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

REASON FOR CONSULTATION:,  Syncope.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode.  According to the patient and the daughter who was with her, she was shopping when she felt abdominal discomfort with nausea, profuse sweating, and passed out.  As soon as she was laid on the floor and her leg raised up, she woke up with no post-event confusion.  According to the daughter, she has had episodes of weakness, but no syncope.  She has blood pressure medications and has had some postural hypotensions, which has been managed by Dr. X. She also states there was a history of pulmonary embolism and the presentation at that time was very similar when she had a syncopal episode.  At that time, she was admitted at Hospital, had a V/Q scan, which was positive for PE.  Initial V/Q scan done at Hospital was negative.  She was anticoagulated with Coumadin resulting in severe GI bleed.  Anticoagulation was stopped and an IVC filter was placed at that time.  She has a history of malignant hypertension and has had a renal stent placed in February 2007.  She also has peripheral vascular disease with stent placements.  There is a history of spinal canal stenosis and iron deficiency anemia, currently on Procrit injections every two weeks done by Dr. Y. The patient denies any chest pain or any worsening of any shortness of breath.  There are no acute EKG changes or cardiac enzyme elevations.  She has had no stress test done following a bypass surgery.,PAST MEDICAL HISTORY,1.  Coronary artery disease, status post coronary artery bypass grafting.,2.  History of mitral regurgitation, unable to repair the valve.,3.  History of paroxysmal atrial fibrillation, on amiodarone.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of abdominal aortic aneurysm.,8.  Carotid artery disease, mild-to-moderate on recent carotid ultrasound.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,11.  Pulmonary embolism.,PAST SURGICAL HISTORY,1.  Coronary artery bypass grafting.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy and adenoidectomy.,5.  Cosmetic surgery to breast and abdomen.,HOME MEDICATIONS,1.  Aspirin 81 mg once a day.,2.  Klor-Con 10 mEq once a day.,3.  Lasix 40 mg once a day.,4.  Levothyroxine 125 mcg once a day.,5.  Lisinopril 20 mg once a day.,6.  Pacerone 200 mg once a day.,7.  Protonix 40 mg once a day.,8.  Toprol 50 mg once a day.,9.  Vitamin B once a day.,10.  Zetia 10 mg once a day.,11.  Zyrtec 10 mg once a day.,ALLERGIES:,  CODEINE, ERYTHROMYCIN, SULFA, VICODIN, AND ZOCOR.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies any fevers, chills, recent weight gain or weight loss.  She has had abdominal symptoms with diarrhea.,EYES:  Decreased visual acuity.,ENT:  Sinus drainage.,CARDIOVASCULAR:  As described above.  Denies any chest pains.,RESPIRATORY:  He has chronic shortness of breath.  No cough or sputum production.,GI:  History of reflux symptoms.,GU:  No history of dysuria or hematuria.,ENDOCRINE:  No history of diabetes.,MUSCULOSKELETAL:  Denies arthritis, but has leg pain.,SKIN:  No history of rash.,PSYCHIATRIC:  No history of anxiety or depression.
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DESCRIPTION: Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.

The situation involves a 78-year-old patient with a complex medical history, experiencing a syncopal episode—possibly related to her significant cardiovascular issues. Given her age, history of coronary artery disease, previous bypass surgery, pulmonary embolism, and multiple other comorbidities, the situation could imply serious underlying conditions requiring immediate medical evaluation to prevent potential life-threatening complications. Hence, this scenario is high-stakes due to the potential risk of more severe medical events.


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: Supraventricular Tachycardia - Consult

HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.
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DESCRIPTION: The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.

consult - history and phy., congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,

The situation involves a 4-month-old infant with complex congenital heart disease and a history of supraventricular tachycardia, which is a serious medical issue. The infant requires immediate medical treatment and careful planning for future surgical interventions to manage their condition. The stakes are high because this concerns a young patient with a life-threatening condition requiring specialized care and decision-making that will have significant implications on their health and survival.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Supraclavicular Lymphadenopathy

On review of systems, the patient admits to hypertension and occasional heartburn.  She undergoes mammograms every six months, which have been negative for malignancy.  She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure.  She has had negative PPD.,PAST MEDICAL HISTORY:,  Hypertension.,PAST SURGICAL HISTORY:,  Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore.  She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation:  She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:,  Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP:  133/72
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DESCRIPTION: The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy.  She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy.  She is now referred to the thoracic surgery clinic for evaluation.

The presence of supraclavicular lymphadenopathy can be significant since this area is a critical site for lymphatic drainage and potential indicator of serious conditions such as malignancy. Although the patient has had negative mammogram results and denies many symptoms related to more acute concerns (like infection or cancer), the persistent lymphadenopathy and her family history of breast cancer increase the stakes of this diagnosis. The referral to the thoracic surgery clinic indicates that this situation is being taken seriously for further exploration of potential underlying causes, possibly malignant. This makes the situation moderately high-stakes as it could indicate a potentially serious disease requiring further investigation and possible intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: Speech Therapy Evaluation

MEDICAL DIAGNOSIS:,  Strokes.,SPEECH AND LANGUAGE THERAPY DIAGNOSIS:  ,Global aphasia.,SUBJECTIVE:  ,The patient is a 44-year-old female who is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.  The patient's sister-in-law was present throughout this assessment and provided all the patient's previous medical history.  Based on the sister-in-law's report, the patient had a stroke on 09/19/08.  The patient spent 6 weeks at XY Medical Center, where she was subsequently transferred to XYZ for therapy for approximately 3 weeks.  ABCD brought the patient to home the Monday before Thanksgiving, because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson.  The patient's previous medical history includes a long history of illegal drug use to include cocaine, crystal methamphetamine, and marijuana.  In March of 2008, the patient had some type of potassium issue and she was hospitalized at that time.  Prior to the stroke, the patient was not working and ABCD reported that she believes the patient completed the ninth grade, but she did not graduate from high school.  During the case history, I did pose several questions to the patient, but her response was often "no."  She was very emotional during this evaluation and crying occurred multiple times.,OBJECTIVE:  ,To evaluate the patient's overall communication ability, a Western Aphasia Battery was completed.  Also tests were not done due to time constraint and the patient's severe difficulty and emotional state.  Speech automatic tests were also completed to determine if the patient had any functional speech.,ASSESSMENT:,  Based on the results of the Weston aphasia battery, the patient's deficits most closely resemble global aphasia.  On the spontaneous speech subtest, the patient responded "no" to all questions asked except for how are you today where she gave a thumbs-up.  She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly.  The patient's sister-in-law did state that the patient wore glasses, but she currently does not have them and she did not know the extent the patient's visual deficit.,On the auditory verbal comprehension portion of the Western Aphasia Battery, the patient answered "no" to all "yes/no" questions.  The auditory word recognition subtest, the patient had 5 out of 60 responses correct.  With the sequential command, she had 10 out of 80 corrects.  She was able to shut her eyes, point to the window, and point to the pen after directions.  With repetition subtest, she repeated bed correctly, but no other stimuli.  At this time, the patient became very emotional and repeatedly stated "I can't".  During the naming subtest of the Western Aphasia Battery, the patient's responses contained numerous paraphasias and her speech was often unintelligible due to jargon.  The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech.  In regards to speech automatics, the patient is able to count from 1 to 9 accurately; however, stated 7 instead of 10 at the end of the task.  She is not able to state the days of the week or months in the year or her name at this time.  She cannot identify the day on calendar and was unable to verbally state the date or month.,DIAGNOSTIC IMPRESSION:  ,The patient's communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication.  She does perseverate and is very emotional due to probable frustration.  Outpatient skilled speech therapy is recommended to improve the patient's functional communication skills.,PATIENT GOAL: , Her sister-in-law stated that they would like to improve upon the patient's speech to allow her to communicate more easily at home.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week for the next 12 weeks.  Therapy to include aphasia treatment and home activities.,SHORT-TERM GOALS (8 WEEKS):,1.  The patient will answer simple "yes/no" questions with greater than 90% accuracy with minimal cueing.,2.  The patient will be able to complete speech automatic tasks with greater than 80% accuracy without models or cueing.,3.  The patient will be able to complete simple sentence completion and/or phrase completion with greater than 80% accuracy with minimal cueing.,4.  The patient will be able to follow simple one-step commands with greater than 80% accuracy with minimal cueing.,5.  The patient will be able to name 10 basic everyday objects with greater than 80% accuracy with minimal cueing.,SHORT-TERM GOALS (12 WEEKS):,  Functional communication abilities to allow the patient to express her basic wants and needs.
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DESCRIPTION: Global aphasia.  The patient is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke.

