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

FAMILY HISTORY: , His parents are deceased.  He has two brothers ages 68 and 77 years old, who are healthy.  He has siblings, a brother and a sister who were twins who died at birth.  He has two sons 54 and 57 years old who are healthy.  He describes history of diabetes and heart attack in his family.,SOCIAL HISTORY:  ,He is married and has support at home.  He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.,ALLERGIES:,  Garamycin.,MEDICATIONS: , Insulin 20 to 25 units twice a day.  Lorazepam 0.05 mg, he has a history of using this medication, but most recently stopped taking it.  Glipizide 5 mg with each meal, Advair 250 as needed, aspirin q.h.s., cod liver oil b.i.d., Centrum AZ q.d.,PAST MEDICAL HISTORY:  ,The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years.  He also has a history of prostate cancer, which was treated by radiation.  He says his PSA is at 0.01.,PAST SURGICAL HISTORY:,  In 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer.,REVIEW OF SYSTEMS: , Musculoskeletal:  He is right-handed.  Respiratory:  For shortness of breath.  Urinary:  For frequent urination.  GI:  He denies any bowel or bladder dysfunction.  Genital:  He denies any loss of sensation or erectile problems.  HEENT:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Cardiac:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Psychiatric:  Negative and noncontributory.,PHYSICAL EXAMINATION: , He is 5 feet 10 inches tall.  Current weight is 204 pounds, weight one year ago was 212.  BP is 130/66.  Pulse is 78.  On physical exam, the patient is alert and oriented with normal mentation and appropriate speech, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, poor dentition.  Cranial nerves II, III, IV, and VI, vision intact, visual fields full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cardiac, regular rate, a holosystolic murmur is also noted which is about grade 1 to 2.  Chest and lungs are clear bilaterally.  Skin is warm and dry, normal turgor and texture.  No rashes or lesions are noted.  Peripheral vascular, no cyanosis, clubbing, or edema is noted.  General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy.  Station and gait are appropriate.  He ambulates well without any difficulties or assistance.  No antalgic or spastic gait is noted.  Examination of the low back reveals no paralumbar spasms.  He is nontender to palpation over his spinous process, SI joints, or paralumbar musculature.  Deep tendon reflexes are 2+ bilaterally at the knees and 1+ at the ankles.  No ankle clonus is elicited.  Babinski, toes are downgoing.  Sensation is intact.,He does have some decreased sensation to pinprick, dull versus sharp over the right lower extremity compared to that of the left.  Strength is 5/5 and equal bilateral lower extremities.  He is able to ambulate on his toes and his heels without any weakness noted.  He has negative straight leg raising bilaterally.,FINDINGS:,  The patient brings in lumbar spine MRI for 11/15/2007, which demonstrates degenerative disc disease throughout.  At L4-L5 and L5-S1 he has severe disc space narrowing.  At L3-L4, he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge, which caused moderate neuroforaminal narrowing.  At L4-L5, degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis.  At L5-S1, there is an annular disc bulge more to the right causing right-sided neuroforaminal stenosis, which is quite severe compared to that on the left.,ASSESSMENT: , Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.,PLAN: , We discussed treatment options with this patient including:,1.  Do nothing.,2.  Conservative therapies.,3.  Surgery.,The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed.  We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam.  I did phone the patient's primary care doctor, Dr. O.  Unfortunately Dr. O is out of the country, and I did speak with Dr. K, who is covering for Dr. O.  I informed Dr. K that the patient had a new-onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before, so I obtained an EKG.  A copy was provided to the patient and the patient was referred back to his primary care physician for workup.  He was also released from our care at this time to a p.r.n. basis, but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications, which he will receive from his primary doctor.,All questions and concerns were addressed.  If he should have any further questions, concerns, or complications, he will contact our office immediately.  Otherwise, we will see him p.r.n.  Warning signs and symptoms were gone over with him.  Case was reviewed and discussed with Dr. L.
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DESCRIPTION: New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.

consult - history and phy., back pain, ligamentum flavum hypertrophy, annular disc bulge, degenerative disc disease, spinal stenosis, cranial nerves, degenerative,

This medical consultation concerns multiple significant health issues, including low back pain from degenerative disc disease and spinal stenosis, long-term diabetes, and a history of prostate cancer. The patient is also experiencing a new-onset heart murmur, potentially serious if untreated. However, the patient is not in immediate distress, is managing symptoms, and the medical team appears to handle conditions appropriately. The stakes increase due to the new medical findings (heart murmur), but the overall risk is mitigated given the patient's relatively stable condition and proactive care management plan.


