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

PRESENT ILLNESS: , The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.  The patient states that he had his first colonoscopy 6 years ago and it was negative.  His mother was diagnosed with colon cancer probably in her 50s, but she died of cancer of the esophagus at age 86.  The patient does have hemorrhoidal bleed about once a week.  Otherwise, he denies any change in bowel habits, abdominal pain, or weight loss.  He gets heartburn mainly with certain food such as raw onions and he has had it for years.  It will typically occur every couple of weeks.  He has had no dysphagia.  He has never had an upper endoscopy.,MEDICAL HISTORY: , Remarkable for hypertension, adult-onset diabetes mellitus, hyperlipidemia, and restless legs syndrome.,SURGICAL HISTORY: , Appendectomy as a child and cholecystectomy in 2003.,MEDICATIONS:  ,His medications are lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice a day, Januvia 100 mg daily, clonazepam 10 mg at bedtime for restless legs syndrome, Crestor 10 mg nightly, and Flomax 0.4 mg daily.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient is retired.  He is married.  He had 4 children.  He quite smoking 25 years ago after a 35-year history of smoking.  He does not drink alcohol.,FAMILY HISTORY: , Mother had colon cancer in her 50s, esophageal cancer in her 80s.  Her mother smoked and drank.  Father got a mesothelioma at age 65.  There is a brother of 65 with hypertension.,REVIEW OF SYSTEMS: , He has had prostatitis with benign prostatic hypertrophy.  He has some increased urinary frequency from a history of prostatitis.  He has the heartburn, which is diet dependent and the frequent rectal bleeding.  He also has restless legs syndrome at night.  No cardio or pulmonary complaints.  No weight loss.,PHYSICAL EXAMINATION: , Reveals a well-developed, well-nourished man in no acute distress.  BP 112/70.  Pulse 80 and regular.  Respirations non-labored.  Height 5 feet 7-1/2 inches.  Weight 209 pounds.  HEENT exam:  Sclerae are anicteric.  Pupils equal, conjunctivae clear.  No gross oropharyngeal lesions.  Neck is supple without lymphadenopathy, thyromegaly, or JVD.  Lungs are clear to percussion and auscultation.  Heart sounds are regular without murmur, gallop, or rub.  The abdomen is soft and nontender.  There are no masses.  There is no hepatosplenomegaly.  The bowel sounds are normal.  Rectal examination:  Deferred.  Extremities have no clubbing, cyanosis or edema.  Skin is warm and dry.  The patient is alert and oriented with a pleasant affect and no gross motor deficits.,IMPRESSION:,1.  Family history of colon cancer.,2.  Rectal bleeding.,3.  Heartburn and a family history of esophageal cancer.,PLAN:,  I agree with the indications for repeat colonoscopy, which should be done at least every 5 years.  Also, discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable.  I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett's esophagus.  If he does not have it now then it should not be a significant risk in the future.  The indications and benefits of EGD, colonoscopy, and IRC were discussed.  The risks including sedation, bleeding, infection, and perforation were discussed.  The importance of a good bowel prep so as to minimize missing any lesions was discussed.  His questions were answered and informed consent obtained.  It was a pleasure to care for this nice patient.
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DESCRIPTION: Patient with family history of colon cancer and has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks.

consult - history and phy., heartburn, family history of esophageal cancer, repeat colonoscopy, colonoscopy, egd, irc, barrett's esophagus, restless legs syndrome, esophageal cancer, rectal bleeding, colon cancer, rectal, bleeding, cancer,

This is a moderately high-stakes situation because the patient has an elevated risk for colon cancer due to family history and is experiencing rectal bleeding, which can be a symptom of serious conditions like colorectal cancer. His heartburn and family history of esophageal cancer also warrant investigation for Barrett's esophagus, a precursor to esophageal cancer. The recommended procedures, such as colonoscopy and EGD, are invasive and carry some risks, but they are crucial for early detection of cancer, making the situation moderately high-stakes.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Pulsatile Tinnitus

