Medical Specialty: Consult - History and Phy.
Sample Name: Feet & Hand Cramping

HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps.  He states that for the past six months he has experienced cramps in his feet and hands.  He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.  They may occur about three times per week.  When he develops these cramps, he stands up to relieve the discomfort.  He notices that the toes are in an extended position.  He steps on the ground and they seem to "pop into place."  He develops calf pain after he experiences the cramp.  Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs.  These do not occur at night and are completely random.  He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past.  He started taking Bactrim about nine months ago.  He had taken this in the past briefly, but has never taken it as long as he has now.  He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years.  He was taking antiretroviral medications, but stopped about six or seven years ago.  He reports that he was unable to tolerate the medications due to severe stomach upset.  He has a CD4 count of 326.  He states that he has never developed AIDS.  He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:,  He has diabetes, but this is well controlled.  He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone.  He recently lost his partner.  This happened about six months ago.  He denies alcohol, tobacco, or illicit drug use.  He is now retired.  He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 130/70
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DESCRIPTION: Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.

The patient's situation involves muscle cramping and contractions, which may be influenced by his medication and existing health conditions such as HIV, diabetes, and hepatitis C. These cramps can impact quality of life, especially considering his reluctance to resume antiretroviral therapy due to past side effects. The stakes are moderate because while these symptoms are not life-threatening, they could indicate potential complications in his existing conditions, particularly concerning his HIV status and medications. The cramping, albeit uncomfortable and disruptive to his sleep, is not immediately life-threatening and adjustments in medication or lifestyle might help alleviate the symptoms.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Consult - History and Phy.
Sample Name: Erythema Nodosum - Consult

REASON FOR VISIT:,  The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes.  She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands.  At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum.  Part of her workup included a colonoscopy.  The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway.  Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions.  She was seen in our clinic and by Dermatology on several occasions.  Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP.  In the following visits, no evident abnormality has been detected.  In the first visit, here some MTP discomfort detected.  It was thought that erythema nodosum may be present.  However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture.  When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised.  She had an equivocal rheumatoid fracture, but her CCP was negative.  She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative.  Her cardiolipin panel antibodies were negative as well.  We followed the IgM, IgG, and IgA being less than 10.  However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern.  It was thought that the onset of lupus may be the case.  It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum.  For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis.  It was done also in order to rule out sarcoid and the result was unremarkable.  Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed.  The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal.  A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen.  However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that.  Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.,In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne.  We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily.  While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain.  She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present.  Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes.  However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August.  I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently.  She also has evidence of acne, which does not seem to be present at the moment.  She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,Her workup during the initial appointment included an ACE level, which was normal.  She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110.  Her RVVT was normal, her rheumatoid factor was negative.  Her ANA was 1:40, speckled pattern.  The double-stranded DNA was negative.  Her RNP and Smith were negative as well.  RO and LA were negative and cardiolipin antibodies were negative as well.  A urinalysis at the moment was completely normal.  A CRP was 2.3 in the initial appointment, which was high.  A CCP was negative.  Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7.  This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles.  I am mentioning here that photosensitivity rash was mentioned in the past.  She tells me that she had it twice back in Europe after skiing where her whole face was swollen.  Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily.  Today we discussed about the effect of colchicine on a possible pregnancy.,MEDICATIONS: , Prednisone was stopped.  Vitamin D and calcium over the counter, we need to verify that.  Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,FINDINGS:,  On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress.  There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum.  Stasis dermatitis changes in both lower extremities present.  Mild livedo reticularis is present as well.,There is some periarticular ankle edema as well.  Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228.  Her microcytosis and hypochromia has resolved.  Her serum electrophoresis does not show a monoclonal abnormality.  Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation.  This points again towards some ileum pathology.  Her ANCA B and C were negative.  Her PF3 and MPO were unremarkable.  Her endomysial antibodies were negative.  Her sed rate at this time were 19.  The highest has been 30, but prior to her appointment here was even higher.  Her ANA continues to be positive with a titer of 1:40, speckled pattern.  Her double-stranded DNA is negative.  Her serum immunofixation confirmed the absence of monoclonal abnormality.  Her urine immunofixation was not performed.  Her IgG, IgA, and IgM levels are normal.  Her IgE levels are normal as well.  A urinalysis was not performed this time.  Her CRP is 0.4.  Her tissue transglutaminase antibodies are negative.  Her ASCA is normal and anti-OmpC was not tested.  Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific.  I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal.  Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency.  Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30.  Her TIBC was 345 pointing towards an iron deficiency anemia.  I am reminding you that her ACE levels in the past were normal and that she has a microcytosis.  Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive.  Her pelvic ultrasound showed normal uterus adnexa.  Her bladder was normal as well.  Subcentimeter inguinal nodes were found.  There was no large lytic or sclerotic lesion noted.  Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease.  Her capsule endoscopy was limited secondary to rapid transit.  There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum.  However, no significant inflammation or bleeding was seen and this could be small bowel crisis.  Neither evidence of bleeding or inflammation were seen as well.  Specifically, the terminal ileum appeared normal.  Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,ASSESSMENT:,  This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004.  She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers.  Since I took over her care, I have not seen a clear-cut erythema nodosum being present.  No evidence of synovitis was there.  Her serologies apart from an ANA of 1:40 were negative.  She has a livedo pattern, which has been worrisome.  The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency.  She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV.  We never received the x-ray of her hands which she had and she never had a DEXA scan.  Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well.  Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal.  We are going check a PPD to rule out tuberculosis.  We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern.  An anti-intrinsic factor will be added as well.  Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency.  In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash.  Regarding her heart murmur, we are going to proceed with an echocardiogram.  A PPD should be placed as well.  In her next appointment, we may fax a requisition for vitamin B replacement.,PROBLEMS/DIAGNOSES:,  1.  Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2.  Iron deficiencies, according to iron studies.,3.  Borderline B12 with increased methylmalonic acid and homocystine.,4.  On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.,5.  Typical ANCA, per records, were not verified here.  ANCA and ASCA were negative and the OmpC was not ordered.,6.  Acne.,7.  Recurrent arthralgia not present.  Rheumatoid factor, CCP negative, ANA 1:40 speckled.,8.  Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today.  Needs vaccination for influenza and pneumonia.,9.  Vitamin D deficiency.  She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10.  Recurrent ankle discomfort which necessitates ankle x-rays.,PLANS:,  We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies.  We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly.  We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome.  She should be taking vitamin D and calcium after the completion of vitamin D replacement.  She should be seen by her primary care physician, have the iron and B12 deficiency worked up.  She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist.  Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum.  We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies.  Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum.  An anti-intrinsic factor would be added, as I mentioned.  I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers.  She does not give a history of oral contraceptives or medications that could be related to erythema nodosum.  She does not have any evidence of lupus __________ mycosis.  Histoplasmosis coccidioidomycosis would be accompanied by other symptoms.  Hodgkin disease has probably been ruled out with a CAT scan.  However, we are going to add an LDH in future workup.  I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy.  The patient will return in 1 month.
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DESCRIPTION: The patient presents for a followup for history of erythema nodosum.

