Chief Complaint
Patient is a 80 year old female presenting today for confusion and headaches accompanied with blurred vision in one eye.
Patient reports having a fever 1 week ago. In that same week, their son noticed the patient being “confused and looked very dehydrated”. Patient tends to get more confused in the afternoons. They reports being paranoid, stating “maybe somebody is stealing” from them.
Other reported symptoms include weakness, increased appetite (6 meals a day), and headaches that are different from the usual. They treated headaches with Excedrin without significant improvement.
For the past 3 months, patient’s usual headaches are associated with mild blurred vision in one eye that resolves 30 minutes after taking Excedrin. They state “my vision is actually gone 24/7 in both eyes but on the left side”. Denies slurred speech, numbness in arms or legs, excessive sweating, coordination or balance issues, chest pain, or vomiting.
Patient was diagnosed with migraine when they were 40 years old. Furthermore, they reports history of TIAs from headaches for which the patient was followed by a neurologist who ordered various tests such as MRI. Denies any recent MRI.
In addition, patient reports increased urinary frequency (at least 10x a day). They do not drink a lot of water. Denies other urinary symptoms or back pain. Normal BMs.
History of UTI treated with antibiotics.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 80 year old female presenting today with recent onset of confusion, headaches, blurred vision, fevers, and increased urination.
Patient reports recent onset of confusion, headaches, blurred vision, fevers, and increased urination. Patient first noticed symptoms about a week ago on their 80th birthday. Patient's son observed that the patient was acting confused and appeared dehydrated.
Patient has a history of migraines and transient ischemic attacks (TIA) for the past 40 years with previous full workups for these diagnoses with ENT and Neuro providers. Workups included MRIs, though patient denies a recent MRI. Patient typically takes Excedrin for relief, but is unsure how much they have taken recently due to confusion. Patient's confusion is worse in the afternoons and patient notes that when their son came to visit them on their birthday they could not remember who their son was or that it was even their birthday. Patient reports that recent headaches are different from their typical migraines, with these headaches being a "constant ache".
Patient reports blurred vision in both eyes, onset 3 months ago, with inability to see out of the left side of both eyes. Patient has a history of cataract surgery, but does not believe this is related to current symptoms.
Patient reports increased urination with baseline urination frequency, urinating 10+ times per day when their baseline urination frequency was 3 times per day. Patient denies pain with urination, burning with urination, back pain or vaginal discharge. Patient has a history of one UTI in the past that was easily treated with antibiotics, but reports that current symptoms are different.
Patient also reports increased appetite (eating 6 meals a day) and feeling weak. Patient endorses being more forgetful and is also paranoid believing that people are watching them and stealing items from their home. Patient denies chest pain, numbness, tingling, incontinence, diaphoresis, emesis, or abnormal bowel movements.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 80 year old female presenting today with confusion, headaches, blurred vision.
Chief Complaint
Patient is a 65 year old female presenting today for cardiovascular symptoms.
Symptoms include dyspnea, mild dizziness when standing up, and palpitations 1 day ago. Patient is concern for possible myocardial infarction. Treated symptoms with aspirin (2 tablets) and rest.
In addition, patient initially experienced chest pain on January 13. They described it as “tightness” which is associated with tingling sensation in the left hand, mild dyspnea, and dizziness when standing up.
Patient was diagnosed with tachycardia. Currently followed by a cardiologist and was last seen about 6 months ago.
Tested positive for COVID-19 6 weeks ago, then tested negative 2 weeks ago. Had RSV symptoms 2-3 weeks ago.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 65 year old female presenting today with concern for recent episodes of chest pain, tachycardia, and shortness of breath.
Patient reports recent episodes of chest pain, tachycardia, and shortness of breath that began around six weeks ago, coinciding with a positive COVID-19 test. Patient has since tested negative for COVID-19, but continues to experience intermittent episodes of chest pain, dizziness described as “room-spinning”, tachycardia, palpitations described as “skipping a beat” and shortness of breath. Patient denies syncopal episodes.
Describes the chest pain as a "tightness" and reports occasional tingling in the left hand. Patient has a family history of heart disease, with both parents passing away from cardiac-related events. Patients father passed away due to myocardial infarction at 50 years old, and patient’s mother had a stroke.
Patient has been previously diagnosed with tachycardia with full cardiology workup, but has not been diagnosed with an arrhythmia. Patient is currently taking Lipitor for high cholesterol and daily baby aspirin. Patient reports history of hypertension, but is not taking any medications specifically for hypertension. Patient last saw a cardiologist six months ago.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 65 year old female presenting today with chest pain and shortness of breath.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 30 year old male presenting today for depression.
Patient reports worsening of depression x 2 months. Patient was prompted to seek this assessment by their family.
