SAMPLE CONSULTATION REPORT

CHIEF COMPLAINT: A 5-month-old boy with cough.

HISTORY OF PRESENT ILLNESS: A 5-month-old boy brought by his parents because of 2

days of cough. Mother took him when cough started 2 days go to Clinic where they told the
mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and
he also started having fever. Mother did not measure it.

REVIEW OF SYSTEMS: No vomiting. No diarrhea. He had runny nose started with the cough
two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding, he is bottle-fed 2
ounces every 2 hours. Mother states he urinates like 5 to 6 times a day, stools 1 time a day. He is
still feeding good to mom.

IMMUNIZATIONS: He received first set of shot and due for the second set on 11/17/2021.

BIRTH HISTORY: He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks
for feeding problem as the mother said. Mother had good prenatal care at 4 weeks for more than
12 visits. No complications during pregnancy. Rupture of membranes happened two days before
the labor. Mother received the antibiotics, but she is not sure, if she received steroids also or not.

FAMILY HISTORY: No history of asthma or lung disease.

SOCIAL HISTORY: Lives with parents and with two siblings, one 18-year-old and the other is
14-year-old in house, in Corrales. They have animals, but outside the house and father smokes
outside house. No sick contacts as the mother said.

PAST MEDICAL HISTORY: No hospitalizations.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

MEDICATIONS: No medications.

History of 2 previous ear infection, last one was in last November treated with ear drops, because
there was pus coming from the right ear as the mother said.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg.
GENERAL: In no acute distress.
HEAD: Normocephalic and atraumatic. Open, soft, and flat anterior fontanelle.
NECK: Supple.
NOSE: Dry secretions.
EAR: Right ear full of yellowish material most probably pus and necrotic tissue. Tympanic
membrane bilaterally visualized.
MOUTH: No pharyngitis. No ulcers. Moist mucous membranes.
CHEST: Bilateral audible breath sound. No wheezes. No palpitation.
HEART: Regular rate and rhythm with no murmur.
ABDOMEN: Soft, nontender, and nondistended.
GENITOURINARY: Tanner I male with descended testes.
EXTREMITIES: Capillary refill less than 2 seconds.

LABS: White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6,
segments 41, and bands 41. RSV positive. Chest x-ray evidenced bronchiolitis with
hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis
in the right upper lobe and left lung base.

ASSESSMENT: A 5-month-old male with 2 days of cough and 1 day of fever. Chest x-ray
shows bronchiolitis with atelectasis, and RSV antigen is positive.

DIAGNOSES: Respiratory syncytial virus bronchiolitis with right otitis externa.

PLAN: Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa
eardrops twice daily.
SAMPLE DISCHARGE SUMMARY

ADMITTING DIAGNOSIS: Abscess with cellulitis, left foot.

DISCHARGE DIAGNOSIS: Status post I&D, left foot.

PROCEDURES: Incision and drainage, first metatarsal head, left foot with culture and
sensitivity.

HISTORY OF PRESENT ILLNESS: The patient presented to Dr. X's office on 06/14/07
complaining of a painful left foot. The patient had been treated conservatively in office for
approximately 5 days, but symptoms progressed with the need of incision and drainage being
decided.

MEDICATIONS: Ancef IV.

ALLERGIES: ACCUTANE.

SOCIAL HISTORY: Denies smoking or drinking.

PHYSICAL EXAMINATION: Palpable pedal pulses noted bilaterally. Capillary refill time
less than 3 seconds, digits 1 through 5 bilateral. Skin supple and intact with positive hair growth.
Epicritic sensation intact bilateral. Muscle strength +5/5, dorsiflexors, plantar flexors, invertors,
evertors. Left foot with erythema, edema, positive tenderness noted, left forefoot area.

