Medical Specialty: Consult - History and Phy.
Sample Name: Normal Male Exam Template

MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.
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DESCRIPTION: Sample/template for a normal male multisystem exam.

consult - history and phy., within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,

The provided document is a standard, routine physical examination template for a normal male patient, often used by healthcare providers as a reference for conducting thorough check-ups. There are no indications of immediate medical concerns or emergencies, and the exam results are normal across all systems. This type of document is typically used as a reference or guide in everyday healthcare practice.


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: Normal ENT Exam

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.
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DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

consult - history and phy., erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: 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.,

The text describes a normal ear, nose, and throat (ENT) examination with no abnormalities found. It appears to be a routine medical assessment with the purpose of documenting normal findings in ENT physical exams. This situation carries low stakes as it doesn't indicate any medical emergencies or abnormalities that require immediate attention or intervention.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Child Exam Template

CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.
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DESCRIPTION: Normal child physical exam template.

Normal child physical exam template.

consult - history and phy., child physical examination, physical, genitalia, child,

The situation described involves a normal child physical examination and provides a template for documenting this in medical records. The stakes in this context are not tied to an urgent medical decision or immediate intervention but rather to routine record-keeping and ensuring all relevant health metrics are documented. While accurate documentation is crucial for healthcare records and future reference, it doesn't typically involve high-stakes immediate consequences unless an abnormality was found that needed urgent attention, which is not the case here.


Medical Specialty: Consult - History and Phy.
Sample Name: New Onset Seizure

REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.
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DESCRIPTION: A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.

The situation involves a young child with a history of febrile seizures experiencing potential new-onset seizures that could indicate a different or evolving neurological condition. While life-threatening consequences are not immediately present, the need to adjust medication and closely monitor the child indicates moderate stakes. Quick action and effective management are essential to prevent any escalation or worsening of her condition.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal ENT Exam - 1

EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.
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DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

consult - history and phy., oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,

The situation described is a routine ENT examination with all findings reported as normal. There are no indications of acute or critical medical issues present in this description. Such assessments are typically low-risk because they are conducted to ensure general health and to identify any potential issues early. There is no evidence of any urgent or life-threatening conditions in the provided information.


Medical Specialty: Consult - History and Phy.
Sample Name: Neuropsychological Evaluation - 5

PROBLEMS AND ISSUES:,1.  Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2.  Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.  I obtained and documented a full history and physical examination.  I reviewed the new patient questionnaire, which she completed prior to her arrival today.  I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25.  She recalls that in 1996 when her husband died her headaches became more frequent.  They were pulsating.  She was given papaverine, which was successful in reducing the severity of her symptoms.  After six months of taking papaverine, she no longer had any headaches.  In 2004, her headaches returned.  She also noted that she had "zig-zag lines" in her vision.  Sometimes she would not see things in her peripheral visions.  She had photophobia and dizziness, which was mostly lightheadedness.  On one occasion she almost had a syncope.  Again she has started taking Russian medications, which did help her.  The dizziness and headaches have become more frequent and now occur on average once to twice per week.  They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:,  Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY:  ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms.  Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:,  On examination, the patient was pleasant.  She was able to speak English fairly well.  Her blood pressure was 130/84.  Heart rate was 80.  Respiratory rate was 16.  Her weight was 188 pounds.  Her pain score was 0/10.  Her general exam was completely unremarkable.  Her neurological examination showed subtle weakness in her left arm due to discomfort and pain.  She had reduced vibration sensation in her left ankle and to some degree in her right foot.  There was no ataxia.  She was able to walk normally.  Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable.  She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:,  The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s.  She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms.  Her diagnosis is consistent with vestibular migraine.  I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet.  I gave her instructions including a list of foods times, which worsen migraine.  I reviewed this information for more than half the clinic visit.  I would like to start her on amitriptyline at a dose of 10 mg at time.  She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms.  I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.
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DESCRIPTION: The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.

consult - history and phy., nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia,

The situation involves a comprehensive medical consultation for a patient experiencing significant health issues, including vestibular migraines and peripheral neuropathy. While the patient is dealing with chronic health conditions that impact her quality of life, the current medical plan includes treatment recommendations and lifestyle adjustments. The stakes are moderate because these conditions, while impactful, are not life-threatening in the short term and the patient is being actively managed by healthcare professionals.


