomegaly.  No tenderness.  No free fluid noted.  No bruits noted.
NEUROLOGIC:  Alert and oriented x2.  Moving all four extremities to command.
EXTREMITIES:  No edema.  No Homans.  No cyanosis.  Pulses 2+.
LYMPH NODES:  No palpable lymphadenopathy.
SKIN:  No petechiae.  No purpura.  No hematomas.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.4, pulse 72, respirations 18, and blood pressure 132/72.
GENERAL:  An elderly lady in no acute respiratory distress.
HEENT:  Atraumatic.
NECK:  Supple without bruits.
HEART:  Regular rate and rhythm.  No murmur.
LUNGS:  Clear.
EXTREMITIES:  Without clubbing or cyanosis.
NEUROLOGIC:  Mental Status:  Fully conscious and oriented x3.  Normal language and speech.  The patient was able to follow complex commands and name objects.  Short memory 1/3 in 5 minutes.  Cranial nerves II through XII, right fundus is not visualized.  Left fundus is sharp.  There is evidence of disconjugate eye movements.  Normal extraocular muscles.  Visual fields are full.  No facial weakness.  Tongue protrudes in the midline.  Motor exam:  Strength is 5/5 in proximal and distal muscles of upper and lower extremities.  Deep tendon reflexes are 1/4 in bilateral biceps, triceps, knees, and ankles.  Toes are downgoing bilaterally.  Sensory exam:  Normal to pinprick sensation.  Cerebellar:  Normal finger-to-nose bilaterally.  Gait normal.

PHYSICAL EXAMINATION:
GENERAL:  An elderly female, obese.
VITAL SIGNS:  Morning temperature 97.2; pulse 72, radial artery; respirations 20; and blood pressure measured at that time 144/78.
HEAD AND NECK:  The patient's temporal arteries are palpable.  We did not hear carotid bruits, and there is no jugular vein distention noted.  Some fullness in the neck is present but no definite thyromegaly.
HEART:  Regular rate.  No murmurs.
LUNGS:  Clear, although the patient’s inspiratory effort was not very strong.
ABDOMEN:  Soft and benign with bowel sounds present.  No abdominal pulsations and no tenderness.
EXTREMITIES:  Both upper extremity pulses were palpable with no evidence of any compromise.  In the lower extremities, on the right side, the femoral pulse could be palpated.  The popliteal and pedal pulses are not, but the entire extremity including foot and toes were warm and not compromised.  Motor and sensory function was preserved.  On the left side, the patient did not even have a femoral pulse palpable and more distal pulses were clearly absent.  The leg was cool from approximately knee down and blanched in the distal portion of the foot, and she was unable to move both foot and toes.  Sensation was also absent in the foot and abnormal in the calf; although, she did not have swelling in the calf or extreme tenderness.  She did not have evidence of peripheral aneurysms, varicose, or venous insufficiency.  Chronic pitting edema was noted to be present.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 98.4, pulse 70, and blood pressure 114/62.
GENERAL APPEARANCE:  Old lady, in no acute respiratory distress.
HEAD AND NECK:  Atraumatic.  Supple without bruits.
HEART:  Irregular.  Irregular heart beats.  No murmur.
LUNGS:  Clear.
EXTREMITIES:  Without clubbing, cyanosis, or edema.
NEUROLOGIC:  Mental Status:  Fully conscious and oriented x3.  Normal language and speech.  Cranial nerves II through XII, sharp discs.  Pupils are equal and reactive to light.  Extraocular muscles are intact.  No facial weakness.  Tongue protrudes in the midline.  Motor Exam:  Strength is 5/5 in proximal and distal muscles of upper extremities and 4/5 in the proximal lower extremities.  The patient is able to dorsiflex her right foot.  Left foot is 5/5.  Deep tendon reflexes are 0/4 in bilateral biceps, triceps, knees, and ankles. Toes are downgoing bilaterally.  Sensory Exam:  Normal to pinprick sensation.  Cerebellar, normal finger-to-nose bilaterally.