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: Lobar Holoprosencephaly

CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with "lazy eye." No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable.
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DESCRIPTION: A 21-month-old male presented for delayed motor development, "jaw quivering" and "lazy eye."

consult - history and phy., delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine,

The context involves a child with developmental delays and specific physical symptoms, such as 'jaw quivering' and 'lazy eye', without a definite diagnosis. The healthcare scenario described involves an initial delay in motor skills and developmental testing. The decision to forego an MRI indicates that the family might not perceive immediate risk, and no acute medical interventions are described. However, assessing and identifying potential underlying conditions like lobar holoprosencephaly are crucial for future developments. The situation is sensitive as it affects a child's development and quality of life, making accurate diagnosis and management essential. However, it's not immediately life-threatening, indicating moderate stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Limbic Encephalitis

CC:, Rapidly progressive amnesia.,HX: ,This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally. There was no mass affect. The areas mildly enhanced with gadolinium.,PMH:, 1) CAD; MI x 2 (1978 and 1979). 2) PVD; s/p aortic endarterectomy (3/1991). 3)HTN. 4)Bilateral inguinal hernia repair.,FHX/SHX:, Mother died of a stroke at age 58. Father had CAD and HTN. The patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. He had been a feed salesman all of his adult life.,ROS:, Unremarkable. No history of cancer.,EXAM:, BP 136/75 HR 73 RR12 T36.6,MS: Alert but disoriented to person, place, time. He could not remember his birthdate, and continually asked the interviewer what year it was. He could not remember when he married, retired, or his grandchildren's names. He scored 18/30 on the Follutein's MMSE with severe deficits in orientation and memory. He had moderate difficulty naming. He repeated normally and had no constructional apraxia. Judgement remained good.,CN: unremarkable.,Motor: Full strength throughout with normal muscle tone and bulk.,Sensory: Intact to LT/PP/PROP,Coordination: unremarkable.,Station: No pronator drift, truncal ataxia or Romberg sign.,Gait: unremarkable.,Reflexes: 3+ throughout with downgoing plantar responses bilaterally.,Gen Exam: unremarkable.,STUDIES:, MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor. EEG was normal awake and asleep. Antineuronal antibody screening was unremarkable. CSF studies were unremarkable and included varicella zoster, herpes zoster, HIV and HTLV testing, and cytology. The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes, but no organism or etiology was concluded. TFT, B12, VDRL, ESR, CRP, ANA, SPEP and Folate studies were unremarkable. Neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,IMPRESSION:, Limbic encephalitis secondary to cancer of unknown origin.,He was last seen 7/26/96. MMSE 20/30 and category fluency 20 . Disinhibited affect. Mild right grasp reflex. The clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .
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DESCRIPTION: Patient with a 1-year history of progressive anterograde amnesia

consult - history and phy., mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory,

The case involves a patient with severe memory impairments due to limbic encephalitis, a condition that can be associated with underlying malignancies. This situation is high-stakes medically due to the significant impact on the patient's quality of life and the potential underlying causes that could be life-threatening. Memory loss suggests serious neurological involvement. However, the clinical course seems to be benign and non-progressive at the moment, providing some reassurance, but the potential for underlying cancer of unknown origin remains a serious concern.


Medical Specialty: Consult - History and Phy.
Sample Name: Leaking Nephrostomy Tube

CHIEF COMPLAINT:  ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  The leaking began this a.m.  The patient denies any pain, does not have fever and has no other problems or complaints.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  The patient states he feels like his usual self and has no other problems or concerns.  The patient denies any fever or chills.  No nausea or vomiting.  No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  HEENT:  Eyes are normal with clear sclerae and cornea.  NECK:  Supple, full range of motion.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  No dependent edema.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  Normal benign abdominal exam.  MUSCULOSKELETAL:  The patient has nontender back and flank.  No abnormalities noted to the back other than the bilateral nephrostomy tubes.  The nephrostomy tube left has no abnormalities, no sign of infection.  No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  There is no obvious active leak from the ostomy site.  No sign of infection.  No erythema, swelling or tenderness.  The collection bag is full of clear urine.  The patient has no abnormalities on his legs.  SKIN:  No rashes or lesions.  No sign of infection.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal ambulation, normal speech.  PSYCHIATRIC:  Alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:,  Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X.  Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1.  WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2.  PROSTATE CANCER, METASTATIC.,3.  URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X.  The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.
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DESCRIPTION: Urine leaked around the ostomy site for his right sided nephrostomy tube.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.

consult - history and phy., nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes,

The patient's situation involves a leaking nephrostomy tube, which is a medical device necessary for managing complications from metastatic prostate cancer. While the patient is currently stable, failure to address a leaking nephrostomy tube could potentially lead to infection, worsening of renal obstruction, or other complications. However, the patient is scheduled for a tube replacement the next day and is currently stable without signs of infection or distress. Therefore, the situation is serious given the underlying conditions but not immediately life-threatening since a medical plan is in place.


