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Chief complaint atypical is a 74-year-old patient of Dr. Jew Briar who presented to the emergency room with atypical chest pain {period}

atypical chest pain, needing to rule out acute coronary syndrome. Patient is now being admitted for serial troponin and CK-MB and if the trend is going up then might need cardiology consult versus Lexiscan. Assessment and plan number two hiatal hernia with GERD, which I suspect is what is causing more of her symptoms. We will give her Protonix 40 mg IV once daily.

right breast abnormality, which was also confirmed by ultrasound {period} On 18, 2016, she underwent a biopsy showing a invasive lobular carcinoma, ER positive, PR positive, and HER-2 negative {period} The patient then underwent a lumpectomy and sentinel lymph node biopsy on, which identified an invasive lobular carcinoma, 1.5 cm, positive capital LCIS, no lymphovascular invasion, grade 2, ER positive 90%, PR

%, HER-2 negative (IHC 1+), and Ki-67 of 15%, negative margins, Oncotype DX of 21, disease in 0 of 4 sentinel lymph nodes, staging pT10pN0 (stage IA) {period} Planning adjuvant radiation

and adjuvant Arimidex{period}considering the high hormone receptor positivity, low Ki-67, small size, and the intermediate risk Oncotype Dx (DX score of 21 with intermediate range lying from 18 to 32),

patient's benefit of chemotherapy was minimal and was outweighed by risk of toxicities, so did not pursue a chemotherapy {period}

Plan to pursue capital letter [skip] pursue capital DEXA scan in addition to referral to lymphedema clinic in the future {period} two {period} Hypothyroidism three {period} Neuropathy {period}History of thrombcytosis {period} Per the patient did have history of platelets in the 500s, although more recently was told it was in the lower 400s (this was information collected at her initial consultation visit on)

The patient was initially on aspirin in the past for this {period} with platelet count on of 494 {period} Next section is medications please copy medication section from my prior clinic visit note on date of service next section allergies no known drug allergies next section social history please copy the social history section from my prior clinic visit note on date of service next section review of systems all systems were reviewed and were negative except as listed above in the interval history section next section performance status capital

performance score of zero next section physical examination vital signs weight of 93 kg, pulse 90, blood pressure 126/74, temperature 97.3 general exam comfortable appearing {period}No acute distress {period} Alert {period} Answering questions appropriately {period} HEENT exam no scleral icterus extremities no edema neuro exam nonfocal skin no rash or bruising breasts exam deferred exam today {period}

Plan to pursue complete breast exam in next clinic visit in seven weeks {period} next section labs new line labs on 134, potassium 4.1, chloride 99, bicarb 28, glucose 83, BUN of 14, creatinine 0.94, AST 16, alk phos 53, ALT 17, total protein 6.9, albumin 4.5, total bilirubin 0.7, calcium 9.5 new line white blood cell count 5.7, hemoglobin 14.6, hematocrit 42.7, platelet count of 494 next section is

is a 59-year-old postmenopausal woman with a stage IA right breast invasive lobular carcinoma, ER positive, PR positive, HER-2 negative, status post lumpectomy and sentinel lymph node biopsy {period} number one {period} Breast cancer {period} Plan is to initiate adjuvant radiation on {period} We will have the patient return for clinic visit after radiation to initiate Arimidex at that time {period} At that time, we will also pursue complete breast exam and order capital DEXA scan and

on calcium, vitamin D and discuss referral to lymphedema clinic {period} Additionally, we will initiate Arimidex at that time {period} Plan next screening mammogram on two {period} Hot flashes {period} Attributing to post menopausal status, which started [skip] which started in

Assessment and plan number three osteoarthritis and depression. Continuing with her Norco and Prozac and we will inform her regular primary care, the physician, to follow up in the morning. Oh addendum to the past medical history also with history of depression and possible

2012 {period} Currently having two to three hot flashes per week. Arimidex potentially worsen this in the future when started {period} We will monitor this {period} sorry should say we will to continue this reassess this at future clinic visit {period} Three {period} Fatigue {period} Notably the patient has a very strenuous nature of job consistent with capital ECOG performance score of zero. We will continue to reassess at future clinic visits {period} four