PHYSICAL EXAMINATION:
GENERAL:  This is a (XX)-year-old lady.
VITAL SIGNS:  Blood pressure 142/76, respiratory rate is 20, temperature 96.8, and O2 saturation on 3 liters 93%.
NECK:  Revealed jugular venous distention of 45 degrees.  There are no surgical scars noted.  On palpation, there is no adenopathy.  No thyromegaly.  Carotid pulses, upstroke is normal, but rhythm appears to be irregularly irregular.  On auscultation, there are no venous hums or bruits.
CHEST:  Inspection of the chest is normal.  Percussion reveals slight dullness on both basilar regions.  On auscultation, breathing sounds are diminished at the basilar regions.
HEART:  Palpation, negative for thrills, heaves, or lifts.  On auscultation, the rhythm was irregularly irregular.  First heart sound is normal.  Second sound is split physiologically.  There is an S3 gallop present with a grade 1/6 systolic at the apical region.
ABDOMEN:  Soft.  No pulsatile mass or bruits.  No organomegaly.  Bowel sounds were normal.
EXTREMITIES:  Lower extremities, dorsalis pedis and posterior tibialis, popliteal, and femorals all present and equal bilaterally at 4+.  No edema.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE:  Alert, oriented, and very pleasant gentleman in no distress at all at the time of evaluation.
VITAL SIGNS:  Blood pressure in the supine position in the right arm 120/62, temperature 97, O2 saturation 97% on 2 liters nasal cannula, and respiratory rate 18.
NECK:  Obese.  Difficult to examine, but at least on palpation there was no thyromegaly.  Carotid pulses appear to have normal upstroke.  On auscultation, there were venous hums or bruits.
LUNGS/CHEST:  Clear and normal to percussion and inspection.  Anterior chest demonstrated well-healed prior remote median sternotomy scars.  On palpation, there was no tenderness on the chest wall.  There were no heaves and no lifts.
HEART:  Rhythm was regular.  The rate was 50.  First and second sounds were normal.  There was no gallop, murmur, rubs, or clicks.
ABDOMEN:  Obese.  Quite difficult to examine because of size but grossly no organomegaly.  No tenderness.  No rebound tenderness.  Bowel sounds appeared normal, and pulsatile masses could not be excluded because of size.
EXTREMITIES:  Some skin changes are present in the lower extremities suggestive of chronic edema, now resolved.  Pulses, dorsal pedis and posterior tibialis not felt.  Popliteal is not felt.  Femoral is 2+.

PHYSICAL EXAMINATION:
GENERAL:  A well-developed, well-nourished, well-oriented, well-cooperative, very pleasant (XX)-year-old woman.  Her weight is 150 pounds which is 68 kilograms. Height is 5 feet 2 inches which is 158.49 cm.
VITAL SIGNS:  Blood pressure is 116/80 mmHg, pulse rate is 76 beats per minute, respirations are 18 breaths per minute, temperature 98.6 degrees Fahrenheit, and O2 saturation 99%.
HEENT:  Eyes, moving in all directions without anisocoria and reactive to light.  Funduscopic examination shows there is no hard exudate.  No blot hemorrhage in both fundi.  Tongue not dehydrated.
NECK:  Supple.  No JVD.  Carotid upstroke normal without bruit.
HEART:  There is no S3 gallop.  No murmurs.
LUNGS:  Clear without expiratory wheezing or without inspiratory rales.
ABDOMEN:  Distended with a fetus.  There is no tenderness.  Fetal heart sound is not audible with the stethoscope at this time.
EXTREMITIES:  No pedal edema.  Pain and touch sensation are good in both feet and peripheral pulsations are palpable, dorsalis pedis artery as well as posterior tibial artery bilaterally.


Review of Systems Common Words and Phrases

REVIEW OF SYSTEMS:  She denies any recent fever, chills, change in appetite, loss of weight, productive cough with sputum, wheezing, or chronic lung disease.  Her cardiac history is as stated above.  She denies any abdominal pain, vomiting, diarrhea, blood in the stool or urine, dysuria, hematuria.  She has degenerative joint disease and rheumatoid arthritis with multiple arthritic complaints in multiple joints.  She admits to lot of dizziness and near syncope, coming on for the past couple of months, but she denies total syncope, stroke, or seizure.

REVIEW OF SYSTEMS:  The patient denies recent weight changes, persistent fever, headache, blurred vision, tinnitus, double vision, sore throat, cough, sputum production, chest pain, shortness of breath, wheezing, hemoptysis, palpitation, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematemesis, melena, jaundice, abdominal pain, dysuria, hematuria, nocturia, back pain, joint swelling, seizure, or syncopal episode.

REVIEW OF SYSTEMS:  The patient is not very reliable right now but denies any change in weight, appetite, or sleep pattern.  HEENT:  No blurred vision, tinnitus, rhinorrhea, odynophagia, or antalgia, postnasal drip, dysphagia, decreased hearing, or tinnitus.  CVS:  No chest pain, shortness of breath, orthopnea, PND, palpitation.  RESPIRATORY:  No cough or hemoptysis.  GI:  No nausea, vomiting, abdominal pain, hematemesis, hematochezia, melena.  CNS:  No blurred vision.  Still has a few shakes but no dizziness, lightheadedness.  No headaches, no blurred vision, focal weakness, or slurred speech.  No numbness or tingling.  SKIN:  No rashes or itching.  ENDOCRINE:  No polyuria, polyphagia, or polydipsia.  EXTREMITIES:  No pain or edema.  No back pain.  No bone pain.  Review of systems otherwise negative.