consult - history and phy., speech automatic tasks, minimal cueing, sentence completion, western aphasia battery, skilled speech therapy, global aphasia, speech therapy, speech, aphasia,

The situation involves a patient with global aphasia after a stroke, which necessitates speech therapy. While the patient's condition is serious and impactful on daily life, it is a rehabilitative situation rather than an acute medical emergency. The stakes are primarily centered around improving the quality of life through therapy. This is important, but not life-threatening, thus not extremely high-stakes in a medical sense.


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

REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.
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DESCRIPTION: Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

The situation involves an 80-year-old patient with sepsis, a potentially life-threatening condition. The patient's underlying conditions, including a history of dementia, coronary artery disease, and a cerebrovascular accident, increase the risk of complications. The CT scan findings suggest an acute urinary obstruction, adding further complexity to the patient's condition. Sepsis, particularly in elderly patients with multiple comorbidities, is a high-stakes medical situation that requires immediate and thorough medical intervention.


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

SUBJECTIVE:,  This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:,  She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited.  She does not drink a whole lot of pop.  Her stools are normal.  Brushes her teeth, sees a dentist.,Developmental History:  Hearing and vision is okay.  She did well in school last year.  She will be going to move to Texas, will be going to Bowie High School.  She will be involved in cheerleading, track, volleyball, and basketball.  She will be also playing the clarinet and will be a freshman in that school.  Her menarche was 06/30/2004.,PAST MEDICAL HISTORY:,  She is still on medications for asthma.  She has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg.  She had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,Review of her immunizations, her last tetanus shot was 06/17/2003.,MEDICATIONS:  ,Advair 100/50 b.i.d., Allegra 60 mg b.i.d., Flonase q.d., Xopenex, Intal, and albuterol p.r.n.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Weight:  112 pounds about 40th percentile.  Height:  63-1/4 inches, also the 40th percentile.  Her body mass index was 19.7, 40th percentile.  Temperature:  97.7 tympanic.  Pulse:  80.  Blood pressure:  96/64.,HEENT:  Normocephalic.  Fundi benign.  Pupils equal and reactive to light and accommodation.  No strabismus.  Her vision was 20/20 in both eyes and each with contacts.  Hearing:  She passed that test.  Her TMs are bilaterally clear and nonerythematous.  Throat was clear.  Good mucous membrane moisture and good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Abdomen:  No hepatosplenomegaly.,Respiratory:  Clear.  No wheezes.  No crackles.  No tachypnea.  No retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.,GU:  Normal female genitalia.  Tanner stage 3, breast development and pubic hair development.  Examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,Extremities:  She has good range of motion of upper and lower extremities.  Deep tendon reflexes were 2+/4+ bilaterally and equal.  Romberg negative.,Back:  No scoliosis.  She had good circumduction at shoulder joint and her duck walk was normal.,SKIN:  She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption.  No honey crusting was noted on the skin.  She also had some mild rash on the anterior abdominal area near the panty line similar to that rash.  It was raised and blanch with pressure, it was slightly erythematous.,ASSESSMENT AND PLAN:,1.  Sports physical.,2.  The patient received her first hepatitis A vaccine.  She will get a booster in 6 to 12 months.  Prescription for Atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for Elocon ointment to be applied topically, except for the face, once a day with a refill.  She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician.  We talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen.  We talked about avoidance of drugs and alcohol and sexual activity.  Continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on PO steroid medication, but presently that was held and moved to treatment with Atarax and Elocon.  Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.
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DESCRIPTION: This patient was seen in clinic for a school physical.

consult - history and phy., school physical, calcium intake, hearing and vision, hepatitis a vaccine, booster, anticipatory guidance, developmental, percentile, physical, school, rash,

The situation described is a routine school physical examination. Although the patient has a few medical issues like a rash possibly from poison ivy and asthma, these are being managed with medications and follow-up care. The primary purpose of the visit is a standard check-up to ensure eligibility for school sports and activities. There is no indication of immediate life-threatening conditions or critical decisions needed at this moment. Therefore, while it involves ensuring the patient's health and readiness for physical activities, the stakes are relatively low compared to more urgent or severe medical situations.


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

HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She was followed by another rheumatologist.  She says she has been off and on, on prednisone and Arava.  The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone.  She says she had been on prednisone for the last 6 to 9 months.  She is on 5 mg a day.  She recently had a left BKA and there was a question of infection, so it had to be debrided.  I was consulted to see if her prednisone is to be continued.  The patient denies any joint pains at the present time.  She says when this started she had significant joint pains and was unable to walk.  She had pain in the hands and feet.  Currently, she has no pain in any of her joints.,REVIEW OF SYSTEMS: , Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,PAST MEDICAL HISTORY: , Significant for hypertension, peripheral vascular disease, and left BKA.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Denies tobacco, alcohol or illicit drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS:  BP 130/70, heart rate 80, and respiratory rate 14.,HEENT:  EOMI.  PERRLA.,NECK:  Supple.  No JVD.  No lymphadenopathy.,CHEST:  Clear to auscultation.,HEART:  S1 and S2.  No S3, no murmurs.,ABDOMEN:  Soft and nontender.  No organomegaly.,EXTREMITIES:  No edema.,NEUROLOGIC:  Deferred.,ARTICULAR:  She has swelling of bilateral wrists, but no significant tenderness.,LABORATORY DATA:,  Labs in chart was reviewed.,ASSESSMENT AND PLAN:,  A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone.  She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that.  As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow.  If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone.  I would defer that to Dr. X.  If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone.  I discussed this at length with the patient and she is in full agreement with the plan.  I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there.
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DESCRIPTION: A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She is not on DMARD, but as she recently had a surgery followed by a probable infection.

consult - history and phy., prednisone, joint pains, rheumatoid arthritis, arthritis, dmard, rheumatologist, rheumatoid, pains,

The situation involves a 71-year-old female patient with a history of rheumatoid arthritis and recent surgery leading to complications such as a probable infection. Although her current condition seems stable, deciding the long-term management of her rheumatoid arthritis medication, particularly the use of prednisone, is crucial considering her medical history. This decision impacts her overall health, quality of life, and the management of her autoimmune condition. However, the patient's stability and collaborative agreement on the plan reduce immediate risks.


