Medical Specialty: Consult - History and Phy.
Sample Name: H&P - Nausea & Vomiting

CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,PAST MEDICAL HISTORY:,1. Diabetes mellitus (poorly controlled).,2. Hypertension (poorly controlled).,3. Chronic renal insufficiency.,4. Adrenal mass.,5. Obstructive sleep apnea.,6. Arthritis.,7. Hyperlipidemia.,PAST SURGICAL HISTORY:,1. Removal of ovarian cyst.,2. Hysterectomy.,3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.,4. Colonoscopy in June, 2005, showing diverticular disease.,5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. Laparoscopic adrenalectomy in January, 2006.,MEDICATIONS:,1. Reglan 10 mg orally every 6 hours.,2. Nexium 20 mg orally twice a day.,3. Labetalol.,4. Hydralazine.,5. Clonidine.,6. Lantus 20 units at bedtime.,7. Humalog 30 units before meals.,8. Prozac 40 mg orally daily.,SOCIAL HISTORY:, She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use.,FAMILY HISTORY:, Significant for diabetes and hypertension.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,HEENT: See has had headaches, and some dizziness. She denies any vision changes.,CARDIAC: She denies any chest pain or palpitations.,RESPIRATORY: She denies any shortness of breath.,GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis.,NEUROLOGICAL: She denies any neurological deficits.,All other systems were reviewed and were negative unless otherwise mentioned in HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98.,GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well.,HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear.,NECK: Supple. No JVD. No lymphadenopathy.,LUNGS: Clear to auscultation bilaterally, nonlabored.,HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops.
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DESCRIPTION: Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis.

The situation involves a 43-year-old female with a history of serious and chronic health conditions, including poorly controlled diabetes, hypertension, chronic renal insufficiency, and gastroparesis. She has been medically noncompliant in the past and is now presenting with intractable nausea and vomiting, as well as very high blood pressure, both of which require urgent medical intervention. Given the combination of poor compliance, potentially life-threatening hypertension, and complex medical history, this is a high-stakes situation. Failure to properly manage these conditions could result in severe health complications or even life-threatening consequences.


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: Glioma - 1

CC:, Dysarthria,HX: ,This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of "tumor or reactive lymphocytosis." One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR, Mammogram, PPD, ANA, TFT, and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images.,MEDS: ,none.,PMH:, 1)G3P3, 2)last menses one year ago.,FHX:, Mother suffered stroke in her 70's. DM and Htn in family.,SHX:, Married, Secretary, No h/o tobacco/ETOH/illicit drug use.,ROS:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,EXAM:, BP139/74, HR 90, RR20, 36.8C,MS: Drowsy to somnolent, occasionally "giddy." Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart).,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout. Normal muscle tone and bulk.,Sensory: No deficit to LT/PP/VIB/PROP.,Coord: difficulty with RAM in BUE, and ataxia on FNF and HKS in all extremities.,Station: Romberg sign present.,Gait: unsteady, wide-based, with notable difficulty on TW, TT and HW.,Reflexes: 2/2 BUE, 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45), Albumin 68 (normal 14-20), IgG10mg/dl (normal <6.2), IgG index -O.1mg/24hr (normal),,No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil), RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE, SPEP, Urine histoplasmin were negative.,Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted.,Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA, LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable.,She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma.,She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal , HSV, CMV and AFB cultures were negative. HSV, and VZV antigen was negative.,Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility.
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DESCRIPTION: Dysarthria.  Probable brainstem glioma.

Dysarthria.  Probable brainstem glioma.

This situation involves a complex medical case with a potentially serious condition (probable brainstem glioma) that led to significant neurological decline and the necessity for extensive supportive care. It required detailed diagnostic evaluation, including MRI scans, lumbar punctures, and a brain biopsy, yet an inconclusive diagnosis was reached. The patient's condition worsened to the point of requiring 24-hour care and a decision for 'Do Not Resuscitate' (DNR) status was made by the family. The seriousness of the medical condition and the life-altering implications for the patient and family contribute to the high-stakes nature of the case.

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

CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female.  Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, Diagnostic laparoscopic exam for pelvic pain/adhesions.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS:, No current medications.,OCCUPATIONAL /SOCIAL HISTORY:, Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs.,FAMILY MEDICAL HISTORY:, There is no significant, contributory family medical history.,OB GYN HISTORY:, LMP: 5/15/1999. Gravida: 1. Para: 1.  Date of last pap smear: 1/15/1998.,REVIEW OF SYSTEMS:,Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax.,Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment.,Neurological: Patient admits to symptoms of seizures and ataxia.,Skin: Denies scaling, rashes, blisters, photosensitivity.,PHYSICAL EXAMINATION:,Appearance: Healthy appearing. Moderately overweight.,HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions.,Neck: Neck mobile. Trachea is midline.,Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy.,Breast: Normal appearing breasts bilaterally, nipples everted.  No nipple discharge, skin changes.,Chest: Normal breath sounds heard bilaterally without rales or rhonchi.  No pleural rubs. No scars.,Cardiovascular: Regular heart rate and rhythm without murmur or gallop.,Abdominal: Bowel sounds are high pitched.,Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal.,Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions.,IMPRESSION DIAGNOSIS:  ,  Gall Bladder Disease. Abdominal Pain.,DISCUSSION:, Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure.,PLAN:, We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram.,MEDICATIONS PRESCRIBED:,
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DESCRIPTION: Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.

The patient is experiencing significant and persistent symptoms that affect daily life, such as nausea, abdominal pain, and intolerance to fatty foods, which have been ongoing for three months. The symptoms suggest a gallbladder issue, confirmed by ultrasound (cholelithiasis) and laboratory findings. Although the situation requires surgical intervention (Laparoscopic Cholecystectomy), it is a common procedure with a relatively low risk and high success rate. Hence, while the condition is undoubtedly important to address for the patient's health and quality of life, it does not present an immediate risk of severe consequences or life-threatening condition. Therefore, it should be considered as moderately high-stakes, primarily due to the need for invasive surgical intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: Glioblastoma Multiforme - Consult

REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.
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DESCRIPTION: Asked to see the patient in regards to a brain tumor.  She was initially diagnosed with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.

This situation involves a patient with glioblastoma multiforme, a highly aggressive and malignant form of brain tumor. The stakes are high because the condition is life-threatening and requires immediate and accurate treatment decisions. The patient is currently experiencing increased confusion due to tumor progression, indicating a potential worsening of her condition. There is an urgent need to clarify her treatment plan with another doctor, Dr. Y, to determine the next steps in managing her care, including the use of Temodar, a chemotherapy medication. The high-stakes nature is further emphasized by the patient's confusion and the need for coordinated and timely intervention to address her deteriorating neurological status.


