Patient Name: [REDACTED]

Age: [REDACTED]
Date of Visit: [REDACTED]

CHIEF COMPLAINT:
Fall from ladder with right wrist pain.

HISTORY OF PRESENT ILLNESS:

The patient is a [age]-year-old male who fell approximately 10 feet from a ladder while painting
his house. He landed on his outstretched right hand and has had significant right wrist pain
since the fall. He reports no loss of consciousness, no head trauma, and no other injuries. The
patient has no significant past medical history and takes no medications. He denies any
allergies.

PHYSICAL EXAMINATION:
The patient appears in moderate distress, favoring his right arm. Vital signs are stable.
Examination of the right wrist reveals swelling and tenderness over the distal radius. There is
limited range of motion, and the patient has pain with any wrist movement. No neurovascular
deficits were noted.

IMPRESSION:

Right distal radius fracture.

PLAN:

X-rays of the right wrist.

Splint application to the right wrist.
Analgesia for pain control.
Orthopedic surgery consultation for further management.
Discharge instructions with follow-up in the orthopedic clinic.
X-rays of the right wrist reveal a displaced distal radius fracture. The patient was given
intravenous pain medication and a splint was applied to the right wrist. The orthopedic surgery
team was consulted, and the patient was scheduled for surgery the following day. The patient
was discharged home with instructions to follow up in the orthopedic clinic for further
management.

SUMMARY:
This [age]-year-old male fell approximately 10 feet from a ladder and sustained a right distal
radius fracture. He was evaluated in the emergency department, given pain medication, and
had a splint applied to the affected wrist. He was scheduled for surgery and discharged home
with follow-up instructions.
Patient Name: [REDACTED]
Age: [REDACTED]
Date of Admission: [REDACTED]
Date of Note: [REDACTED]

ADMISSION DIAGNOSIS:
Acute myocardial infarction.

HISTORY:
The patient is a [age]-year-old male with a history of hypertension, hyperlipidemia, and smoking,
who presented to the emergency department with chest pain and was diagnosed with an acute
myocardial infarction. He was admitted to the hospital for further management and treatment.

CURRENT CONDITION:
The patient has been in the hospital for three days and has been receiving appropriate medical
management for his acute myocardial infarction. He has been stabilized and is improving. He
reports no chest pain or shortness of breath. His vital signs are stable, and he is ambulating
without difficulty. His laboratory values have improved, and his cardiac enzymes have
normalized.

MEDICATIONS:

Aspirin
Clopidogrel
Metoprolol
Lisinopril
Atorvastatin
PLAN:

Continue current medications.

Continue to monitor cardiac enzymes and EKG.
Cardiology consultation for further management.
Discharge planning.
The patient has been stable for the past 24 hours and is showing signs of improvement. He will
continue to be monitored closely for any changes in his cardiac status. A cardiology consultation
has been requested for further management. Discharge planning has begun, and the patient will
likely be discharged home in the next 24-48 hours with appropriate follow-up appointments.

SUMMARY:
This [age]-year-old male was admitted to the hospital with an acute myocardial infarction and
has been receiving appropriate medical management. He has stabilized and is showing signs of
improvement. A cardiology consultation has been requested, and discharge planning has
begun. He will continue to be monitored closely until discharge.
Patient Name: [REDACTED]
Age: [REDACTED]
Date of Admission: [REDACTED]
Date of Note: [REDACTED]

ADMISSION DIAGNOSIS:
Acute myocardial infarction.

HISTORY:
The patient is a [age]-year-old male with a history of hypertension, hyperlipidemia, and smoking,
who presented to the emergency department with chest pain and was diagnosed with an acute
myocardial infarction. He was admitted to the hospital for further management and treatment.

CURRENT CONDITION:
The patient has been in the hospital for three days and has been receiving appropriate medical
management for his acute myocardial infarction. He has been stabilized and is improving. He
reports no chest pain or shortness of breath. His vital signs are stable, and he is ambulating
without difficulty. His laboratory values have improved, and his cardiac enzymes have
normalized.

MEDICATIONS:

Aspirin
Clopidogrel
Metoprolol
Lisinopril
Atorvastatin
PLAN:

Continue current medications.

Continue to monitor cardiac enzymes and EKG.
Cardiology consultation for further management.
Discharge planning.
The patient has been stable for the past 24 hours and is showing signs of improvement. He will
continue to be monitored closely for any changes in his cardiac status. A cardiology consultation
has been requested for further management. Discharge planning has begun, and the patient will
likely be discharged home in the next 24-48 hours with appropriate follow-up appointments.

SUMMARY:
This [age]-year-old male was admitted to the hospital with an acute myocardial infarction and
has been receiving appropriate medical management. He has stabilized and is showing signs of
improvement. A cardiology consultation has been requested, and discharge planning has
begun. He will continue to be monitored closely until discharge.
Patient Name: [REDACTED]
Age: [REDACTED]
Date of Visit: [REDACTED]

CHIEF COMPLAINT:
Marble stuck in the nose.

HISTORY OF PRESENT ILLNESS:

The patient is a [age]-year-old female who presented to the office with a marble stuck in her
nose. The patient's mother reports that the patient was playing with marbles and inserted one
into her nostril. The mother attempted to remove the marble but was unsuccessful.

PHYSICAL EXAMINATION:
The patient appears in no acute distress. Vital signs are within normal limits. Examination of the
nose reveals a marble lodged in the left nostril.

IMPRESSION:

Foreign body in the left nostril.

PLAN:

Attempt removal of the foreign body using forceps.

Refer to an ear, nose, and throat (ENT) specialist if unsuccessful.
Provide instructions for the patient and parents on prevention of future incidents.
The foreign body, a marble, is lodged in the left nostril. Attempts to remove the marble with
forceps were successful. No further intervention was required. Instructions were provided to the
patient and parents on prevention of future incidents.

SUMMARY:
This [age]-year-old female presented to the office with a marble lodged in the left nostril.
Attempts to remove the marble with forceps were successful. Instructions were provided to the
patient and parents on prevention of future incidents. No further int