Patient had their first depression at age 9 as their family transferred to a new place and did not have many friends in school at that time for which they attended therapy but did not help at all. In addition, patient was seen by a psychiatrist due to depression in their early 20s.
Patient was admitted in a psychiatric facility at age 22 due to suicidal attempt, depression, and hallucinations for which they were prescribed two psychotropic medications including Prozac and a mood stabilizer that improved their symptoms.
Patient admits having passive suicidal ideations in the past. Denies manic episodes.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 30 year old male presenting today with concern for depression and possible hallucinations.
Patient reports a long history of feeling depressed, beginning around age 9 after a family move that left the patient feeling isolated without their normal friend group. Patient has seen a therapist and psychiatrist in the past, with some relief.
In the patient's early 20s, they were hospitalized after an incident in which they were found in their garage with rope in their hands that was interpreted as a suicide attempt. Patient denies intent to harm themselves, but acknowledges they were thinking about it at the time. Patient reports occasional thoughts of self-harm, but denies acting on them since the incident in their early 20s.
Patient was diagnosed with depression and possible hallucinations in the past, and was prescribed Prozac and an unknown mood stabilizer. Patient reports occasional experiences of auditory hallucinations in which the voice in their head tells them they are not "worthwhile" and that they should kill their-self.
Patient denies experiencing periods of mania, but does report times when they feel better and engage in risk-taking behaviors. Patient denies any substance use beyond occasional use of marijuana.
Currently, patient reports being in a lower mood for the past two months. Patient states their periods of low mood last much longer than when they are feeling "up".
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 30 year old male presenting today with depression and hallucinations.
Physical exam limited secondary to patient visit occurring over virtual platform.
Chief Complaint
Patient is a 54 year old female presenting today with concern for sore throat.
Patient experiences a scratchy throat, and mild cough. Their symptoms have worsened today. Additionally, they report a lesion at the back of the throat. Patient is uncertain when she initially noticed the lesion.
Patient denies dysphagia, post nasal drip, fever, or chills.
Patient has tested negative (RAT) for COVID-19 this morning. Patient reports a recent exposure to their great niece who attends daycare.
Patient cannot recall if they received COVID-19 vaccines in the past.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 54 year old female presenting today with concern for a sore throat and a sore on the back of the throat.
Patient reports a sore throat and a sore on the back of the throat that has been present for a few months. Patient is unsure if the sore throat is due to the sore or another illness such as COVID-19 or strep throat.
The sore is located on the left side of the throat and is difficult to see, but can be felt with the tongue. Patient reports a scratchy throat, but denies difficulty swallowing, nasal drip, or fever. Patient has a mild cough.
Patient recently tested negative for COVID-19 with an at-home rapid test, but is unsure of the accuracy of the test. Patient has not received a COVID-19 vaccine and may have been exposed to the virus through a family member.
Patient wants to ensure that any medications prescribed today do not interact with their diabetes medications, though they are unsure what medications they are taking currently.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 54 year old female presenting today with a sore throat.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 75 year old female presenting today with concern for body pains.
Patient reports body pain which they attributes to their arthritis. Additionally, patient notes pain in the throat, ear, nose, and mouth.
Patient experiences chest pain secondary to COPD; however, symptoms have worsened 2 days ago. They describes pain as burning. Patient also reports chest pressure/tightness, and dry throat accompanied by mucus. They received nebulizer treatment yesterday which improved symptoms.
Patient has a history of anxiety and depression. Patient expressed frustration in their son who said to stop calling.
Patient denies palpitations, SI, or auditory/visual hallucinations.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 75 year old female presenting today with concern for multiple symptoms including pain in the ear, throat, nose, chest, and head, as well as an ingrown toenail.
Patient reports waking up a few days ago with pain in multiple areas of the body, including the ear, throat, nose, chest, and head. Patient has a history of arthritis and COPD, but reports that the current pain is different from their usual symptoms.
Patient reports chest pain that has worsened over the past few days, describing it as a burning sensation with pressure and tightness. Pain is exacerbated by breathing and coughing. Cough is productive. Patient has been without their inhalers, which they usually use to manage COPD symptoms. Patient lives in assisted living. A nurse administered a nebulizer treatment yesterday that resolved the patients chest pain and cough.
Patient also notes an ingrown toenail that has been causing pain for some time. Patient is wondering if wearing different shoes would relieve some of their pain.
Patient also reports feeling anxious and depressed, which has been exacerbated by recent symptoms. Patient also notes feelings of depression have become worse after their son began visiting them less frequently. Denies suicidal ideation, homicidal ideation or hallucinations.
Physical exam limited secondary to patient visit occurring over virtual platform.
Patient is a 75 year old female presenting today with pain, cough, and chest pain.
Physical exam limited secondary to patient visit occurring over virtual platform.