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

REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  She did well for the next 10 years or so, and developed Parkinson disease, possibly related to radiation therapy.  She has been followed by neurology, Dr. Z, to treat seizure activity.  She has a vagal stimulator in place to help control her seizure activity.,Over the last few months, she has had increasing weakness on the right side.  She has been living in a nursing home.  She has not been able to walk, and she has not been able to write for the past three to four years.,MRI scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  There was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,Surgery was performed during this admission to remove some of the posterior part of the tumor.  She tolerated the procedure well.  She has noticed no worsening or improvement in her weakness.  Pathology shows a low- to intermediate-grade glioma.  The second opinion by Dr. A is still pending.,The patient is feeling well today.  She is not having headache, and reports no new neurologic symptoms.  She has not had leg swelling, cough, shortness of breath, or chest pain.,CURRENT MEDICATIONS:  ,1.  Ambien p.r.n.  ,2.  Vicodin p.r.n.  ,3.  Actonel every Sunday.  ,4.  Colace.  ,5.  Felbatol 1200 mg b.i.d.  ,6.  Heparin injections for prophylaxis.  ,7.  Maalox p.r.n.  ,8.  Mirapex 0.5 mg t.i.d.  ,9.  Protonix 40 mg daily.  ,10.  Tylenol p.r.n.  ,11.  Zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  ,12.  She has Zofran p.r.n., albuterol inhaler q.i.d., and Aggrenox, which she is to start.,The rest of the history is mostly from the chart.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,PAST MEDICAL HISTORY:  ,1.  Parkinson's, likely secondary to radiation therapy.,2.  History of prior stroke.,3.  Seizure disorder secondary to her brain tumor.,4.  History of urinary incontinence.,5.  She has had hip fractures x2, which have required surgical pinning.,6.  Appendectomy.,7.  Cholecystectomy.,SOCIAL HISTORY:,  Shows that she does not smoke cigarettes or drink alcohol.  She lives in a nursing home.,FAMILY HISTORY:,  Shows a family history of breast cancer.,PHYSICAL EXAMINATION:,  ,GENERAL:  Today, she is sitting up in the chair, alert, and appropriate.  She tends to lean towards the right.  The right arm and hand are noticeably weaker than the left.  She is quite thin.,VITAL SIGNS:  Temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,HEENT:  There is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  The oropharynx shows no thrush or mucositis.,LUNGS:  Clear bilaterally to auscultation.,CARDIAC:  Exam shows regular rate.,ABDOMEN:  Soft.,EXTREMITIES:  No peripheral edema or evidence of deep venous thrombosis (DVT) is noted on the lower extremities.,IMPRESSION AND PLAN:,  Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.,We reviewed the phase II trials that have used Temodar in the setting of grade 2 gliomas.  Although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  We discussed using Temodar after she heals from her surgery.  Toxicities would include fatigue, nausea, and myelosuppression primarily.
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DESCRIPTION: Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.

The case involves a 71-year-old woman with a history of a brain tumor diagnosed over 20 years ago, currently dealing with progressive low-grade glioma and other complex health issues, such as Parkinson's, seizure disorder, and a history of stroke and falls. The patient has undergone multiple surgeries and therapies, and the management of her condition involves significant decisions about ongoing treatment, including the potential use of Temodar. The context involves high-stakes due to the life-altering implications of these medical decisions on the patient's health, especially given her age and comorbidities. The stakes are heightened by the fact that the outcome of treatment directly impacts her quality of life.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med H&P - 1

CHIEF COMPLAINT:, Left leg pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage IIIC papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on Saturday. The patient noticed the pain in her left groin and left thigh and also noticed swelling in that leg. A Doppler ultrasound of her leg that was performed today noted a DVT. She is currently on course one, day 14 of 21 of Taxol and carboplatin. She is scheduled for intraperitoneal port placement for intraperitoneal chemotherapy to begin next week. She denies any chest pain or shortness of breath, nausea, vomiting, or dysuria. She has a positive appetite and ambulates without difficulty.,PAST MEDICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Mitral valve prolapse.,3. Stage IIIC papillary serous adenocarcinoma of the ovaries.,PAST SURGICAL HISTORY:,1. A D and C.,2. Bone fragment removed from her right arm.,3. Ovarian cancer staging.,OBSTETRICAL HISTORY:, Spontaneous miscarriage at 3 months approximately 30 years ago.,GYNECOLOGICAL HISTORY: ,The patient started menses at age 12; she states that they were regular and occurred every month. She finished menopause at age 58. She denies any history of STDs or abnormal Pap smears. Her last mammogram was in April 2005 and was within normal limits.,FAMILY HISTORY:,1. A sister with breast carcinoma who was diagnosed in her 50s.,2. A father with gastric carcinoma diagnosed in his 70s.,3. The patient denies any history of ovarian, uterine, or colon cancer in her family.,SOCIAL HISTORY:, No tobacco, alcohol, or drug abuse.,MEDICATIONS:,1. Prilosec.,2. Tramadol p.r.n.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.3, pulse 91, respiratory rate 18, blood pressure 142/46, O2 saturation 99% on room air.,GENERAL: Alert, awake, and oriented times three, no apparent distress, a well-developed, well-nourished white female.,HEENT: Normocephalic and atraumatic. The oropharynx is clear. The pupils are equal, round, and reactive to light.,NECK: Good range of motion, nontender, no thyromegaly.,CHEST: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.,CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur on her left side.,ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly, a well-healing midline incision.,EXTREMITIES: 2+ pulses bilaterally, right leg without swelling, nontender, no erythema, negative Homans' sign bilaterally, left thigh swollen, erythematous, and warm to the touch compared to the right. Her left groin is slightly tender to palpation.,LYMPHATICS: No axillary, groin, clavicular, or mandibular nodes palpated.,LABORATORY DATA:, White blood cell count 15.5, hemoglobin 11.4, hematocrit 34.5, platelets 159, percent neutrophils 88%, absolute neutrophil count 14,520. Sodium 142, potassium 3.3, chloride 103, CO2 26, BUN 15, creatinine 0.9, glucose 152, calcium 8.7. PT 13.1, PTT 28, INR 0.97.,ASSESSMENT AND PLAN:, Miss Bolen is a 59-year-old gravida 1, para 0-0-1-0 with stage IIIC papillary serous adenocarcinoma of the ovary. She is postop day 21 of an exploratory laparotomy with ovarian cancer staging. She is currently with a left leg DVT.,1. The patient is doing well and is currently without any complaints. We will start Lovenox 1 mg per kg subcu daily and Coumadin 5 mg p.o. daily. The patient will receive INR in the morning; the goal was obtain an INR between 2.5 and 3.0 before the Lovenox is instilled. The patient is scheduled for port placement for intraperitoneal chemotherapy and this possibly may be delayed.,2. Aranesp 200 mcg subcu was given today. The patient's absolute neutrophil count is 14,520.
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DESCRIPTION: History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).

The situation involves a 59-year-old patient with a history of stage IIIC papillary serous adenocarcinoma of the ovary who has developed a deep vein thrombosis (DVT) in the left leg. DVT is a serious condition that can potentially lead to life-threatening complications such as pulmonary embolism if not treated promptly. The patient is also undergoing chemotherapy, which complicates her health further. This indicates that the situation is high-stakes due to the potential for severe complications, the need for timely intervention, and the presence of advanced cancer.


