Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Bipolar Affective Disorder

IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance.  According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police.  On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder.  The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup.  Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed.  The patient resides independently.  The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION:  ,Attitude:  Suspicious, but cooperative.,Appearance:  Shows appropriate hygiene and grooming.,Psychomotor Behavior:  Within normal limits.  No agitation or retardation.  No EPS or TDS noted.,Affect:  Labile.,Mood:  Euphoric.,Speech:  Pressured.,Thoughts:  Disorganized.,Thought Content:  Remarkable for grandiose delusions as noted.  The patient denies auditory hallucinations.,Psychosis:  Grandiose delusions as noted above.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is oriented x 3.,Judgment:  Poor shown by noncompliance to the outpatient treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I:  BAD, manic with psychosis.,AXIS II:  None.,AXIS III:  None known.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely.  The patient will be evaluated for more structural outpatient followup following stabilization.
---
DESCRIPTION: A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.

This medical scenario involves a patient with bipolar affective disorder who has not been compliant with outpatient treatment, resulting in increased mood lability and behavior that required police intervention. The stakes are high due to the patient's recurrent psychosis, grandiose delusions, and the need for immediate psychiatric intervention to prevent harm to himself or others. The patient also displays poor insight into his illness, which complicates his ability to seek help voluntarily and could worsen his clinical and social outcomes. The plan to restart medication and closely monitor the patient addresses the urgency of the situation.


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: Psych Consult - Assaultive Behavior

IDENTIFYING DATA:  ,The patient is a 40-year-old white male.  He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION:  ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS:  ,The patient was very sleepy this morning, only minimally cooperative with interview.  Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone.  The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury.  The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain.  His ER course is notable for yelling, spitting, and striking multiple staff members.  The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others.  On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications.  He was contrite about the violence.  When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium.  He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday.  She reports that she has been in contact with him since his arrival in our facility and reports that he is "back to normal." She denies feeling that he currently represents a threat to her or her five children.  She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review.  The patient denies any outpatient mental health treatment before or since this hospitalization.  He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:,  Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:,  From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known.  His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY:  ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury.  He lives with his wife and children.  He has a history of domestic violence, but not recently.  Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:,  Records indicate a previous history of methamphetamine and alcohol abuse/dependence.  The wife states that he has not consumed either since 12/07.  Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY:  ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years.  It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude:  The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor:  There is no obvious psychomotor agitation or retardation.  There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect:  His affect is notably restricted probably due to the fact that he is sleepy.,Mood:  Describes his mood as "okay.",Speech:  Speech is normal rate, volume, and tone.,Thought Processes:  His thought processes appear to be linear.,Thought Content:  His thought content is notable for his expressions of contrition about violence at Hospital last night.  He denies suicidal or homicidal ideation.,Cognitive Assessment:  Cognitively, he is alert and oriented to person, place, and date but not situation.  Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight:  His insight and judgment are both appear to be improving.,Assets:  Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations:  Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION:  ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium.  He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved.  He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I:  Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.)  Rule out bipolar affective disorder.,AXIS II:  Deferred.,AXIS III:  Chronic pain status post back surgery.,AXIS IV:  Appears to be moderate.  He is currently on medical leave from his job.,AXIS V:  Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:,  Three days.,PLAN:,  I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications.  The patient will be placed on CIWA protocol given that one of the medications he overused was Valium.  Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge.  I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care.  The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.
---
DESCRIPTION: The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.

The situation involves a patient who has been involuntarily admitted for a 72-hour treatment due to dangerous behavior related to misuse of prescribed medications. The patient has a history of domestic violence and past substance abuse. Despite improvement, the situation requires careful management to ensure the safety of the patient and others. The potential for future violent behavior and the unclear details about his mental health history contribute to the seriousness of the case.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Anxiety

REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:,  "I felt anxious yesterday.",HPI:,  A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath.  The patient was consulted by Psychiatry for anxiety.  I know this patient from a previous consult.  During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with "syncopal episodes."  She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours.  The patient was seen by Abc, MD, and Def, Ph.D.  The laboratories were reviewed and were positive for UTI, and anemia is also present.  The TSH level was within normal limits.  She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety.  A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to bone.  The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:,  The patient has a history of depression and anxiety.  She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:,  There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:,  The patient is married and lives at home with her husband.  She has a history of smoking one pack per day for 18 years.  The patient quit in 1967.  According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1.  Klonopin 0.25 mg p.o. every evening.,2.  Fluconazole 200 mg p.o. daily.,3.  Synthroid 125 mcg p.o. everyday.,4.  Remeron 15 mg p.o. at bedtime.,5.  Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1.  Tylenol 650 mg p.o. every 4 hours.,2.  Klonopin 0.5 mg p.o. every 8 hours.,3.  Promethazine 12.5 mg every 4 hours.,4.  Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90.  White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000.  TSH level 0.88.  The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE:  The patient is dressed in a hospital gown.  She is lying in bed during the interview.  She is well groomed with good hygiene.,MOTOR ACTIVITY:  No psychomotor retardation or agitation noted.  Good eye contact.,ATTITUDE:  Pleasant and cooperative.,ATTENTION AND CONCENTRATION:  Normal.  The patient does not appear to be distracted during the interview.,MOOD:  Okay.,AFFECT:  Mood congruent normal affect.,THOUGHT PROCESS:  Logical and goal directed.,THOUGHT CONTENT:  No delusions noted.,PERCEPTION:  Did not assess.,MEMORY:  Not tested.,SENSORIUM:  Alert.,JUDGMENT:  Good.,INSIGHT:  Good.,IMPRESSION:,1.  AXIS I:  Possibly major depression or generalized anxiety disorder.,2.  AXIS II:  Deferred.,3.  AXIS III:  Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4.  AXIS IV:  Interpersonal stressors.
---
DESCRIPTION: Psychiatric Consultation of patient with anxiety.