Medical Specialty: Consult - History and Phy.
Sample Name: Rotator cuff syndrome - H&P

CHIEF COMPLAINT:  ,This 18 year old male presents today with shoulder pain right.  Location:  He indicates the problem location is the right shoulder diffusely.  Quality:  Quality of the pain is described by the patient as aching, throbbing and tolerable.  Patient relates pain on a scale from 0 to 10 as 5/10.  Severity:  The severity has worsened over the past 3 months.  Timing (onset/frequency):  Onset was gradual and after pitching a baseball game.  Modifying Factors:  Patient's condition is aggravated by throwing.  He participates with difficulty in basketball.  Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY:  ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam:  BP Standing:  116/68 Resp:  16 HR:  68 Temp:  98.1 Height:  5 ft.  11 in.  Weight:  165 lbs.  Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Oriented to person, place and time.  Right shoulder shows evidence of swelling and tenderness.  Radial pulses are 2 /4, bilateral.  Brachial pulses are 2 /4, bilateral.,Appearance:  Normal.,Tenderness:  Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion:  Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  L shoulder normal.,Strength:  External rotation - fair.  Internal rotation - poor right.,AC Joint:  Pain with ABD and cross-chest - mild right.,Rotator Cuff:  Impingement - moderate.  Painful arc - moderate right.,Instability:  None.,TEST & X-RAY RESULTS:,  X-rays of the shoulder were performed.  X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  I noted that this is a very common condition resulting in significant difficulties with use of the arm.  Several treatment options and their potential benefits were described.  Nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  Cortisone shots can be very effective and are quite safe.  Often more than one injection may be required.  Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear.  Injected shoulder joint and with Celestone Soluspan 1.0 cc .  Ordered x-rays of shoulder right.,PRESCRIPTIONS:,  Vioxx Dosage:  25 mg tablet Sig:  TID Dispense:  60 Refills:  0 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient was instructed to restrict activity.  Patient was given instructions on RICE therapy.
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DESCRIPTION: Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.

The situation involves a medical consultation for an 18-year-old male with rotator cuff syndrome. While painful and potentially impacting the patient’s quality of life and athletic activity, this condition is commonly managed effectively with treatments such as NSAIDs, cortisone injections, and physical therapy. Although the situation requires professional medical attention and management, it is not life-threatening or critical in nature. Therefore, it can be considered low to moderate stakes.

Furthermore, the patient is in otherwise good health with no significant medical history that would exacerbate his current condition into a high-stakes situation. The medical practitioner has a clear plan involving non-invasive treatments and possible diagnostics (MRI, shoulder arthrogram) if needed. These factors contribute to the assessment that the stakes are not high.


Medical Specialty: Consult - History and Phy.
Sample Name: Renal Failure - Consult

REASON FOR CONSULTATION:, Acute renal failure.,HISTORY: , Limited data is available; I have reviewed his admission notes. Apparently this man was found down by a family member, was taken to Medical Center, and subsequently flown here. He has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. Markers of renal function have been fairly stable. I do not presently see indicators that he historically has been oliguric. The BUN and creatinine have been fairly stable. It is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. Earlier thoughts had been that he could have had rhabdomyolysis, but the highest CPK I find recorded is 1500, the phosphorus is not elevated, though I acknowledge the serum calcium is low. I see no markers of myoglobinuria nor serum level of myoglobin. He has received IV fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition.,PAST MEDICAL HISTORY:, Not obtained from the patient, but is reviewed in other physician's notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking Imdur and digoxin, reportedly. A suggestion of hypertensive disease versus BPH, he was on terazosin. Suggestion of CHF versus hypertension versus volume overload, treated with Lasix. He was iron, I presume for anemia. He was on potassium, lisinopril and aspirin.,ALLERGIES:, OTHER PHYSICIAN'S NOTES INDICATE NO KNOWN ALLERGIES.,FAMILY HISTORY:, Not available.,SOCIAL HISTORY:, Not available.,REVIEW OF SYSTEMS:, Not available.,PHYSICAL EXAMINATION:,GENERAL: An older white male who is intubated, edematous, and appears uncomfortable.,HEENT: Male pattern baldness. Pupils equally round, no icterus. Intubated. OG tube in place.,NECK: Not tested for suppleness, no carotid bruits are heard. Neck vein distention is not seen.,LUNGS: He has diffuse expiratory wheezing anteriorly, laterally and posteriorly. I would describe the wheezes as coarse. I hear no present rales. Breath sounds otherwise are symmetrical.,HEART: Heart tones regular to auscultation, currently without audible rub or gallop sounds.,BREASTS: Not enlarged.,ABDOMEN: On plane. Bowel sounds presently are normal. Abdomen, I believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no HJR, no spleen tip, no suprapubic fullness.,GU: Catheter draining a dark yellow urine.,EXTREMITIES: Very edematous. Pulses not palpable. Cyanosis not observed. Fungal changes are not observed.,NEUROLOGICAL: Not otherwise assessed.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Acute renal failure, suspected. Likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. He also reportedly was on Lasix prior to hospitalization, ? hypovolemia as a consequence.,2. Multi-organ system failure/systemic inflammatory response syndrome, with septic shock.,3. I am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum CK recorded is 1500.,4. Antecedent hypoxemia, with renal hypoperfusion.,5. Diffuse aspiration pneumonitis suggested.,DISCUSSION/PLAN: ,I think the renal function will follow the patient. Supportive care, attention to stability of a euvolemic state, will be important at this time. He is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. He is on TPN, antimicrobials, and has been on vasopressive agents. Blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission.,I would use diuretics to maintain central euvolemia. Recorded I's are substantially O's during the course of the hospitalization, I presume as part of his resuscitation effort. No central pressures or monitoring of same is currently available. I will follow with you. No present indication for hemodialysis. Antimicrobials are being handled by others.
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DESCRIPTION: Acute renal failure, suspected, likely due to multi-organ system failure syndrome.