{period} Secondary to osteoarthritis at neck which causes paresthesias especially at the left hand for which the patient is currently on gabapentin {period} We will continue to reassess at future clinic visits {period} five {period} History of thrombocytosis {period} Most recent CBC on did show elevated platelet count of 494 {period} We will just continue to monitor this for now {period} after the patient undergoes radiation and let us say it again several months after completing radiation if platelet count is still elevated

pursue further evaluation {period} next section is followup new line clinic visit in seven weeks End of dictation end of dictation

Erica Bussel dictating on Calvin McSwain date is 2016 medical record 300638. History is as follows patient is a is a 64-year-old African American male who is well known to our service from an inpatient stay at HealthSouth City View from 09,08. Patient was originally admitted to Texas

Hospital in Fortworth following a basketball injury right hip I’m sorry he injured his knees playing basketball with his daughter and was admitted to Texas in Fortworth and underwent bilateral patellar tendon rupture repair Bajaj. He was admitted to HealthSouth City View for comprehensive inpatient rehabilitation

2016. During his rehab hospitalization, he underwent physical therapy to upgrade mobility and occupational therapy to upgrade activities of daily living. He originally was discharged from Texas South on 09, 07 and admitted to City View Care Center, but left against medical advice and presented back to the emergency department. He has now he was he has now been stabilized and is being admitted to Mira Vista Court for subacute rehabilitation.

Oh state that add into the during his rehab hospitalization, the patient was followed Mark Linda from the Internal Medicine Service. Patient from the Urology Service secondary to bilateral testicular hydroceles. Workup included a CT scan of the abdomen and pelvis which revealed an adrenal mass.

will be following with us at Mira Vista Court. Past medical history is significant for lumbar stenosis with chronic low back pain. Past surgical history appendectomy and lumbar discectomy with interbody fusion. Allergies Morphine. Medications on admission; Norco as needed for pain,

Flexeril as needed for muscle spasm, Norco as needed for pain and Xanax as needed for anxiety. The Xarelto 10 mg q. p.m. and Xanax as needed for anxiety. Review of systems he complains of bilateral knee pain and testicular pain. He denies any nausea, vomiting, diarrhea, constipation, wheezing, shortness of breath, cough, chest pain, abdominal pain, neck pain, headaches or dizziness, fever,

chills. He denies any dysuria. The remainder of the 14-point review of system is essentially negative. Family history father is alive at age 70 and healthy. Mother is alive in her late 60s and healthy. No diabetes, heart disease or cancer in the immediate family. Social history he lives in Fortworth. His two daughters live with him in a single-level home. There is one step to enter and two steps to get up to the bathroom. He does not have a family physician. On exam, well developed male in no acute distress. Vital signs are stable.

chronic recurrent UTI since she had been on Prozac and Macrobid. End of report.

Blood pressure is blood pressure is 140/83, temperature 97.3, heart rate 89. HEENT extraocular motions intact. Mucous membranes moist without lesions. Neck supple without lymphadenopathy. Lungs clear to auscultation without rhonchi or crepitus. No wheezing. Heart regular rate and rhythm without murmurs or extra sounds. Abdomen protuberant, soft, nontender. No organomegaly. Extremities with trace edema. Knee incisions are well opposed without erythema or any drainage. Spine without

Neurologic moves all extremities without focal weakness. Labs WBC 6.1, hemoglobin 13.1, hematocrit 39.9. Sodium 138, potassium 3.9, chloride 99, CO2 25, glucose 88, BUN 15, creatinine 1.0. Functional status feeding, grooming, bathing, dressing, and toileting are modified to independent transfer supervision. The patient is nonambulatory. Assessment number one

assessment number one bilateral patellar tendon rupture, status post bilateral tendon bilateral patellar tendon surgical repair. Number two chronic kidney disease stage two, creatinine 1.0. We will avoid nephrotoxic agents. Number three morbid obesity, BMI is 37 kg/m2, benefits of weight loss discussed with the patient. Dietician will follow with us. Number four DVT prophylaxis managed with Xarelto. Number five testicular

followed by DR. Pompfrey from the Urology Service. Number six adrenal mass noted on pelvic scan. Workup is in progress. Abdominal MRI is pending. Plan I felt that the patient would benefit from continued subacute rehabilitation with physical therapy to upgrade mobility and occupational therapy to upgrade activities