The situation involves a comprehensive medical and psychiatric evaluation of a patient with multiple significant medical and psychological issues, including metastatic breast cancer, anxiety, and depression. The stakes are high due to the complexity of the patient's health conditions and the need for careful management to ensure both psychiatric and medical stability. The patient's history of panic attacks and current severe anxiety necessitates professional oversight to avoid exacerbating her health conditions. Additionally, the presence of metastatic cancer adds a layer of urgency to ensure quality of life and manage symptoms effectively.


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

REASON FOR REFERRAL: , The patient was referred to me by Dr. X of the Hospitalist Service at Children's Hospital due to a recent admission for pseudoseizures.  This was a 90-minute initial intake completed on 10/19/2007 with the patient's mother.  I have reviewed with her the boundaries of confidentiality and the treatment consent form, and she stated that she had understood these concepts.,PRESENTING PROBLEM: , It is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity.  These were confirmed by video EEG and consist of trembling, shaking, and things of that nature.  She does have a history of focal seizures and perhaps simple seizures, which were diagnosed when she was 5 years old, but the seizure activity that was documented during the hospital stay is of a significant different quality.  I had met with them in the hospital and introduced myself and gathered some basic background information, but this is a supplement to that information, which is contained within this chart.  It was reported to me that she has been under considerable stress.  First of all, it should be noted that the patient is developmentally delayed.  Although she is 17 years old, she operates at about a fourth grade level.  Mother reported that The patient becomes stressed because she thinks that everyone is against her, that she cannot do anything unless someone is there, that she needs a lot of direction, that she gets confused easily, that she thinks that people become angry at her, that she misinterprets what people are saying and thinks that they are upset.  It is reported, the patient feels that her mother yells at her, and that is mad at her often.  It was reported that in addition she recently has had change in her visitation with her father, that she within the last 6 months, has started seeing her father every other weekend after he had been discharged from prison.  She reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him, also additional stressor is at school.  She reports that she has no friends that she feels unwanted and picked on.  She gets confused easily at school, worries about things, and believes that the teachers become angry with her.  In regards to her mood, mother reported that she is usually happy, unless things do not go her way, and then, she becomes upset and says that nobody cares about her.  She sits in the couch, she become angry, does not speak.  Mother sends her to her room, and she calms down, takes a couple of deep breaths, and that passes.  It is reported that the patient has "always been this way" and that is not a change in her behavior.  Mother did think that she did seem a little more depressed, that she seems more lonely.  Over the last few months, she has seemed a little bit more down because she does not have any friends and that she is bored.  Mother reported that she frequently complains of being bored, but has always been this way.  No sleep disturbance was noted.  No changes in weight.  No suicidal ideation.  No deficits in energy were noted.  Mother did report that she does tend to worry, but her worries tend to be because she gets confused, does not understand what she needs to do, and is quite rigid, but mother did not feel that the worry was actually affecting her functioning on a daily basis.,DEVELOPMENTAL HISTORY:,  The patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery.  She was delivered at 36 weeks' gestation.  Mother reported that she received prenatal care.  Difficulties during the pregnancy were denied.  The use of drugs, alcohol, tobacco during the pregnancy were denied.  No eating or sleeping difficulties during the perinatal period were reported.  Temperament was described as easy.  The patient is described as a cuddly baby.  In terms of serious injuries, they were denied.  Serious illnesses:  She has been diagnosed since age 5 with seizures.  Mother was not able to tell me the exact kind of seizures, but it would appear from I could gather that they are focal seizures and possibly simple-to-complex partial seizures.  The patient does not have a history of allergy or toileting problems.  She is currently taking Trileptal 450 mg b.i.d., and she is currently taking Depakote, although she is going to be weaned off the Depakote by her neurologist.  She is taking Prevacid and ibuprofen.  The neurologist that she sees is Dr. Y here at Children's Hospital.,FAMILY BACKGROUND:,  In terms of family background, the patient lives with her mother age 38 and her mother's partner, who is age 40, and with her 16-year-old sister who does not have any developmental delays.  Mother had been married to the patient's father, but they were together as a couple beginning 1990, married in 1997, separated in 2002, and divorced in 2003; he lives in the ABC area and visits them every other Saturday, but there are no overnight visits.  The paternal grandparents are both living here in California, but are separated.  They are 3 paternal uncles and 2 paternal aunts.  In terms of the maternal family, maternal grandmother and grandfather are deceased.  Maternal grandfather deceased in 1991 due to cancer.  Maternal grandmother deceased in 2001 due to cancer.  There are 5 maternal aunts and 2 maternal uncles, all who live in California.  She reported that the patient is particularly close to her maternal aunt, whose name is Carmen.  Mother's partner had been married previously; he has 2 children from that relationship, a 23-year-old, and a 20-year-old female, who really are not part of the patient's daily life.  