Medical Specialty: Consult - History and Phy.
Sample Name: Left Lower Quadrant Pain - ER Visit

HISTORY OF PRESENT ILLNESS:,  The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.  She denies any leaking of fluid, vaginal bleeding, or uterine contractions.  She reports good fetal movement.  She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only.  Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant.  She continues to yell out for requesting pain medication and about how much "it hurts.",PAST MEDICAL HISTORY:,1.  Irritable bowel syndrome.,2.  Urinary tract infections times three.  The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:,  Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day.  Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits.  Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old.  G2 is current.  Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use.  She endorses marijuana use and a history of cocaine use five years ago.  Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS:  Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit.  Fetal heart tones are 130s with moderate long-term variability.  No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL:  Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,BACK:  Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN:  Tender to palpation in left lower quadrant.  No guarding or rebound.  Normal bowel sounds.,EXTREMITIES:  Scar track marks from bilateral arms.,PELVIC:  External vaginal exam is closed, long, high, and posterior.  Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279.  CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6.  Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN:  ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation.  I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery.  Plans are made for transfer at this time.  This was discussed with Dr. Y who is in agreement with the plan.
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DESCRIPTION: The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.

The situation involves a pregnant patient at 28 weeks gestation experiencing significant pain and not having had a bowel movement in two weeks, combined with nausea, vomiting, and inability to void. These symptoms, together with her history of drug use and existing medical conditions like irritable bowel syndrome and recurrent urinary tract infections, could indicate a risk for complications that could affect both her and her fetus. The presence of ketones and bacteria in the urinalysis could suggest dehydration or infection, adding further risk. The need for transfer to Labor and Delivery for monitoring implies a certain level of urgency and potential risk to the pregnancy, making this a moderately high-stakes situation.


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

REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.  The patient had some cardiac workup in the past, results are as mentioned below.  Denies any specific chest pain.  Activities fairly stable.  She is actively employed.  No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,CORONARY RISK FACTORS: , No history of hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol normal.  No history of established coronary artery disease and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Tubal ligation.,MEDICATIONS: , On pain medications, ibuprofen.,ALLERGIES:,  SULFA.,PERSONAL HISTORY: , She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , History of chest pain in the past.  Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal.  Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal.  An echocardiogram at that time was also normal.  At this time, presentation with lightheaded, dizziness, and palpitation.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No carotid bruits.  No thyromegaly.  No lympyhadenopathy.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI normal.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Benign.,PSYCHOLOGICAL:  Normal.,MUSCULOSKELETAL:  Nonsignificant.,EKG: , Normal sinus rhythm, incomplete right bundle-branch block.,LABORATORY DATA:,  H&H stable.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.  Chest x-ray unremarkable.,IMPRESSION:,1.  Lightheaded, dizziness in a 50-year-old female.  No documented arrhythmia with the symptoms of palpitation.,2.  Normal cardiac structure by echocardiogram a year and half ago.,3.  Normal cardiac catheterization in 11/07.,4.  Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile.
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DESCRIPTION: Lightheaded, dizziness, and palpitation.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.

The patient's symptoms of lightheadedness, dizziness, and palpitations are concerning and warranted an ER visit. She has a history of abnormal myocardial perfusion but normal cardiac catheterization and echocardiogram. The ER evaluation shows normal sinus rhythm and no evidence of an acute cardiac event. Although the absence of syncope and a negative cardiac workup reduce immediate risk, ongoing symptoms like these can indicate potential cardiovascular issues. This makes it a moderately high-stakes situation as further monitoring and potentially diagnostic testing are required to rule out serious conditions.