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

REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the "early stages of a likely dementia" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began "as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was "too derogatory."  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated "diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined."  It concluded that "results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot "like dragging."  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test
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DESCRIPTION: The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.

The situation involves a 58-year-old female patient who was dismissed from her role due to cognitive issues suspected to be early dementia, impacting her livelihood and quality of life. This evaluation determines her cognitive status, potentially influencing her future employment, disability application, and treatment. The stakes are high as the evaluation outcomes will impact her career, finances, and healthcare decisions significantly.


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

SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed.  There are no changes, otherwise.,REVIEW OF SYSTEMS:,  Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented.  Extraocular movements are full.  The face is symmetric.  The uvula is midline.  Speech has normal prosody.  Today there is much less guarding of the left shoulder.  In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full.  The gait is narrow based and noncircumductive.  Rapid alternating movements are slightly off bilaterally.  The gait does not have significant slapping characteristics.  Sensory examination is largely unremarkable.  Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same.  We discussed the issue of adherence to Copaxone.  In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm.  His wife continues to inject him.  He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.
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DESCRIPTION: Neurologic consultation and follow-up.

Neurologic consultation and follow-up.

consult - history and phy., neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone,

The situation involves a neurologic consultation, where the patient's treatment regimen with Copaxone is discussed. Copaxone is used for managing multiple sclerosis, which can significantly affect a patient's quality of life but is not an immediate life-threatening condition. The stakes involve ensuring the patient adheres to his medication schedule to manage his condition effectively. Although important for long-term health, it does not involve critical, life-threatening decisions or emergency care in this context.


Medical Specialty: Consult - History and Phy.
Sample Name: Neurologic Consultation - 3

HISTORY: , Neurologic consultation was requested to assess and assist with her seizure medication.  The patient is a 3-year 3 months old girl with refractory epilepsy.  She had been previously followed by XYZ, but has been under the care of the UCSF epilepsy program and recently by Dr. Y.  I reviewed her pertinent previous neurology evaluations at CHCC and also interviewed mom.,The patient had seizure breakthrough in August 2007, which requires inpatient admission, Thanksgiving and then after that time had seizures every other day, up-to-date early December.  She remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with Diastat.  She presented to our ER today with prolonged convulsive seizure despite receiving 20 mg of Diastat at home.  Mom documented 103 temperature at home.  In the ER, this was 101 to 102 degrees Fahrenheit.  I reviewed the ER notes.  At 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5.  UCSF fellow was contacted.  She was given additional fosphenytoin and had a total dose of 15 mg/kg administered.  Vital weight was 27.  Seizures apparently had stopped.  The valproic acid level obtained at 0835 hours was 79.  According to mom, her last dose was at 6 p.m. and she did not receive her morning dose.  Other labs slightly showed leukocytosis with white blood cell count 21,000 and normal CMP.,Previous workup here showed an EEG on 2005, which showed a left posterior focus.  MRI on June 2007 and January 2005 were within normal limits.  Mom describes the following seizure types:,1.  Eye blinking with unresponsiveness.,2.  Staring off to one side.,3.  Focal motor activity in one arm and recently generalized tonic seizure.,She also said that she was supposed to see Dr. Y this Friday, but had postponed it to some subsequent time when results of genetic testing would be available.  She was being to physicians' care as Dr. Z had previously being following her last UCSF.,She had failed most of the first and second line anti-epileptic drugs.  These include Keppra, Lamictal, Trileptal, phenytoin and phenobarbital.  These are elicited to allergies, but she has not had any true allergic reactions to these.  Actually, it has resulted in an allergic reaction resulting in rash and hypotension.,She also had been treated with Clobazam.  Her best control is with her current regimen of valproic acid and Tranxene.  Other attempts to taper Topamax, but this resulted increased seizures.  She also has oligohidrosis during this summertime.,CURRENT MEDICATIONS: , Include Diastat 20 mg; Topamax 25 mg b.i.d., which is 3.3 per kilo per day; Tranxene 15 mg b.i.d.; Depakote 125 mg t.i.d., which is 25 per kilo per day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 15 kg.,GENERAL:  The patient was awake, she appeared sedated and postictal.,NECK:  Supple.,NEUROLOGICAL:  She had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed.,She was able to follow commands such as when I request that she gave mom a kiss.  She acknowledged her doll.  Left fundus is sharp.  She resisted the rest of the exam.  There was no obvious lateralized findings.,ASSESSMENT:,  Status epilepticus resolved.  Triggered by a febrile illness, possibly viral.  Refractory remote symptomatic partial epilepsy.,IMPRESSION: , I discussed the maximizing Depakote to mom and she concurred.  I recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime.  For today, she did give an IV Depacon 250 mg and the above dosage can be continued IV until she is taking p.o.  Dr. X agreed with the changes and orders were written for this.  She can continue her current doses of Topamax and Tranxene.  This can be given by NG if needed.  Topamax can be potentially increased to 25 mg in the morning and 50 mg at night.  I will be available as needed during the rest of her hospitalization.  Mom will call contact Dr. Y an update him about the recent changes.
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DESCRIPTION: Neurologic consultation was requested to assess and assist with seizure medication.