This case involves a complex clinical scenario with multiple overlapping medical conditions such as presumptive erythema nodosum, possible inflammatory bowel disease, vitamin deficiencies, and potential autoimmune disorders. The stakes are moderate to high due to the complexity involved in diagnosing and managing these conditions, which require coordinated care across different specialties. There's also a suggestion of several serious potential diagnoses like antiphospholipid syndrome, lymphoma, and lupus, which add to the seriousness of the case. However, it does not involve an immediate life-threatening situation, but it demands thorough investigation and multidisciplinary management to avoid long-term complications.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: End Stage Renal Disease - Consult

REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night.  He took some nitroglycerin tablets at home with no relief.  He came to the ER.  He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock.  This is a late entry dictation.  Presently lying in bed, but he feels fine.  Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea.  Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1.  Coronary artery disease, status post stent placement two years ago.,2.  Diabetes mellitus for the last 12 years.,3.  Hypertension.,4.  End-stage renal disease.,5.  History of TIA in the past.,PAST SURGICAL HISTORY:,1.  As mentioned above.,2.  Cholecystectomy.,3.  Appendectomy.,4.  Right IJ PermaCath placement.,5.  AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:,  He smoked 2 to 3 packets per day for at least last 10 years.  He quit smoking roughly about 20 years ago.  Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES:  ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL:  He is alert, seems to be in no apparent distress.,VITAL SIGNS:  Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT:  Atraumatic and normocephalic.,NECK:  No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation.  Air entry bilateral equal.,HEART:  S1 and S2.  No pericardial rub.,ABDOMEN:  Soft and nontender.  Normal bowel sounds.,EXTREMITIES:  No edema.,NEUROLOGIC:  The patient is alert without focal deficit.,LABORATORY DATA:,  Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1.  End-stage renal disease, plan for dialysis today.,2.  Diabetes mellitus.,3.  Chest pain for coronary angiogram today.,4.  Hypertension, blood pressure stable.,PLAN: , Currently follow the patient.  Dr. Z is going to assume the care.
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DESCRIPTION: Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.

The situation involves a patient with end-stage renal disease who is currently experiencing chest pain, a potentially serious symptom indicating possible acute cardiac events. The patient has a history of coronary artery disease, which significantly elevates the risk of a heart attack or other cardiac complications. Additionally, the patient is undergoing a coronary angiogram to assess the situation further, which underscores the urgency and potential severity of the condition. Given the combination of critical chronic health issues and acute symptoms, this is a high-stakes medical situation that requires immediate and comprehensive medical management to prevent life-threatening outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Elbow Pain - Consult

CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.
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DESCRIPTION: Left elbow pain.  Fracture of the humerus, spiral.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.

The situation involves a medical consultation for a 17-year-old male with a confirmed spiral fracture of the humerus and potential nerve injuries. While the fracture and possible nerve issues are serious medical concerns, they do not immediately appear life-threatening. The patient is in a stable condition with no indication of urgent or life-threatening complications, such as compartment syndrome. Immediate measures, such as immobilization with a splint, have been taken to manage comfort and prevent further injury. The patient has been prescribed pain management medication and advised on follow-up care. This scenario, though serious, is more about appropriate follow-up and pain management rather than being a high-stakes, life-or-death situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Ecstasy Ingestion - ER Visit

CHIEF COMPLAINT:,  "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.
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DESCRIPTION: Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.

consult - history and phy., nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy,

While the patient is currently stable and not experiencing acute distress, the underlying situation involves a 17-year-old who has ingested a significant amount of Ecstasy, which is a potentially dangerous and illegal drug, along with alcohol. There is a potential risk for adverse reactions or complications, such as dehydration, hyperthermia, or serotonin syndrome. Additionally, given her age, there are legal and developmental concerns regarding substance use. Thus, the situation requires monitoring and education to prevent future occurrences.