The situation involves acute renal failure and multi-organ system failure syndrome, which are serious medical conditions. The patient is intubated, requires mechanical ventilation, and receives complex medical interventions such as IV fluid resuscitation, broad-spectrum antibiotics, and vasopressive agents. These medical issues indicate a high degree of complexity and urgency, as they involve multiple organ systems and potentially life-threatening conditions. The presence of septic shock and acute renal failure further underscores the critical nature of the patient's condition, suggesting that the medical team's decisions could have significant impacts on patient outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Revocation Admission

IDENTIFYING DATA:,  This is a 40-year-old male seen today for a 90-day revocation admission.  He had been reported by his case manager as being noncompliant with medications, refusing oral or IM medications, became agitated, had to be taken to ABCD for evaluation, admitted at that time to auditory hallucinations and confusion and was committed for admission at this time.  He has a psychiatric history of schizophrenia, was previously admitted here at XYZ on 12/19/2009, had another voluntary admission in ABCD in 1998.,MEDICATIONS: , Listed as Invega and Risperdal.,ALLERGIES: , None known to medications.,PAST MEDICAL HISTORY:  ,The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil.  The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.,FAMILY HISTORY: , Listed as unknown in the chart as far as other psychiatric illnesses.  The patient himself states that his parents are deceased and that he raised himself in the Philippines.,SOCIAL HISTORY:,  He immigrated to this country in 1984, although he lists himself as having a green card still at this time.  He states he lives on his own.  He is a single male with no history of marriage or children and that he had high school education.  His recreational drug use in the chart indicates that he has had a history of methamphetamines.  The patient denies this at this time.  He also denies current alcohol use.  He does smoke.  He is unable to tell me of any PCP.  He is in counseling service with his case manager being XYZ.,LEGAL HISTORY:  ,  He had an assault in December 2009, which led to his previous detention.  It is unknown whether he is under legal constraints at this time.,OBJECTIVE FINDINGS:  ,VITAL SIGNS: , Blood pressure is 125/75.  His weight is 197 with height 5 feet 4 inches.,GENERAL:,  He is cooperative, although disorganized and focusing entirely and telling me that he is here because there was some confusion in how he took his medications.  He does not endorse any voices at this time.,HEENT: , His head exam is normal with normal scalp.  HEENT is unremarkable.  Pupils equal and reactive to light and accommodation.  TMs are normal.,NECK:,  Unremarkable with no masses or tenderness.,CARDIOVASCULAR:,  Normal S1 and S2.  No murmurs.,LUNGS:,  Clear.,ABDOMEN:  ,Negative with no scars.,GU:  ,Not done.,RECTAL:,  Not done.,DERM:,  He does have a scarring of acne lesions, both face and back.,EXTREMITIES:,  Otherwise negative.,NEUROLOGIC: , Cranial nerves II through X normal.  Reflexes are normal and gait is unremarkable.,LABORATORY DATA: , His labs done at ABCD showed his CMP to be normal with an elevated white count of 17.2.  Chest x-ray was indicated as being done and normal as was a UA and he did apparently receive hydration in the hospital with IV fluids.,ASSESSMENT: , History of hyperlipidemia with elevated triglycerides.  We will maintain his gemfibrozil 600 b.i.d. and for health maintenance issues, we will also maintain just a vitamin daily and we will obtain recheck on his labs and lipid levels in one week after treatment is initiated.
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DESCRIPTION: A 40-year-old male seen today for a 90-day revocation admission.  Noncompliant with medications, refusing oral or IM medications, became agitated.  History of hyperlipidemia with elevated triglycerides.

This situation is high-stakes due to the patient's severe psychiatric condition, history of schizophrenia, recent agitation, medication noncompliance, and the necessity for a 90-day revocation admission. The patient has reported auditory hallucinations and confusion, necessitating immediate and careful management to prevent harm to himself or others. Ensuring the patient receives appropriate psychiatric care and monitoring his medication compliance is critical, making the stakes high in terms of health and safety.


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

CHIEF COMPLAINT: , Recurrent nasal obstruction.,HISTORY OF PRESENT ILLNESS:,  The patient is a 5-year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea.  Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis.  All of his symptoms had resolved when he had seen Dr. F, so no surgical plan was made and no further followup was needed.  However, the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes.  Again, the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature.  It sounds like he is snoring loudly and does have some nasal obstruction at nighttime.  He also is sniffing a lot through his nose.  He has been tried on some nasal steroids but they only use this on a p.r.n. basis about one or two days every month and we are unsure if that has even helped at all, probably not.  The child is not having any problems with his ears including ear infections or hearing.  He is also not having any problems with strep throat.,PAST MEDICAL HISTORY: , Eczema.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , No family history of bleeding diathesis or anesthesia difficulties.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 43 pounds, height 37 inches, temperature 97.4, pulse 65, and blood pressure 104/48.,GENERAL:  The patient is a well-nourished male in no acute distress.  Listening to his voice today in the clinic, he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation.,NOSE:  Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea.,EARS:  The patient tympanic membranes are clear and intact bilaterally.  There is no middle ear effusion.,ORAL CAVITY:  The patient has 2+ tonsils bilaterally.  There are clearly nonobstructive.  His uvula is midline.,NECK:  No lymphadenopathy appreciated.,ASSESSMENT AND PLAN: , This is a 5-year-old male, who presents for repeat evaluation of a possible nasal obstruction, questionable sleep apnea.  Again, the mother gives a confusing sleep history but it does not really sound like he is having apneic events.  They deny any actual gasping events.  It sounds like true obstructive events.  He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis.  I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately.  I have given them prescription for Nasacort Aqua one spray to each nostril twice a day.  I instructed them on correct way to use this and the importance to use it on a daily basis.  They may not see any benefit for several weeks.  I would like to evaluate him in six weeks to see how we are progressing.  If he continues to have problems, I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child.  He may also need an allergy evaluation at that point if he continues to have problems.  However, I would like to be fairly conservative in this child.  Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen (I did instruct her call us if it worsens), we may even need to pursue a sleep study just to settle that issue once and for all.  We will see him back in six weeks.
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DESCRIPTION: Patient with suspected nasal obstruction, possible sleep apnea.

consult - history and phy., recurrent nasal obstruction, allergic rhinitis, apneic events, sleep apnea, nasal obstruction, nasal, apnea, allergic, obstruction, sleep,

The situation involves a 5-year-old child experiencing recurrent nasal obstruction with potential sleep disturbances. While parental concerns about sleep and breathing issues can be anxiety-inducing, the medical assessment does not indicate any immediately life-threatening conditions. The plan is conservative, focusing on medical management with nasal corticosteroids and potential follow-ups. The stakes are moderate, as unresolved nasal obstruction and snoring can affect quality of life and sleep but are not urgently critical conditions in the absence of clear sleep apnea or related complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Rectal Bleeding - Consult

REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS:  ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  He has had some physical therapy for his lower back secondary to pain after hernia repair.  He states that the pain worsened after this.  He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal.  He denies any dysuria.  He denies any hematemesis.  He denies any pleuritic chest pain.  He denies any hemoptysis.,PAST MEDICAL HISTORY:,1.  History of bilateral hernia repair by Dr. X in 8/2008.,2.  History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Cipro.,2.  Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Pulse 117, respirations 18, and blood pressure 117/55.  Saturating 98% on room air.,GENERAL:  The patient is alert and oriented x3.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is clear without exudates.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Tachycardic.  Regular rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN:  Positive bowel sounds.  Soft and nontender with no guarding.,EXTREMITIES:  No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC:  Nonfocal.,LABORATORY STUDIES:,  Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils.  EKG shows sinus tachycardia.,PROBLEM LIST:,1.  Colitis.,2.  Sepsis.,3.  Rectal bleeding.,RECOMMENDATIONS:,1.  GI consult with Dr. Y's group.,2.  Continue Levaquin and Flagyl.,3.  IV fluids.,4.  Send for fecal WBCs, O&P, and C. diff.,5.  CT of the abdomen and pelvis to rule out abdominal pathology.,6.  PPI for PUD prophylaxis.
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DESCRIPTION: A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.