HISTORY: , The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus.  The patient reports she has been having daily headaches since 02/25/2008.  She has been getting pulsations in the head with heartbeat sounds.  Headaches are now averaging about three times per week.  They are generally on the very top of the head according to the patient.  Interestingly, she denies any previous significant history of headaches prior to this.  There has been no nausea associated with the headaches.  The patient does note that when she speaks on the phone, the left ear has "weird sounds."  She feels a general fullness in the left ear.  She does note pulsation sounds within that left ear only.  This began on February 17th according to the patient.  The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family.  The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks.  Interestingly, there has been no significant drop or change in her hearing.  She does report she has had dizzy episodes in the past with nausea, being off balance at times.  It is not associated with the pulsations in the ear.  She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear.  She is denying any vision changes.  The headaches are listed as moderate to severe in intensity on average about three to four times per week.  She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: , ,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Hypercholesterolemia.,PULMONARY:  Negative.,GASTROINTESTINAL:  Pertinent for nausea.,GENITOURINARY:  The patient is noted to be a living kidney donor and has only one kidney.,NEUROLOGIC:  History of dizziness and the headaches as listed above.,VISUAL:  Negative.,DERMATOLOGIC:  History of itching.  She has also had a previous history of skin cancer on the arm and back.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  She has had an increased weight gain and fatigue over the past year.,PAST SURGICAL HISTORY:,  She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.,FAMILY HISTORY:,  Father, history of cancer, hypertension, and heart disease.,CURRENT MEDICATIONS: , Tylenol, Excedrin, and she is on multivitamin and probiotic's.,ALLERGIES: , She is allergic to codeine and penicillin.,SOCIAL HISTORY: , She is married.  She works at Eye Center as a receptionist.  She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,GENERAL:  The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  There is an old mastoidectomy scar, left ear.  The ear canals are clean and dry.  Drums intact and mobile.  Weber exam is midline.  Grossly hearing is intact.  Please note audiologist not available at today's visit for further audiologic evaluation.,NASAL:  Reveals clear drainage.  Deviated nasal septum to the left, listed as mild to moderate.  Ostiomeatal complexes are patent and turbinates are healthy.  There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy.  See fiberoptic nasopharyngoscopy separate exam.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION:  ,1.  Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology.  Consider, also normal pressure hydrocephalus.,2.  Recurrent headaches.,3.  Deviated nasal septum.,4.  Dizziness, again also consider possible Meniere disease.,RECOMMENDATIONS: , I did recommend the patient begin a 2 g or less sodium diet.  I have also ordered a carotid ultrasound study as part of the workup and evaluation.  She has had a recent CAT scan of the brain though this was without contrast.  It did reveal previous mastoidectomy, left temporal bone, but no other mass noted.  I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related.  Hearing protection devices should be used at all times as well.  I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues.  I am going to recheck her in three weeks.  If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office.  She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.
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DESCRIPTION: Chronic headaches and pulsatile tinnitus.

This medical consultation describes a patient with pulsatile tinnitus and chronic headaches, possibly linked to an eustachian tube disorder. While the symptoms described, such as pulsatile tinnitus and headaches, can significantly impact the patient's quality of life, they are generally not life-threatening conditions. The situation requires thorough medical evaluation and management to alleviate symptoms and improve quality of life, but it does not involve imminently life-threatening conditions or emergencies. Hence, while it demands medical attention, it's not extremely high-stakes compared to situations involving severe acute medical emergencies.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Normal Pressure Hydrocephalus

REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.  He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:,  I first saw him nearly a year ago on December 20, 2007.  At that time, he had had a traumatic deterioration over the course of approximately eight months.  This included severe cognitive impairment, gait impairment, and incontinence.  He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted.  When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine.  I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008.  According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago.  He is virtually unable to walk at all.  He needs both a walker and support from an assistant to be able to stand or walk.  Therefore, he is always in the wheelchair.,He is completely incontinent.  He never indicates his need to the go to the bathroom.  On the other hand when asked, he will indicate that he needs to go.  He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse.  For the most part, he is apathetic.  He does not talk very much.  He lives in a skilled nursing facility in the Alzheimer's section.  He does have some daytime activities.  He takes a nap once a day.  He does not read very much.  On the other hand, he did recently exercise the right to vote in the presidential election.  He needs full assistance at the nursing home.,MEDICATIONS:,  From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair.  He is well developed, well nourished, and kempt.,Vital Signs:  Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head:  The head is normocephalic and atraumatic.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 14/30.  He was not at all oriented.  He did know we were at Sinai Hospital on the second floor.  He could spell 'world' forward, but was mute when asked to spell backwards.  He was mute when asked to recall 3/3 objects for delayed recall.  He could not copy a diagram of intersecting pentagons.  For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions.  Additionally, there are times when he stutters or stammers.  I do not see any paraphasic errors.  There is some evidence of ideomotor apraxia.  He is also stimulus bound.  There is a tendency to mimic.,Cranial Nerve Exam:  There is no upgaze that I can elicit today.  The horizontal gaze and down gaze are intact.  This is a change from a year ago.  The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam:  Normal bulk and strength.  The tone is characterized by paratonia.  There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam:  Intact to light touch.,Cerebellar Exam:  Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait:  Severely impaired.  When in the wheelchair, he leans to one side.  He cannot getup on his own.  He needs assistance.  Once up, he can bear weight, but cannot maintain his balance.  This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago.  The ventricles appear larger to me now in comparison to a year ago.  The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm.  The 3rd ventricular span is about 15 mm.  There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy.  The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:,  The patient has had worsening of his gait, his dementia, and his incontinence.  The new finding for me today is the limited upgaze.  This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1.  Question of idiopathic normal pressure hydrocephalus (331.5).,2.  Possible supranuclear palsy.,3.  Severe gait impairment.,4.  Urinary urgency and incontinence.,5.  Dementia.,PLAN: , I had a long talk with him and his family.  Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again.  I do so on the basis that there is further enlargement of the ventricles on the scan.  His family and I discussed the facts that it is not likely to be only hydrocephalus.  Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference.  I have advised them to think it over for a day and contact my office to see whether they would wish to proceed.  I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives.  I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection.
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DESCRIPTION: The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.

The situation involves the medical evaluation and management options for an 84-year-old patient with potential normal pressure hydrocephalus and accompanying complications such as severe gait impairment and dementia. Deciding on medical procedures like CSF drainage and potential shunt surgery, given the patient's age and complex medical history, has significant implications for quality of life and entails risks such as infection. The outcome of these decisions can significantly impact both the patient's and the family's future well-being.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - ICU Management