Medical Specialty: Consult - History and Phy.
Sample Name: Dog Bite

CHIEF COMPLAINT:,  Dog bite to his right lower leg.,HISTORY OF PRESENT ILLNESS:,  This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to.  Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him.  He sustained a bite to his right lower leg.  Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that.  The dog has given no prior history of any reason to believe he is not a healthy dog.  The patient himself developed a puncture wound with a flap injury.  The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot.  It appears to be viable.  The wound is open about may be roughly a centimeter in the inside of the flap.  He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.,PAST MEDICAL HISTORY:  ,Significant for history of pulmonary fibrosis and atrial fibrillation.  He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.,ALLERGIES:  ,There are no known allergies.,MEDICATIONS:,  Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin.,FAMILY HISTORY: , Consistent with a sister of his has ovarian cancer and his father had liver cancer.  Heart disease in the patient's mother and father, and father also has diabetes.,SOCIAL HISTORY:,  He is a non-cigarette smoker.  He has occasional glass of wine.  He is married.  He has one biological child and three stepchildren.  He works for ABCD.,REVIEW OF SYSTEMS:,  He denies any chest pain.  He does admit to exertional shortness of breath.  He denies any GI or GU problems.  He denies any bleeding disorders.,PHYSICAL EXAMINATION,GENERAL:  Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3 or S4 gallop.  There is no obvious murmur.,ABDOMEN:  Soft.  It is nontender.  Bowel sounds are present.  There is no tenderness.,SKIN:  He does have like a Chevron incisional scar across his lower chest and upper abdomen.  It appears to be well healed and unremarkable.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  He has about 1+ pitting edema to both legs and they have been present since the surgery.  In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap.  The wound is spread apart about may be a centimeter all along that area and it is relatively clean.  There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate.  There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc.  The flap appeared to be viable.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.  He is on multiple medications and he is on chronic Bactrim.  We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult.  We will see him back in the office early next week to reassess his wound.  He is to keep the wound clean with the moist dressing right now.  He may shower several times a day.
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DESCRIPTION: A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.

The situation involves a dog bite with potential for infection, especially given the patient's medical history, including a lung transplant and being on immunosuppressive medications. There is a potential risk of complications, but immediate steps have been taken for treatment. The patient's overall health condition and history of significant medical issues elevate the stakes, but the event is not immediately life-threatening due to prompt medical intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: Dizziness - Recurrent

CHIEF COMPLAINT:,  Recurrent dizziness x1 month.,HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness.  She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  She is not able to describe what direction she feels like she is spinning.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.  She does note that it is worse when she turns to the right and when she turns to the left.  She also complains that she gets similar sensations when she looks up.  She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches.  She also notes occasional tinnitus to her right ear.,PAST MEDICAL HISTORY:,1.  CHF (uses portable oxygen).,2.  Atrial fibrillation.,3.  Gout.,4.  Arthritis (DJD/rheumatoid).,5.  Diabetes mellitus.,6.  Hypothyroidism.,7.  Hypertension.,8.  GERD.,9.  Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , She is married.  She does not smoke, use alcohol or use illicit drugs.,MEDICATIONS: , Please see medication sheet in the chart.  It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness).,REVIEW OF SYSTEMS:,  Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented.  Tinnitus in the right ear.  Diabetes and hypothyroidism.  Chronic nausea.  Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back.  Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking.  She says her mood is sad and may be depressed and she is also extremely anxious.  She has chronic shortness of breath and coughs easily when has to breathe deeply.  She also endorses poor sleep.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66.  Respiratory rate is 20.  Weight is 257 pounds.  Pain scale is 7.,GENERAL:  This is a somewhat anxious elderly African-American female who tends to amplify findings on examination.  It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw.  She is obese.,HEENT:  She is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  Tympanic membranes were visualized bilaterally.  There is tenderness to palpation of any sinus region.  There are no palpable cervical nodes.,NECK:  Supple although she complains of pain when rotating her neck.,CHEST:  Clear to auscultation bilaterally.,HEART:  Heart sounds are distant.  There are no carotid bruits.,EXTREMITIES:  She has 1-2+ pitting edema to the mid shins bilaterally.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  She is alert and oriented x3.  Her speech is fluent; however, she is extremely tangential.  She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation.,CRANIAL NERVES:  Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline.,MOTOR:  This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity.  There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout.  Her tone is normal throughout.,SENSORY:  She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg.  She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact.,COORDINATION:  There is no obvious dysmetria.,GAIT:  She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker.  There are some mild right lower extremity circumduction present.,REFLEXES:  Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent.  Toes are equivocal.,OTHER:  Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, "Oh my back, oh my back", and was unable to complete the maneuver.  Brief inspection of her eyes failed to show any nystagmus at that time.,IMPRESSION AND PLAN:,  This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology.  Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings.  I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise.  I agree with symptomatic treatment with Antivert.,We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency.  In addition, we will attempt to get further objective data by ENG testing.  I will see the patient again after these tests are completed and she has a trial of the Antivert.
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DESCRIPTION: Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.