This situation involves a 68-year-old male with rectal bleeding, diarrhea, stomach discomfort, and a history of hernia repair. Given the age of the patient and the symptoms presented, these could indicate a serious underlying condition such as colitis or sepsis, which are already flagged in the problem list. The presence of tachycardia and an elevated white count further suggests a possible acute infection or inflammatory process. Immediate medical assessment and intervention are necessary to manage potential complications, rendering this a high-stakes scenario.


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

CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.
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DESCRIPTION: Obstructive sleep apnea syndrome.  Loud snoring.  Schedule an overnight sleep study.

The consultation document describes a common medical assessment for suspected obstructive sleep apnea (OSA) in a patient. While OSA can have significant health impacts if untreated, including cardiovascular problems and increased risk for accidents, the immediate stakes of this consultation are not life-threatening. The patient is already scheduled for an overnight sleep study to confirm the diagnosis, and there are no urgent or critical symptoms that require immediate intervention. The situation is standard and routine in the practice of managing suspected OSA, which affects a significant percentage of the population. Given that the patient's daytime functioning is only mildly affected (e.g., dozing off during boring activities), this further suggests the situation is not urgent.


Medical Specialty: Consult - History and Phy.
Sample Name: Rectal Bleeding - 1-year-old

HISTORY OF PRESENT ILLNESS:,  This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  He had one more episode that day of stool; the stool was hard with blood in it.  Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  No history of fever, no diarrhea, no history of easy bruising.  Excessive bleeding from minor cut.  He has been slightly fussy.,PAST MEDICAL HISTORY:  ,Nothing significant.,PREGNANCY DELIVERY AND NURSERY COURSE: , He was born full term without complications.,PAST SURGICAL HISTORY: , None.,SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: , Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,DIET:,  Regular table food, 24 ounces of regular milk.  He is n.p.o. now.,TRAVEL HISTORY: , Negative.,IMMUNIZATION: , Up-to-date.,ALLERGIES: , None.,MEDICATIONS: , None, but he is on IV Zantac now.,SOCIAL HISTORY: , He lives with parents and siblings.,FAMILY HISTORY:,  Nothing significant.,LABORATORY EVALUATION: , On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3.  Albumin 3.3.  AST 56 and ALT 26.  CRP less than 0.3.  Stool rate is still negative.,DIAGNOSTIC DATA: , CT scan of the abdomen was read as normal.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute.  Weight 9.6 kilogram.,GENERAL:  He is alert and active child in no apparent distress.,HEENT:  Atraumatic and normocephalic.  Pupils are equal, round and reactive to light.  Extraocular movements, conjunctivae and sclerae fair.  Nasal mucosa pink and moist.  Pharynx is clear.,NECK:  Supple without thyromegaly or masses.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Soft and nondistended.  Bowel sounds positive.  No mass palpable.,GENITALIA:  Normal male.,RECTAL:  Deferred, but there was no perianal lesion.,MUSCULOSKELETAL:  Full range of movement.  No edema.  No cyanosis.,CNS:  Alert, active and playful.,IMPRESSION: , A 1-year-old male patient with history of rectal bleeding.  Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.,PLAN:,  To proceed with Meckel scan today.  If Meckel scan is negative, we will consider upper endoscopy and colonoscopy.  We will start colon clean out if Meckel scan is negative.  We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg.  Monitor hemoglobin.
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DESCRIPTION: Pediatric Gastroenterology - Rectal Bleeding Consult.

This situation involves a 1-year-old child with rectal bleeding, which is a potentially acute and serious medical issue. Rectal bleeding in young children can be indicative of significant underlying conditions such as Meckel's diverticulum, polyps, infections, or vascular malformations. The case includes abnormal vital signs (an elevated pulse) and concerning lab results (low hemoglobin and hematocrit), which suggest possible anemia due to blood loss. The plan includes diagnostic measures such as a Meckel scan and other potential invasive procedures like endoscopy or colonoscopy. Given that this involves a very young child with significant symptoms and potential for serious conditions, it is high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Pulmonary Embolism

REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:,  The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life.  The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.  At that time, her daughter was with her.  No tonic-clonic movements.  No cyanosis.  The patient woke up on her own.  The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years.  She cannot get up one flight of stairs, but feels short of breath.  She gets exerted and thinks to take a shower.  She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1.  Pulmonary embolism diagnosed one year ago.  At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers.  Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2.  Coronary artery disease status post CABG at that time.  She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3.  Mitral regurgitation.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of aortic aneurysm.,8.  History of renal artery stenosis.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,PAST SURGICAL HISTORY,1.  CABG.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy.,5.  Adenoidectomy.,6.  Cosmetic surgery.,7.  Renal stent.,8.  Right femoral stent.,HOME MEDICATIONS,1.  Aspirin.,2.  Potassium.,3.  Lasix.,4.  Levothyroxine.,5.  Lisinopril.,6.  Pacerone.,7.  Protonix.,8.  Toprol.,9.  Vitamin B.,10.  Zetia.,11.  Zyrtec.,ALLERGIES:,  SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore.  She drinks 2 to 3 glasses of wine per week.  She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE:  In no acute distress.,VITAL SIGNS:  Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT:  No lymph nodes or masses.,NECK:  No jugular venous distension.,LUNGS:  Clear to auscultation bilaterally.
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DESCRIPTION: Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.

The situation involves a 78-year-old patient with a history of pulmonary embolism, who has experienced a syncopal episode. The patient's extensive medical history, especially previous pulmonary embolism, coronary artery disease, and paroxysmal atrial fibrillation without anticoagulation due to GI bleed, presents potentially serious health risks. The syncopal episode could indicate cardiovascular issues or another pulmonary embolism, which can be life-threatening. Therefore, the stakes are high given the potential health risks and the patient's significant medical history.