REASON FOR CONSULTATION: , ICU management.,HISTORY OF PRESENT ILLNESS: , The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.  The patient was transferred to the ABCD Hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting.  The patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a CT scan.  Repeat CT scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen.  The patient was taken emergently to the operating room last night by the General Surgery Service where proximal half of the jejunum was noted to be liquified with 3 perforations.  This section of small bowel was resected, and a wound VAC placed for damage control.  Plan was to return the patient to the Operating Room tomorrow for further exploration and possible re-anastomosis of the bowel.  The patient is currently intubated, sedated, and on pressors for septic shock and in the down ICU.,PAST MEDICAL HISTORY:,  Prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and GERD.,PAST SURGICAL HISTORY:,  Included a cardiac cath with no interventions taken.,HOME MEDICATIONS:,  Include Lantus insulin as well as oral hypoglycemics.,CURRENT MEDS:,  Include Levophed, Ativan, fentanyl drips, cefepime, Flagyl, fluconazole, and vancomycin.  Nexium, Synthroid, hydrocortisone, and Angiomax, which is currently on hold.,REVIEW OF SYSTEMS:,  Unable to be obtained secondary to the patient's intubated and sedated status.,ALLERGIES: , None.,FAMILY HISTORY:,  Includes diabetes on his father side of the family.  No other information is provided.,SOCIAL HISTORY:,  Includes tobacco use as well as alcohol use.,PHYSICAL EXAMINATION:,GENERAL: The patient is currently intubated and sedated on Levophed drip.,VITAL SIGNS: Temperature is 100.6, systolic is 110/60 with MAP of 80, and heart rate is 120, sinus rhythm.,NEUROLOGIC: Neurologically, he is sedated, on Ativan with fentanyl drip as well.  He does arouse with suctioning, but is unable to open his eyes to commands.,HEAD AND NECK EXAMINATION: His pupils are equal, round, reactive, and constricted.  He has no scleral icterus.  His mucous membranes are pink, but dry.  He has an EG tube, which is currently 24-cm at the lip.  He has a left-sided subclavian vein catheter, triple lumen.,NECK: His neck is without masses or lymphadenopathy or JVD.,CHEST: Chest has diminished breath sounds bilaterally.,ABDOMEN: Abdomen is soft, but distended with a wound VAC in place.  Groins demonstrate a left-sided femoral outline.,EXTREMITIES: His bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left.  His toes are cool, and pulses are not palpable.,LABORATORY EXAMINATION: , Laboratory examination reveals an ABG of 7.34, CO2 of 30, O2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, CO2 18, BUN 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22.  After stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively.  LFTs are all normal.  Amylase and lipase are normal.  Triglycerides are 73, INR is 2.2, PTT is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211.  UA was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria.  Chest x-rays performed and show the tip of the EG tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles.  Tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted.,ASSESSMENT AND PLAN:,  This is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion.  He is status post small bowel resection.  We plan to go back to operating room tomorrow for further debridement and possible closure.  Neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands.  I did not suspect any sort of pathologic abnormality of his neurologic status as he has further CT scan of his brain, which was normal.  Currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator.  We will form daily sedation holidays to assess his neurologic status and avoid over sedating with Ativan.,1.  Cardiovascular.  The patient currently is in septic shock requiring vasopressors maintained on MAP greater than 70.  We will continue to try to wean the vasopressin after continued volume loading, also place SvO2 catheter to assess his oxygen delivery and consumption given his state of shock.  Currently, his rhythm is of sinus tachycardia, I do not suspect AFib or any other arrhythmia at this time.  If he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function.  Once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.,2.  Pulmonology.  Currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, PEEP of 6, and FiO2 of 60.  We will wean his FiO2 as tolerated to keep his saturation greater than 90% and wean his PEEP as tolerated to reduce preload compromise.  We will keep the head of bed elevated and start chlorhexidine as swish and swallow for VAP prevention.,3.  Gastrointestinal.  The patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the SMV.  He is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum.  We will maintain NG tube as he has a blind stump there, and we will preclude any further administration of any meds through this NG tube.  I will keep him on GI prophylaxis as he is intubated.  We will currently hold his TPN as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes.  He will have a long-term TPN after this acute episode.  His LFTs are all normal currently.  Once he is postop tomorrow, we will restart the Angiomax for his venous occlusion.,4.  Renal.  The patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium.  His critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail.  He currently is started to make more urine since being volume resuscitated with Hespan as well as bicarb drip.  Hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis.  We will re-consult Nephrology at this time.,5.  Endocrine.  The patient has adrenal insufficiency based on lack of stem to cosyntropin.  We will start hydrocortisone 50 q.6h.,6.  Infectious Disease.  Currently, the patient is on broad-spectrum antibiotic prophylaxis imperially.  Given his bowel ischemia, we will continue these, and appreciate ID service's input.,7.  Hematology.  Hematologically, the patient has a hypercoagulable syndrome, also had HIT secondary to his heparin administration.  We will restart the Angiomax once he is back from the OR tomorrow.  Currently, his INR is 2.2.  Therefore, he should be covered at the moment.  Appreciate the Hematology's input in this matter.,Please note the total critical care time spent at the bedside excluding central line placement was 1 hour.
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DESCRIPTION: Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.

The situation involves a critically ill patient in the ICU following major complications from mesenteric ischemia, including multiple organ dysfunctions and required surgical interventions. This is high-stakes due to the life-threatening nature of the condition, the need for continuous monitoring, and dynamic management to prevent further deterioration or complications.