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

HISTORY OF PRESENT ILLNESS: , I have seen ABC today.  He is a very pleasant gentleman who is 42 years old, 344 pounds.  He is 5'9".  He has a BMI of 51.  He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260.  He is pursuing surgical attempts of weight loss to feel good, get healthy, and begin to exercise again.  He wants to be able to exercise and play volleyball.  Physically, he is sluggish.  He gets tired quickly.  He does not go out often.  When he loses weight he always regains it and he gains back more than he lost.  His biggest weight loss is 25 pounds and it was three months before he gained it back.  He did six months of not drinking alcohol and not taking in many calories.  He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin's Diet for one month two years ago.,PAST MEDICAL HISTORY: , He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, difficulty walking, high cholesterol, and high blood pressure.  He has asthma and difficulty walking two blocks or going eight to ten steps.  He has sleep apnea and snoring.  He is a diabetic, on medication.  He has joint pain, knee pain, back pain, foot and ankle pain, leg and foot swelling.  He has hemorrhoids.,PAST SURGICAL HISTORY: , Includes orthopedic or knee surgery.,SOCIAL HISTORY: , He is currently single.  He drinks alcohol ten to twelve drinks a week, but does not drink five days a week and then will binge drink.  He smokes one and a half pack a day for 15 years, but he has recently stopped smoking for the past two weeks.,FAMILY HISTORY: , Obesity, heart disease, and diabetes.  Family history is negative for hypertension and stroke.,CURRENT MEDICATIONS:,  Include Diovan, Crestor, and Tricor.,MISCELLANEOUS/EATING HISTORY:  ,He says a couple of friends of his have had heart attacks and have had died.  He used to drink everyday, but stopped two years ago.  He now only drinks on weekends.  He is on his second week of Chantix, which is a medication to come off smoking completely.  Eating, he eats bad food.  He is single.  He eats things like bacon, eggs, and cheese, cheeseburgers, fast food, eats four times a day, seven in the morning, at noon, 9 p.m., and 2 a.m.  He currently weighs 344 pounds and 5'9".  His ideal body weight is 160 pounds.  He is 184 pounds overweight.  If he lost 70% of his excess body weight that would be 129 pounds and that would get him down to 215.,REVIEW OF SYSTEMS: , Negative for head, neck, heart, lungs, GI, GU, orthopedic, or skin.  He also is positive for gout.  He denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, pulmonary embolism, or CVA.  He denies venous insufficiency or thrombophlebitis.  Denies shortness of breath, COPD, or emphysema.  Denies thyroid problems, hip pain, osteoarthritis, rheumatoid arthritis, GERD, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer.  He denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:  ,He is alert and oriented x 3.  Cranial nerves II-XII are intact.  Neck is soft and supple.  Lungs:  He has positive wheezing bilaterally.  Heart is regular rhythm and rate.  His abdomen is soft.  Extremities:  He has 1+ pitting edema.,IMPRESSION/PLAN:,  I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding, infection, deep venous thrombosis, pulmonary embolism, leakage from the gastrojejuno-anastomosis, jejunojejuno-anastomosis, and possible bowel obstruction among other potential complications.  He understands.  He wants to proceed with workup and evaluation for laparoscopic Roux-en-Y gastric bypass.  He will need to get a letter of approval from Dr. XYZ.  He will need to see a nutritionist and mental health worker.  He will need an upper endoscopy by either Dr. XYZ.  He will need to go to Dr. XYZ as he previously had a sleep study.  We will need another sleep study.  He will need H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobin, and fasting blood sugar.  After this is performed, we will submit him for insurance approval.
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DESCRIPTION: Consult for laparoscopic gastric bypass.

consult - history and phy., laparoscopic gastric bypass, heart attacks, body weight, pulmonary embolism, potential complications, sleep study, weight loss, gastric bypass, anastomosis, loss, sleep, laparoscopic, gastric, bypass, heart, pounds, weight,

The situation described is a consult for a laparoscopic gastric bypass for a patient with morbid obesity and associated comorbidities like diabetes, asthma, sleep apnea, and hypertension. The stakes are substantial because of the multiple health issues and surgical intervention planned, which carries inherent risks and complications. The decision carries long-term implications on the patient's health and quality of life. However, it's a planned, elective procedure rather than an emergency. Thus, it's high-stakes but not at the utmost level.


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

HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty.  The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time.  She was found to have an L5 compression fracture.  She was treated conservatively over several months, but did not improve.  Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing.  The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence.  She does complain of back pain.  She has been wearing a back brace and corset.  She does not have weakness.,PAST MEDICAL HISTORY:,  The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:,  She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy.  She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally.  She is a widow.  She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL:  The patient is an elderly frail white female in no distress.  LUNGS:  Clear.  HEART:  Sounds are regular.  ABDOMEN:  She has a protuberant abdomen.  She has tenderness to palpation in the lumbosacral area.  Sciatic notch tenderness is not present.  Straight leg raise testing evokes back pain.  NEUROLOGICAL:  She is awake, alert, and oriented.  Speech is intact.  Comprehension is normal.  Strength is intact in the upper extremities.  She has giveaway strength in the lower extremities.  Reflexes are diminished at the knees and ankles.  Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture.  A CT scan has shown some healing of this fracture.  She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain.  She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments.  At this point, I believe the patient is a good candidate for L5 kyphoplasty.  I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery.  Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed.  The patient understands the issues involved.  She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.
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DESCRIPTION: The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty.  The patient has a history of back and buttock pain for some time.

consult - history and phy., leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture,

The situation involves a planned surgical procedure for an elderly patient with a history of significant medical issues and an incomplete healing of a spine fracture. Kyphoplasty is generally a low to moderate risk surgery, but the patient's age and medical history increase the stakes. The risks discussed (bleeding, infection, paralysis, death, etc.) indicate the potential for serious complications, making it a moderately high-stakes situation, especially given the patient's frail condition which may complicate recovery.


Medical Specialty: Consult - History and Phy.
Sample Name: Itchy Rash - ER Visit

CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.
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DESCRIPTION: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.

consult - history and phy., urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash,

The patient presented with a rash and was experiencing an acute allergic reaction with symptoms of urticaria and pruritus, but no respiratory distress or swelling of the airways, which are critical indicators for severe allergic reactions like anaphylaxis. He was treated effectively with epinephrine and Benadryl, with his symptoms improving. While allergic reactions can escalate, in this case, the patient responded well to treatment and was stable on discharge, reducing immediate high-stakes risk. However, the presence of allergies and the potential for reaction escalation in future exposures does require caution.