In terms of other family background, it was reported that the mother's partner gets frustrated with The patient, does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things.  The sister was described as having some resentment towards her older sister, that she feels like she was just to watch out for her, care for her, and that sister has always wanted to follow her around and do the things that she does.  The biological father allegedly was in jail for a year due to drug possession.  Mother reported that he had a problem with methamphetamine.  In addition, she reported there is an accusation that he had molested their niece; however, she stated that there was a trial, and he was found to be not guilty of that.  She stated there was no evidence that he had ever molested the patient or her sister.  There had been quite a bit of chaos in the family when the mother and father were together.  There was a lot of arguing.  There were a lot of moves, there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother's report.  The patient did observe this.  After the separation, it was reported that there were continued difficulties that the father took the patient and her sister from school without mother's knowledge and had filed to get custody of them and actually ended up having custody of them for a month, and told the patient and her sister that the mother had abandoned them.  Mother reported that they went to court, and there was a court order giving the mother custody back after the father went to jail.  Mother stated that was approximately 5 years ago.  In terms of current, mother reports that she currently works 2 jobs from 8 to 5 on Monday and Friday and from 6 to 10 on Monday, Wednesday's, and Friday's, but she does have the weekends off.  The patient was reported also to have a job through her school on several weeknights.,Mother reported that she graduated from high school, had a year of college.  She was an average student, had learning difficulties in reading.  No psychological or drug or alcohol history was reported by mother.  In terms of the biological father, mother stated that he graduated from high school, had a couple of years of college, was a good student, no learning problems or psychological problems for him were reported.  Mother reported that he had a history of methamphetamine use.,Other psychiatric history in the family was denied.,SOCIAL HISTORY: , She reported that the patient feels like she does not have any friends, that she is lonely and bored, really does not do much for fun.  Her fun consists primarily of doing crafts with mother, sewing, painting, drawing, beadwork, and things like that.  It was reported that she really feels that she is bored and does not have much to do.,ACADEMIC BACKGROUND:  ,The patient is in the 11th grade at High School.  She has 2 regular education classes, mother could not tell me what they were, but the rest of her classes are special education.  Mother could not tell me what her IQ was, although she noticed she works at about a 4th or 5th grade level.  Mother reported that the terminology most often used with the patient was developmental delay.  Her counselor's name is Mr. XYZ, but she reported that overall she is a good student, but she does have sometimes some difficulties at school, becoming upset or angry regarding the little things that she does not seem to understand.  It is reported that the patient feels that she has no friends at school that she is lonely, and that is she does not really care for school.  She reported that the patient is involved in a work program through the school where she works at Pet Extreme on Mondays and Wednesdays from 3 to 8 p.m. where she stocks shelves.  It is reported that she does not like to go to school because she feels like nobody likes her.  She is not involved in any kind of clubs or groups at school.  Mother reported that she is also not receiving CVRC services.,PREVIOUS COUNSELING: , Mother reported that she has been in counseling before, but mother could not give me any information about that, who did the counseling, or what it was about.  She does receive evidently some peer counseling at school because she gets upset and needs help in calming down.,DIAGNOSTIC SUMMARY AND IMPRESSION:,  It appears that the patient best qualifies for a diagnosis of conversion disorder, and information from Neurology suggests that the "seizure episodes" are not true seizures, but appear to be pseudoseizures.  The patient is experiencing quite bit of stress with a lot of changes in her life, also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand.,PLAN:,  My plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her, and then to begin teaching coping skills as well as explore ways for reducing her stress.,DSM IV DIAGNOSES:  ,AXIS I:  Conversion disorder (300.11).,AXIS II:  Diagnoses deferred.,AXIS III:  Seizure disorder.,AXIS IV:  Problems with primary support group, peer problems, and educational problems.,AXIS V:  Global assessment of functioning equals 60.
---
DESCRIPTION: The patient was referred due to a recent admission for pseudoseizures.

consult - history and phy., conversion disorder, global assessment of functioning, primary support group, peer problems, developmental delays, seizures, developmentally, axis, pseudoseizures,

The referral for pseudoseizures involves several moderate-stakes elements, such as frequent hospital admissions for episodes mistaken for seizures, a developmental delay in a 17-year-old, and significant stress due to familial and social issues. However, the situation currently lacks critical, life-threatening symptoms or an immediate risk to life (e.g., no suicidal ideation, stable seizure management). While there are significant social and emotional challenges that impact the quality of life, immediate clinical urgency does not seem critical based on the report. The stakes are heightened due to the patient's vulnerability and need for ongoing psychological and medical support. Managing these psychosocial issues is crucial but doesn't reach the highest stakes in a clinical sense.