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

PROBLEM:  ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland.  The patient is not a great historian.  Most of the history is obtained through the old history and chart that the patient has with her.  According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting.  During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr.  A in August 2001.  It was assumed that this was caused by biliary dyskinesia.  Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.
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DESCRIPTION: GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.

The situation involves a young patient with chronic and complex symptoms related to abdominal pain, nausea, vomiting, and abnormal liver function tests. These symptoms have persisted despite previous medical interventions, indicating a complex and potentially serious underlying condition. The need for further evaluation points to the potential for serious health implications, which may significantly affect the patient's quality of life and long-term health outcomes. However, this is a routine part of medical evaluation and such consultations are fairly common in the field of gastroenterology.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 49

HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.  The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks.  I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus type 2.,2.  Diabetic nephropathy.,3.  Chronic kidney disease, stage 4.,4.  Hypertension.,5.  Hypercholesterolemia and hyperlipidemia.,6.  Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:,  Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:,  NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room.  Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out.  Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better.  Denies any fever and chills.  Denies any dysuria, frequency or hematuria.  States that the urine output was decreased considerably, and she could not urinate.  Denies any cough, hemoptysis or sputum production.  Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General:  The patient is alert and oriented, in no acute distress.,Vital Signs:  Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20.  The patient's weight is 105.6 kg.,Head:  Normocephalic.,Neck:  Supple.  No JVD.  No adenopathy.,Chest:  Symmetric.  No retractions.,Lungs:  Clear.,Heart:  RRR with no murmur.,Abdomen:  Obese, soft, and nontender.  No rebound.  No guarding.,Extremity:  She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date.  The patient's white cell is 12.7, hematocrit 26.1.  The patient has 90% segs and 0% bands.  Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9.  Sed rate was 121.  BNP was 851.  Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1.  Urinary tract infection.,2.  Acute gouty attack.,3.  Diabetes mellitus with diabetic nephropathy.,4.  Hypertension.,5.  Hypercholesterolemia.,6.  Peripheral vascular disease, status post recent PTA in the right side.,7.  Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment.  We will add allopurinol 50 mg daily.  This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results.
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DESCRIPTION: A female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.

The patient has a complex medical history, including chronic conditions like stage 4 chronic kidney disease, diabetes mellitus with complications, and hypertensive and vascular diseases. These conditions require careful management and can lead to significant health issues if not monitored appropriately. The immediate medical issue, a gout attack, could exacerbate kidney issues given her chronic kidney disease. Furthermore, swelling and pain can indicate severe acute manifestations that need timely intervention. Given the multiple comorbidities, each treatment decision can have significant consequences, hence making the situation high-stakes for the patient’s overall health and well-being.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 51

CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.  He described the pain as 8/10 in severity and the intensity varied.  The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission.  The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting.  The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction.  The patient was subsequently admitted for possible obstruction.  The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.)  He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily.  Esophageal reflux treated with Nexium 40 mg daily.  Allergic rhinitis treated with Allegra 180 mg daily.  Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly.  Glaucoma treated with Xalatan drops.  History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES:  ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of "old age," mother died at age 89 of "old age."  Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease.  Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY:  ,The patient is widowed and a retired engineer.  He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss.  HEENT:  Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat.  Neck:  Denies neck stiffness, no pain or masses in the neck.  Respiratory:  Denies cough, sputum production, hemoptysis, wheezing or shortness of breath.  Cardiovascular:  Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation.  Gastrointestinal:  See history of the present illness.  Urinary:  Denies dysuria, frequency, urgency or hematuria.  Neuro:  Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT:  Atraumatic, normocephalic.  Eyes, EOMs full, PERRLA.  Fundi benign.  TMs normal.  Nose clear.  Throat benign.,NECK:  Supple with no adenopathy.  Carotid upstrokes normal with no bruits.  Thyroid is not enlarged.,LUNGS:  Clear to percussion and auscultation.,HEART:  Regular rate, normal S1 and S2 with no murmurs or gallops.  PMI is nondisplaced.,ABDOMEN:  Mildly distended with mild diffuse tenderness.  There is no rebound or guarding.  Bowel sounds are hypoactive.,EXTREMITIES:  No cyanosis, clubbing or edema.  Pulses are strong and intact throughout.,GENITALIA:  Atrophic male, no scrotal masses or tenderness.  Testicles are atrophic.  No hernia is noted.,RECTAL:  Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:,  WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000.  Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44.  Alkaline phosphatase, AST and ALT are all normal.  UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1.  Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2.  Hypertension.,3.  Esophageal reflux.,4.  Allergic rhinitis.,5.  Glaucoma.,PLAN: , The patient is admitted to the medical floor.  He has been kept NPO and will be given IV fluids.  He will also be given antiemetic medications with Zofran and an analgesic as necessary.  General surgery consultation was obtained.  Abdominal series x-ray will be done.
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DESCRIPTION: Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.  The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.

The situation involves an elderly patient with a history of recurrent small bowel obstructions and recent acute symptoms such as severe abdominal pain and vomiting. Recurrent small bowel obstructions can be life-threatening if not managed appropriately, as they may lead to complications like perforation or ischemia. The patient's advanced age and medical history add complexity and potential risks to the situation. Given that he has been admitted for evaluation and potential intervention, this indicates a moderate to high-stakes scenario in the medical context.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 46

DIAGNOSES:,1.  Pneumonia.,2.  Crohn disease.,3.  Anasarca.,4.  Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY:  ,The patient is a 41-year-old gentleman with a long history of Crohn disease.  He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months.  He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers.  This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital.  He has been treated with IV antibiotics and is growing Streptococcus.  At this time, he seems relatively stable although slightly dyspneic.  Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities.  At this time, he continues to have symptoms consistent with diarrhea and malabsorption.  He also has some episodes of nausea and vomiting at times.  He currently has a cough and symptoms of dyspnea.  Further review of systems was not otherwise contributory.,MEDICATIONS:,1.  Prednisone.,2.  Effexor.,3.  Folic acid.,4.  Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1.  Small bowel resections.,2.  Appendectomy.,3.  A vasectomy.,ALLERGIES:  ,He has no known drug allergies.,SOCIAL HISTORY:  ,He does smoke two packs of cigarettes per day.  He has no alcohol or drug use.  He is a painter.,FAMILY HISTORY:  ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL:  He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS:  His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Nasal and oropharynx are clear.,NECK:  Supple.  No jugular venous pressure distention is noted.  There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST:  Reveals some crackles in the right chest, in the base, and in the upper lung fields.  His left is relatively clear with decreased breath sounds.,HEART:  Regular rate and rhythm.,ABDOMEN:  Slightly protuberant.  Bowel sounds are present.  He is slightly tender and it is diffuse.  There is no organomegaly and no ascites appreciable.,EXTREMITIES:  There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC:  Shows thin skin.  No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3.  There is no M-spike observed.  His B12 is 500 with a folic acid of 11.  His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1.  Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate.  I believe that he needs a calorie count.  We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered.  I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist.  I will help in anyway that I can to improve the patient's laboratory abnormalities.  However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time.  I have explained this in detail to the patient and his family.  Everybody expresses understanding and all questions were answered.  At this time, follow him up during his hospital stay and plan to see him in the office as well.
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DESCRIPTION: Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.