consult - history and phy., eye blinking, status epilepticus, seizure medication, valproic acid, allergic reactions, neurologic consultation, seizure, neurologic, seizures,

The situation involves a young child with refractory epilepsy experiencing frequent and severe seizures. The child has not responded well to various medications in the past, and there was a recent breakthrough seizure despite home treatment. The medical team made immediate adjustments to the medication regimen, and close monitoring is required during hospitalization. This involves significant health risks given the young age of the patient, the potential for serious complications from seizures, and the necessity for precise management of medication, making it high-stakes.


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

REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:,  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  ,PAST MEDICAL HISTORY: ,1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.,2.  Gastroesophageal reflux disease.,3.  Gastritis.,4.  Hiatal hernia.,5.  H. pylori infection x3 in the last six months treated.,6.  Chronic hypokalemia secondary to chronic diarrhea.,7.  Recurrent admissions with nausea, vomiting, and dehydration.  ,8.  Renal cysts found on a CAT scan of the abdomen.,9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  Stomach bypass surgery 1975 with chronic diarrhea.,11.  History of UTI multiple times recently.,12.  Questionable history of kidney stones.,13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14.  Depression.,15.  Diffuse degenerative disc disease of the spine.,16.  Hypothyroidism.,17.  History of iron deficiency anemia in the past.  ,18.  Hyperuricemia.  ,19.  History of small bowel resection with ulcerative fibroid.  ,20.  Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: ,  The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  ,CURRENT MEDICATIONS: ,1.  Nexium 40 mg q.d.,2.  Synthroid 1 mg q.d. ,3.  Potassium one q.d., unsure about the dose.  ,4.  No history of nonsteroidal drug use.,ALLERGIES:
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DESCRIPTION: Nephrology Consultation - Patient with renal failure.

The consultation involves a patient with renal failure, a potentially serious condition. The patient's complex medical history, including multiple surgeries, chronic conditions, and complications like chronic diarrhea and hypokalemia, adds to the risk and urgency of the situation. Renal failure can lead to severe complications if not managed properly, and the presence of elevated creatinine levels suggests significant kidney dysfunction. Additionally, the patient's history of UTIs and other health issues increases the complexity and stakes of the consultation.


Medical Specialty: Consult - History and Phy.
Sample Name: Neuro Consult - Leg Weakness

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.  He has difficulty recollecting the exact details and chronology of his problem.  To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg.  He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe.  Since that time, he has had difficulty pushing off when he walks.  He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness.  He has chronic mild back pain, but this has been persistent for many years and has not changed.  He has experienced cramps in both calves for the past year.  This dissipated about two months ago.  He does not think that his left leg is weak.  He does not have any bowel or bladder incontinence.  There is no radicular pain.  He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October.  He then saw you a couple of months later.  He has undergone an EMG and nerve conduction studies.  Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant.  He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia.  He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me.  He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it.  Once it was started, it increased to about 800 and then came down to about 500 when it was stopped.  He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s.  I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this.  More recently, he has been started taking Zetia.  He does not have any proximal weakness.  He denies any myalgias., ,PAST MEDICAL HISTORY:,  He has coronary artery disease and has received five stents.  He has hypertension and hypercholesterolemia.  He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  He believes that his glucose shot up to over 300 with this testing.  He does not take any medications for this and his blood glucoses are generally normal when he checks it.  He has had plastic surgery on his face from an orbital injury.  He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix.  , ,ALLERGIES:,  He has no known drug allergies., ,SOCIAL HISTORY:,  He lives with his wife.  He works at Shepherd Pratt doing network engineering.  He smokes a pack of cigarettes a day and is working on quitting.  He drinks four alcoholic beverages per night.  Prior to that, he drank significantly more.  He denies illicit drug use.  He was athletic growing up., ,FAMILY HISTORY:,  His mother died of complications from heart disease.  His father died of heart disease in his 40s.  He has two living brothers.  One of them he does not speak too much with and does not know about his medical history.  The other is apparently healthy.  He has one healthy child.  His maternal uncles apparently had polio.  When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg.  He is fairly certain that they had polio.  He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus.  He has difficulty sleeping.  Otherwise, 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:
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DESCRIPTION: The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.