The situation involves a 77-year-old female with a history of multiple serious health conditions, such as CHF, atrial fibrillation, and a possible previous stroke, who presents with recurrent dizziness. This is a potentially high-stakes situation because her symptoms could indicate benign positional vertigo or a more serious condition like vertebrobasilar insufficiency or a stroke. The need for further diagnostic tests such as a CT scan, CT angiogram, and ENG testing outlines the seriousness of the case. The presence of potential life-threatening conditions related to her symptoms adds to the high-stakes nature of this situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Dural AVM

CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The "vascular blush" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.
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DESCRIPTION: Patient with episode of lightheadedness and suddenly experienced vertigo.

consult - history and phy., avm, episode of lightheadedness, vascular malformation, cavernous angioma, vascular blush, cerebellar hemisphere, malformation, cavernous, angioma, angiography, lightheadedness, hemisphere, vertigo, cerebellar,

The medical report details a complex case involving episodes of vertigo, numbness, and prior stroke history, indicating potential serious underlying vascular issues like a dural arteriovenous malformation (AVM). Given the symptoms and prior strokes, the stakes are high as it involves risks of further neurological damage and complications. The presence of vascular anomalies seen on MRI, although not confirmed by other diagnostics, suggests a serious condition that could have major implications for the patient's health. However, as it seems the immediate life-threatening risks were not confirmed, this is not at the absolute highest end of the scale.


Medical Specialty: Consult - History and Phy.
Sample Name: Ear Pain - Drainage

CHIEF COMPLAINT:,  Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:,  This is a 12-year-old white male here with his mother for complaints of his right ear hurting.  Mother states he has been complaining for several days.  A couple of days ago she noticed drainage from the right ear.  The patient states it has been draining for several days and it has a foul smell to it.  He has had some low-grade fever.  The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever.  The patient was evaluated for Strep throat which was negative and just had been doing supportive care.  He did have a recent airplane ride a couple of weeks ago also.  There has been no cough, shortness of breath or wheezing.  No vomiting or diarrhea.,PHYSICAL EXAM:,General:  He is alert in no distress.,Vital Signs:  Temperature:  99.1 degrees.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  The left TM is clear.  The right TM is poorly visualized secondary to purulent secretions in the right ear canal.  There is no erythema of the ear canals.  Nares is patent.  Oropharynx is clear.  The patient does wear braces.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,ASSESSMENT:,1.  Right otitis media.,2.  Right otorrhea.,PLAN:,  Ceftin 250 mg by mouth twice a day for 10 days.  Ciprodex four drops to the right ear twice a day.  The patient is to return to the office in two weeks for followup.
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DESCRIPTION: Right ear pain with drainage - otitis media and otorrhea.

consult - history and phy., drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear,

The case involves a 12-year-old boy with right ear pain and drainage, which has been diagnosed as right otitis media (an ear infection) and otorrhea. While ear infections are quite common, especially in children, and typically do not constitute an emergency, they can potentially lead to more serious complications if not treated properly. The situation has been assessed and a treatment plan with antibiotics and ear drops has been implemented, with a follow-up scheduled. This suggests that the situation is being managed appropriately, reducing the immediate stakes involved. However, because it involves a child's health and potential complications of untreated ear infections, it holds a moderate level of stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Difficulty Distance Vision & Fine Print at Near

REASON FOR VISIT: , Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient.  He states that he has difficulty with both his distance vision and also with fine print at near.,HISTORY OF PRESENT ILLNESS:,  Mr. ABC states that over the last year, he has had increasing difficulty with distance vision particularly when he is driving.  He is also having trouble when he is reading.  He does occasionally wear over-the-counter reading glasses, which do help with his near vision.,Past ocular history is significant for astigmatism for which he wore glasses since he was 18 years old.  However, Mr. ABC mentioned today that he has not worn his glasses for the last few years.,His past medical history is significant for hypertension, low serum testosterone level, hypercholesterolemia, GERD, depression, actinic keratoses, and a history of Pityrosporum folliculitis.,His family history is significant for diabetes in both parents.  He states that his mother is seen by Mrs. Goldberg, but he is not aware of her ocular history.  He has no known family history of glaucoma, age-related macular degeneration or hereditary blindness.,MEDICATIONS: , Wellbutrin XL 450 mg daily, Ritalin long-acting 60 mg daily, hydrochlorothiazide at an unknown dose, Vytorin at an unknown dose, and aspirin.,ALLERGIES: , No known drug allergies.,FINDINGS:,  Visual acuity today without correction was 20/20 -2 pinholing to 20/16 in the right eye, and 20/40 +2 pinholing to 20/16 in the left eye.  Near vision unaided was J2 in both eyes.,Manifest refraction today following pharmacological dilation was -0.50, +0.50 times 155 in the right eye revealing a vision of 20/16.  Manifest refraction was -1.00, +0.25 times 005 revealing a vision of 20/16 in the left eye.  The add was +2 in both eyes.  Visual fields are full to finger counting in both eyes.,Extraocular movements were within normal limits.  Intraocular pressure by applanation was 16 mmHg in the right eye and 18 mmHg in the left eye measured at 11.30 in the morning.,Examination of the anterior segment was unremarkable in both eyes except for mild nuclear sclerotic opacities in both eyes.,Dilated fundus examination of the right eye revealed a sharp and pink optic disc with a healthy rim and cup-to-disc ratio of 0.7; however, there was central excavation of the disc, but no disc hemorrhages were noted.  On examination of the macula, there were drusen scattered temporally.  Examination of the vasculature was normal.  Peripheral retinal examination was entirely normal.,On funduscopic examination of the left eye, there was a sharp and pink disc with a healthy rim, but with central excavation and a cup-to-disc ratio of 0.6.  Of note, there were no disc hemorrhages.  On examination of the macula, there was scattered tiny drusen centrally and superiorly.  Examination of the vasculature was entirely normal.  Peripheral fundus examination was unremarkable.,ASSESSMENT:,1.  Age-related macular degeneration category three (right greater than sign left).,2.  Glaucoma suspect based on disc appearance (increased cup-to-disc ratio and disc asymmetry).,3.  Presbyopia and astigmatism.,4.  Non-visually significant cataracts bilaterally.,PLANS:,1.  The above diagnoses and management plans each were discussed with the patient who expressed understanding.,2.  Commence Ocuvite PreserVision capulets one tablet twice a day by mouth for age-related macular degeneration.,3.  Humphrey visual field and disc photographs today for baseline documentation in view of glaucoma suspicion.,4.  Followup in Glaucoma Clinic arranged in 4 months' time with repeat Humphrey visual fields at this time for reevaluation and comparison.,5.  Follow up with Mrs. Braithwaite in the Comprehensive Eye Service Clinic for undilated refraction.,6.  We will follow up this gentleman in our clinic in 12 months' time; however, I have asked him to return to us soon should he develop any worsening ocular symptoms in the interim.
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DESCRIPTION: Difficulty with both distance vision and with fine print at near.