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

HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.  Neurology consult was called to evaluate the patient in view of the current symptomatology.  The headaches were refractory to the treatment.  The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY:  ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY:  ,No history of any smoking, alcohol, or drug abuse.  The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:,  Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT:  Head, normocephalic, atraumatic.  Neck supple.  Throat clear.  No discharge from the ears or nose.  No discoloration of conjunctivae and sclerae.  No bruits auscultated over temple, orbits, or the neck.,LUNGS:  Clear to auscultation.,CARDIOVASCULAR:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.,SKIN:  No rash.  No neurocutaneous disorder.,MENTAL STATUS:  The patient is awake, alert and oriented to place and person.  Speech is fluent.  No language deficits.  Mood normal.  Affect is clear.  Memory and insight is normal.  No abnormality with thought processing and thought content.  Cranial nerve examination intact II through XII.  Motor examination:  Normal bulk, tone and power.  Deep tendon reflexes symmetrical.  Downgoing toes.  No sign of any myelopathy.  Cortical sensation intact.  Peripheral sensation grossly intact.  Vibratory sense not tested.  Gait not tested.  Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines.  Complicated migraines by clinical criteria.  Rule out sinusitis.  Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today.  Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially.  The patient already had MRI of the brain and the cervical spine.  MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache.  Plan and followup discussed with the patient in detail.
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DESCRIPTION: The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches.  In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.

The patient's condition involves uncontrolled migraine headaches, which led them to seek emergency medical care. Although the initial tests show no immediate life-threatening concerns (as the CT scan was negative and the lumbar puncture was normal), the migraines are still severe enough to warrant admission and a comprehensive workup to rule out other possible significant conditions like sinusitis, vasculitis, and various vascular diseases. There is a risk of more serious conditions being underlying causes, but current findings have not indicated any acute emergencies such as stroke or hemorrhage.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Coronary Artery Disease

REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG:
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DESCRIPTION: Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.

The consult concerns a 70-year-old gentleman with coronary artery disease (CAD) and a history of prior bypass surgery, alongside other health concerns such as elevated PSA and BPH. While the immediate presenting issue is the management of fever, his complex medical history, particularly concerning CAD, places the situation in a higher-stakes category due to the potential for acute changes in cardiac health. CAD can lead to serious complications, making close monitoring critical. Given the patient's age and existing comorbidities, the stakes are heightened if any new symptoms or complications arise.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Enlarged Tonsils

HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils.  The patient has been having difficult time with having two to three bouts of tonsillitis this year.  She does average about four bouts of tonsillitis per year for the past several years.  She notes that throat pain and fever with the actual infections.  She is having no difficulty with swallowing.  She does have loud snoring, though there have been no witnessed observed sleep apnea episodes.  She is a mouth breather at nighttime, however.  The patient does feel that she has a cold at today's visit.  She has had tonsil problems again for many years.  She does note a history of intermittent hoarseness as well.  This is particularly prominent with the current cold that she has had.  She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home.  For the two tonsillitis, she is on antibiotics again on an average about four times per year.  They do seem to help with the infections, but they tend to continue to recur.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Negative.,PULMONARY:  Negative.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  Negative.,VISUAL:  Negative.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:,  No family history of bleeding disorder.  She does have a sister with a current ear infection.  There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single.  She is a student.  Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  The external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  Hearing is grossly normal.  Tuning fork examination with normal speech reception thresholds noted.,NASAL:  She has clear drainage, large inferior turbinates, no erythema.,ORAL:  Her tongue, lip, floor of mouth are noted to be normal.  Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic.  Mirror examination of the larynx reveals some mild edema of the larynx at this time.  The nasopharynx could not be visualized on mirror exam today.,NECK:  Obese, supple.  Trachea is midline.  Thyroid is nonpalpable.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION: , ,1.  Chronic adenotonsillitis with adenotonsillar hypertrophy.,2.  Upper respiratory tract infection with mild acute laryngitis.,3.  Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy.  All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family.  This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc.  The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks.  We will make further recommendations afterwards.
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DESCRIPTION: Chronic adenotonsillitis with adenotonsillar hypertrophy.  Upper respiratory tract infection with mild acute laryngitis.