The situation involves a medical consultation for a patient experiencing right leg weakness. The seriousness of this condition could be indicative of a neurological disorder. Despite the chronic nature and the fact that it hasn't worsened, the inability to perform an MRI due to an ear implant complicates diagnosis. This situation is relatively high-stakes due to the potential for undiagnosed neurological issues, possible complications from known hyperCKemia, coronary disease, and the influence of his medications. However, since the condition seems stable, it's not extremely high-stakes compared to life-threatening conditions. The stakes are significant due to potential impacts on quality of life and the need for correct diagnosis and treatment, which has implications on long-term health.


Medical Specialty: Consult - History and Phy.
Sample Name: Neonatal Consult

INFORMANT:,  Dad on phone.  Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY:  ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.  The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis.  All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done.  The patient was put on ampicillin and cefotaxime.  Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime.  The patient was n.p.o. when he came in.  He was on 3/4 L of oxygen.  According to the note, it conveyed that he had some subcostal retractions.  On arriving here, baby looks very healthy.  He has no subcostal retractions.  He is not requiring any oxygen and he is positive for urine and stool.  The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile.  ED called that case is a direct admit.,REVIEW OF SYSTEMS:  ,The patient supposedly had fever, some weight loss, poor appetite.  The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria.  According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color.  He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low.  Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:,  None.,HOSPITALIZATIONS:,  Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY:  ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications.  Hospital stay 24 hours.  Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:,  None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY:  ,Lives with mom and dad.  Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog.  They usually visit to a ranch, but not recently.  No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:,  No allergies.,DIET:,  Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS:  Weight 3.725 kg.,GENERAL:  Alert and comfortable and sleeping.,SKIN:  No rash.,HEENT:  Intact extraocular movements.  PERRLA.  No nasal discharge.  No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK:  Soft, nontender, supple.,CHEST:  CTAP.,GI:  Bowel sounds present.  Nontender, nondistended.,GU:  Bilaterally descended testes.,BACK:  Straight.,NEUROLOGIC:  Nonfocal.,EXTREMITIES:  No edema.  Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:,  As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000.  Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5.  Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4.  Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal.  UA and LP results are pending.  Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative.  We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime.  The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis.  These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient.  He does not need any further workup.,GASTROINTESTINAL:
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DESCRIPTION: This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.

The situation involves a 3-week-old baby transferred to a new hospital to rule out serious conditions like sepsis and congenital heart disease. Both conditions can be life-threatening, particularly in neonates, given their vulnerability and the rapid progression of certain infections or heart-related issues. The baby is undergoing various tests and is under observation with antibiotic treatment. The stakes are increased by the potential diagnoses, the age of the patient, and the need for timely medical intervention.