Medical Specialty: Consult - History and Phy.
Sample Name: Psych H&P - 2

HISTORY OF PRESENT ILLNESS:,  The patient is a 69-year-old single Caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and dyslipidemia who presents to the emergency room with the complaint of "manic" symptoms due to recent medication adjustments.  The patient had been admitted to St. Luke's Hospital on Month DD, YYYY for altered mental status and at that time, the medical team discontinued Zyprexa and lithium.  In the emergency room, the patient reported elevated mood, pressured speech, irritability, decreased appetite, and impulsivity.  She also added that over the past three days, she felt more confused and reported having blackouts as well as hallucinations about white lines and dots on her arms and face from the medication changes.  She was admitted voluntarily to the inpatient unit and medications were not restarted for her.  On the unit this morning, the patient is loud and nonredirectable, she is singing loudly and speaking in a very pressured manner.  She reports that she would like to speak with Dr. A, the neurologist who saw her at St. Luke's, because she "trust him."  The patient is somewhat reluctant to answer questions stating that she has answered enough of people's questions; however, she is talkative and reports that she feels as though she needs a sedative.  The patient reports that she is originally from Brooklyn, New York, and she moved down to Houston about a year ago to be with her daughter.  She also expressed frustration over the fact that her daughter wanted her removed from the apartment she was in initially and had her placed in a nursing home due to inability to care for herself.  The patient also complains that her daughter is "trying to tell me what medications to take."  The patient sees Dr. B in the Woodlands for outpatient care.,PAST PSYCHIATRIC HISTORY:,  Per chart.  The patient has been mentally ill for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia.  She has been stable on lithium and Zyprexa according to her daughter and was recently taken off those medications, changed to Seroquel, and the daughter reports that she has decompensated since then.  It is not known whether the patient has had prior psychiatric inpatient admissions; however, she denies that she has.,MEDICATIONS: ,1.  Seroquel 100 mg, 1 p.o. b.i.d.,2.  Risperdal 1 mg tab, 1 p.o. t.i.d.,3.  Actos 30 mg, 1 p.o. daily.,4.  Lipitor 10 mg, 1 p.o. at bedtime.,5.  Gabapentin 100 mg, 1 p.o. b.i.d.,6.  Glimepiride 2 mg, 1 p.o. b.i.d.,7.  Levothyroxine 25 mcg, 1 p.o. q.a.m.,8.  Protonix 40 mg, 1 p.o. daily.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY:,  Per chart; her mother died of stroke, father with alcohol abuse and diabetes, one sister with diabetes, and one uncle died of leukemia.,SOCIAL HISTORY:,  The patient is from Brooklyn, New York and moved to Houston approximately one year ago.  She lived independently in an apartment until about one month ago when her daughter moved her into a nursing home.  She has been married once, but her spouse left her when her three children were young.  Her children are ages 47, 49, and 51.  She had one year of college, and she currently is retired after working in New York public schools for 20 or more years.  She reports that her spouse was physically abusive to her.  She reports occasional alcohol use and quit smoking 11 years ago.,MENTAL STATUS EXAM:  ,GENERAL:  The patient is an obese, white female who appears older than stated age, seated in a chair wearing large dark glasses.,BEHAVIOR:  The patient is singing loudly and joking with interviewers.  She is pleasant, but non-cooperative with interview.,SPEECH:  Increased volume, rate, and tone.  Normal in flexion and articulation.  MOTOR:  Agitated.,MOOD:  Okay.,AFFECT:  Elevated and congruent.,THOUGHT PROCESSES:  Tangential and logical at times.,THOUGHT CONTENTS:  Denies suicidal or homicidal ideation.  Denies auditory or visual hallucination.  Positive grandiose delusions and positive paranoid delusions.,INSIGHT:  Poor to fair.,JUDGMENT:  Impaired.  The patient is alert and oriented to person, place, date, year, but not day of the week.,LABORATORY DATA:,  Sodium 144, potassium 4.2, chloride 106, bicarbonate 27, glucose 183, BUN 23, creatinine 1.1, and calcium 10.6.  Acetaminophen level 3.3 and salicylate level less than 0.14.  WBC 7.41, hemoglobin 13.8, hematocrit 43.1, and platelets 229,000.  Urinalysis within normal limits.,PHYSICAL EXAMINATION:,GENERAL:  Alert and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure 152/92, heart rate 81, and temperature 97.2.,HEENT:  Normocephalic and atraumatic.  PERRLA.  EOMI.  MMM.  OP clear.,NECK:  Supple.  No LAD, no JVD, and no bruits.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.  S1 and S2 heard.  No murmurs, rubs, or gallops.,ABDOMEN:  Obese, soft, nontender, and nondistended.  Positive bowel sounds x4.,EXTREMITIES:  No cyanosis, clubbing, or edema.,ASSESSMENT:,  This is a 69-year-old Caucasian female with a past medical history of schizoaffective disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and GERD who presents to the emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over the past 3 days, which she attributes to a recent change in medication after an admission to St. Luke's Hospital during which time the patient was taken off her usual medications of lithium and Zyprexa.  The patient is manic and disinhibited and is unable to give a sufficient interview at this time.,AXIS I:  Schizoaffective disorder.,AXIS II:  Deferred.,AXIS III:  Diabetes, hypothyroidism, osteoarthritis, gastroesophageal reflux disease, and dyslipidemia.,AXIS IV:  Family strife and recent relocation.,AXIS V:  GAF equals 25.,PLAN:
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DESCRIPTION: Psychiatric History and Physical - Patient with schizoaffective disorder.

The situation involves a 69-year-old woman with complex mental health and somatic issues presenting serious mental health concerns, likely exacerbated by medication changes. The patient exhibits manic symptoms, possibly due to medication-related factors, leading to impulsivity, mood elevation, and other destabilizing behaviors. These symptoms can pose significant risks to the patient's health and safety, affecting her living situation and family dynamics. The patient's disorientation and potential for impaired judgment further increase the stakes, necessitating prompt and effective management to prevent deterioration or harm.


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

HISTORY OF PRESENT ILLNESS:,  This is a 53-year-old widowed woman, she lives at ABC Hotel.  She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis.  She has been refusing cardiac catheter and she may well need aortic valve replacement.  She states that she does not want heart surgery or valve replacement.  She has a history of bipolar disorder and has been diagnosed at times with schizophrenia.  She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day.  The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel.  She denies hallucinations, psychosis, paranoia, and suicidal ideation at this time.  States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks.  The patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ.  She is a high-school graduate from ABCD High School.  She did have an abusive childhood.  She is married four times.  She notes she developed depression when a number of her children died.,PHYSICAL EXAMINATION:  ,GENERAL: , This is an obese woman in bed.  She is somewhat restless and moving during the interview.,VITAL SIGNS,:  Temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 L of oxygen.,PSYCHIATRY:  ,Speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level.  There is no overt thought disorder.  She does not appear psychotic.  She is not suicidal on formal testing.  She gives the date as Sunday, 05/19/2007 when it is the 20th and 207 when it is 2007.  She is oriented to place.  She can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits.  She had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, "December, November, September, October, June, July, August, September," but recognizes this was not right and then said, "March, April, May."  She is able to name objects appropriately.,LABORATORY DATA: , Chest x-ray showing no acute changes.  Carotid duplex shows no stenosis.  Electrolytes and liver function tests are normal.  TSH normal.  Hematocrit 31%.  Triglycerides 152.,DIAGNOSES:  ,1.  Bipolar disorder, apparently stable on medications.,2.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3.  Aortic stenosis.,4.  Sleep apnea.,5.  Obesity.,6.  Anemia.,7.  Gastroesophageal reflux disease.,RECOMMENDATIONS:,  It is my impression at present that the patient retains ability to make decisions on her own behalf.  Given this lady's underlying mental problems, I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel.  While she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her.  She clearly at this time wants to leave this hospital; she normally gets her care through XYZ Health.  Again, in summary, I would consider her to retain the ability to make decisions on her own behalf.,Please feel free to contact me at digital pager if additional information is needed.
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DESCRIPTION: Bipolar disorder, apparently stable on medications.  Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.

