Normal Physical Exam Template – 7
Most commonly used phrases in physical exam.
Multiple Medical Problems – Discharge Summary
Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia,
and congestive heart failure.
Mantle Cell Lymphoma – Consult
Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.
Leaking Nephrostomy Tube
Urine leaked around the ostomy site for his right sided nephrostomy tube. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.
Knee Arthroplasty – Discharge Summary
Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.
Jaw Pain – ER Visit
Patient started out having toothache, now radiating into his jaw and towards his left ear. Ellis type II dental fracture.