The case involves a 41-year-old patient with several significant health issues, including pneumonia, severe Crohn disease, protein-losing enteropathy, severe malnutrition, anasarca, and associated anemia with leukocytosis. Crohn disease exacerbates his underlying conditions and contributes to other complications like severe malnutrition and edema. Given these multiple, interconnected serious health issues, this situation is high-stakes because it requires immediate and comprehensive medical management to prevent further deterioration of the patient's health. The presence of pneumonia on top of severe malnutrition and other chronic conditions increases the risk of complications, which makes the situation critical.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 44

PAST MEDICAL HISTORY:  Include:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Hyperlipidemia.,4.  Gastroesophageal reflux disease.,5.  Renal insufficiency.,6.  Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7.  Enterocutaneous fistula.,8.  Respiratory failure.,9.  History of atrial fibrillation.,10.  Obstructive sleep apnea.,11.  History of uterine cancer, status post total hysterectomy.,12.  History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY:  The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY:  Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS:  Currently include,,1.  Albuterol inhaler q.4 h.,2.  Paradox swish and spit mouthwash twice a day.,3.  Digoxin 0.125 mg daily.,4.  Theophylline 50 mg q.6 h.,5.  Prozac 20 mg daily.,6.  Lasix 40 mg daily.,7.  Humulin regular high dose sliding scale insulin subcu. q.6 h.,8.  Atrovent q.4 h.,9.  Lantus 12 units subcu. q.12 h.,10.  Lisinopril 10 mg daily.,11.  Magnesium oxide 400 mg three times a day.,12.  Metoprolol 25 mg twice daily.,13.  Nitroglycerin topical q.6 h.,14.  Zegerid 40 mg daily.,15.  Simvastatin 10 mg daily.,ALLERGIES:  Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS:  The patient currently denies any pain, denies any headache or blurred vision.  Denies chest pain or shortness of breath.  She denies any nausea or vomiting.  Otherwise, systems are negative.,PHYSICAL EXAM:,General:  The patient is awake, alert, and oriented.  She is in no apparent respiratory distress.,Vital Signs:  Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24.  The patient has a tracheostomy in place.  She will also have an esophageal gastric tube in place.,Cardiac:  Regular rate and rhythm without audible murmurs, rubs or gallops.  Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases.  No adventitious sounds are noted.,Abdomen:  Obese.  There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery.  The area is covered with bandage with serosanguineous fluid.  Abdomen is nontender to palpation.  Bowel sounds are heard in all 4 quadrants.,Extremities:  Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA:  Pending.  Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT:  This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN:  For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours.  The patient had been previously controlled on this.  We will continue to check her sugars every 6 hours and adjust insulin as necessary.
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DESCRIPTION: An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.

The patient's medical history and current condition are quite complex, involving multiple serious chronic conditions such as Type II diabetes mellitus, hypertension, hyperlipidemia, renal insufficiency, respiratory failure, and a history of atrial fibrillation. Additionally, she has recently experienced sepsis and respiratory failure, which are critical events, and is now dependent on tube feeds. The comprehensive list of medications and known allergies also adds complexity to her management. This situation is further complicated by previous surgeries and the presence of an open abdominal wound. The overall health situation is precarious, requiring careful monitoring and continuous medical intervention. These factors indicate a high-stakes scenario due to the potential for rapid deterioration in the patient's condition if not managed properly.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 48

HISTORY:,  The patient presents today for medical management.  The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity.  Stomach gets upset with pain.  She has been off her supplements for four weeks with some improvement.  She has loose bowel movements.  She complains of no bladder control.  She has pain in her hips.  The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.,DIAGNOSES:,1.  Type II diabetes mellitus.,2.  Generalized fatigue and weakness.,3.  Hypertension.,4.  Peripheral neuropathy with atypical symptoms.,5.  Hypothyroidism.,6.  Depression.,7.  Long-term use of high-risk medications.,8.  Postmenopausal age-related symptoms.,9.  Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.,CURRENT MEDICATIONS: , Her list of medicines is as noted on 04/22/03.  There is a morning and evening lift.,PAST SURGICAL HISTORY:,  As listed on 04/22/04 along with allergies 04/22/04.,FAMILY HISTORY: , Basically unchanged.  Her father died of an MI at 65, mother died of a stroke at 70.  She has a brother, healthy.,SOCIAL HISTORY:  ,She has two sons and an adopted daughter.  She is married long term, retired from Avon.  She is a nonsmoker, nondrinker.,REVIEW OF SYSTEMS:,GENERAL:  Certainly at the present time on general exam no fever, sweats or chills and no significant weight change.  She is 189 pounds currently and she was 188 pounds in January.,HEENT:  HEENT, there is no marked decrease in visual or auditory function.  ENT, there is no change in hearing or epistaxis, sore throat or hoarseness.,RESPIRATORY:  Chest, there is no history of palpitations, PND or orthopnea.  The chest pains are nonspecific, tenderness to palpation has been reported.  There is no wheezing or cough reported.,CARDIOVASCULAR:  No PND or orthopnea.  Thromboembolic disease history.,GASTROINTESTINAL:  Intermittent symptoms of stomach pain, they are nonspecific.  No nausea or vomiting noted.  Diarrhea is episodic and more related to nerves.,GENITOURINARY:  She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.,MUSCULOSKELETAL:  Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.,NEUROLOGICAL:  No marked paralysis, paresis or paresthesias.,SKIN:  No rashes, itching or changes in the nails.,BREASTS:  No report of any lumps or masses.,HEMATOLOGY AND IMMUNE:  No bruising or bleeding-type symptoms.,PHYSICAL EXAMINATION:,WEIGHT:  189 pounds.  BP:  140/80.  PULSE:  76.  RESPIRATIONS:  20.  GENERAL APPEARANCE:  Well developed, well nourished.  No acute distress.,HEENT:  Head is normocephalic.  Ears, nose, and throat, normal conjunctivae.  Pupils are reactive.  Ear canals are patent.  TMs are normal.  Nose, nares patent.  Septum midline.  Oral mucosa is normal in appearance.  No tonsillar lesions, exudate or asymmetry.  Neck, adequate range of motion.  No thyromegaly or adenopathy.,CHEST:  Symmetric with clear lungs clear to auscultation and percussion.,HEART:  Rate and rhythm is regular.  S1 and S2 audible.  No appreciable murmur or gallop.,ABDOMEN:  Soft.  No masses, guarding, rigidity, tenderness or flank pain.,GU:  No examined.,EXTREMITIES:  No cyanosis, clubbing or edema currently.,SKIN AND INTEGUMENTS:  Intact.  No lesions or rashes.,NEUROLOGIC:  Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.,Additional information, the patient has been off metformin for few months and this is not part of her medication list.,IMPRESSION:,
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DESCRIPTION: The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity.  Stomach gets upset with pain.