Medical Specialty: Consult - History and Phy.
Sample Name: Physical Exam and Pap - 1

SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.
---
DESCRIPTION: A white female presents for exam and Pap.

The situation is a routine medical consultation involving a gynecological exam and Pap smear, with additional minor health concerns like rhinitis and dermatitis. These issues are common and not life-threatening. The consultation includes preventive care recommendations such as nutrition and exercise advice. The stakes are typical for a standard medical check-up with no indication of urgent or severe health issues.


Medical Specialty: Consult - History and Phy.
Sample Name: Pericardial Effusion

REASON FOR CONSULTATION:,  Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.  A CT of the chest was done, which shows pericardial effusion.  This consultation is for the same.  The patient denies any lightheadedness or dizziness.  No presyncope or syncope.  Activity is fairly stable.,CORONARY RISK FACTORS: , History of borderline hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is within normal limits.  No history of established coronary artery disease.  Family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY:  ,Hysterectomy and bladder surgery.,MEDICATIONS AT HOME:  ,Aspirin and thyroid supplementation.,ALLERGIES:,  None.,PERSONAL HISTORY:,  She is a nonsmoker.  She does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,1.  Hypothyroidism.,2.  Borderline hypertension.,3.  Arthritis.,4.  Presentation at this time with chest pain and shortness of breath.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, blurring of vision, or glaucoma.,CARDIOVASCULAR:  Chest pain.  No congestive heart failure.  No arrhythmia.,RESPIRATORY:  No history of pneumonia in the past, valley fever.,GASTROINTESTINAL:  Epigastric discomfort.  No hematemesis or melena.,UROLOGICAL:  Frequency.  No urgency.  No hematuria.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.  No significant carotid bruit.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA:  ,White count of 20 and H&H 13 and 39.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.,RADIOGRAPHIC STUDIES: , CT of the chest preliminary report, pericardial effusion.  Echocardiogram shows pericardial effusion, which appears to be chronic.  There is no evidence of hemodynamic compromise.,IMPRESSION:,1.  The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder.  She has elevated white count, possible infection.,2.  Pericardial effusion without any hemodynamic compromise, could be chronic.
---
DESCRIPTION: The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.

The consultation involves an 84-year-old female with symptoms including shortness of breath, fatigue, and chest pain, who was found to have a pericardial effusion—a condition which can potentially lead to cardiac tamponade, a life-threatening situation, if it causes hemodynamic compromise. However, the echocardiogram shows no evidence of hemodynamic compromise currently, and it is being characterized as possible chronic, suggesting careful monitoring is required but there is no immediate life-threatening risk at this moment.


Medical Specialty: Consult - History and Phy.
Sample Name: Physical Exam and Pap -2

SUBJECTIVE:,  The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam.  Her last Pap smear was 05/02/2002.  Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest.  Has awakened her at night on occasion and only last about 15 to 20 minutes.  Denies nausea, vomiting, diaphoresis or shortness of breath with it.  This has not happened in almost two months.  She had a normal EKG one year ago.  Otherwise, has been doing quite well.  Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:,  Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:,  Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is married.  Denies tobacco, alcohol and drug use.  She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs:  Weight 146.  Blood pressure 100/64.  Pulse 80.  Respirations 16.  Temperature 97.7.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Grossly within normal limits.,Neck:  Supple.  No lymphadenopathy.  No thyromegaly.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Positive bowel sounds, soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Atrophic vaginal mucosa.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Rectal:  Normal sphincter tone.  No stool present in the vault.  No rectal masses palpated.,Extremities:  No cyanosis, clubbing or edema.  She does have obvious rheumatoid arthritis of her hands.,Neurologic:  Grossly intact.,ASSESSMENT/PLAN:,1.  Chest pain.  The patient will evaluate when it happens next; what she has been eating, what activities she has been performing.  She had normal ECG one year ago.  In fact this does not sound cardiac in nature.  We will not do further cardiac workup at this time.  Did discuss with her she may be having some GI reflux type symptoms.,2.  Hypothyroidism.  We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3.  Rheumatoid arthritis.  Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4.  Osteoporosis.  It is time for her to have a repeat DEXA at this time and that will be scheduled.,5.  Health care maintenance, Pap smear was obtained today.  The patient will be scheduled for mammogram.
---
DESCRIPTION: A white female who presents for complete physical, Pap and breast exam.

The situation involves a routine medical examination for a 68-year-old woman, aimed at maintaining general health with checks like Pap smear, mammogram scheduling, and assessments of existing conditions. While the patient's chest pain could be concerning, it doesn't appear immediately life-threatening or suggest a high risk, especially since the symptoms are not recent and previous EKG was normal. The other health issues like hypothyroidism, RA, and osteoporosis are being managed. Overall, while there are multiple health considerations, none seem urgent or critical at this moment, indicating a relatively low-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Penile Discharge