consult - history and phy., organic brain syndrom, substance abuse, bipolar disorder, mental, abuse,

The situation involves a 53-year-old woman with severe aortic stenosis who is refusing necessary cardiac surgery due to personal reasons, past substance abuse, and chronic mental health conditions. The decision not to undergo surgery is high-stakes because it affects her long-term health outcomes and involves complex interplay between her physical and mental health. The patient's decision-making capacity is significant, but so are the potential consequences of untreated aortic stenosis, which can be life-threatening. Her refusal, despite being considered competent to make her own medical decisions, places her in a situation where her life could be in jeopardy if the condition is left untreated. Furthermore, the interplay of her mental health conditions with her medical needs complicates the situation, requiring nuanced discussions between her regular care providers and hospital staff.


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 - Paranoia

IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , "I am not sure." The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas.  According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle.  The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid.  The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY:  ,No acute medical problems noted.,CURRENT MEDICATIONS: , None.  The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston.  The patient has no known history of substances abuse.  The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:,  Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude:  Calm and cooperative.,Appearance:  Shows poor hygiene and grooming.,Psychomotor:  Behavior is within normal limits without agitation or retardation.  No EPS or TDS noted.,Affect:  Is suspicious.,Mood:  Anxious but cooperative.,Speech:  Shows normal rate and rhythm.,Thoughts:  Disorganized,Thought Content:  Remarkable for paranoia "they want to hurt me.",Psychosis:  The patient endorses paranoid delusions as above.  The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation:  The patient denies on admission.,Cognitive Assessment:  Grossly intact.  The patient is alert and oriented x 3.,Judgment:  Poor, shown by noncompliance with treatment.,Assets:  Include stable physical status.,Limitations:  Include recurrent psychosis.,FORMULATION:  ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I:  Schizophrenia, chronic paranoid.,AXIS II:  None.,AXIS III:  None.,AXIS IV:  Severe.,AXIS V:  10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN:  ,The patient will be restarted on Invega and Abilify for psychosis.  The patient will also be continued on Cogentin for EPS.  Increased database will be obtained.
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DESCRIPTION: A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.

The situation involves a patient with a known history of paranoid schizophrenia experiencing increased paranoia, disorganized thoughts, and agitation, which led to erratic behavior like breaking a window and being detained. This is a serious mental health situation due to the potential for harm to self or others, particularly given the patient's noncompliance with medication and recent aggressive behavior. Cognitive and psychiatric assessments indicate severe impairment, making this a high-stakes situation for the medical staff involved in ensuring the patient's safety and stabilization.


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

IDENTIFYING DATA:,  The patient is a 45-year-old white male.  He is unemployed, presumably on disability and lives with his partner.,CHIEF COMPLAINT: , "I'm in jail because I was wrongly arrested." The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability.,HISTORY OF PRESENT ILLNESS: , The patient has minimal insight into the circumstances that resulted in this admission.  He reports being diagnosed with AIDS and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition.  Prior to admission, the patient was brought to Emergency Room after he attempted to shoplift from a local department store, during which he apparently slapped his partner.  The patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability.,On the interview, the patient is still disorganized and confused.  He believes that he has been arrested and is in jail.  Reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary.,I was able to contact his partner by telephone.  His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers.  His partner estimates the patient spends about 20% of the year in episodes of worse symptoms.  His partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons.  He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night.  He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently.  He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home.  He reports that the patient has been eating regularly with no recent weight loss.  He states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months.  His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening.  He reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine.  He also reports that the patient has expressed the belief in the past that he does not suffer from either condition.,PAST PSYCHIATRIC HISTORY: , The patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown.  The patient was last enrolled in an outpatient mental health treatment in mid 2009.  He dropped out of care about six months ago when he moved with his partner.  His partner reports the patient was most recently prescribed Seroquel, which, though the patient denied benefiting from, his partner felt was "useful, but not dosed high enough." Past medication trials that the patient reports include Haldol and lithium, neither of which he found to be particularly helpful.,MEDICAL HISTORY: , The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis.  He is currently followed at Clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year.  The patient is fairly vague on his history of AIDS related conditions, but does identify the following:  Thrush, skin lesions, and lung infections; additional details of these problems are not currently known.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  No known drug allergies.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with his partner.  He is unemployed.  Details of his educational and occupational history are not currently known.  His source of finances is also unknown, though social security disability is presumed.,SUBSTANCE AND ALCOHOL HISTORY: , The patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month.  His partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently.  The patient reports smoking marijuana a few times in his life, but not recently.  Denies other illicit substance use.,LEGAL HISTORY:  ,Unknown.,GENETIC PSYCHIATRIC HISTORY:,  Also unknown.,MENTAL STATUS EXAM:,Attitude:  The patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions.  His appearance is cachectic.  The patient is poorly groomed.,Psychomotor:  There is no psychomotor agitation or retardation.  No other observed extrapyramidal symptoms or tardive dyskinesia.,Affect:  His affect is fairly detached.,Mood:  Describes his mood is "okay.",Speech:  His speech is normal rate and volume.  Tone, his volume was decreased initially, but this improved during the course of the interview.,Thought Process:  His thought processes are markedly tangential.,Thought content:  The patient is fairly scattered.  He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time.  He denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline.  Paranoid delusions are elicited.,Homicidal/Suicidal Ideation:  He denies suicidal or homicidal ideation.  Denies previous suicide attempts.,Cognitive Assessment:  Cognitively, he is alert and oriented to person and year only.  His memory is intact to names of his Madison Clinic providers.,Insight/Judgment:  His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses.  His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.,Assets:  His assets include his housing and his history of supportive relationship with his partner over many years.,Limitations:  His limitations include his AIDS and his history of poor compliance with treatment.,FORMULATION:  ,The patient is a 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.  It is unclear to me how much his presentation is a direct expression of an AIDS-related condition, though I suspect the impact of his HIV status is likely to be substantial.,DIAGNOSES:,AXIS I:  Schizophrenia by history.  Rule out AIDS-induced psychosis.  Rule out AIDS-related cognitive disorder.,AXIS II:  Deferred.,AXIS III:  AIDS (stable by his report).  Anemia.,AXIS IV:  Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and HIV-related providers.,AXIS V:  Global Assessment Functioning is currently 15.,PLAN: , I will attempt to increase the database, will specifically request records from the last mental health providers.  The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis.  With the patient's permission, I will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past.  I anticipate titrating further for effect during the course of his admission.
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DESCRIPTION: A 45-year-old white male with a history of schizophrenia and AIDS.  He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.