Dr. date. Medical status patient was seen and examined on rounds. She continues to make progress in all therapeutic areas. She is tolerating physical therapy and occupational therapy. Review of systems she complains of back pain. She voices no other new complaints. Remainder of the fourteen-point review of systems essentially are negative. On exam frail elderly

no acute distress. Vital signs are stable. Blood pressure is blood pressure is 141/83, temperature 97.2, heart rate 82. HEENT extraocular motions are intact. Mucous membranes are moist without lesions. Neck supple without lymphadenopathy. Lungs clear to auscultation without rhonchi or crepitus. No wheezing. Heart regular rate and rhythm without murmurs or extra sounds. Abdomen soft nontender. No organomegaly.

Extremities with trace edema in the lower extremities. Spine minimal lumbosacral paraspinal muscle tenderness noted. Diffuse neurologic diffuse weakness at the hips and knees with give way weakness of 4/5 muscle strength noted. Labs labs pro-time 21.6, INR 1.9.

Sodium 134, potassium 4.2, chloride 95, CO2 32, glucose 88, BUN 11, creatinine 0.66. WBC 7.8, hemoglobin 11.3, hematocrit 33.0. Assessment number one T12 compression fracture with retropulsion and fragments managed

Miacalcin nasal spray and Os-Cal D. Number two thoracolumbar spondylosis with myelopathy and lower extremity weakness. Number three a number three paroxysmal atrial fibrillation rate controlled on Coreg and digoxin. Number four chronic anticoagulation secondary to atrial fibrillation, managed with Coumadin. INR is 1.9. Number five hypertension, managed with multidrug regimen. Number six hypercholesterolemia, managed with statin. Number seven coronary artery disease with history of myocardial infarct, managed with aspirin, statin

Coumadin therapy. Number nine diffuse osteoarthritis number sorry number eight diffuse osteoarthritis. Number nine cataracts status post lens replacements. Number ten hyponatremia, much improved. Sodium is now 134. Plan I felt that the patient will benefit from continued inpatient rehabilitation with physical therapy to upgrade mobility and occupational therapy to upgrade activities of daily living

Reason for consult PEG malfunction. History of present illness, patient is a 73-year-old African-American male with history of CVA with residual left-sided hemiplegia and associated dysphagia, dependent on chronic gastrostomy tube feedings; who was admitted

thank you very much.

Medical status patient was seen and examined on rounds. She is making slow, but steady progress in all therapeutic areas. She is tolerating physical therapy, occupational therapy and speech therapy. Review of systems she complains of tremor and weakness. She voices no other new complaints. Remainder of the 14-point review of systems essentially are negative. On exam

pleasant female in no acute distress. Vital signs are stable. Blood pressure is 132/67, temperature 98.2, heart rate 82. HEENT extraocular motions intact. Mucous membranes moist without lesions. Neck supple without lymphadenopathy. Lungs clear to auscultation without rhonchi or crepitus.

wheezing. Heart regular rate and rhythm without murmurs. No extra sounds. Abdomen soft, nontender. No organomegaly. P E G site is clean without erythema, no drainage. Extremities with trace edema in the lower extremities. Spine without paraspinal muscle tenderness. Neurologic severe resting tremor noted. Cogwheeling noted on range of motion of the upper extremities. Decreased sensation in stocking distribution. Labs

sodium 144, potassium 3.4, chloride 107, CO2 of 25, glucose 98, BUN 34, creatinine 0.6, glucose 98, WBC 6.0, hemoglobin 12.5, hematocrit 36.9. Assessment Parkinson’s disease with