CHIEF COMPLAINT: , Penile discharge, infected-looking glans.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for wet gangrene.  The patient was transferred to Nursing Home and presents today from the nursing home with complaints of bleeding from the right AKA stump and penile discharge.  As per the patient during his hospitalizations over here, he had indwelling Foley catheter for a few days and when he was discharged at the nursing home he was discharged without the catheter.  However, the patient was brought back to the ED today when he suffered fall yesterday and started bleeding from his stump.  While placing the catheter in the ED on retraction of foreskin purulent discharge was seen from the penis and the glans appeared infected, so urology consult was placed.,REVIEW OF SYSTEMS: , Negative except as in the HPI.,PAST MEDICAL HISTORY: , Significant for end-stage renal disease on dialysis, hypertension, peripheral vascular disease, coronary artery disease, congestive heart failure, diabetes, and hyperlipidemia.,PAST SURGICAL HISTORY:  ,Right AKA,MEDICATIONS:,  Novolin, Afrin, Nephro-Vite, Neurontin, lisinopril, furosemide, Tums, labetolol, Plavix, nitroglycerin, Aricept, omeprazole, oxycodone, Norvasc, Renagel, and morphine.,ALLERGIES: , PENICILLIN and ADHESIVE TAPE.,FAMILY HISTORY: , Significant for hypertension, hyperlipidemia, diabetes, chronic renal insufficiency, and myocardial infarction.,SOCIAL HISTORY: , The patient lives alone.  He is unemployed, disabled.  He has history of tobacco use in the past.  He denies alcohol or drug abuse.,PHYSICAL EXAMINATION:,GENERAL:  A well-appearing African-American male lying comfortably in bed, in acute distress.,NECK:  Supple.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2, normal.,ABDOMEN:  Soft, nondistended, and nontender.,GENITOURINARY:  Penis is not circumcised.  Currently, indwelling Foley catheter in place.  On retraction of the foreskin, pale-looking glans tip with areas of yellow-white tissue.  The proximal glans appeared pink.  The patient currently has indwelling Foley catheter and glans slightly tender to touch.  However, no purulent discharge was seen on compression of the glans.  Otherwise on palpation, no other deformity noticed.  Bilateral testes descended.  No palpable abnormality.  No evidence of infection in his perineal area.,EXTREMITIES:  Right AKA.,NEUROLOGIC:  Awake, alert, and oriented.  No sensory or motor deficit.,LABORATORY DATA: , I independently reviewed the lab work done on the patient.  The patient had a UA done in the ED which showed few bacteria, white blood cells 6 to 12, and a few epithelial cells which were negative.  His basic metabolic panel with creatinine of 7.2 and potassium of 5, otherwise normal.  CBC with a white blood cell count of 11.5, hemoglobin of 9.5, and INR of 1.13.,IMPRESSION: , A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans.  It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease.  I think it is due to chronic ischemic changes.,RECOMMENDATIONS: , Our recommendation would be:,1.  To remove the Foley catheter.,2.  Local hygiene.,3.  Local application of bacitracin ointment.,4.  Antibiotic for urinary tract infection.,5.  Follow up as needed.  Of note, it was explained to the patient that the appearance of this glans may improve or may get worsened but at this point, there is no indication to operate on him.  If increased purulent discharge, the patient was asked to call us sooner, otherwise follow up as scheduled.
---
DESCRIPTION: Penile discharge, infected-looking glans.  A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease.

This is a complex medical case involving a 67-year-old male with multiple significant comorbidities such as end-stage renal disease, diabetes, and peripheral vascular disease. The patient presents with penile discharge, which could indicate a potential infection or complications related to recent catheter use. Given the patient's history and current medical conditions, careful management is necessary to prevent further complications or hospital admissions. While the situation is concerning and requires medical attention, it doesn't appear to be immediately life-threatening or critical at this moment, as there are clear recommendations for non-surgical treatment and follow-up. However, the stakes are elevated due to the risk of infection spreading or worsening, especially considering the patient's compromised health.


Medical Specialty: Consult - History and Phy.
Sample Name: Otitis Media - H&P

CHIEF COMPLAINT:,  This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include:  cough, fever, irritability and speech and language delay.  Duration (ENT):  Duration of symptom:  12 rounds of antibiotics for otitis media.  Quality of ear problems:  Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:,  None currently.,PMH:,  Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:,  Parent admits child is in a large daycare.,FAMILY HISTORY:,  Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM:,  Temp:  99.6 Weight:  38 lbs.,Patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.,The child is accompanied by her mother who communicates well in English.,Head & Face:  Inspection of head and face shows no abnormalities.  Examination of salivary glands shows no abnormalities.  Facial strength is normal.,Eyes:  Pupil exam reveals PERRLA.,ENT:  Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck:  Neck exam reveals no abnormalities.,Lymphatic:  No neck or supraclavicular lymphadenopathy noted.,Respiratory:  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric:  Testing of cranial nerves reveals no deficits.  Mood and affect normal and appropriate to situation.,TEST RESULTS:,  Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.,PLAN:,  Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003.  Surgery will be performed at Children's Hospital.  Pre-operative consent form read and signed by parent.  Common risks and side effects of the procedure and anesthesia were mentioned.  Parent questions elicited and answered satisfactorily regarding planned procedure.  ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:,  Augmentin  Dosage:  400 mg-57 mg/5 ml powder for reconstitution  Sig:  One PO Q8h  Dispense:  1 Refills:  0  Allow Generic:  No
---
DESCRIPTION: A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.