Medical Specialty: Consult - History and Phy.
Sample Name: Knee Injury

HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury.  She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.  At this time, she complains of pain and instability in the knee.  The patient's past medical history is significant for having had an ACL injury to the knee in 2008.  She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008.  The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:,  She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008.  She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY:  ,The patient is single.  She is a full-time student at University.  Uses no tobacco, alcohol, or illicit drugs.  She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS:  ,Significant for recent weight gain, occasional skin rashes.  The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL:  The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES:  She ambulates with some difficulty with a marked limp on the right side.  Inspection of the knee reveals a significant effusion in the knee.  She has difficulty with passive range of motion of the knee secondary to pain.  She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR:  She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft.  In the meantime, she will continue to use ice as needed.  Moderate her activities and use crutches.  She will follow up as soon as the MRI is performed.
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DESCRIPTION: Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.  While playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.

consult - history and phy., acl graft, acl reconstruction, knee, anterior cruciate ligament, internal derangement, contact injury, knee injury, injury, cruciate, acl, anterior,

The situation involves a young patient with a history of significant knee injuries and surgeries. An ACL tear can have significant implications for her physical activity and long-term joint health. Additionally, the patient is a full-time student, which may affect her ability to participate in sports or daily activities. However, it is not immediately life-threatening, but it has substantial implications for her quality of life and future activity levels.


Medical Specialty: Consult - History and Phy.
Sample Name: Jaw Pain - ER Visit

CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS:  ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear.  Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began.  The patient denies any facial swelling.  No headache.  No swelling to the throat.  No sore throat.  No difficulty swallowing liquids or solids.  No neck pain.  No lymph node swelling.  The patient denies any fever or chills.  Denies any other problems or complaints.,REVIEW OF SYSTEMS:,  CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  HEENT:  No headache.  No neck pain.  No eye pain or vision change.  No rhinorrhea.  No sinus congestion, pressure, or pain.  No sore throat.  No throat swelling.  The patient does have the toothache on the left lower side that radiates towards his left ear as previously described.  The patient does not have ear pain or hearing change.  No pressure in the ear.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath.  GASTROINTESTINAL:  No nausea or vomiting.  No abdominal pain.  MUSCULOSKELETAL:  No back pain.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No speech change.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:,  None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana.  The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be healthy.  The patient is calm, comfortable in no acute distress, looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctivae bilaterally.  Nose, normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  Ears are normal without any sign of infection.  No erythema or swelling of the canals.  Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it.  MOUTH:  The patient has a dental fracture at tooth #18.  The patient states that the fracture is a couple of months old.  The patient does not have any obvious dental caries.  The gums are normal without any erythema, swelling, or evidence of infection.  There is no fluctuance or suggestion of abscess.  There is slight tenderness of the tooth #18.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion, or swelling.  Mucous membranes are moist.  Floor of the mouth is normal without any tenderness or swelling.  No suggestion of abscess.  There is no pre or post auricular lymphadenopathy either.  NECK:  Supple.  Nontender.  Full range of motion.  No meningismus.  No cervical lymphadenopathy.  No JVD.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to the back, arms, or legs.  The patient has normal use of the extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  No evidence of clinical intoxification.  HEMATOLOGIC/LYMPHATIC:  No lymphadenitis is palpated.,DIAGNOSES:,1.  ACUTE LEFT JAW PAIN.,2.  #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3.  ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation.  The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain.  The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain.  He was given precautions for drowsiness and driving with the use of this medication.  The patient was also given a prescription for pen V.  The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.
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DESCRIPTION: Patient started out having toothache, now radiating into his jaw and towards his left ear.  Ellis type II dental fracture.

consult - history and phy., jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,

The patient is experiencing jaw pain due to an Ellis type II dental fracture, which is a notable concern but generally not acutely life-threatening. The patient's vital signs are mostly stable, although blood pressure is slightly elevated, and there is no indication of systemic infection or severe complications like difficulty swallowing or breathing that might suggest a high-stakes emergency. The patient is being sent home with follow-up instructions and pain management, indicating that the situation is manageable and not immediately life-threatening.


Medical Specialty: Consult - History and Phy.
Sample Name: Iron deficiency anemia

CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia.  She was seen in consultation by Dr. X.  She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis.  On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells.  Her iron levels were 5 and her percent transferrin was 2.  There was no evidence of hemolysis.  Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth.  She currently has an IUD, so she is not menstruating.  She was discharged from the hospital on iron supplements.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.  She specifically denies melena or hematochezia.,CURRENT MEDICATIONS: , Iron supplements and Levaquin.,ALLERGIES: , Penicillin.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:  ,She is status post birth of a baby girl 5 months ago.  She is G1, P1.  She is currently using an IUD for contraception.,SOCIAL HISTORY: , She has no tobacco use.  She has rare alcohol use.  No illicit drug use.,FAMILY HISTORY: , Her maternal grandmother had stomach cancer.  There is no history of hematologic malignancies.,PHYSICAL EXAM:,GEN:
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DESCRIPTION: Iron deficiency anemia.  She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.