decline in functional status, managed with Sinemet 75/300 four times daily. We have increased this to five times daily from Neurology. Number two hypertension, managed with multidrug regimen. Number three diabetes mellitus type 2 with neurologic manifestations. Number four diabetic neuropathy, managed with Neurontin. Number five hyperlipidemia, managed with statin. Number six

history of cerebrovascular accident with late effects of dysphagia. Number seven dysphagia, status post P E G tube placement, managed with a ground diet and nectar thick liquids with P E G tube supplementations. Number eight depression and anxiety disorder, managed with Lexapro and anxiolytics as needed. Plan it is felt that the patient will benefit from continued inpatient rehabilitation with physical therapy to upgrade mobility, occupational therapy to upgrade activities of daily living and speech therapy for cognitive and swallow rehabilitation

thank you very much.

Medical status patient was seen and examined on rounds. He continues to make progress in all therapeutic areas. He is tolerating three hours of therapy daily no he is tolerating physical therapy and occupational therapy. Review of systems he complains of left shoulder pain. He voices no other new complains. Remainder of the 14-point review of system is essentially negative. On exam pleasant male in no acute distress. Vital signs are stable. Blood pressure 135/67,

temperature 98.4, heart rate 72. HEENT extraocular motions are intact. Mucous membranes are moist without lesions. Neck supple without lymphadenopathy. Lungs clear to auscultation without rhonchi, crepitus, or wheezing. Heart regular rate and rhythm without murmurs. No extra sounds. Abdomen soft, nontender. No organomegaly. Extremities trace edema in the lower extremities. Spine without paraspinal tenderness. Neurologic alert and cooperative. No focal motor deficits noted. Antalgic weakness noted above the left shoulder. Assessment no I am sorry labs

to outside hospital with acute onset of shortness of breath. This was attributed to pneumonia, likely from aspiration. Hospital course was complicated by paroxysmal AFib, for which he was treated with Cardizem drip Barlope. In Barlope, patient initially was in the ICU and on Cardizem drip. Once stabilized, he was transferred to the floor. While in ICU, patient's gastrostomy tube was accidently removed. NG tube was

sodium 144, potassium 4.0, chloride 108, CO2 32, glucose 142, BUN 10, creatinine 0.81, WBC 7.2, hemoglobin 11.5, hematocrit 34.5. Assessment

number one left shoulder dislocation with humeral intact humeral head fracture, treated conservatively with Codman exercises and left shoulder sling. Number two left shoulder pain secondary to fracture, managed with lidocaine patch and Norco as needed. Number three cardiovascular prophylaxis managed with Plavix and statin. Number four coronary artery disease with history of coronary artery bypass graft times three vessels. Number five hypertension, managed with multidrug regimen. Number six hyperlipidemia, managed with diet and statin. Number seven

diabetes mellitus type 2 with neurologic manifestation. Number eight diabetic neuropathy, managed without neuropathic medication. Number nine DVT prophylaxis, completed with Lovenox. Plan I felt that the patient will benefit from continued subacute rehabilitation with physical therapy to upgrade mobility and occupational therapy to upgrade activities of daily living. Patient should be ready for discharge to home soon MD thank you very much.

Medical status patient was seen and examined on rounds. He continues to make slow but steady progress in all therapeutic areas. He has been followed by speech therapy who feels he has severe dysphagia with aspiration and has recommended an n.p.o. status. Family is considering hospice and

feeding way versus P E G tube. Review of systems he believes he has no new complaints. He feels he can swallow fine. The remainder of the 14-point review of systems essentially negative. On exam, cachectic appearing male in no acute distress. Vital signs are stable. Blood pressure is 140/80, temperature 98.2, heart rate 72. HEENT extraocular

and patient has been receiving feedings via the NG tube since, which he has been tolerating well {period} Past, patient himself is nonverbal, unable to provide any history. All history is obtained from the chart {period} Past medical and surgical history includes CVA with residual left-sided hemiplegia and aphasia. Next number, recurrent aspiration. Next number, diabetes mellitus. Next number, paroxysmal AFib. Next number, seizure disorder. Next number, COPD. Next number, functional