This patient's situation, involving vision issues and potential glaucoma and age-related macular degeneration, has significant implications for quality of life and visual health. Proper management is crucial to prevent deterioration. However, it is not life-threatening at this moment, as the issues are mostly manageable with eyewear, medication, and monitoring. Therefore, the stakes are moderate but not extremely high.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consultation - 2

SUBJECTIVE:,  This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes.  She did attend diabetes education classes at Abc Clinic.  She comes however, wanting to really work at weight reduction.  She indicates that she has been on the Atkins' diet for about two years and lost about ten pounds.  She is now following a veggie diet which she learned about in Poland originally.  She has been on it for three weeks and intends to follow it for another three weeks.  This does not allow any fruits or grains or starchy vegetables or meats.  She does eat nuts for protein.  She is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet.  She also wants to know that if she gets skinny enough, if the diabetes will go away.  Her problem time, blood sugar wise, is in the morning.  She states that if she eats too much in the evening that her blood sugars are always higher the next morning.,OBJECTIVE:,  Weight:  189 pounds.  Reported height:  5 feet 5 inches.  BMI is approximately 31-1/2.  Diabetes medications include metformin 500 mg daily.  Lab from 5/12/04:  Hemoglobin A1C was 6.4%.,A diet history was obtained.  I instructed the patient on dietary guidelines for weight reduction.  A 1200-calorie meal plan was recommended.,ASSESSMENT:,  Patient's diet history reflects that she is highly restricting carbohydrates in her food intake.  She does not have blood sugar records with her for me to review, but we discussed strategies for improving blood sugar control in the morning.  This primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts.  She is doing some physical activity two to three times a week.  This includes aerobic walking with weights on her arms and her ankles.  She is likely going to need to increase frequency in this area to help support weight reduction.  Her basal metabolic rate was estimated at 1415 calories a day.  Her total calorie requirements for weight maintenance are estimated at 1881 calories a day.  A 1200-calorie meal plan should support a weight loss of at least one pound a week.,PLAN:,  Recommend patient increase the frequency of her walking to five days a week.  Encouraged a 30-minute duration.  Also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations.  And lastly, I encouraged caloric intake of just under 1200 calories daily.  Recommend keeping food records and tracking caloric intake.  It is unlikely that her blood sugars would drop significantly low on the current dose of Glucophage.  However, I encouraged her to be careful not to reduce calories below 1000 calories daily.  She may want to consider a multivitamin as well.  This was a one-hour consultation.
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DESCRIPTION: Dietary consultation for weight reduction secondary to diabetes.

consult - history and phy., consultation, atkins' diet, blood sugar reaction, diabetes, diabetes education, diabetes education classes, diet history, dietary consultation, dietary guidelines, meal plan, protein, veggie diet, weight reduction, caloric intake, blood sugar, reduction, sugar, calories, blood, dietary, weight,

The patient is consulting regarding dietary changes to manage weight and diabetes, which requires careful consideration and monitoring since dietary changes can significantly impact diabetes management and blood sugar levels. However, the patient seems to be on a controlled regime, with recommendations to adjust the diet and exercise frequency. The stakes involve managing diabetes effectively to prevent complications, but it doesn't present an immediate severe risk since the medication (metformin) reduces the likelihood of severe hypoglycemia and the consultation addresses safe dietary changes.


Medical Specialty: Consult - History and Phy.
Sample Name: Disseminated Intravascular Coagulation

DIAGNOSES:,1.  Disseminated intravascular coagulation.,2.  Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.  At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer.  At this time, I am being consulted for further evaluation and recommendations for treatment.  The nurses report that she has actually improved clinically over the last 24 hours.  Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion.  There is no prior history of coagulopathy.,PAST MEDICAL HISTORY:  ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY:  ,There were possible illicit drugs.  Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY:  ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL:  She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS:  She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT:  Her sclerae showed conjunctival hemorrhage.  There are no petechiae.  Her nasal vestibules are clear.  Oropharynx has ET tube in place.,NECK:  No jugular venous pressure distention.,CHEST:  Coarse breath sounds bilaterally.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender with good bowel sounds.  There was some oozing around the site of her central line.,EXTREMITIES:  No clubbing, cyanosis, or edema.  There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES:  ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN:  ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease.  My recommendation for the patient is to continue factor replacement as you are.  It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time.  There is no indication at this point for Xigris.  However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions.  I will repeat her laboratory studies in the morning and give more recommendations at that time.
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DESCRIPTION: Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis.  Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.