The patient in the presented scenario has multiple chronic health conditions, including Type II diabetes mellitus, hypertension, hypothyroidism, peripheral neuropathy, depression, and others. These conditions require careful management to prevent complications. The patient's symptoms, including extreme fatigue, chest and back discomfort, and gastrointestinal issues, could indicate worsening of her chronic illnesses or new complications. Considering her medical history and the array of current symptoms, the stakes are moderately high, as failing to address these issues timely could lead to further complications or hospitalization.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 40

CHIEF COMPLAINT:, Altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. When asked why he came to the emergency room, the patient replies that it started about 2 PM yesterday. However, he is unable to tell me exactly what started at 2 PM yesterday. The patient's speech is clear, but he speaks nonsensically using words in combinations that don't make any sense. No other history of present illness is available.,PAST MEDICAL HISTORY:, Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia.,PAST SURGICAL HISTORY:, Unknown.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, The patient denies smoking and drinking.,MEDICATIONS:, Per the emergency room record, medications are Lotensin 20 mg daily, Toprol 50 mg daily, Plavix 75 mg daily and aspirin 81 mg daily.,ALLERGIES:, UNKNOWN.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature: 97.9. Pulse: 79. Respiratory rate: 20. Blood pressure: 117/84.,GENERAL: Well-developed, well-nourished male in no acute distress.,HEENT: Eyes: Pupils are equal, round and reactive. There is no scleral icterus. Ears, nose and throat: His oropharynx is moist. His hearing is normal.,NECK: No JVD. No thyromegaly.,CARDIOVASCULAR: Irregular rhythm. No lower extremity edema.,RESPIRATORY: Clear to auscultation bilaterally with normal effort.,ABDOMEN: Nontender. Nondistended. Bowel sounds are positive.,MUSCULOSKELETAL: There is no clubbing of the digits. The patient's strength is 5/5 throughout.,NEUROLOGICAL: Babinski's are downgoing bilaterally. Deep tendon reflexes are 2+ throughout.,LABORATORY DATA:, By report, head CT from the outlying facility was negative. An EKG showed atrial fibrillation with a rate of 75. There is no indication of any acute cardiac ischemia. A chest x-ray shows no acute pulmonary process, but does show cardiomegaly.,Labs are as follows: White count 9.4, hemoglobin 17.2, hematocrit 52.5, platelet count 219. PTT 24, PT 13, INR 0.96. Sodium 135, potassium 3.6, chloride 99, bicarb 27, BUN 13, creatinine 1.4, glucose 161, calcium 9, magnesium 1.9, total protein 7, albumin 3.7, AST 22, ALT 41, alkaline phosphatase 85, total bilirubin 0.7, total cholesterol 193. Cardiac isoenzymes are negative times one with a troponin of 0.09.,ASSESSMENT AND PLAN:,1. Probable stroke. The patient has an expressive aphasia. He does not have dysarthria, however. Also, his strength is not affected. I suspect that the patient has had strokes or TIAs in the past because he was taking aspirin and Plavix at home. Head CT is reportedly negative. I will ask our radiologist to re-read the head CT. I will also order MRI and MRA, carotid Doppler ultrasound and echocardiogram in addition to a fasting lipid profile. I will consult neurology to evaluate and continue his aspirin and Plavix.,2. Atrial fibrillation. The patient's rate is controlled currently. I will continue him on his amiodarone 200 mg twice daily and consult CHI to evaluate him.,3. Hypertension. I will continue his home medications and add clonidine as needed.,4. Hyperlipidemia. The patient takes no medications for this currently. I will check a fasting lipid profile.,5. Hyperglycemia. It is unknown whether the patient has a history of diabetes. His glucose is currently 171. I will start him on sliding scale insulin for now and monitor closely.,6. Renal insufficiency. It is also unknown whether the patient has a history of this and what his baseline creatinine might be. Currently he has only mild renal insufficiency. This does not appear to be prerenal. Will monitor for now.
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DESCRIPTION: Patient with a diagnosis of stroke.

Patient with a diagnosis of stroke.

The situation involves a 69-year-old male patient with altered mental status and a suspected stroke. Strokes are medical emergencies that can lead to serious long-term health problems, making timely and appropriate intervention critical. In addition, the patient has a history of atrial fibrillation, hypertension, and hyperlipidemia, which are risk factors for stroke, and these conditions require ongoing management. Given the acute nature of the stroke assessment and the need for a comprehensive diagnostic approach, including MRI, MRA, and consultation with specialists, this situation is high-stakes in the medical context.


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

CHIEF COMPLAINT:,  Jaw pain this morning.,BRIEF HISTORY OF PRESENT ILLNESS:,  This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease.  The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day.  Also, history of chronic diverticulitis with recent bouts.  The patient has been doing well, seen in my office at the end of December for complete physical examination.  I had ordered a stress test for him, then delayed due to a family illness.  However, denies any chest pain or chest tightness with exertion.  The patient was doing well.  He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand.  He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain.  He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event.  The patient's pain resolved.  He was given nitroglycerin in the emergency room drawing his blood pressure 67/32.  Blood pressure quickly came back to normal with the patient's reverse Trendelenburg.,FAMILY HISTORY: , Strongly positive for heart disease in his father.  He had a bypass at age 60.  Both parents are alive.  Both have dementia.  His father has history of coronary artery disease and multiple vascular strokes.  He is in his 80s.  His mother is 80, also with dementia.  The patient does not smoke or drink.,PAST MEDICAL HISTORY:,  Remarkable for tonsillectomies.,MEDICATIONS:,  Synthroid and Lipitor.,ALLERGIES:,  PENICILLIN AND BIAXIN.,REVIEW OF SYSTEMS:,  Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18.  He is afebrile.,GENERAL:  He is well-developed, well-nourished white male, in no acute distress.,HEENT:  Pupils equal, round, and reactive to light and accommodation.  Extraocular movements were intact.  Throat was clear.,NECK:  Supple.  There is no organomegaly or thyromegaly.  Carotids are +2 without bruits.,CHEST:  Lungs are clear to auscultation and percussion.,CV:  Without any murmurs or gallops.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.  Bowel sounds are active.  No tenderness.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Peripheral pulses 2+.,NEUROLOGICAL:  Intact.  Motor exam is 5/5.,LABORATORY STUDIES:,  EKG is within normal limits, good sinus rhythm.  His axis is somewhat leftward.  CBC and BMP were normal and cardiac enzymes were negative x1.,IMPRESSION:,1.  Jaw pain, sounds musculoskeletal.  We will rule out angina equivalent.,2.  Hypercholesterolemia.,3.  Hypothyroidism.,PLAN: , Lipitor and thyroid have been ordered.  His chest pain unit protocol for the stress thallium that will be done in the morning.  If test is negative, we will discharge home.  If positive, we will consult Cardiology.  The patient requests Dr. ABC.
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DESCRIPTION: Consultation for jaw pain.

Consultation for jaw pain.