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

HISTORY:,  The patient was in the intensive care unit setting; he was intubated and sedated.  The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated.  He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output.  His creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia.  Nephrology input has been requested for management of acute renal failure and acidosis.,PAST MEDICAL HISTORY:,1.  Pancreatitis.,2.  Poison ivy.  The patient has recently been on oral steroids.,3.  Hypertension.,MEDICATIONS: , Include Ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment.,INPATIENT MEDICATIONS: , Include Protonix IV, half-normal saline at 125 mL an hour, D5W with 3 ounces of bicarbonate at 150 mL an hour.  The patient was initially on dopamine, which has now been discontinued.  The patient remains on Levophed and Invanz 1 g IV q.24 h.,PHYSICAL EXAMINATION:,  Vitals, emergency room presentation, the blood pressure was 82/45.  His blood pressure in the ICU had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% FiO2.  The patient has had minimal urine output since admission.  HEENT, the patient is intubated at the moment.  Neck examination, no overt lymph node enlargement.  No jugular venous distention.  Lungs examination is benign in terms of crackles.  The patient has some harsh breath sounds secondary to being intubated.  CVS, S1 and S2 are fairly regular at the moment.  There is no pericardial rub.  Abdominal examination, obese, but benign.  Extremity examination reveals no lower extremity edema.  CNS, the patient is intubated and sedated.,LABORATORY DATA: , Blood work, sodium 152, potassium 2.7, bicarbonate 13, BUN 36, and creatinine 4.2.  The patient's BUN and creatinine yesterday were 23 and 2.1 respectively.  H&H of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning.  The patient's liver function tests are all out of whack and his alkaline phosphatase is 226, ALT is 539, CK 1103, INR 1.66, and ammonia level of 55.  Latest ABGs show a pH of 7.04, bicarbonate of 10.7, pCO2 of 40.3, and pO2 of 120.7.,ASSESSMENT:,1.  Acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% FiO2.  He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis.  The patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight.  Given the fact that he would need dialytic support for his electrolyte derangements and for volume control, I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.,2.  Hypotension, which is significant and is related to his sepsis.  Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment.,3.  Acidosis, which is again secondary to his renal failure.  The patient was administered intravenous bicarbonate as mentioned above.  Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.,4.  Pancreatitis, which has been managed by his gastroenterologist.,5.  Sepsis, the patient is on broad-spectrum antibiotic therapy.,6.  Hypercalcemia.  The patient has been given calcium chloride.  We will need to watch for rebound hypercalcemia.,7.  Hypoalbuminemia.,8.  Hypokalemia, which has been repleted.,RECOMMENDATIONS: , Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration.
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DESCRIPTION: Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.

consult - history and phy., intubated, consultation, hypercalcemia, hypoalbuminemia, iv fluid, nephrology, acidosis, creatinine, hemodiafiltration, hypokalemia, hypotension, intravenous, pancreatitis, renal failure, respiratory, urine output, continuous venovenous hemodiafiltration, electrolyte derangements, conventional hemodialysis, continuous venovenous, venovenous hemodiafiltration, blood pressure, venovenous, bicarbonate, sepsis,

The situation involves a critically ill patient in the ICU with multiple organ failures including acute renal failure, hypotension, sepsis, respiratory failure, and significant acidosis. The patient requires immediate nephrology consultation and intervention, specifically continuous venovenous hemodiafiltration, due to hemodynamic instability and electrolyte derangements. The patient's condition is life-threatening and requires urgent and precise medical management.


Medical Specialty: Consult - History and Phy.
Sample Name: Meningioma

CC: ,Progressive loss of color vision OD,HX:, 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago.,EXAM: ,Visual acuity with correction: 20/25+1 OD; 20/20-1 OS. Pupils were 3.5mm OU. There was a 0.8 log unit RAPD OD. Intraocular pressures were 25 and 24, OD and OS respectively; and there was an increase to 27 on upgaze OD, but no increase on upgaze OS. Optic disk pallor was evident OD, but not OS. Additionally, there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye. Foveal flicker fusion occurred at a frequency of 21.9 OD and 30.7 OS. Color plate testing scores: 6/14 OD and 10/14 OS. Goldman visual field examination showed an enlarged and deepened blind spot with an infero-temporal defect especially in the smaller diopters.,IMPRESSION ON 2/6/89: ,Optic neuropathy/atrophy OD, rule out mass lesion affecting optic nerve. Particular attention was paid to the area of the optic canal, cavernous sinus and sphenoid sinus.,BRAIN CT W/CONTRAST, 2/13/89:, Enhancing calcified lesion in the posterior aspect of the right optic nerve, probable meningioma.,MRI ORBITS W/ AND W/OUT GADOLINIUM CONTRAST, 4/26/89:, 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD. The mass is just proximal to the orbital apex. There is relatively homogeneous enhancement of the mass. The findings are most consistent with meningioma.,MRI 1995:, Mild enlargement of tumor with possible slight extension into the right cavernous sinus.,COURSE: ,Resection and biopsy were deferred due to risk of blindness, and suspicion that the tumor was a slow growing meningioma. 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD. Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam. There was greater red color desaturation of the temporal field OD. Visual acuity had decreased from 20/20 to 20/64, OD. All other deficits seen on her initial exam remained stable or slightly worsened. By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection.
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DESCRIPTION: Progressive loss of color vision OD.