motions intact. Mucous membranes are moist without lesions. Necks supple without lymphadenopathy. Lungs clear to auscultation without rhonchi, crepitus, no wheezing. Heart ready heart regular rate and rhythm without murmurs, no extra sounds. Abdomen soft, nontender. No organomegaly. Extremities with 1+ edema with venostasis changes noted. Spine without paraspinal muscle tenderness. Neurologic alert and cooperative. He is disoriented. Labs

sodium 144, potassium 4.8, chloride 112, CO2 25, BUN 41, creatinine 1.65, glucose 146. WBC 6.3, hemoglobin 9.2, hematocrit 27.2. Assessment traumatic brain injury with loss of consciousness

for less than 30 minutes. Number two post-concussive syndrome. Speech therapy is following for cognitive and language rehabilitation. Number three diabetes mellitus type 2 with neurologic manifestations. Number four diabetic polyneuropathy, managed without neuropathic medication. Number four hypertension, managed with Lasix. Number six cachexia with failure to thrive. Nutrition the dietician following for nutritional support. Number seven asthmatic bronchitis, managed with

inhaled steroids and bronchodilators. Number eight acute on chronic renal insufficiency, creatinine is 1.6. We will follow labs. Number nine dysphagia. Speech is recommended speech therapy is recommending n.p.o. Family is deciding on a on a feeding tube. Number 10 hyperkalemia, resolved.

Potassium is 4.8. Plan it is felt that the patient will benefit from continued subacute rehabilitation with physical therapy to upgrade mobility and occupational therapy to upgrade activities of daily. Thank you very much.

History is as follows the patient is a 66-year-old female who is well known to our service from an inpatient [skip]

She originally woke up in the morning with nausea and vomiting and left-sided weakness. She was she had tried to get out of bed but was unable to. She was ended up on the floor for greater than 24 hours. She was seen by EMS and brought to the hospital. MRI revealed an acute versus subacute infarct in the left posterior inferior cerebellar artery.

She was not a candidate for TPA. She was stabilized and . During her rehab hospitalization, she underwent physical therapy to upgrade mobility and occupational therapy to upgrade activities of daily living, speech therapy for cognitive and language rehabilitation. She has now been stabilized and is being discharged to she is being subacute rehabilitation. Past medical history

significant for diabetes mellitus type 2 with neurologic manifestation, diabetic neuropathy, leukemoid reaction, nicotine or tobacco addiction and hyperlipidemia. Past surgical history none. Social history He lives she lives in an apartment in alone

I am unsure who her family doctor is. Allergies no known drug allergies. Medications on admission include aspirin 81 mg q. day, clonidine 0.1 mg q. day

quadriplegia. Next number, sacral bilateral buttock ulcers. Review of systems, unable to obtain. Patient with underlying encephalopathy. Social history patient is a skilled nursing facility resident. History of tobacco, alcohol is unknown. Family history, not available. Allergies, no known drug allergies. Medications, aspirin, atorvastatin, Unasyn, neomycin suspension, Protonix 40

Benadryl q.6 hours as needed for itching, Flonase nasal spray two sprays each nostril q. day, Anusol suppositories as needed twice daily, Levemir insulin 70 units q.h.s., sliding scale NovoLog, acidophilus probiotic capsule twice daily, lisinopril 5 mg q. day, Claritin 10 mg q. day, melatonin 6 mg q.h.s.,

metoprolol 25 mg b.i.d., nitroglycerin 0.4 mg as needed for chest pain, Sudafed 60 mg q. 4 hours as needed, Zocor 20 mg q.h.s. Review of systems she complains of left-sided weakness and difficulty to swallow. She denies any nausea, vomiting, diarrhea, constipation, wheezing, shortness of breath, cough, chest pain, abdominal pain, back pain, neck pain, headaches, dizziness,

fevers nor chills. She denies any dysuria the remainder of the 14 point review of systems is essentially negative. On exam overweight female in no acute distress. Vital signs are stable. Blood pressure is 128/73, temperature 98.2, heart rate 99. HEENT