consult - history and phy., trilineage hematopoiesis, cellular marrow, bone marrow biopsy, iron deficiency anemia, bone marrow, anemia, hemoglobin, lymphadenopathy, deficiency, tobacco,

The consultation details a 19-year-old woman with iron deficiency anemia who was recently hospitalized. While anemia can be a serious condition, especially given the low hemoglobin level (6.5), the patient has already been treated with a blood transfusion and is on iron supplements, which are typical initial responses. There's no immediate life-threatening condition noted in the current details since she is discharged and stable. Key points like the absence of excessive postpartum bleeding, no ongoing menstruation due to an IUD, and no systemic signs of infection or serious bleeding suggest the situation is not in a critical phase. However, underlying causes that aren't immediately evident (such as a family history of cancer or other undiagnosed factors) need consideration, but they do not escalate this consultation moment to high-stakes. Therefore, the stakes are moderate to low for urgent intervention but require monitoring and follow-up.


Medical Specialty: Consult - History and Phy.
Sample Name: Iliopsoas Hematoma - 2

CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.
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DESCRIPTION: Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.

consult - history and phy., cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac,

The situation described involves a patient who experienced a life-threatening cardiac event, requiring advanced emergency interventions including defibrillation and cardiac catheterization. Complications included renal and liver failure, and the patient eventually required the implantation of an internal cardiac defibrillator. There are also issues with neurological function due to anoxic injury and permanent weakness in the right lower extremity due to iliopsoas hematoma and severe axonal degeneration. These medical scenarios indicate a high-stakes situation as they involve life-preserving measures, complex care management, and significant long-term health implications.


Medical Specialty: Consult - History and Phy.
Sample Name: Infantile Spasms

CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to "borderline labs."  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:
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DESCRIPTION: A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.

The situation involves a newborn experiencing abnormal movements and potential infantile spasms, which is a serious condition. Early diagnosis and treatment are critical to prevent developmental delays or other complications. The presence of a sibling with seizures elevates the stakes due to genetic considerations. While there are no immediate life-threatening signs like apnea or cyanosis, the potential for underlying neurological issues or the development of a seizure disorder makes this high-stakes in a medical context.


Medical Specialty: Consult - History and Phy.
Sample Name: Hyperthyroidism Following Pregnancy

HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.
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DESCRIPTION: Chief complaint of chest pain, previously diagnosed with hyperthyroidism.

consult - history and phy., hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy,

The patient is experiencing significant health issues related to severe hyperthyroidism, which is causing cardiac symptoms and requiring radioactive treatment. Additionally, she has postpartum considerations and must manage multiple medications and avoid certain activities like breastfeeding and close contact with her baby post-treatment. These factors indicate the situation involves critical care needs and significant personal implications such as family planning, making it relatively high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Hypertension & Cardiomyopathy

PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.
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DESCRIPTION: Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.

consult - history and phy., congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,

The patient's condition involves multiple severe health issues including nonischemic cardiomyopathy, coronary artery disease, congestive heart failure (Class III), history of ventricular tachycardia, and uncontrolled hypertension. The patient was recently hospitalized and is now non-compliant with prescribed medication, leading to exacerbation of symptoms. Additionally, there's a complexity added by social factors, such as lack of insurance and potential substance use, which can complicate management and adherence to medical advice. The situation is life-threatening and requires close monitoring and intervention to prevent potentially fatal outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Insect Sting

HISTORY OF PRESENT ILLNESS:,  Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today.  He did not note any immediate reaction.  Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath.  He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction.  He did windup taking Benadryl at that time.  He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT:  Head is normocephalic and atraumatic.  The face shows no edema.  The tongue is not swollen and the airway is widely patent.,NECK:  No stridor.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,EXTREMITIES:  Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals.  There was some slight edema of the fourth digit, on which he still is wearing his wedding band.  The right hand shows no reaction.  The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty.  Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting.  I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction.  I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone.  I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction.  If he is not improved in the next four days, follow up with his PCP for a re-exam.
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DESCRIPTION: Local reaction secondary to insect sting.  Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today.

consult - history and phy., stung by a bee, local reaction, insect sting, reaction, insect, bee, knee, edema, sting, swelling, hand

The patient's condition, a local reaction from an insect sting, is not presenting with severe or systemic symptoms such as difficulty breathing, tongue swelling, or anaphylaxis, which would necessitate emergency care. The patient has been effectively managed with antihistamines and there is a follow-up plan in place should symptoms not improve. This scenario is typical for many regional allergic reactions to insect stings, which are generally not life-threatening.


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: Huntington's Disease - Consult

CHIEF COMPLAINT: , "A lot has been thrown at me.",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.
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DESCRIPTION: This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.

The described case involves a 69-year-old patient with a severe and worsening medical condition (Huntington's disease) and a history of multiple recent suicide attempts. She has significant depressive symptoms and her mental state is unstable. The situation involves multiple healthcare interventions, including psychiatric care, a careful medication regimen, and close monitoring for her safety. The potential consequences of any missteps in the management of her condition are severe, potentially life-threatening. Therefore, this is a high-stakes situation as it involves critical patient safety concerns, potential for severe health deterioration, and the need for careful coordination of medical and psychiatric care.