The case involves a 15-year-old patient with chronic adenotonsillitis and recurrent tonsillitis, leading to a recommendation for an adenotonsillectomy. While surgery always carries some risks, such as bleeding and infection, tonsillectomy is a common, routine procedure with relatively low risk. The patient's condition does not seem to be life-threatening and is managed through surgical intervention to improve quality of life. The overall situation appears to be standard for ENT consultations. Therefore, the stakes, while important for patient comfort and long-term health, are not extremely high.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - CHF & Lymphedema

HISTORY OF PRESENT ILLNESS:,  The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.  He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung.  This consultation was made for better control of his blood sugars.  On questioning, the patient says that he does not have diabetes.  He says that he has never been told about diabetes except during his last admission at Jefferson Hospital.  Apparently, he was started on glipizide at that time.  His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem.  He is not sure.  He is not following any specific diet.  He says "my doctor wants me to lose 30-40 pounds in weight" and he would not mind going on a diet.  He has a long history of numbness of his toes.  He denies any visual problems.,PAST MEDICAL HISTORY: , As above that includes CA of the lung, COPD, bilateral cataracts.  He has had chronic back pain.  There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,SOCIAL HISTORY: , The patient has been a smoker since the age of 10.  So, he was smoking 2-3 packs per day.  Since being started on Chantix, he says he has cut it down to half a pack per day.  He does not abuse alcohol.,MEDICATIONS: ,1.  Glipizide 5 mg p.o. daily.,2.  Theophylline.,3.  Z-Pak.,4.  Chantix.,5.  Januvia 100 mg daily.,6.  K-Lor.,7.  OxyContin.,8.  Flomax.,9.  Lasix.,10.  Advair.,11.  Avapro.,12.  Albuterol sulfate.,13.  Vitamin B tablet.,14.  OxyContin and oxycodone for pain.,FAMILY HISTORY: , Positive for diabetes mellitus in the maternal grandmother.,REVIEW OF SYSTEMS: , As above.  He says he has had numbness of toes for a long time.  He denies any visual problems.  His legs have been swelling up from time to time for a long time.  He also has history of COPD and gets short of breath with minimal activity.  He is also not able to walk due to his weight.  He has had ulcers on his legs, which he gets discharge from.  He has chronic back pain and takes OxyContin.  He denies any constipation, diarrhea, abdominal pain, nausea or vomiting.  There is no chest pain.  He does get short of breath on walking.,PHYSICAL EXAMINATION:,The patient is a well-built, obese, white male in no acute distress.,Vital signs:  Pulse rate of 89 per minute and regular.  Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18.,HEENT:  Head is normocephalic and atraumatic.  Eyes, PERRLA.  EOMs intact.  Fundi were not examined.,Neck:  Supple.  JVP is low.  Trachea central.  Thyroid small in size.  No carotid bruits.,Heart:  Shows normal sinus rhythm with S1 and S2.,Lungs:  Show bilateral wheezes with decreased breath sounds at the bases.,Abdomen:  Soft and obese.  No masses.  Bowel sounds are present.,Extremities:  Show bilateral edema with changes of chronic venostasis.  He does have some open weeping sores.  Pulses could not be palpated due to leg swelling.,IMPRESSION/PLAN:,1.  Diabetes mellitus, type 2, new onset.  At this time, the patient is on Januvia as well as glipizide.  His blood sugar right after eating his supper was 101.  So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet.  We will continue to follow his blood sugars closely and make adjustments as needed.,2.  Neuropathy, peripheral, query etiology.  We will check TSH and B12 levels.,3.  Lymphedema.,4.  Recurrent cellulitis.,5.  Obesity, morbid.,6.  Tobacco abuse.  He was encouraged to cut his cigarettes down to 5 cigarettes a day.  He says he feels like smoking after meals.  So, we will let him have it after meals first thing in the morning and last thing at night.,7.  Chronic venostasis.,8.  Lymphedema.  We would check his lipid profile also.,9.  Hypertension.,10.  Backbone pain, status post back surgery.,11.  Status post hernia repair.,12.  Status post penile implant and removal.,13.  Umbilical hernia repair.
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DESCRIPTION: The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.