The situation involves a 53-year-old male with jaw pain and a background that suggests potential cardiac issues. While his symptoms might be musculoskeletal in nature, the context of hypercholesterolemia, family history of heart disease, and the potential for angina make this a situation that requires careful medical assessment to rule out a cardiac event, which could be high-stakes. Immediate follow-up examinations, such as a stress thallium test, are planned to evaluate his condition. Given the potential risk associated with heart issues, if a cardiac problem were present, it could lead to serious health outcomes, hence the necessity of thorough investigation.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 33

MEDICAL PROBLEM LIST:,1.  Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.,2.  Dementia and depression.,3.  Hypertension.,4.  History of atrial fibrillation.  The patient has been in sinus rhythm as of late.  The patient is not anticoagulated due to fall risk.,5.  Glaucoma.,6.  Degenerative arthritis of her spine.,7.  GERD.,8.  Hypothyroidism.,9.  Chronic rhinitis (the patient declines nasal steroids).,10.  Urinary urge incontinence.,11.  Chronic constipation.,12.  Diabetes type II, 2006.,13.  Painful bunions on feet bilaterally.,CURRENT MEDICINES: , Aspirin 81 mg p.o. daily, Cymbalta 60 mg p.o. daily, Diovan 80 mg p.o. daily, felodipine 5 mg p.o. daily, omeprazole 20 mg daily, Toprol-XL 100 mg daily, Levoxyl 50 mcg daily, Lantus insulin 12 units subcutaneously h.s., simvastatin 10 mg p.o. daily, AyrGel to both nostrils twice daily, Senna S 2 tablets twice daily, Timoptic 1 drop both eyes twice daily, Tylenol 1000 mg 3 times daily, Xalatan 0.005% drops 1 drop both eyes at bedtime, and Tucks to rectum post BMs.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  ACE INHIBITOR MAY HAVE CAUSED A COUGH.,CODE STATUS:,  Do not resuscitate, healthcare proxy, palliative care orders in place.,DIET:,  No added salt, no concentrated sweets, thin liquids.,RESTRAINTS:,  None.  The patient has declined use of chair check and bed check.,INTERVAL HISTORY: , Overall, the patient has been doing reasonably well.  She is being treated for some hemorrhoids, which are not painful for her.  There has been a note that she is constipated.,Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188.  I see a couple in the 150s.  However, I also see one that is in the one teens and a couple in the 120s range.,She is not bothered by cough or rib pain.  These are complaints, which I often hear about.,Today, I reviewed Dr. Hudyncia's note from psychiatry.  Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year.,She is not having problems with breathing.  No neurologic complaints or troubles.  Pain is generally well managed just with Tylenol.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is pleasant and cooperative.  She is in no apparent distress.  Her lungs are clear to auscultation and percussion.  Heart sounds regular to me.  Abdomen:  Soft.  Extremities without any edema.  At the rectum, she has a couple of large hemorrhoids, which are not thrombosed and are not tender.,ASSESSMENT AND PLAN:,1.  Hypertension, good control, continue current.,2.  Depression, well treated on Cymbalta.  Continue.,3.  Other issues seem to be doing pretty well.  These include blood pressure, which is well controlled.  We will continue the medicines.  She is clinically euthyroid.  We check that occasionally.  Continue Tylenol.,4.  For the bowels, I will increase the intensity of regimen there.  I have a feeling she would not tolerate either the FiberCon tablets or Metamucil powder in a drink.  I will try her on annulose and see how she does with that.
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DESCRIPTION: Patient with hypertension, dementia, and depression.

The patient has an extensive list of chronic conditions, including previous multiple cerebrovascular accidents, diabetes, atrial fibrillation, and others. However, the current assessment shows that these conditions are generally well managed. The medical issues do require careful monitoring and management, especially given the patient's 'Do Not Resuscitate' and palliative care status. While the situation involves multiple serious health conditions, the patient's condition seems stable with routine health management. Therefore, the urgency or immediate risk level appears moderate rather than high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 30

CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes.  She usually does not take her meal on time, and also not having her regular meals lately.  The patient usually still takes her diabetic medication.  Today, the patient was found to have decrease in mental alertness, but no other GI symptoms.  Some sweating and agitation, but no fever or chills.  No other rash.  Because of the above symptoms, the patient was treated in the emergency department here.  She was found to glucose in 30 range, and hypertension.  There was some question whether she also take her blood pressure medication or not.  Because of the above symptoms, the patient was admitted to the hospital for further care.  The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement.  At this time, the patient's glucose was in the 175 range.,PAST MEDICAL HISTORY: , Diabetes, hypertension.,PAST SURGICAL HISTORY:,  None.,FAMILY HISTORY: , Unremarkable.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  In Spanish label.  They are the diabetic medication, and also blood pressure medication.  She also takes aspirin a day.,SOCIAL HISTORY:  ,The patient is a Mazatlan, Mexico resident, visiting her son here.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,HEENT:  Clear, atraumatic, normocephalic.  No sinus tenderness.  No obvious head injury or any laceration.  Extraocular movements are intact.  Dry mucosal linings.,HEART:  Regular rate and rhythm, without murmur.  Normal S1, S2.,LUNGS:  Clear.  No rales.  No wheeze.  Good excursion.,ABDOMEN:  Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,EXTREMITIES:  No edema, clubbing, or cyanosis.  No rash.,LABORATORY FINDINGS: , On Admission:  CPK, troponin are negative.  CMP is remarkable for glucose of 33.  BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7.  Urinalysis shows specific gravity of 10.30.  CT of the brain showed no hemorrhage.  Chest x-ray showed no acute cardiomegaly or any infiltrates.,IMPRESSION:,1.  Hypoglycemia due to not eating her meals on a regular basis.,2.  Hypertension.,3.  Renal insufficiency, may be dehydration, or diabetic nephropathy.,PLAN: , Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.
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DESCRIPTION: Patient was found to have decrease in mental alertness

The situation involves a patient with a significant drop in glucose levels (hypoglycemia), leading to decreased mental alertness, alongside hypertension and possible renal insufficiency. These conditions are serious, particularly the hypoglycemia which can be life-threatening if not addressed promptly. The patient was already treated in the emergency department, indicating an urgent need for medical intervention. The complexity and combination of conditions make this a high-stakes medical situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 21

SUBJECTIVE:,  The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage.  She does take Zyrtec on a fairly regular basis.  Mom is having some allergy trouble herself right now.  She does not know her colors.  She knows some of her shapes.  She speaks in sentences.  She is not showing much interest in the potty.  She is in the 80th percentile for height and weight, and still over 95th percentile for head circumference.  Mom has no other concerns.,ALLERGIES:,  Eggs and peanuts.,OBJECTIVE:,General:  Alert, very talkative little girl.,HEENT:  TMs clear and mobile.  Eyes:  PERRL.  Fundi benign.  Pharynx clear.  Mouth moist.  Nasal mucosa is pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Clear.  No tachypnea, wheezing, rales or retractions.,Abdomen:  Soft and nontender without mass or organomegaly.,GU:  Normal female genitalia.  Tanner stage I.,Extremities:  No clubbing, cyanosis or edema.  Pulses 2+ and equal.,Hips:  Intact.,Neurological:  Normal.  DTRs are 2+.  Gait was normal.,Skin:  Warm and dry.  No rashes noted.,ASSESSMENT:,  Allergic rhinitis.  Otherwise healthy 2-year-old young lady.,PLAN:,  In addition to her Zyrtec, I put her on Nasonex spray one spray each nostril daily.  If this works for her, certainly she can do it through the ragweed season.  Otherwise she is doing well.  I talked about ways to improve her potty training.  She is a very good eater.  I will see her yearly or p.r.n.  Unfortunately she is not able to get the flu shot due to her egg allergy.
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DESCRIPTION: A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis

consult - history and phy., allergic rhinitis, nasal drainage, stuffiness, congestion, drainage,

The situation involves a routine pediatric consultation for allergic rhinitis, which is commonly seen in young children. The child's symptoms are being managed with medication, and there are no immediate life-threatening conditions described. Though her allergy to eggs prevents her from receiving the flu shot, this does not significantly elevate the stakes in terms of immediate health risks. The primary issues are managing her current mild symptoms and allergies, which the proposed treatment plan addresses. As such, the situation does not involve any critical or urgent medical concerns.