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

SUBJECTIVE:,  This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh.  It cleared for awhile.  This has been an intermittent problem.  Now it is back again on his right lower abdomen.  At first, it was thought that he may have early zoster.  This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area.  He has had no treatment on this; there are no skin changes at all.  The patient bathes everyday but tries to use little soap.  The patient is married.  He works as an airplane mechanic.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  The patient has sinus and CVA.  He is a nonsmoker.  No known drug allergies.,CURRENT MEDICATIONS:,  Lipitor, aspirin, folic acid.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  He does have psoriasis with some psoriatic arthritis, and his skin looks normal today.  On his trunk, he does have the hyperesthesia.  As you touch him, he winces.,IMPRESSION:,  Hyperesthesia, question etiology.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Discontinue hot soapy water to these areas.,3.  Increase moisturizing cream and lotion.,4.  I referred him to Dr. ABC or Dr. XYZ for neurology evaluation.  We did not see anything on skin today.  Return p.r.n. flare.
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DESCRIPTION: Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.

consult - history and phy., dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation

The patient is experiencing hyperesthesia, a condition characterized by heightened sensitivity, but there are no indications of immediate danger or severe health implications based on the information provided. The condition has persisted intermittently but has not shown progression to more serious symptoms or complications. The treatment plan involves conservative measures like discontinuing hot soapy water and using moisturizing cream, while a neurology referral is also suggested to further evaluate the condition. While there is a question of etiology, there's no immediate threat to the patient's life or significant deterioration in health status, making this a moderate to low-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Hematuria & Urinary Retention

REASON FOR CONSULTATION:,  Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia.  The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.  Foley catheter was repositioned 18 Coude was used.  About over a liter of fluids of urine was obtained with light pink urine, which was irrigated.  The bladder and the suprapubic area returned to normal after the Foley placement.  The patient had some evidence of clots upon irrigation.  The patient has had a chest CT, which showed possible atelectasis versus pneumonia.,PAST MEDICAL HISTORY:  ,Coronary artery disease, diabetes, hypertension, hyperlipidemia, Parkinson's, and CHF.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Married and lives with wife.,HABITS:,  No smoking or drinking.,REVIEW OF SYSTEMS: , Denies any chest pain, denies any seizure disorder, denies any nausea, vomiting.  Does have suprapubic tenderness and difficulty voiding.  The patient denies any prior history of hematuria, dysuria, burning, or pain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,GENERAL:  The patient is a thin gentleman,GENITOURINARY:  Suprapubic area was distended and bladder was palpated very easily.  Prostate was 1+.  Testes are normal.,LABORATORY DATA: , The patient's white counts are 20,000.  Creatinine is normal.,ASSESSMENT AND PLAN:,1.  Pneumonia.,2.  Dehydration.,3.  Retention.,4.  BPH.,5.  Diabetes.,6.  Hyperlipidemia.,7.  Parkinson's.,8.  Congestive heart failure.,About 30 minutes were spent during the procedure and the Foley catheter was placed, Foley was irrigated and significant amount of clots were obtained.  Plan is for urine culture, antibiotics.  Plan is for renal ultrasound to rule out any pathology.  The patient will need cystoscopy and evaluation of the prostate.  Apparently, the patient's PSA is 0.45, so the patient is at low to no risk of prostate cancer at this time.  Continued Foley catheter at this point.  We will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.
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DESCRIPTION: The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.

The situation involves an elderly patient with multiple comorbidities including coronary artery disease, diabetes, hypertension, and Parkinson's disease, all of which increase the complexity and risks associated with their current medical issues of hematuria and urinary retention. These medical issues can lead to serious complications if not managed properly. Additionally, the improper placement of a Foley catheter could have caused or exacerbated hematuria, demanding careful medical intervention to prevent further complications. The need for continued monitoring, a renal ultrasound, and further evaluation like cystoscopy increases the stakes as these involve assessing and ruling out potentially serious underlying conditions. While the patient's situation is currently stable, with a plan in place, the stakes remain high due to the vulnerability and multiple health risks presented by the patient's age and medical history.