REVIEW OF SYSTEMS:  The patient denies any headache.  The patient has had a fever today.  She denies any neck pain or stiffness.  She does have postoperative shoulder pain.  She denies any chest pain.  She has no purulent sputum production, no hemostasis, no abdominal pain, nausea, vomiting, heartburn, or diarrhea.  She has no increase in lower extremity edema.

REVIEW OF SYSTEMS:  The 10-system review of systems includes in general no pain.  HEENT:  No auditory or visual changes recently.  Cardiovascular:  Currently without chest pain or palpitations.  Pulmonary:  Currently without shortness of breath or cough.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  Genitourinary:  No dysuria, no hematuria, although dysuria was experienced previously.  The rest of the review, otherwise, negative.

REVIEW OF SYSTEMS:  He has osteoarthritis, obesity, type 2 diabetes mellitus, hypertension, skin cancer removal, cataract removal and lens implant as mentioned.  He is having BMs every day, including this morning.  He denies headache, nausea, vomiting, chest pain, shortness of breath, or abdominal pain.  He denies bladder dysfunction.

REVIEW OF SYSTEMS:  The patient does not have impaired hearing.  He claims not to have any swallowing difficulties.  He is unable to speak currently secondary to tracheostomy, on continuous aerosolized trach collar.  There is no goiter.  He does have ankle swelling secondary to his pulmonary disease as well as shortness of breath with exertion.  He denies any chest pains.  He does not have palpitations.  The patient does take a p.o. diet.  There is no tube feeding.  He denies any heartburn, nausea, vomiting, diarrhea, or constipation.  There have not been any bloody or tarry stools.  He does have a Foley catheter in place.  There are no rashes other than venous stasis changes on his lower extremities bilaterally.  He denies any headaches, blackouts, dizzy spells, or seizures.

REVIEW OF SYSTEMS:  The patient denies any headache, nausea, vomiting, chest pain, dyspnea, fevers, or chills.  She denies any dysuria, urgency, frequency, diarrhea, or abdominal pain.  She does report anorexia, which has been present for several months.  She denies any focal numbness, weakness, or tingling.  She does report chronic low back pain, particularly on the left side, which radiates into the back of her left leg.  She denies any hematochezia or melena.  She denies any cough or dyspnea.  She does report generalized fatigue.

REVIEW OF SYSTEMS:  The patient notes no fever or weight change or malaise prior to admission.  HEENT:  No sore throat, no allergic rhinitis history, no vision changes, no ear pain.  Cardiovascular:  She does have a history of hypertension.  Denies history of heart attack.  She denies history of myocardial infarction.  No chest pain.  No palpitations.  No history of valve disease.  No paroxysmal nocturnal dyspnea.  No change in the quality of her back pain.  Pulmonary:  No wheeze, no cough, no purulence is noted.  She is a never smoker.  No sputum prior to admission.  The patient has no prior history of lung history.  No past exposures of tuberculosis that she knows of.  No history of asthma.  GI:  No abdominal pain.  No esophageal reflux.  No hematuria or frequency noted.  No hematochezia.  The patient notes she is stooling normally.  No history of colon CA.  Endocrine:  No fibroid abnormalities.  No diabetes.  Neurological:  No headaches or change in level of consciousness recently.  No recent falls at home.

REVIEW OF SYSTEMS:  The patient denies chronic anemia, easy bruising, or previous blood transfusion reaction.  HEENT:  Denies chronic headaches or sinus problems.  Respiratory:  Currently with dyspnea. Denies chronic cough or recent sputum production, hemoptysis, TB, or pneumonia.  Cardiac:  See HPI.  Positive orthopnea. No PND. No prior myocardial infarction.  Denies varicose veins and claudication.  Gastrointestinal:  Denies nausea, vomiting, hematemesis, or melena.  Genitourinary:  Denies dysuria, urgency, frequency, or hematuria.  Musculoskeletal:  Denies acutely swollen, painful or warm joints or evidence of deep venous thrombosis.  Endocrine:  Denies diabetes mellitus or thyroid disease.  Neurologic:  Denies stroke, TIA, any muscle retraction, or syncope.

REVIEW OF SYSTEMS:  Apparently, there is no history of seizures, heart disease.  There is lung disease.  There is no mention of hepatitis, yellow jaundice, diabetes, thyroid disorders, bleeding disorders, kidney, rheumatologic, or dermatologic disorders.  Psychiatric reveals obviously positive for addictive behavior.  The patient's vital signs are stable, but she is on a ventilator with full support.