LABORATORY: White blood cell count never was abnormal. The remaining within normal
limits. X-ray is negative for osteomyelitis. On 06/14/07, the patient was taken to the OR for
incision and drainage of left foot abscess. The patient tolerated the procedure well and was
admitted and placed on vancomycin 1 g q.12h after surgery and later changed Ancef 2 g IV
every 8 hours. Postop wound care consists of Aquacel Ag and dry dressing to the surgical site
everyday and the patient remains nonweightbearing on the left foot. The patient progressively
improved with IV antibiotics and local wound care and was discharged from the hospital on
06/19/07 in excellent condition.

DISCHARGE MEDICATIONS: Lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken
by mouth q.6h as needed for pain. The patient was continued on Ancef 2 g IV via PICC line and
home health administration of IV antibiotics.

DISCHARGE INSTRUCTIONS: Included keeping the foot elevated with long periods of rest.
The patient is to wear surgical shoe at all times for ambulation and to avoid excessive
ambulation. The patient to keep dressing dry and intact, left foot. The patient to contact Dr. X for
all followup care, if any problems arise. The patient was given written and oral instruction about
wound care before discharge. Prior to discharge, the patient was noted to be afebrile. All vitals
were stable. The patient's questions were answered and the patient was discharged in apparent
satisfactory condition. Followup care was given via Dr. X' office.
SAMPLE RADIOLOGY REPORT

2-D M-MODE
1. Left atrial enlargement with left atrial diameter of 4.7 cm.
2. Normal size right and left ventricle.
3. Normal LV systolic function with left ventricular ejection fraction of 51%.
4. Normal LV diastolic function.
5. No pericardial effusion.
6. Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.
7. PA systolic pressure is 36 mmHg.

DOPPLER
1. Mild mitral and tricuspid regurgitation.
2. Trace aortic and pulmonary regurgitation.
SAMPLE PATHOLOGY REPORT

CLINICAL HISTORY: Probable right upper lobe lung adenocarcinoma.

SPECIMEN: Lung, right upper lobe resection.

GROSS DESCRIPTION: Specimen is received fresh for frozen section, labeled with the
patient's identification and "Right upper lobe lung". It consists of one lobectomy specimen
measuring 16.1 x 10.6 x 4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural
surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray
mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest
surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The
tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying
pleura is puckered.

FINAL DIAGNOSIS: Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma,

mucinous type

COMMENT: Right upper lobe, lobectomy.

Tumor type: Bronchioloalveolar carcinoma, mucinous type.
Histologic grade: Well differentiated.
Tumor size (greatest diameter): 3.6 cm.
Blood/lymphatic vessel invasion: Absent.
Perineural invasion: Absent.
Bronchial margin: Negative.
Vascular margin: Negative.
Inked surgical margin: Negative.
Visceral pleura: Not involved.
In situ carcinoma: Absent.
Non-neoplastic lung: Emphysema.
Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.
P53 immunohistochemical stain is negative in the tumor.
SAMPLE SOAP NOTE

SUBJECTIVE: The patient has been coughing, short of breath since Thursday. She said she got
it flared up by someone’s perfume. She was better on Friday. Today, she is worse again, took
some Depo-Medrol 160 mg today. She is coughing. She has no productive phlegm. She has
tightness in her chest, and she took some Vantin 200 mg twice a day for 4 days, doxycycline 200
mg twice a day. She was not put on any oral steroids. Her peak expiratory flow rates at home
have been greater than 250.

OBJECTIVE: On exam today, the patient is coughing, dyspneic. Blood pressure is pending.
Respiratory rate 24. Saturations on room air 98%. HEENT: She has no lesions or thrush. Neck is
supple without adenopathy. Lungs: She has mildly decreased breath sounds with an expiratory
wheeze. She is moving fairly good air. She has increased respiratory effort. Abdomen: Benign.
Extremities: No edema.

ASSESSMENT: She has status asthmaticus with cough. It was secondary to her underlying
asthma, allergic symptoms, and a prolonged QT.

PLAN: The patient needs Vantin, which she will continue for 6 more days. She needs to go
home. Her peak expiratory flow in the office was 400 pre-bronchodilator. She is taking a
treatment right now. We gave her prednisone burst and taper. We will see her back next week. If
her symptoms worsen or she does not improve, she needs to go to the emergency room.