The situation involves a complex case with a patient experiencing severe mental health issues (schizophrenia) alongside a serious physical health condition (AIDS). The patient was admitted for disorganized and assaultive behavior and is undergoing involuntary treatment, indicating immediate safety concerns for himself and others. Additionally, there's significant treatment non-compliance, poor insight into his conditions, strained personal relationships, and poor functional status (GAF of 15). There are also underlying legal and safety concerns, as the patient is perceived by his partner as a threat, which further elevates the risk and stakes of the situation.


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

CC: , "Five years ago, I stopped drinking and since that time, I have had severe depression.  I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again.  I started lithium three weeks ago.",HPI:  ,The patient is a 45-year-old married white female without children currently working as a billing analyst for Northwest Natural.  The patient has had one psychiatric hospitalization for seven days in April of 1999.  The patient now presents with recurrent depressive symptoms for approximately four months.  The patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite.  The patient states her sleep is normal and her ability to concentrate is normal.  The patient states that last night she had an argument with her husband in which he threaten to divorce her.  The patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth.  She felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done.  The patient reports that she has had increased tension with her husband as of recent.  She notes that approximately a week ago she struck her husband several times.  She states that he has never hit her but instead pushed her back after she was hitting him.  She reports no history of abuse in the past.  The patient identifies recent stressors as having ongoing conflict at work with her administrator with them "cracking down on me." The patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child.  She states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant.  The patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment.  She states that she feels "abandoned." The patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband.  The patient states she saw her therapist most recently last Friday.  She sees the therapy weekly and indicates the therapy helps, although she is unable to specify how.  When asked for specifics of what she has learned from the therapy, the patient was unable to reply.  It appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation.  The patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization.  The patient, at that point, stated that she would be safe through Monday despite having made a gesture last night.  At present, the patient's mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after I have given her my assessment, she appears calmed and not depressed.  When asked if she is suicidal at present, she states no.  The patient does not want to go into the hospital.  The patient also indicates at the end of the session she felt hopeful.  The patient reports her current sleep is about eight hours per night.  She states that longest she has been able to stay awake in the past has been 24 hours.  She states that during periods where she feels up she sleeps perhaps six hours per night.  The patient reports no spending sprees and no reports no sexual indiscretions.  The patient states that her sexuality does increase when she is feeling better but not enormously so.  The patient denies any history of delusions or hallucinations.  The patient denies any psychosis.  The patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest.  She states that more predominately she has depression.  The patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so.  The patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment.  The patient indicates some satisfaction when she is called on her behavior "I need to answer for my actions." The patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized.  Most typically, the patient will drink at least a bottle of wine per day.  The patient has attended AA but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility.  The patient states she is not working through any of the steps at present.,PPH: , The patient denies any sexual abuse as a child.  She states that she was disciplined primarily by her father with spankings.  She states that on occasion her mother would use a belt to spank her or with her hand or with a spoon.  The patient has been seeing Dr. A for the past five years.  Prior to that she was admitted to a hospital for her suicide attempt.  The patient also has one short treatment experienced with the Day Treatment Program here in Portland.  The patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with.  The patient, also as a child, had a history of cutting behaviors.  The patient was admitted to the hospital after lacerating her arm.,MEDICAL HISTORY:  ,The patient has hypothyroidism and last had her TSH drawn a week ago but does not know the results.  Janet Green is her primary physician.  The patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically.,CURRENT MEDICATIONS: , The patient currently is taking Synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. The patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test.,ALLERGIES: , No known drug allergies.,SUBSTANCE HISTORY: , The patient has been sober for five years.  She drank one bottle of wine per day as per HPI.  History of drinking for approximately 25 years.  The patient does not currently have a sponsor.  The patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago.,SOCIAL HISTORY: , The patient's mother is age 66, father is age 70, and she has a brother age 44.  Her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage.  He made a suicide attempt at age 17.  The patient's father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem.  He also has arthritis.  The patient's mother is arthritic.  She states that her mother stopped working at middle age after being laid off and appears somewhat reclusive.,EDUCATIONAL HISTORY: , The patient was educated through high school and has two years of Night College.  The patient states that she grew up and was raised in Portland but notes her childhood was primarily lonely.  She states she was unliked and unpopular child because she was "shy" and "not smart enough." The patient denies having secrets.  The patient reports that this is her second marriage, which has lasted two years.  Her first marriage lasted I believe it was five years.  The patient also had a relationship in recovery for four years, which ended after they went "different directions.",MSE:,  The patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals.  The patient is suspicious and somewhat confrontative early in the session.  She asked me regarding my cancellation policy, why I require seven days and not 24 hours.  The patient also is irritated with paper required of her.  Psychomotor is increased slightly.  The patient makes strong eye contact.  Speech is normal rate, rhythm, and volume.  Mood is "irritated." Affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated.  Thought is directed.  Content is nondelusional.  There are no auditory and no visual hallucinations.  The patient has no homicidal ideation.  The patient does endorse suicidal ideations.  Regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none.  The patient states that she will not try to hurt herself currently and that she poses no risk at present.  The patient notes that she does not want to go to the hospital at present.  The patient is alert and oriented x 3.  Recall is three for three at five minutes.  Proverbs are concrete.  She has fair impulse control, poor judgment, and poor insight.,FORMULATION:  ,The patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning.  The patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression.  The patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states.  The patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant.  She notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets.  The patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy.  The patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter.  Symptoms are consistent with a longstanding dysthymia and reoccurring depression.  In addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder.  This latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist's absence and departure.  This is exacerbated by instability in the patient's marital life.,DIAGNOSIS:,Axis I:  Dysthymia.  Major depression, moderate severity, recurrent, with partial remission.,Axis II:  Borderline personality disorder.,Axis III:  Hypothyroidism and cervical disc herniation and sinus surgery.,Axis IV:  Medical access.  Marital discord.,Axis V:  A GAF of 30.,PLAN:  ,The patient is unlikely to have bipolar disorder.  We will recommend the patient's thyroid be rechecked to ensure she is currently euthymic.  We would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient's reaction to her therapist's departure.  We would also recommend dialectical behavioral therapy while the therapist is on leave.  We would recommend continued treatment with SSRIs for dysthymia and depression.  We would suggest prescribing long acting antidepressant such as Prozac, given the patient's ambivalence regarding medications.  Prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg.  We might also supplement the Prozac with a (anti-sleep medication).,Time spent with the patient was 1.5 hours.
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DESCRIPTION: Psychiatric Consultation of patient with recurring depression.

The situation involves a patient experiencing severe depression with a history of suicidal ideation and recent self-harm. The patient also shows signs of borderline personality disorder, significant emotional distress related to personal relationships, and a perceived sense of abandonment due to changes in therapeutic support. The presence of active suicidality increases the risk, highlighting the need for careful psychiatric evaluation and intervention. These factors make it a high-stakes situation as it directly involves risks related to the patient's mental health and safety.