The situation involves the medical diagnosis and planned surgical intervention for a young child suffering from chronic otitis media and associated symptoms. While not life-threatening, it does affect the child's quality of life and could lead to more serious complications if untreated, hence requiring careful management. The planned myringotomy, tube insertion, and adenoidectomy are routine but involve general anesthesia, elevating the stakes slightly due to the risks involved in anesthesia and surgery, especially in a young child. Parental consent and proper understanding of the procedure have been addressed, reducing some potential complications or legal stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Peripheral Effusion - Consult

REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.
---
DESCRIPTION: Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.

The situation involves a 70-year-old female patient with a complex medical history including recurrent pneumonia, COPD, emphysema, and a history of lung cancer with metastasis. The current issue at hand is a moderate pericardial effusion with early signs of tamponade, which is a potentially life-threatening condition if not addressed in a timely manner. The patient is also undergoing a CT surgery consult for a pericardial window to address the effusion, indicating an urgent medical intervention is planned. Given the potential for rapid deterioration without intervention, this situation is relatively high-stakes.


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

SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.  Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1.  She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004.  She was last seen on 04/08/2005 with recurrent pain in her low back on the right.  Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.,The patient comes back to see me today.  She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint.  She is also complaining of pain in both knees.  She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly.  She has not had any x-rays for quite some time.  She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms.  She is also taking Celebrex through Dr. S’ office.,PAST MEDICAL HISTORY:,  Essentially unchanged from my visit of 04/08/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 5 inches.  Weight is 183 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint.  She has no other major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensation is intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.,2.  Improved, spinal right L3-S1 radiofrequency ablation.,3.  Right sacroiliac joint sprain/strain, symptomatic.,4.  Left lumbar facet joint syndrome, stable.,6.  Right thoracic facet joint syndrome, stable.,7.  Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8.  Degenerative disc disease of both knees, symptomatic.,9.  Pes anserinus bursitis, bilaterally symptomatic.,10.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  She has some symptoms in her low back on the right side at the sacroiliac joint.  Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy.  She is also having pain in both knees.  We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally.  I explained the rationale for each of these injections, possible complications and she wishes to proceed.  In the interim, she can continue on Lortab and Celebrex.  We will plan for the follow up following these interventions, sooner if needed.  She voiced understanding and agreement.  Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings.
---
DESCRIPTION: Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.

consult - history and phy., low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet, sacroiliac joint syndrome, lumbar spinal stenosis, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, chronic pain syndrome, degenerative disc disease, pes anserinus bursitis, pes anserine bursa, sacroiliac joint, joint syndrome, degenerative disc, lumbar spinal, bilateral recess, lumbar, joint, intermittent, djd, orthopedic, pes, spinal, spondylosis, sacroiliac, syndrome,

The situation involves a complex and ongoing treatment plan for a 73-year-old patient with multiple chronic conditions including spinal stenosis, degenerative disc disease, and chronic pain syndrome. These conditions require careful management to ensure the patient's quality of life. Injections and pain management medications are part of the treatment, which carry potential risks and complications. While it's not an emergency, it involves significant healthcare decisions affecting the patient's well-being and involves coordination among multiple healthcare providers.


Medical Specialty: Consult - History and Phy.
Sample Name: Oligoarticular Arthritis - 2

HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria.  A was worked up for collagen vascular diseases and is here to find out the results.  Also was recommended to take 7.5 mg of Mobic every day for her joint pains.  She states that she continues with some joint pain and feeling tired all the time.  Mother states that also her seizure has continued without any control so far.  She is having some studies in the next few days.  She is mostly stiff on her legs, neck, and also on her hands.  The rest of the review of systems is in the chart.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Temperature today is 99.2 degrees Fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.,HEENT:  She has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations.  Pupils are reactive to accommodation.  Funduscopic examination is within normal limits.,NECK:  No neck masses.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,SKIN:  No rashes today.,MUSCULOSKELETAL:  Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.,LABORATORY DATA: , Laboratories were not done recently, but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease, but shows some evidence of decreased calcium and vitamin D levels.,ASSESSMENT: , This is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D.  She also has chronic proteinuria and seizure disorder.  My recommendation is to start her on vitamin D and calcium supplements, and also increase the Mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking.  We are going to refer her to physical therapy and see her back in 2 months for followup.  The plan was discussed with A and her parents and they have no further questions.
---
DESCRIPTION: A lady with symptoms consistent with possible oligoarticular arthritis of her knees.

consult - history and phy., arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular,

The situation involves a medical consultation for a young patient with multiple health concerns, including oligoarticular arthritis, seizure disorder, and vitamin D deficiency. While these are significant health issues, the situation described in the history and examination does not indicate an immediate life-threatening condition or emergency. The case involves ongoing management and requires monitoring and adjustment of treatments, which are routine in nature. The stakes are moderate as they involve the patient's quality of life and long-term management of chronic conditions.


