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The patient will follow up after RAST allergy testing for further treatment recommendations. | [
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At this point, no changes in her medication were prescribed until her followup visit. | [
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HISTORY:, I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis. | [
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As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. | [
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She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics. | [
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She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left. | [
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She currently is not taking any medication for her sinuses. | [
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She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness. | [
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Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination. | [
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She has tried topical nasal corticosteroid therapy without much improvement. | [
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She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen. | [
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She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears. | [
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She denies any previous history of sinus surgery or nasal injury. | [
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She believes she has some degree of allergy symptoms. | [
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,PAST MEDICAL HISTORY: ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change. | [
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She is currently 180 pounds. | [
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,PAST SURGICAL HISTORY:, Lower extremity vein stripping, tonsillectomy and adenoidectomy. | [
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,FAMILY HISTORY: , Strong for heart disease and alcoholism. | [
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She rarely drinks any alcohol-containing beverages. | [
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,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches. | [
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,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress. | [
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No masses or lesions noted. | [
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,FACE: No facial tenderness or asymmetry noted. | [
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,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. | [
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Extraocular movements are intact bilaterally. | [
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No nystagmus. | [
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"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.361513 | null |
,EARS: During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position. | [
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} | Default | 2022-12-07T10:15:39.361907 | null |
No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice. | [
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No evidence of any orthostatic hypotension was noted during the exam. | [
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} | Default | 2022-12-07T10:15:39.362662 | null |
Tympanic membranes were noted to be intact. | [
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} | Default | 2022-12-07T10:15:39.362988 | null |
No signs of middle ear effusion or ear canal inflammation. | [
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} | Default | 2022-12-07T10:15:39.363335 | null |
Turbinate hypertrophy is noted. | [
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} | Default | 2022-12-07T10:15:39.363938 | null |
There are no signs of any acute sinusitis. | [
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} | Default | 2022-12-07T10:15:39.364268 | null |
Septum is midline, slightly deviated to the left. | [
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} | Default | 2022-12-07T10:15:39.364605 | null |
No masses or lesions noted. | [
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] | Argilla | null | null | null | {
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} | Default | 2022-12-07T10:15:39.365475 | null |
Both vocal cords move well to midline. | [
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] | Argilla | null | null | null | {
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} | Default | 2022-12-07T10:15:39.365799 | null |
,NECK: The neck is supple with no adenopathy or masses palpated. | [
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} | Default | 2022-12-07T10:15:39.366149 | null |
The trachea is midline. | [
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} | Default | 2022-12-07T10:15:39.366471 | null |
The thyroid gland is of normal size with no nodules. | [
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} | Default | 2022-12-07T10:15:39.366810 | null |
,HEART: Regular rate and rhythm. | [
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} | Default | 2022-12-07T10:15:39.367670 | null |
No murmur noted. | [
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} | Default | 2022-12-07T10:15:39.367973 | null |
,NEUROLOGIC: Facial nerve is intact bilaterally. | [
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The remaining cranial nerves are intact without focal deficit. | [
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} | Default | 2022-12-07T10:15:39.368647 | null |
,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly. | [
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Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms. | [
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Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time. | [
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Inferior turbinate hypertrophy. | [
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Nasal septum deformity. | [
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,RECOMMENDATIONS:, An ENG was ordered to evaluate vestibular function. | [
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She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening. | [
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The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended. | [
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After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations. | [
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In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room. | [
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"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.374088 | null |
,Thank you for allowing me to participate with the care of your patient. | [
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} | Default | 2022-12-07T10:15:39.374519 | null |
ADMITTING DIAGNOSIS: , Kawasaki disease. | [
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"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.375876 | null |
,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.376047 | null |
,HOSPITAL COURSE:, This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. | [
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"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.376413 | null |
When he was sent to the hospital, he had a fever of 102. | [
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Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG. | [
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IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever. | [
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Today, his fever and his rash have completely resolved. | [
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He does not have any conjunctivitis and no redness of mucous membranes. | [
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} | Default | 2022-12-07T10:15:39.377707 | null |
so with a very close followup and a cardiac followup, he will be sent home. | [
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,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. | [
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for 1 day and then aspirin low dose 40 mg q.d. | [
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for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. | [
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Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible. | [
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SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. | [
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She says her asthma has been worse over the last three months. | [
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She has been using her inhaler daily. | [
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Her allergies seem to be a little bit worse as well. | [
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She also notes that in the past she was on Advair but she got some vaginal irritation with that. | [
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,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. | [
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She has been more impatient around that time. | [
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Says otherwise her mood is normal during the rest of the month. | [
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She denies any hot flashes or night sweats with this. | [
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In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. | [
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Her urine has not been rechecked. | [
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She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available. | [
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No fevers, no headaches, no shortness of breath currently. | [
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No chest pain or tightness. | [
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No abdominal pain, no heartburn, no constipation, diarrhea or dysuria. | [
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Occasional stress incontinence. | [
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No muscle or joint pain. | [
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No concerns about her skin. | [
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No polyphagia, polydipsia or polyuria. | [
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,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia. | [
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,OBJECTIVE:,Vital signs: Her weight is 151 pounds. | [
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Blood pressure is 110/60. | [
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Respirations are 20.,General: This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. | [
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,HEENT: Normocephalic, atraumatic. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.394091 | null |
Tympanic membranes are clear. | [
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{
"end": 19,
"label": "KEYPHRASE",
"score": 0,
"start": 10
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.394349 | null |
Pupils are equal, round and reactive to light. | [
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},
{
"end": 37,
"label": "KEYPHRASE",
"score": 0,
"start": 29
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.394838 | null |
Nares without turbinate edema. | [
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{
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"label": "KEYPHRASE",
"score": 0,
"start": 25
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.395108 | null |
,Neck: Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest: Clear to auscultation bilaterally. | [
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{
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"label": "KEYPHRASE",
"score": 0,
"start": 53
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.395640 | null |
,Cardiovascular: Regular rate and rhythm without murmur. | [
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] | [
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"start": 35
},
{
"end": 56,
"label": "KEYPHRASE",
"score": 0,
"start": 50
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.395934 | null |
,Abdomen: Soft, nontender, nondistended. | [
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] | [
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"score": 0,
"start": 17
},
{
"end": 40,
"label": "KEYPHRASE",
"score": 0,
"start": 28
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.396210 | null |
Normoactive bowel sounds. | [
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"bowel",
"sounds",
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] | [
{
"end": 18,
"label": "KEYPHRASE",
"score": 0,
"start": 13
},
{
"end": 25,
"label": "KEYPHRASE",
"score": 0,
"start": 19
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.396465 | null |
No masses or organomegaly to palpation. | [
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"organomegaly",
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] | [
{
"end": 10,
"label": "KEYPHRASE",
"score": 0,
"start": 4
},
{
"end": 39,
"label": "KEYPHRASE",
"score": 0,
"start": 30
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.396734 | null |
,Extremities: Without cyanosis or edema. | [
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] | [
{
"end": 40,
"label": "KEYPHRASE",
"score": 0,
"start": 35
}
] | Argilla | null | null | null | {
"medical_specialty": " Allergy / Immunology"
} | Default | 2022-12-07T10:15:39.396999 | null |
Subsets and Splits