consult - history and phy., intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated,

The situation involves a 20-year-old patient with a serious diagnosis of disseminated intravascular coagulation (DIC) due to sepsis from Streptococcal pneumonia. The patient has developed respiratory failure requiring intubation and mechanical ventilation. Although her condition has shown some clinical improvement with aggressive treatment including factor replacement and platelet infusion, the presence of life-threatening complications like DIC and respiratory failure makes this a high-stakes situation. The risk of organ failure or death is significant if the condition worsens. Therefore, I assess this case as high-stakes in the medical context.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - Weight Reduction

SUBJECTIVE:,  This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.  The patient states that her husband has been diagnosed with high blood cholesterol as well.  She wants some support with some dietary recommendations to assist both of them in healthier eating.  The two of them live alone now, and she is used to cooking for large portions.  She is having a hard time adjusting to preparing food for the two of them.  She would like to do less food preparation, in fact.  She is starting a new job this week.,OBJECTIVE:,  Her reported height is 5 feet 4 inches.  Today’s weight was 170 pounds.  BMI is approximately 29.  A diet history was obtained.  I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well.  Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:,  The patient’s basal energy expenditure is estimated at 1361 calories a day.  Her total calorie requirement for weight maintenance is estimated at 1759 calories a day.  Her diet history reflects that she is making some very healthy food choices on a regular basis.  She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals.  She also is emphasizing lower fat selections.  Her physical activity level is moderate at this time.  She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend.  We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction.  We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well.  We discussed menu selection, as well as food preparation techniques.  The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that.  I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:,  Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk.  Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week.  This translates into a 1200-calorie meal plan.  I encouraged the patient to keep food records in order to better track calories consumed.  I recommended low fat selections and especially those that are lower in saturated fats.  Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well.  This was a one-hour consultation.  I provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.

consult - history and phy., hyperlipidemia, hypertension, gastroesophageal reflux disease, weight reduction, dietary recommendations, healthier eating, meal plan, dietary consultation, low fat, physical activity, weight, gastroesophageal, dietary, calories, food

The consultation revolves around chronic but manageable health conditions such as hyperlipidemia, hypertension, and the need for weight reduction. These conditions require attention and management, primarily through dietary changes and increasing physical activity. While these issues are significant, they are not immediately life-threatening if managed properly and are routine matters in medical practice. The stakes are related to the patient's long-term health, which requires consistent lifestyle changes. It's not an emergency situation, but it does hold importance in terms of the patient's quality of life and long-term health outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - Gestational Diabetes

SUBJECTIVE:,  This is a 38-year-old female who comes for dietary consultation for gestational diabetes.  Patient reports that she is scared to eat because of its impact on her blood sugars.  She is actually trying not to eat while she is working third shift at Wal-Mart.  Historically however, she likes to eat out with a high frequency.  She enjoys eating rice as part of her meals.  She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home.  She sleeps two to four hours at a time throughout the day.  She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:,  Today's weight:  155.5 pounds.  Weight from 10/07/04 was 156.7 pounds.  A diet history was obtained.  Blood sugar records for the last three days reveal the following:  fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88.  I instructed the patient on dietary guidelines for gestational diabetes.  The Lily Guide for Meal Planning was provided and reviewed.  Additional information on gestational diabetes was applied.  A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:,  Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day.  Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day.  Her diet history reveals that she has somewhat irregular eating patterns.  In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m.  We discussed the need for small frequent eating.  We identified carbohydrate as the food source that contributes to the blood glucose response.  We identified carbohydrate sources in the food supply, recognizing that they are all good for her.  The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars.  In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice.  We discussed the need for moderating the portion of carbohydrates consumed at one given time.  Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake.  Her weight loss was discouraged.  Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:,  The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan.  The meal plan was devised to distribute her carbohydrates more evenly throughout the day.  The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time.  The meal plan is as follows:  breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings.  Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep.  Encouraged adequate rest.  Also recommend adequate calories to sustain weight gain of one-half to one pound per week.  If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly.  This was a one-hour consultation.  I provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for gestational diabetes.

consult - history and phy., blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning

The situation involves managing gestational diabetes in a pregnant woman, which is critical for both maternal and fetal health. The patient is experiencing challenges with dietary intake, work schedule, fatigue, and stress, which need careful balancing to prevent complications such as high blood sugar levels and inadequate weight gain during pregnancy. While not immediately life-threatening, improper management could lead to significant health issues for both the mother and the baby. Hence, it is a moderately high-stakes situation due to the potential for adverse outcomes if not managed properly.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consultation - 1

SUBJECTIVE:,  This is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia.  The patient reports that she has resumed food record keeping which she feels like it has given her greater control.  Her physical activity level has remained high.  Her struggle times are in the mid-afternoon if she has not had enough food to eat, as well as in the evening after dinner.,OBJECTIVE:, Vital Signs:  Weight is 189-1/2 pounds.  Food records were reviewed,ASSESSMENT:,  The patient has experienced a weight loss of 1-1/2 pounds in the last month.  She is commended for these efforts.  We have reviewed food records identifying that she has done a nice job keeping a calorie count for the last two or three weeks.  We discussed the value of this and how it was very difficulty to resume it, however, after she suspended the record keeping.  We also discussed its reflection that she is not getting very many fruits and vegetables on a regular basis.  We identified some ways of preventing her from feeling sluggish and having problems with low blood sugar in the middle of the afternoon by routinely planning an afternoon snack that can prevent these symptoms.  This will likely be around 2:30 or 3 p.m. for her.  We also discussed strategies for evening snacking to help put some definition and boundaries to the snacking.,PLAN:,  I recommended the patient routinely include an afternoon snack around 2:30 to 3 p.m.  It will be helpful if this snack includes some protein such as nuts or low-fat cheese.  She is also encouraged to continue with her record keeping for food choices and calorie points.  I also recommended she maintain her high level of physical activity.  Will plan to follow the patient in one month for ongoing support.  This was a 30-minute consultation.
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DESCRIPTION: Dietary consultation for a woman with polycystic ovarian syndrome and hyperlipidemia.