extraocular motions intact. Mucous membranes moist without lesions. Lungs clear to auscultation without rhonchi, crepitus, or wheezing. Heart regular rate and rhythm without murmurs or extra sounds. Abdomen protuberant, soft, nontender, no organomegaly. Extremities with trace edema in the lower extremities. Spine without paraspinal tenderness. Neurologic mild left hemiparesis noted with ataxia. Decreased fine motor control noted in the left hand. Decreased sensation in a stocking distribution is noted. Labs

sodium 140, potassium 4.2, chloride 102, CO2 29, glucose 156, BUN 11, creatinine 0.8, WBC 13.8, hemoglobin 14.3, hematocrit 42.4. Functional status is as follows

left posterior and inferior cerebellar cerebrovascular accident. Number two mild or left-sided dysmetria with decreased fine motor control. Number three mild left hemiparesis. Number four diabetes mellitus type 2 with neurologic manifestation. Number five diabetic neuropathy managed without neuropathic medication. Number six hyperlipidemia managed with diet and Zocor. Number seven morbid obesity or obesity mild obesity. BMI is 26 kg

Benefits of weight loss discussed with patient. Dietitian is following with it. Number eight dysphagia managed with puree diet and nectar thick liquids followed by speech therapy. Impaired mobility. Ambulating 15 feet with minimal-to-moderate assist with a rolling walker. Plan, I felt that the patient will benefit from continued subacute rehabilitation with physical therapy to upgrade mobility and occupational therapy to upgrade activities

thank you

daily lactobacillus, insulin, albuterol, Atrovent, metoprolol 25 q.12, Depakene syrup, and acetaminophen. On physical

exam, patient has a blood pressure of 158/83, pulse is 97, temp is 97.1, respiratory rate is 20, and O2 sat is 97% on 5 liters. Generally, patient is chronically ill-appearing African-American male, in no acute distress. HEENT, head is normocephalic, atraumatic. Pupils are sluggish. Neck is supple. No masses. Lungs, coarse breath sounds bilaterally. Heart is regular rate. Abdomen

soft, nontender, and nondistended. Foley catheter in place with a previously existing gastrostomy tube. Extremities, no cyanosis or clubbing. 1+ pulses. Skin, no rash or lesion appreciated. Neurologically, patient is minimally responsive to pain. Laboratory, patient has a white count of 9.6, hemoglobin is 8.9, platelet count is 127. INR is 1.1, PTT is 42.1. Stool C. diff is negative.

hand orthopedist, Dr Daiman because of right wrist pain and was given meloxicam december {period} She also is aware of having hiatal hernia and having GERD, which was controlled on ranitidine {period} She started taking meloxicam five days ago and had taken once

Creatinine is 0.65, BUN is 20. T-bili is 0.4, alk phos is 58. Chest x-ray to evaluate shows cardiomegaly, bilateral lower lobe pneumonia. Impression and recommendations, patient is a 73-year-old African-American male recovering from aspiration pneumonia

with history of CVA and associated dysphagia, whose gastrostomy tube was dislodged and will need to be replaced so that patient can continue long-term nutritional supports. Patient will benefit from EGD with replacement of gastrostomy tube. Risks, benefits, and alternatives discussed, to be discussed with patient's family to obtain consent {period}

Patient's respiratory status is relatively stable and he should be able to tolerate mild sedation with no difficulty. Continue with bronchodilators. Pulmonary Medicine is following. Regarding anemia, this is stable, no evidence of gastrointestinal bleeding. Peptic ulcer disease will be ruled out at the time of endoscopy {period} Continue with Protonix daily {period} Regarding underlying pneumonia, continue with IV Unasyn. Thank you

Thank you or this consultation. Follow patient with you. End of dictation.