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

CHIEF COMPLAINT (1/1):, This 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. Duration: Condition has existed for 6 months. Severity: Severity of condition is worsening.,ALLERGIES: ,Patient admits allergies to dairy products, penicillin.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY:, Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of eye surgery in 1999.,SOCIAL HISTORY:, Patient denies alcohol use, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:, Psychiatric: (+) poor sleep pattern, Respiratory: (+) breathing difficulties, respiratory symptoms.,PHYSICAL EXAM:, Patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,Cardiovascular: DP pulses palpable bilateral. PT pulses palpable bilateral. CFT immediate. No edema observed.  Varicosities are not observed.,Skin: Skin temperature of the lower extremities is warm to cool, proximal to distal. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Onychomycosis.,PLAN:, Debrided 10 nails.,PRESCRIPTIONS:, Penlac Dosage: 8% Topical Solution Sig:
---
DESCRIPTION: Toenails are discolored, thickened, and painful - Onychomycosis

The situation described involves a patient with symptoms of onychomycosis, a common fungal nail infection. While uncomfortable and potentially affecting quality of life, onychomycosis itself is generally not considered a high-stakes medical condition. It is not life-threatening and typically can be managed with medication and topical treatments. Additionally, the patient's history and examination do not indicate any severe health concerns that would elevate the urgency or risk significantly. Therefore, the situation is low-stakes from a medical urgency perspective.


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

CHIEF COMPLAINT:,  Back pain and right leg pain.  The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:,  The patient is on my schedule today to explore treatment of the above complaints.  She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis.  She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count.  She says she has just finished a series of 10 radiation treatments for pain relief.  She states she continues to have significant pain symptoms.  Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee.  She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times.  She complains of some diffuse, mid back pain.  She describes the pain as sharp, dull, and aching in nature.  She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain.  She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking.  She is on significant doses of narcotics.  She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:,  Significant for cancer as above.  She also has a depression.,PAST SURGICAL HISTORY:,  Significant for a chest port placement.,CURRENT MEDICATIONS:,  Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet.  She does not know of what strength up to eight daily.  She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent.  She is on Neurontin 300 mg three times daily.,HABITS:,  She smokes one pack a day for last 30 years.  She drinks beer approximately twice daily.  She denies use of recreational drugs.,SOCIAL HISTORY:,  She is married.  She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:,  Significant mainly for her pain complaints.  For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs:  Height is 5 feet 2 inches.  Weight is 130 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, regular bowel sounds.,Musculoskeletal:  Examination shows functional range of joint movements.  No focal muscle weakness.  She is deconditioned.,Neurologic:  She is alert and oriented with appropriate mood and affect.  The patient has normal tone and coordination.  Reflexes are 2+ in both knees and absent at both ankles.  Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine:  Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement.  The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally.  She has had increased uptake in the sacroiliac joint regions bilaterally.  CT of the chest showed no evidence of recurrent metastatic disease.  CT of the abdomen showed no evidence of metastatic disease.  MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs.  CT of the pelvis showed a trabecular pattern with healed metastases.  CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan.  MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2.  Symptomatic facet and sacroiliac joint syndrome on the right.,3.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right.  Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today.  I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed.  She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this.  We have asked for stat protime today.  She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications.  She is on significant dose of narcotics already, however, she continues to have pain symptoms.  Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed.  I will plan on evaluating her in the Clinic on Tuesday.  I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead.  She voiced understanding and is in agreement with this plan.  I have also asked her to get an x-ray of the lumbar spine for further evaluation.  Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings.  Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.
---
DESCRIPTION: Back pain and right leg pain.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs

The patient's situation involves managing severe chronic pain due to metastatic cancer, which has significant implications for her quality of life and symptom management. The use of high-dose narcotics and potential changes in her medication for pain management reflect the seriousness of her condition. This is compounded by her medical history and ongoing treatment for small cell lung cancer with metastases. Deciding on immediate treatment options and pain management strategies is crucial, making this a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: OB/GYN Consultation - 4

CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap:  1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable.  Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent.  Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day.  Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C.  1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight:  104. BP:  100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses.  No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery.  Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days.  Doxycycline 100 mg #14 1 BID.
---
DESCRIPTION: Pelvic Pain and vaginal discharge

Pelvic Pain and vaginal discharge

This consultation involves evaluating a patient with pelvic pain and vaginal discharge, which are symptoms that could suggest various gynecological or infectious issues. The patient's history of an abnormal pap smear with high-grade lesions, past mild dysplasia, and current symptoms requires careful medical evaluation for potential conditions like infections or even precancerous conditions. Prompt and accurate diagnosis and treatment are important, but the current plan involves routine tests and antibiotics, indicating that while the condition is serious, it is not immediately life-threatening or requiring emergency intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: OB/GYN Consultation - 2