consult - history and phy., dietary consultation, calorie count, calorie points, consultation, food choices, food record, hyperlipidemia, low-fat cheese, many fruits and vegetables, physical activity, polycystic ovarian syndrome, snack, dietary, polycystic, food, afternoon

This situation describes a dietary consultation for a patient with polycystic ovarian syndrome (PCOS) and hyperlipidemia. The patient is making progress with weight loss and is resuming food record keeping, which is a positive step towards managing her conditions. While PCOS and hyperlipidemia are health concerns that can have serious long-term implications if not managed properly, the consultation itself is a follow-up for ongoing supportive care and not an urgent or emergency scenario. The current state of the patient is stable, and the plan is focused on gradual lifestyle changes and continuous monitoring. This reduces the immediacy of the stakes involved.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - Diabetes - 1

SUBJECTIVE:,  This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy.  Patient reports that she had gestational diabetes with her first pregnancy.  She did use insulin at that time as well.  She does not fully understand what ketones are.  She walks her daughter to school and back home each day which takes 20 minutes each way.  She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:,  Weight is 238.3 pounds.  Weight from last week’s visit was 238.9 pounds.  Prepregnancy weight is reported at 235 pounds.  Height is 62-3/4 inches.  Prepregnancy BMI is approximately 42-1/2.  Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time.  Blood sugar records for the last week reveal the following:  Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116.  Overall average is 140.  A diet history was obtained.  Expected date of confinement is May 1, 2005.  Instructed the patient on dietary guidelines for gestational diabetes.  A 2300 meal plan was provided and reviewed.  The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:,  Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day.  Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day.  Her diet history reveals that she is eating three meals a day and three snacks.  The snacks were just added last week following presence of ketones in her urine.  We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most.  We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget.  We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy.  We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars.  While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day.  Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis.  At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:,  Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate.  Breakfast:  Three carbohydrate servings.  Morning snack:  One carbohydrate serving.  Lunch:  Four carbohydrate servings.  Afternoon snack:  One carbohydrate serving.  Supper:  Four carbohydrate servings.  Bedtime snack:  One carbohydrate serving.  Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack.  Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy.  Recommend patient include a fruit or a vegetable with most of her meals.  Also recommend including solid protein with each meal as well as with the bedtime snack.  Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment:  Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units.  Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial.  Provided my name and number should there be additional dietary questions.
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DESCRIPTION: Dietary consultation for diabetes during pregnancy.

consult - history and phy., diabetes during pregnancy, diabetes, insulin, gestational diabetes, adjusted for obesity, calorie requirements, dietary consultation, carbohydrate, postprandial, meal, calories, dietary, pregnancy, servings, snacks

This case is a dietary consultation for a pregnant woman with gestational diabetes. The stakes are relatively high because pregnancy complications can affect both the mother and unborn child. Managing diabetes is crucial to prevent adverse outcomes like fetal macrosomia, pre-eclampsia, or the need for delivery interventions. However, this is a routine management situation with actionable steps being planned and no immediate life-threatening issues noted. The stakes are significant but common in obstetric care, making it manageable through regular monitoring and adherence to dietary and insulin guidelines.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - 4

SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.
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DESCRIPTION: Counting calorie points, exercising pretty regularly, seems to be doing well

consult - history and phy., overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly

The situation involves a patient who is actively managing her diet and weight, attending support groups, and achieving positive results. While dietary management and weight loss can have significant long-term health implications, the scenario described does not involve immediate or severe health risks. It is a routine follow-up dietary consult, and the patient appears to be doing well, with weight loss and engagement in support systems. High-stakes scenarios in medical contexts typically involve acute medical interventions, life-threatening conditions, or significant changes in health status.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Consult - History and Phy.
Sample Name: Cystic Fibrosis

INTERVAL HISTORY:,  ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit.  He was accompanied by his adopted mother.  He is attending the fourth grade and has not missed significant days for illness.  He has a chronic cough that has been slightly increased for the prior 4 days.  Sputum is not produced.  Sinuses are described as clear.  He is an eager eater, eating a regular diet of increased calorie and protein.  He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half.  Belly complaints are denied.  He has 2 to 3 bowel movements per day.  He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks,  A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Respiratory rate 20 and pulse 91.  Temperature is 100.0 per tympanic membrane.  Oximetry is 98% on room air.  Height is 128 cm, which is an increase of 1.0 cm from prior visit.  Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL:  He is a cooperative school-aged boy in no apparent distress.,HEENT:  Tympanic membranes clear, throat with minimal postnasal drip.,CHEST:  Significant for 1+ hyperinflation.  Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC:  Regular sinus rhythm without murmur.,ABDOMEN:  Palpated as soft, without hepatosplenomegaly.,EXTREMITIES:  Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN.  Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION:  PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons.  He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis.  This situation will be looked into with the hope of restarting soon.  Other than that the patient seems to be doing well.  A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well.  Reinforcement of current medication regime was supplied.  No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family.  Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues.  At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines.  This is despite the fact that he has an excellent appetite.  Mom reports he is taking his enzymes consistently as well as vitamins.  He does have problems meeting his goal for resource drinks per day.  Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely.  A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital.  The patient is doing well in school.  With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1.  Cystic fibrosis.,2.  Poor nutritional status.,PLAN:  ,1.  Give flu vaccine 0.5 mg IM now, this was done.,2.  Continue all other medications and treatment.,3.  Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4.  Needs to augment current high-calorie diet to give more nutrition.  To follow advice by a dietician.,5.  Continue all the medication treatments before.,6.  To continue off and ongoing psychosocial nutritional counseling as necessary.
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DESCRIPTION: A 10 years of age carries a diagnosis of cystic fibrosis