Reason for consult is PEG placement. History of present illness, patient is a 62-year-old male with a history of hypertension, cirrhosis, end-stage renal disease. He was admitted to outside hospital for worsening shortness of breath

Patient required BiPAP on presentation {period} His respiratory insufficiency was probably attributed to pneumonia. Once he was stabilized, he was transferred to for further management. At, he has had complicated hospital course with a trip to the

intensive care unit, but most recently, he has been stable on the floor where he has been tolerating nasogastric tube feeds well. Patient has not been eating well orally, has not been following commands adequately, and is being concerned about oropharyngeal dysphagia

{period} Past medical, surgical histosry, chronic hypoxemic-hypercapnic respiratory failure, end-stage renal disease, cirrhosis, adrenal insufficiency, depression, pancytopenia, paroxysmal AFib, right below-knee amputation. Social history, patient denies use of alcohol or tobacco. He is a skilled nursing facility resident. Family history, no history gastrointestinal malignancy.

sea food. Medications, Procrit, Effexor, Lipitor, depakene, ferrous sulfate, lubiprostone, zinc sulfate, hydrocortisone, simethicone, amiodarone, Colace, lactulose, Protonix, albuterol, Synthroid

Midodrine, Atarax, Norco, and vancomycin.

for the past five days and had been experiencing this discomfort on her lower sternum that she described it like tightness and this had prompted her to come to the emergency room {period} Her workup showed slightly elevated troponin of 0.45 and EKG showing nonspecific ST wave changes

Review of systems, patient stressed, but stable. Patient denies any fevers or chills. No chest pain. No easy bruising or bleeding. No hematuria or dysuria. On physical exam

patient has a blood pressure of 116/57, pulse is 99, temp is 98.1, respiratory rate is 22, O2 sat 100% on 3 liters. Generally, patient is chronically ill-appearing male, no acute distress. HEENT, head is normocephalic, atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular muscles intact. Neck is supple. No JVD. Lungs, coarse breath sounds bilaterally. Heart has regular rate. Abdomen is soft, nontender, nondistended. Good bowel sounds

Extremities, no cyanosis or clubbing. 1+ pulses. Skin, no rash or lesion appreciated. Neurologically, patient alert to person, place; moves all extremities. Follows simple commands. Patient does have the right below-the-knee amputation. Laboratory, transcriptionist please note dictation, the date of this consultation

Laboratory, patient has white count of 4.5, hemoglobin is 10, platelet count is 65. INR is 1.3. PTT is 39.9. Stool occult positive. Chest x-ray done on 1/25

cardiomegaly, mild pulmonary edema. Impression, recommendations, patient is a 62-year-old male with history of end-stage renal disease of hep C cirrhosis

with feeding difficulty [skip] dysphagia. He may benefit from gastrostomy tube placement for long-term enteral nutritional support. Recommend abdominal ultrasound to evaluate for ascites.

Presence of ascites would be developing contraindication to place any gastrostomy tube {period} Additionally for now, a formal swallow evaluation is pending to decide and reconfirm whether patient has any significant underlying

that will prohibit him from continuing oral intake {period} If, if it does confirm underlying dysphagia and there is evidence of ascites and if, if patient's family agree, we will go ahead

to proceed with placement of gastrostomy tube {period} Regarding bowel habits, patient is on both lactulose and Amitiza. Recommend stopping the Amitiza and just continue lactulose so patient has two to three soft bowel movements per day. Additionally, continue with rifaximin b.i.d. for possible underlying encephalopathy, which may contribute underlying dysphagia and poor

and poor oral intake and feeding difficulties {period} Regarding underlying pneumonia, this has been improving. Patient has minimal supplemental oxygen requirement. Continue with, patient

{period} She seems to have been feeling better and her pain had been slowly subsiding {period} She is comfortable resting in the gurney, but due to the slightly elevated troponin that she is being admitted for to rule out possibility of having acute coronary syndrome.

off antibiotic. ID is following patient {period} Regarding end-stage renal disease, Nephrology is following. Continue with hemodialysis {period} Thank you for this consultation. Follow patient with you. End of dictation.

Past medical history is significant for having one episode of high blood pressure most likely due to stress after having ERCP, but not on any medication. History of ulcerative colitis. History of osteoarthritis and osteoporosis. History of melanoma and basal cell cancer.

Reason for consultation is feeding difficulties, perforated gastric ulcer. History of present illness, patient is an 85-year-old Asian female with history of diabetes and hypertension. She was admitted to outside hospital with severe abdominal pain