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

HISTORY OF PRESENT ILLNESS:,  The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis.  We corrected her hematocrit last year with intravenous (IV) iron.  Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis.  Her course has been very complicated since then with needing multiple surgeries for removal of hematoma.  This is partly because she was on anticoagulation for a right arm deep venous thrombosis (DVT) she had early this year, complicated by septic phlebitis.,Chart was reviewed, and I will not reiterate her complex history.,I am asked to see the patient again because of concerns for coagulopathy.,She had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,She is on total parenteral nutrition (TPN) as well.,LABORATORY DATA:,  Labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000.  MCV is 89.  Her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000.  Her hematocrit has been essentially stable for the past month or so.  White blood count has improved.,PT has been markedly elevated and today is 44.9 with an INR of 5.0.  This is despite stopping Coumadin on 05/31/2007, and with administration of vitamin K via the TPN, as well as additional doses IV.  The PT is slightly improved over the last few days, being high at 65.0 with an INR of 7.3 yesterday.,PTT has not been checked since 05/18/2007 and was normal then at 28.,LFTs have been elevated.  ALT is 100, AST 57, GGT 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, LDH normal, and pre-albumin low at 16.  Creatinine is at 1.5, with an estimated creatinine clearance low at 41.7.  Other electrolytes are fairly normal.,B12 was assessed on 05/19/2007 and was normal at 941.  Folic acid was normal.  Iron saturation has not been checked since March, and was normal then.  Ferritin has not been checked in a couple of months.,CURRENT MEDICATIONS: , Erythropoietin 45,000 units every week, started 05/16/2007.  She is on heparin flushes, loperamide, niacin, pantoprazole, Diovan, Afrin nasal spray, caspofungin, daptomycin, Ertapenem, fentanyl or morphine p.r.n. pain, and Compazine or Zofran p.r.n. nausea.,PHYSICAL EXAMINATION: ,GENERAL:  She is alert, and frustrated with her prolonged hospital stay.  She notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,VITAL SIGNS:  Today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95.  She is not requiring oxygen.,SKIN:  No significant ecchymoses are noted.,ABDOMEN:  Ileostomy is in place, with greenish black liquid output.  Midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,EXTREMITIES:  She has no peripheral edema.,CARDIAC:  Regular rate.,LYMPHATICS:  No adenopathy is noted.,LUNGS:  Clear bilaterally.,IMPRESSION AND PLAN:,  Markedly elevated PT/INR despite stopping Coumadin and administering vitamin K.  I will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated LFTs, decreased albumin, and decreased pre-albumin.,It is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated PTT and not PT.  I will check a PTT and check mixing studies if that is prolonged.  It is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting.  I agree with continuing off of anticoagulation for now.,She has markedly elevated platelet count.  I suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,Anemia has been stable, and is multifactorial.  Given her decreased creatinine clearance, I agree with erythropoietin support.  She was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again.  She has had part of her small bowel removed, so there may be a component of poor absorption as well.  If she is iron deficient, this may contribute also to her elevated platelet counts.  I will check a ferritin.  This may be difficult to interpret because of inflammation.  If it is decreased, plan will be to add iron supplementation intravenously.  If it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,She needs continued treatment as you are for her infections.,I will discuss the case with Dr. X as well since there is a question as to whether she might need additional surgery.  She is not a surgical candidate now with her elevated PT/INR.
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DESCRIPTION: Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis.

The situation described involves a patient with a complex medical history, who is currently experiencing significant complications such as markedly elevated PT/INR despite treatment adjustments, a recent surgery for a pelvic hematoma, ongoing infections including one with vancomycin-resistant enterococcus, and the need for total parenteral nutrition. These factors indicate that the patient is in a critical state of health where immediate and careful medical management is necessary. The potential for future surgeries, risk of bleeding, infection control challenges, and the need for detailed evaluation of iron levels and potential further complications like myeloproliferative disorders or additional coagulation issues significantly elevate the stakes of the situation. The patient's life and ongoing health are at significant risk, necessitating high-stakes decision-making and management by medical professionals.


Medical Specialty: Consult - History and Phy.
Sample Name: Head & Neck Cancer Consult

REASON FOR CONSULTATION:,  Newly diagnosed head and neck cancer.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.  He was also noted to have palpable level 2 cervical lymph nodes.  His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck.  The patient comes in to the clinic today after radiation Oncology consultation.  His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010.  The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain.  He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease.  His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia.  He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa.  He was noted to have bilateral neck nodes.  His biopsy was positive for squamous cell carcinoma.,PAST MEDICAL HISTORY:,  Significant for mild hypertension.  He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.,ALLERGIES: ,  Penicillin.,CURRENT MEDICATIONS: , Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.,FAMILY HISTORY: , Significant for father who has stroke and grandfather with lung cancer.,SOCIAL HISTORY: , The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons.  He is retired from the Air Force, currently works for Lockheed Martin.  He was born and raised in New York.  He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27.  He does drink alcohol socially. No use of illicit drugs.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is fatigue.  He has difficulty swallowing and dysphagia.  He is responding well to Lortab and Tylenol for pain control.  He denies any chest pain, shortness of breath, fevers, chills and night sweats.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Newly diagnosed head and neck cancer.  The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.

The situation involves a newly diagnosed head and neck cancer patient at a fairly advanced stage (Stage IV). This is a serious medical condition requiring careful management and treatment planning (potentially involving surgery, radiation, and/or chemotherapy) to improve prognosis and manage symptoms. The complexity of cancer treatment and its potential life-threatening nature make this a high-stakes scenario in the medical context.