The situation involves a routine follow-up for a child with cystic fibrosis, a serious chronic condition that requires comprehensive management, including medication adherence and nutritional support. The follow-up reveals a few areas of concern, particularly the lack of Pulmozyme, nutritional issues, and deviation from the ideal body weight, which are significant for managing cystic fibrosis effectively. However, these issues are being addressed with a coordinated care plan, including medication review, dietary adjustments, and follow-up on medication authorization. While important, these do not indicate an immediate life-threatening situation but require careful monitoring and intervention to prevent escalation.


Medical Specialty: Consult - History and Phy.
Sample Name: Detox from Heroin

CHIEF COMPLAINT:,  Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,PAST MEDICAL HISTORY: , Remarkable for chronic pain.  He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain.  He has previously been followed by ABC but has not seen him for several years.,REVIEW OF SYSTEMS:  ,The patient states that he did use heroin as well as cocaine earlier today and feels under the influence.  Denies any headache or visual complaints.  No hallucinations.  No chest pain, shortness of breath, abdominal pain or back pain.  Denies any abscesses.,SOCIAL HISTORY: , The patient is a smoker.  Admits to heroin use, alcohol abuse as well.  Also admits today using cocaine.,FAMILY HISTORY:,  Noncontributory.,MEDICATIONS: , He has previously been on analgesics and pain medications chronically.  Apparently, he just recently got out of prison.  He has previously also been on Klonopin and lithium.  He was previously on codeine for this pain.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient is afebrile.  He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard.  His respiratory rate is normal at 18.  GENERAL:  The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation.  HEENT:  Unremarkable.  Pupils are actually moderately dilated about 4 to 5 mm, but reactive.  Extraoculars are intact.  His oropharynx is clear.  NECK:  Supple.  His trachea is midline.  LUNGS:  Clear.  He has good breath sounds and no wheezing.  No rales or rhonchi.  Good air movement and no cough.  CARDIAC:  Without murmur.  ABDOMEN:  Soft and nontender.  He has multiple track marks, multiple tattoos, but no abscesses.  NEUROLOGIC:  Nonfocal.,IMPRESSION: , MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN.,ASSESSMENT AND PLAN:  ,At this time, I think the patient can be followed up at XYZ.  I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy.  I do not think he needs any further workup at this time.  He is discharged otherwise in stable condition.
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DESCRIPTION: A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.

consult - history and phy., phenergan, detox from heroin, alcohol abuse, heroin abuse, detox, heroin, alcohol, cocaine, abuse,

This situation involves a patient with a long history of heroin abuse who is currently seeking detoxification, which inherently carries high-risk factors. Heroin addiction is associated with serious health risks, including potential overdose, severe withdrawal symptoms, and high relapse rates. The patient's recent cocaine use adds to the immediate health risks, as evidenced by his markedly high blood pressure and heart rate. Furthermore, substance abuse can lead to complications that require careful management. Although the patient is stable upon discharge, the overall situation is high-stakes due to the potential for life-threatening withdrawal symptoms and relapse.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Prostate Cancer

CONSULT FOR PROSTATE CANCER,The patient returned for consultation for his newly diagnosed prostate cancer.  The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding, infection, rectal injury, impotence, and incontinence.  These were discussed at length.  Alternative therapies including radiation therapy; either radioactive seed placement, conformal radiation therapy, or the HDR radiation treatments were discussed with the risks of bladder, bowel, and rectal injury and possible impotence were discussed also.  There is a risk of rectal fistula.  Hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis, gynecomastia, hot flashes and impotency.  Potency may not recover after the hormone therapy has been completed.  Cryosurgery was discussed with the risks of urinary retention, stricture formation, incontinence and impotency.  There is a risk of rectal fistula.  He would need to have a suprapubic catheter for about two weeks and may need to learn self-intermittent catheterization if he cannot void adequately.  Prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence.  Observation therapy was discussed with him in addition.  I answered all questions that were put to me and I think he understands the options that are available.  I spoke with the patient for over 60 minutes concerning these options.
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DESCRIPTION: Consult for prostate cancer

Consult for prostate cancer

consult - history and phy., prostate cancer, cryosurgery, hdr radiation, prostate surgery, bladder, bleeding, bowel, consultation, impotence, incontinence, infection, prostatectomy, radiation therapy, radical, rectal, rectal fistula, rectal injury, prostate cancer consult, cancer, radiation, prostateNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

This consultation involves a decision about treatment options for newly diagnosed prostate cancer. The stakes are high because the choice of treatment can significantly impact the patient's quality of life and health outcomes. The options discussed carry serious risks such as impotence, incontinence, and even life-threatening complications. The decision made will have lasting effects on the patient's health and quality of life, making this a high-stakes situation.