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: Gen Med Consult - 20

SUBJECTIVE:,  This is an 11-year-old female who comes in for two different things.  1.  She was seen by the allergist.  No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting.  They do not notice a lot of snoring at night though, but she seems to be always like that.  2.  On her right great toe, she has got some redness and erythema.  Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,PAST MEDICAL HISTORY:,  Otherwise reviewed and noted.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home.,REVIEW OF SYSTEMS:,  She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed female, in no acute distress, afebrile.,HEENT:  Sclerae and conjunctivae clear.  Extraocular muscles intact.  TMs clear.  Nares patent.  A little bit of swelling of the turbinates on the left.  Oropharynx is essentially clear.  Mucous membranes are moist.,Neck:  No lymphadenopathy.,Chest:  Clear.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  She has got redness along the lateral portion of her right great toe, but no bleeding or oozing.  Some dryness of her skin.  Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,ASSESSMENT:,1.  History of congestion, possibly enlarged adenoids, or just her anatomy.,2.  Ingrown toenail, but slowly resolving on its own.,PLAN:,1.  For the congestion, we will have ENT evaluate.  Appointment has been made with Dr. XYZ for in a couple of days.,2.  I told her just Neosporin for her toe, letting the toenail grow out longer.  Call if there are problems.
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DESCRIPTION: 11-year-old female.  History of congestion, possibly enlarged adenoids.

consult - history and phy., enlarged adenoids, adenoids, oropharynx, congestion, toenails, toe,

The situation described involves medical concerns for an 11-year-old female, specifically nasal congestion possibly linked to enlarged adenoids, and an ingrown toenail. While these issues need medical attention, they are not immediately life-threatening and have clear plans for management (ENT evaluation and Neosporin application). Hence, the situation is not high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 29

CHIEF COMPLAINT: , This is a previously healthy 45-year-old gentleman.  For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain.  On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia.  He was able to reduce this, with relief of pain.  He is now being admitted for definitive repair.,PAST MEDICAL HISTORY: , Significant only for hemorrhoidectomy.  He does have a history of depression and hypertension.,MEDICATIONS: , His only medications are Ziac and Remeron.,ALLERGIES:,  No allergies.,FAMILY HISTORY: , Negative for cancer.,SOCIAL HISTORY:,  He is single.  He has 2 children.  He drinks 4-8 beers per night and smokes half a pack per day for 30 years.  He was born in Salt Lake City.  He works in an electronic assembly for Harmony Music.  He has no history of hepatitis or blood transfusions.,PHYSICAL EXAMINATION:,GENERAL:  Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,HEENT:  No scleral icterus.,NECK:  No cervical, supraclavicular, or axillary adenopathy.,LUNGS:  Clear.,HEART:  Regular.  No murmurs or gallops.,ABDOMEN:  As noted, obese with mildly visible bulging in the umbilicus at the superior position.  With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,DIAGNOSTIC STUDIES:  ,Normal sinus rhythm on EKG, prolonged QT.  Chest x-ray was negative.  The abdominal x-rays were read as being negative.  His electrolytes were normal.  Creatinine was 0.9.  White count was 6.5, hematocrit was 48, and platelet count was 307.,ASSESSMENT AND PLAN:,  Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.
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DESCRIPTION: Patient with intermittent episodes of severe nausea and abdominal pain.

consult - history and phy., sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent,

The patient is being admitted for a surgical procedure to repair an incarcerated umbilical hernia. While the condition has caused significant discomfort, it has been temporarily relieved by a manual reduction in the emergency department. The patient is undergoing a planned surgery for definitive repair with mesh, which is generally a routine procedure. Although surgery always carries some level of risk, especially with comorbidities like hypertension and depression, this surgery is not considered extremely high-stakes as it is a standard procedure with a good prognosis and has relieved immediate concerns.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 2

HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye.  He states that he was doing his normal job when he felt a foreign body sensation.  He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day.  He has no significant blurriness of vision or photophobia.
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DESCRIPTION: Initial clinic visit for foreign body in left eye.

The situation involves a foreign body in the eye, which could pose a risk to the patient's vision if not treated properly. However, there are no immediate symptoms like significant blurriness or photophobia that suggest severe damage. While it needs timely medical attention, it may not be life-threatening or extremely high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 18

SUBJECTIVE:,  This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks.  Started off as a congestion but then he started coughing about a week ago.  Cough has gotten worsen.  Mother was also worried.  He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened.  He is not running any fevers.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Fairly healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  The sister is in today with clinical sinusitis.  Mother and father have been healthy.,REVIEW OF SYSTEMS:,  He has been congested for about three weeks ago.  Coughing now but no fevers.  No vomiting.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed male in no acute distress, afebrile.,Vital Signs:  Weight:  22 pounds 6 ounces.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular muscles are intact.  TMs are clear.  Nares are very congested.  Oropharynx has drainage in the back of the throat.  Mucous membranes are moist.  Mild erythema though.,Neck:  Some shotty lymphadenopathy.  Full range of motion.  Supple.,Chest:  Clear.  No crackles.  No wheezes.,Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  Clear.  Tone is good.  Capillary refill less than 3 seconds.,RADIOLOGY:,  Chest x-ray:  No foreign body noted as well.  No signs of pneumonia.,ASSESSMENT:,  Clinical sinusitis and secondary cough.,PLAN:,  Amoxicillin a teaspoon twice daily for 10 days.  Plenty of fluids.  Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving.
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DESCRIPTION: 1-year-old male who comes in with a cough and congestion.  Clinical sinusitis and secondary cough.

consult - history and phy., congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis,

The situation involves a 1-year-old child with respiratory symptoms (cough and congestion) that have persisted for several weeks. However, the physical examination and radiology results do not indicate any acute distress or severe issues like pneumonia, and a possible foreign body ingestion has been ruled out on chest x-ray. The child is being prescribed antibiotics for sinusitis and additional medications for symptom management, indicating that medical professionals are taking appropriate steps. Although parental concern is noted, it seems to be reasonably controlled and addressed by medical examination and treatment. Given these elements, the situation doesn't appear to be life-threatening or critical.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 19