She started her periods at age 13.  She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice.  She describes the pain as bilateral, intermittent, and non-radiating.  It decreases slightly when she eats and increases with activity.  She states the pain when it comes can last for half-a-day.  It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting.  She has tried LactAid, which initially helped, but then the pain returned.  She has tried changing her diet and Pepcid AC.  She was seen at XYZ where blood work was done.  At that time, she had a normal white count and a normal H&H.  She was given muscle relaxants, which did not work.,Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done.  This showed a 1.9 x 1.4-cm cyst on the right with no free fluid.  The left ovary and uterus appeared normal.  Two days later, the pain resolved and she has not had a recurrence.  She denies constipation and diarrhea.  She has had some hot flashes, but has not taken her temperature.,In addition, she states that her periods have been very irregular coming between four and six weeks.  They are associated with cramping which she is not happy about.,She has never had a pelvic exam.  She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present.  She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again.,PAST MEDICAL HX:  ,Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant.,PAST SURGICAL HX:  ,Plastic surgery on her ear after a dog bite in 1997.,MEDICATIONS:  ,Zoloft 50 mg a day and LactAid.,ALLERGIES:  ,NO KNOWN DRUG ALLERGIES.,SOCIAL HX: , She enjoys cooking and scrapbooking.  She does have a boyfriend; again she states she is not sexually active.  She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol.,FAMILY HX: , Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age.  She also has a paternal great grandfather who was diagnosed with colon cancer.,PE: , VITALS: Height: 5 feet 5 inches.  Weight: 190 lb.  Blood Pressure: 120/88.  GENERAL: She is well-developed, well-nourished with normal habitus and no deformities.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Deferred.,A/P: , Abdominal pain, unclear etiology.  I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this.  However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill.  She has no personal or familial contraindications to start this.  She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4.  She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.,If she should have the recurrence of her pain, I have advised her to call.
---
DESCRIPTION: Consultation because of irregular periods and ovarian cyst.

consult - history and phy., irregular periods, lactaid, abdominal pain, birth control pills, cyst, ovarian cyst, ovaries, ovary, pelvic exam, sexually active, uterus, lymphadenopathy, pelvic, irregular, periods

The case involves a young woman with a history of abdominal pain and an ovarian cyst, seeking consultation on irregular and painful periods. While there is discomfort and potential life impact due to pain and irregular periods, there is no immediate life-threatening condition or signs of serious complications (e.g., no severe systemic symptoms or critical abnormalities in vitals/Blood reports). The situation appears to be more about managing symptoms and improving quality of life rather than addressing an urgent medical crisis.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal ROS Template - 5

REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
---
DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

consult - history and phy., respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness

The situation described is a review of systems, which is a standard procedure in medical history taking. The template indicates that the patient doesn't have any symptoms across multiple systems. Since the patient doesn't exhibit any notable symptoms or abnormalities, and this is part of routine documentation—or template creation for efficiency—rather than an urgent medical incident, it is not a high-stakes situation. This is routine and non-critical data entry that aids in efficient medical assessment but is not indicative of an immediate risk to patient health.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Normal ROS Template - 2

GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
---
DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

consult - history and phy., nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness,

The content provided is a template for a normal review of systems (ROS) in a medical consultation. It lists multiple negative findings across various body systems, suggesting a patient's report of no issues in these areas. This is standard practice in medical documentation and does not indicate any immediate concern or high-risk conditions. Such templates are used as checklists to ensure all relevant systems are reviewed and documented as negative where appropriate. Therefore, the situation itself is not inherently high-stakes, as it is part of routine documentation.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 7

EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:,  The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.
---
DESCRIPTION: Most commonly used phrases in physical exam.

consult - history and phy., ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination,

This scenario describes a routine and thorough physical examination across multiple systems of the body, noting the absence of any abnormalities or concerns. The language suggests it is a standard procedure for documenting a normal physical exam. As such, there are no indications of immediate health risks or urgent medical concerns. The stakes appear low because the primary goal is assessment without any pressing issues identified.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 6

VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.
---
DESCRIPTION: Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.

consult - history and phy., jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,

The situation describes a normal physical exam template used in a consult for history and physical examination. There are no abnormal findings or indications that the patient is in any distress or suffering from any conditions that would be considered high-stakes. The examination notes that everything appears normal across various systems (vital signs, respiratory, cardiovascular, etc.). Therefore, this situation is routine and low-stakes from a clinical perspective.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Female ROS Template

CONSTITUTIONAL:,  Normal; negative for fever, weight change, fatigue, or aching.,HEENT:,  Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  Ears normal; Negative for hearing or balance problems.  Nose normal; Negative for runny nose, sinus problems, or nosebleeds.  Mouth normal; Negative for dental problems, dentures, or bleeding gums.  Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:,  Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:,  Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:,  Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.
---
DESCRIPTION: Normal female review of systems template.  Negative for fever, weight change, fatigue, or aching.

consult - history and phy., cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint,

The described situation involves a routine normal review of systems (ROS) for a female patient, which is a standard part of clinical practice. It systematically checks for symptoms across various body systems to ensure the patient's systems are functioning normally. As this document does not involve any acute or critical medical findings, and only reports normal health, it does not present high-stakes information usually associated with urgent medical issues.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Newborn H&P Template

HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,
---
DESCRIPTION: Template for History and Physical for a newborn.

The situation described is a template for a history and physical examination for a newborn, including details on the birth and immediate postnatal status. It is part of standard medical documentation and does not seem to involve any immediate or critical clinical decisions that could alter the newborn's health dramatically. The template is designed for routine use and anticipates typical scenarios for newborns, indicating low-stakes involvement. The stakes may elevate depending on the specific data inserted during an actual patient's evaluation, but the template itself is neutral in urgency or risk.