Progressive loss of color vision OD.

consult - history and phy., goldman visual field examination, loss of color vision, visual field examination, visual acuity, cavernous sinus, color vision, visual field, optic nerve, meningioma,

The case involves a 58-year-old woman with a probable slow-growing meningioma affecting her right optic nerve, leading to progressive loss of color vision and other visual deficits. While the tumor's current impact is primarily on vision without immediate life-threatening implications, it presents a significant risk to her quality of life, particularly given the progressive nature of the symptoms. The potential for blindness if the condition deteriorates further adds urgency, but the fact that surgery is being deferred indicates the condition is currently being managed. This medical situation involves careful monitoring and decision-making about treatment options, so it is relatively high-stakes due to the potential for significant quality of life impact and the need for ongoing careful medical management.


Medical Specialty: Consult - History and Phy.
Sample Name: Major Depressive Disorder - IME Consult

IDENTIFYING DATA:  ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  His confidence and self-esteem are significantly low.  He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  He has had suicidal ideation, but this is currently in remission.  Furthermore, he continues to have hopeless thoughts and crying spells.  Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee." This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him "bitch." Mr. T then retaliated, and went to hit the other employee.  Due to this event, Mr. T was fired.  It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to "deal with it.",There are no other apparent stressors in Mr. T's life at this time or in recent months.  Mr. T stated that work was his entire life and he based his entire identity on his work ethic.  It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:,  There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time.  Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:,  Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  He denied any suicide attempts, or profound suicidal or homicidal ideation.  Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:,  Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth.  Originally, he was raised by both parents, but they separated at an early age.  When he was about seven years old, he was raised by his mother and stepfather.  He did not sustain a relationship with his biological father from that time on.  He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old.  He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company.  He then became a homemaker while his wife worked for Chrysler for approximately two years.  Mr. T was married for eleven years, and divorced in 1993.  He has a son who is currently 20 years old.  After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam:  Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  At times he showed some involuntary movements that would be more akin to a resting tremor.  There was no psychomotor retardation, but there was some mild psychomotor excitement.  His speech was clear, concise, but pressured.  His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  There was no evidence of euphoria or diurnal mood variation.  His affective expression was restricted range, but there was no evidence of lability.  At times, his affective tone and facial expressions were inappropriate to the interview.  There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  There was no evidence of illusions, depersonalizations, or derealizations.  Mr. T presented with a sequential and goal directed stream of thought.  There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  There was evidence of concreteness for similarities and proverbs.  His intelligence was average.  His concentration was mildly impaired, and there was no evidence of distractibility.  He was oriented to time, place, person and situation.  There was no evidence of clouded consciousness or dissociation.  His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  There was a moderate preoccupation with his physical health pertaining to his headaches.  His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem.  His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  His credibility seemed good.  There was no evidence for potential self-injury, suicide, or violence.  The reliability and completeness of information was very good, and there were no barriers to communication.  The information gathered was based on the patient's self-report and objective testing and observation.  His attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy.  At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment.  Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year.  As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  Furthermore, it only appears logical that this would precipitate a major depressive episode.
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DESCRIPTION: Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.

consult - history and phy., muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric,

The situation described involves a patient with a major depressive disorder, which includes symptoms like suicidal ideation (albeit in remission) and considerable impact on the patient's daily functioning and potential employability. The mental health concerns are directly affecting Mr. T's life, particularly after losing his job, leading to significant psychological distress. While there are no immediate life-threatening symptoms like active suicidality or psychosis, the ongoing nature of his mental health issues and their impact on his well-being and quality of life make it a moderately high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Lumbar Spine HNP - Consult

CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset.,PAST SPINE HISTORY:, Unremarkable.,PRESENT LUMBAR SYMPTOMS:, Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset.,PRESENT RIGHT LEG SYMPTOMS:, Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset.,PRESENT LEFT LEG SYMPTOMS:, None.,NEUROLOGIC SIGNS/SYMPTOMS:, The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.
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DESCRIPTION: Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.

The situation involves a medical consultation for low back and right lower extremity pain, potentially linked to a lumbar spine herniated nucleus pulposus (HNP). While the patient is experiencing significant pain impacting daily life, which requires proper medical assessment and treatment, the condition has not yet led to neurologic complications (like loss of bowel/bladder function), which would raise the stakes considerably. The patient is seeking a second opinion, indicating the importance of the assessment, but the lack of acute emergency symptoms such as neurological deficits or life-threatening issues suggests that this isn't a critical emergency but rather a significant quality-of-life concern.