REVIEW OF SYSTEMS:  HEENT:  No epistaxis, blurry vision, headache, earache or discharge.  Cardiovascular: History of coronary artery bypass graft surgery in the past.  Denies chest pain, palpitations, PND, or orthopnea.  Pulmonary: The patient was recently diagnosed with lung cancer.  Currently, status post thoracotomy with right lower lobe resection.  Ex-smoker. Gastrointestinal: No nausea, vomiting, diarrhea, GI bleed.  Genitourinary: No dysuria or hematuria.  Musculoskeletal: No muscle weakness or tenderness.  Neurologic:  No focal motor or sensory deficits.  Other systems are negative.

REVIEW OF SYSTEMS:  The patient denies any recent weight changes, persistent fever, headache, double vision, blurred vision, or tinnitus.  She denies sore throat, cough, sputum production, hemoptysis, wheezing, chest pain, shortness of breath, palpitations, or paroxysmal nocturnal dyspnea.   She denies nausea, vomiting, abdominal pain, diarrhea, constipation, hematemesis, or melena.  She denies history of jaundice, dysuria, hematuria, or nocturia.  No back pain, joint swelling, seizures, or syncopal episodes.

REVIEW OF SYSTEMS:  No fever, chills, or night sweats.  Heart:  The patient denies chest pain, orthopnea, dyspnea on exertion, paroxysmal nocturnal dysuria, murmur, claudication, peripheral edema, or palpitations.  Gastrointestinal:  The patient complains of nausea, vomiting, abdominal pain, and constipation.  Denies any hemoptysis or melena.

REVIEW OF SYSTEMS:  Mostly negative with the exception of fatigue, dizziness, syncopal episodes x1 week.  He denies melena, bright blood per rectum, or change in bowel habits.  He is having a bowel movement approximately every other day.  Denies hematuria, epistaxis, hemoptysis, or petechiae.  He denies any recent infections, pneumonia, productive cough, history of heart disease, or chest pain.  He denies any history of osteoporosis, musculoskeletal fractures, or difficulty ambulating.  Neurologic:  Denies any history of seizures, headaches, or neuropathies.  Genitourinary:  Denies any dysuria, urgency, frequency, hematuria, or nocturia.

REVIEW OF SYSTEMS:  Negative for chest pain or palpitations, positive for nausea, anorexia, decreased p.o. intake, weakness, generalized malaise, voiding symptoms such as incomplete voiding sensation, urgency, and no frequency.  Diminished urine output, dark colored urine.  Negative for neurological symptoms, hematochezia, melena, and hemoptysis.  The rest of the 10 point review of systems is negative.

REVIEW OF SYSTEMS:  HEENT:  Denies any acute vision or hearing problems, epistaxis, rhinorrhea, diplopia, or tinnitus.  Pulmonary:  Occasional shortness of breath.  No cough, sputum production, hemoptysis, or wheezing.  Cardiac:  As above.  Gastrointestinal:  No nausea, vomiting, diarrhea, constipation, abdominal pain, epigastric pain, heartburn or blood in stool.  Neurologic:  No headache or weakness.  He does have chronic neck and back problems, C-spine problems.  Genitourinary:  No dysuria, hematuria, or frequency.  Hematologic:  No easy bruising or bleeding.  Constitutional:  No fever, weight loss, weight gain, or lack of appetite.

REVIEW OF SYSTEMS:  HEENT:  No acute vision or hearing problems, epistaxis, rhinorrhea, diplopia, or tinnitus.  Pulmonary:  No cough, sputum production, hemoptysis, or wheezing.  Cardiac:  As above.  Gastrointestinal:  No nausea, vomiting, diarrhea, constipation, abdominal pain, epigastric pain, heartburn, or dark stool.  Neurologic:  No headache, weakness, seizure, or tingling.  Genitourinary:  He does have BPH.  Hematologic:  No easy bruising or bleeding.  Constitutional:  No fever, weight loss, weight gain, or lack of appetite.  Endocrine:  No heat or cold intolerance, polyuria, polyphagia, or polydipsia.  Musculoskeletal:  No joint pain, rash, or swelling.

REVIEW OF SYSTEMS:  ENT:  Complains of headache.  Denies diplopia, blurry vision, loss of visual field, or hearing loss.  Denied of any sinus problems or sore throat.  Cardiac:  Complains of chest pain with associated palpitations as described above.  Denies orthopnea or pedal edema.  Pulmonary:  Complains of mild shortness of breath associated with chest pain.  Denies cough, sputum production, hemoptysis, pleuritic pain, or wheezing.  Gastrointestinal:  Denies nausea, vomiting, constipation, diarrhea, hematochezia, or hematemesis.  Genitourinary:  Denies dysuria, hematuria, nocturia.  However, does complain of occasional urgency.  Neurologic:  Denies dizziness, syncope, seizures, vertigo, paresthesia, or tremor.

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