SUBJECTIVE:,  This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.  The patient is in foster care, has a long history of the prematurity, born at 22 weeks.  She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic.  She is on 2-1/2 liters of oxygen and does require that.  Her diet has been fluctuating.  They have been trying to figure out what works best with her.  She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her.  They have been doing more pureed foods and that seems to loosen her up, so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure.  She was hospitalized a couple of weeks back for the distension she had in the abdomen.  Dr. XYZ has been working with her G-tube, increasing her Mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her G-tube site is looking.  She also has been seen Dr. Eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.,CURRENT MEDICATIONS:,  Flagyl, vitamins, Zyrtec, albuterol, and some Colace.,ALLERGIES TO MEDICINES: , None.,FAMILY SOCIAL HISTORY:,  As mentioned, she is in foster care.  Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient.  Biological Mom and Grandma do visit on Thursdays for about an hour.,REVIEW OF SYSTEMS:,  The patient has been eating fairly well, sleeping well, doing well with her sprints.  A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.,PHYSICAL EXAMINATION:,Vital Signs:  She is 28 pounds 8 ounces today, 33-1/2 inches tall.  She is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.,HEENT:  Sclerae and conjunctivae are clear.  TMs are clear.  Nares are patent.  Oropharynx is clear.  Trach site is clear of any signs of infection.,Chest:  Coarse.  She has got little bit of wheezing going on, but she is moving air fairly well.,Abdomen:  Positive bowel sounds and soft.  The G-tube site looks fairly clean today and healthy.  No signs of infection.  Her tone is good.  Capillary refill is less than three seconds.,ASSESSMENT:,  A 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.,PLAN:,  At this point is to continue with the Isomil and pureed baby foods, a little bit of Pediasure.  They are going to see Dr. XYZ towards the end of this month and follow up with Dr. Eisenbaum.  I would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand.  She is just doing wonderful progression on her development.  Each time I see her, I am very impressed, that relayed to foster mom.  Approximately 25 minutes spent with the patient, most of it counseling.
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DESCRIPTION: 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.

consult - history and phy., chronic lung disease, signs of infection, breathing status, foster mom, foster care, pediasure

The situation involves a 2-year-old with a history of prematurity, chronic lung disease, and various medical interventions such as a G-tube and oxygen support. While her condition appears stable, she requires ongoing monitoring and adjustments to her care plan. The foster care situation and potential for hospitalization when the foster mom is away complicate her care. However, she is not currently in a life-threatening situation, and her follow-up is planned with a reasonable timeline. Thus, the stakes are moderate given her medical needs and social situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 14

HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.
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DESCRIPTION: Complaint of left otalgia (serous otitis) and headache.  History of atopic dermatitis.

The case involves a 49-year-old female presenting with symptoms primarily related to otalgia, sinus pressure, and dermatitis. While the patient has a history of sinusitis and is currently dealing with discomfort, there are no acute or life-threatening symptoms reported. The physical examination indicates no distress, and the treatment plan involves non-critical interventions such as medication refills and nasal sprays. The situation is routine in the context of general medical practice and does not involve any immediate risk to the patient's health.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 11

CHIEF COMPLAINT:,1.  Infection.,2.  Pelvic pain.,3.  Mood swings.,4.  Painful sex.,HISTORY OF PRESENT ILLNESS:,  The patient is a 29-year-old female who is here today with the above-noted complaints.  She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past.  She is requesting antibiotics.  She has been squeezing them and some of them are very bruised and irritated.  She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again.  She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all.  She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off.  She states she does not wish to be on any medication at the current time.  She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she "wants to.",PAST MEDICAL HISTORY:,  Significant for cleft palate.,ALLERGIES:,  She is allergic to Lortab.,CURRENT MEDICATIONS:,  None.,REVIEW OF SYSTEMS:,  Please see history of present illness.,Psychiatric:  She has had some suicidal thoughts, but no plans.  She denies being suicidal at the current time.,Cardiopulmonary:  She has not had any chest pain or shortness of breath.,GI:  Denies any nausea or vomiting.,Neurological:  No numbness, weakness or tingling.,PHYSICAL EXAMINATION:,General:  The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,Vital signs:  Weight:  160 pounds.  Blood pressure:  100/60.  Pulse:  62.,Psychiatric:  I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,Extremities:  Her inner thighs are covered with multiple areas of folliculitis and mild abscesses.  They are bruised from her squeezing them.  We talked about that in detail.,ASSESSMENT:,1.  Folliculitis.,2.  Pelvic pain.,3.  Mood swings.,4.  Dyspareunia.,PLAN:,1.  I would like her to go to the lab and get a CBC, chem-12, TSH and UA.,2.  We will put her on cephalexin 500 mg three times a day.,3.  We will send her back to see Dr. XYZ regarding the pelvic pain per her request.,4.  We will get her an appointment with a psychiatrist for evaluation and treatment.,5.  She is to call if she has any further problems or concerns.  Otherwise I will see her back for her routine care or sooner if there are any further issues.
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DESCRIPTION: Infection (folliculitis), pelvic pain, mood swings, and painful sex (dyspareunia).

The situation involves multiple health concerns, including infection (folliculitis), pelvic pain, and dyspareunia, impacting the patient's quality of life. Additionally, the patient is experiencing significant mood swings and has a history of suicidal thoughts, although she is not currently suicidal. She has discontinued psychiatric medication, which can further complicate her mental health state. The combination of these physical and mental health issues makes it a moderately high-stakes situation, due to the potential for complications if not adequately addressed. However, there are no immediate life-threatening conditions apparent from the information provided.


Medical Specialty: Consult - History and Phy.
Sample Name: Gastric Bypass Discussion - 1

HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities.  He is also an ex-smoker.  He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. ,PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us.  His pulse is 78, temperature is 97.5, blood pressure is 132/74.  Lungs are clear.  He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size.  Abdomen is soft, nontender.  No incisions.  No umbilical hernia, no groin hernia, has a large abdominal pannus.  No hepatosplenomegaly.  Lower extremities; no pedal edema.  No calf tenderness.  Deep tendon reflexes are normal.  Lungs are clear.  S1, S2 is heard.  Regular rate and rhythm. ,DISCUSSION:,  I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,All these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient.  The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities.  Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk.  He will be seen by cardiologist, pulmonologist.  He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities.  He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox.  He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so.  All these were discussed with the patient.  The patient understands.  He wants to go to surgery.  All questions were answered.  I will see him in few weeks before the planned date of surgery.
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DESCRIPTION: Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7

consult - history and phy., medifast, medifast dieting, hypertension, atrial fibrillation, hyperlipidemia, sleep apnea, morbid obesity, metabolic comorbidities, weight loss, supermorbid obesity, gastric bypass, bypass,

The situation involves a 55-year-old patient with morbid obesity (BMI of 69.7) discussing the possibility of undergoing gastric bypass surgery. This is a high-stakes situation due to the significant health risks associated with the surgery given the patient's severe comorbidities (hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and osteoarthritis) and history of smoking, which increases his risks of surgery complications such as DVT, PE, and cardiac issues. The decision to undergo such surgery carries significant potential health impacts, both positive and negative. The patient will need comprehensive preoperative preparation and long-term lifestyle changes, which adds to the seriousness of the situation.