Medical Specialty: Consult - History and Phy.
Sample Name: Lung Cancer & MI - Hospice Cosult

REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.
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DESCRIPTION: Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.

The situation involves a patient with advanced metastatic lung cancer on hospice care, who has experienced a significant cardiac event (inferior ST-elevation myocardial infarction) and presents with complex medical needs. The patient has a poor prognosis, and critical decisions are being made about whether to pursue aggressive interventions. The context of hospice care and the balance between possible interventions and the patient's quality of life highlight the high stakes, as the outcomes have major implications for the patient's remaining quality of life and comfort. Additionally, the patient's communication limitations complicate decision-making and increase the stakes.


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: Lumbosacral Polyradiculopathy

HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic.  I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours.  She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time.  She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time.  On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk.  She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all.  Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg.  She is not able to walk by herself, and needs assistance to stand.  She was discharged from hospital after the Cesarean section on the 3rd of November.  Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge.  She was then seen at ABC Hospital on November 05, 2008.  She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma.  She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December.  At the present time, she also complains of a pressure in both her legs and in her thighs.  She complains that her right foot hurts and that she has some hyperesthesia there.  She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal.  She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal.  There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above.  She has seasonal allergies.,CURRENT MEDICATIONS:,  Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension.  There is no family history of a neuropathy or other neurological disease.  She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home.  She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby.  She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  P 74, BP 144/75, and a pain score of 0.,GENERAL:  Her general physical examination was unremarkable.,CARDIOVASCULAR:  Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY:  Unremarkable, both lung bases were clear, and respiration was normal.,GI:  Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE:  The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal.  Executive function was normal.,CRANIAL NERVES:  The cranial nerve examination II through XII was unremarkable.  Both disks were normal, with normal retina.  Pupils were equal and reactive to light.  Eye movements were full.  Facial sensation and strength was normal.  Bulbar function was normal.  The trapezius had normal strength.,MOTOR:  Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities.  Muscle strength was 5/5 in all muscle groups in the upper extremities.  In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES:  Reflexes in the upper extremities were 2+ bilaterally.  In the lower extremities, they were 0 bilaterally at the knee and ankles.  The abdominal reflexes were present above the umbilicus and absent below the umbilicus.  The plantar responses were mute.  The jaw reflex was normal.,SENSATION:  Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe.  There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly.  There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation.  To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side.  In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left.  There was no evidence of allodynia or hyperesthesia.  Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION:  Coordination for rapid alternating movements and finger-to-nose testing was normal.  Coordination could not be tested in the lower extremities.,GAIT:  The patient was unable to stand and therefore we were unable to test gait or Romberg's.  There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6.  The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency.  I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast.  This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable.  The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers.  The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots.  A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity.  Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities.  A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities.  We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008.  The complete study included the cervical, thoracic, and lumbar spine.  There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November.  It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section.  It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function.  She was severely weak in both lower extremities, slightly worse on the right than the left.  There has been some interval improvement in her strength since the beginning of November 2008.  Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy.  The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural.  There had been no response to IV methylprednisolone given to her at ABC.  The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself.  The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition.  At the present time, she is able to stand with aid but is unable to walk.  There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1.  The diagnostic issues were discussed with the patient at length.  She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2.  She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory.  If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility.  I am not prescribing these because at the present time she does not need them.,3.  We discussed increasing the dose of gabapentin.  The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain.  If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day.  She may need other neuropathic pain medications as needed.  She will determine whether her current symptoms are significant enough to require this increase in dosage.,4.  The patient will follow up with Dr. Y and his team at ABC Hospital.  She will also continue with physical therapy within the ABC system.
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DESCRIPTION: Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.

Lumbosacral polyradiculopathy with temporal association to an epidural anesthetic presents significant implications for the patient's quality of life, as it involves potential permanent disability in mobility. The inability to walk independently and the limited mobility affect the patient's daily activities, professional life, and responsibilities as a new mother. Although there is no immediate life-threatening threat, the psychological and long-term quality of life implications make it a high-stakes scenario. However, since the patient is not facing immediate critical medical deterioration or life-threatening circumstances, it is not at the highest possible level of urgency.