The patient has multiple significant health issues, including congestive heart failure (CHF), lymphedema, a history of lung cancer, obesity, chronic obstructive pulmonary disease (COPD), and possibly newly diagnosed type 2 diabetes mellitus. The management of these conditions requires careful intervention and coordination to maintain his health and prevent complications. The stakes are elevated due to his complex medical history, multiple comorbidities, and the potential for serious complications from poorly managed diabetes, CHF, and other conditions. The presence of open, weeping sores also raises concerns for infection or worsening cellulitis, further contributing to the high-stakes nature of his care. The situation has moderate to high stakes as it involves managing chronic, life-impacting conditions that require ongoing medical oversight.


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

Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,
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DESCRIPTION: The patient has been suffering from intractable back and leg pain.

consult - history and phy., multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar

The situation described is not immediately life-threatening, as the patient shows improvement and can participate in activities such as golfing. The medical decision involves pain management and does not require immediate or high-risk surgical intervention. While chronic pain can significantly impact quality of life, the stakes here involve careful monitoring and management of the condition rather than an urgent medical crisis.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Breast Cancer

CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:,  Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.
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DESCRIPTION: Patient presents with complaint of lump in the upper outer quadrant of the right breast

The patient has been diagnosed with breast cancer, which is a serious and potentially life-threatening condition. The diagnosis, staging, and treatment decisions are crucial for the patient's prognosis and quality of life. Although the stage is I, which typically indicates a good prognosis, the situation involves cancer management, making it a high-stakes scenario given the potential implications for the patient's health and survival.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Cerebral Peduncle Infarction

FAMILY HISTORY AND SOCIAL HISTORY:,  Reviewed and remained unchanged.,MEDICATIONS:,  List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:,  She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS:  ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain.  Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs:  Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General:  She was a pleasant person in no acute distress.,HEENT:  Normocephalic and atraumatic.  No dry mouth.  No palpable cervical lymph nodes.  Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:,  Remained unchanged.,Mental Status:  Normal.,Cranial Nerves:  Mild decrease in the left nasolabial fold.,Motor:  There was mild increased tone in the left upper extremity.  Deltoids showed 5-/5.  The rest showed full strength.  Hip flexion again was 5-/5 on the left.  The rest showed full strength.,Reflexes:  Reflexes were hypoactive and symmetrical.,Gait:  She was mildly abnormal.  No ataxia noted.  Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement.  She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes.  She will continue to follow with endocrinology for diabetes and thyroid problems.  I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery.  I will see her back in about four months or sooner if needed.
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DESCRIPTION: Patient with a history of right upper pons and right cerebral peduncle infarction.

consult - history and phy., internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle,

The provided scenario involves a patient with a history of a cerebrovascular accident (stroke) and an upcoming surgical intervention for the internal carotid artery. Given the complexity of the patient's medical situation—recent stroke, ongoing medications, and scheduled surgery—the context is high-stakes. The possibility of complications during or after the surgery and the need for careful management of multiple health issues, particularly in a patient with pre-existing conditions such as diabetes and hypertension, further elevates the stakes. Medical decisions or actions taken can significantly impact the patient's recovery and long-term health outcomes.


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

CHIEF COMPLAINT: , Left breast cancer.,HISTORY:,  The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center.  On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial).  The biopsy returned showing infiltrating ductal carcinoma high histologic grade.  The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging.  She prior to that area, denied any complaints.  She had no nipple discharge.  No trauma history.  She has had been on no estrogen supplementation.  She has had no other personal history of breast cancer.  Her family history is positive for her mother having breast cancer at age 48.  The patient has had no children and no pregnancies.  She denies any change in the right breast.  Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y.  I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy.  The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning.  The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact.  CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:,  Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:,  She is currently on omeprazole for reflux and indigestion.,ALLERGIES:,  SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,  Negative for any recent febrile illnesses, chest pains or shortness of breath.  Positive for restless leg syndrome.  Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:,  Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY:  ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL:  The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT:  Head is atraumatic and normocephalic.  Sclerae are anicteric.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,BREASTS:  Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle.  There are no nipple retractions.  No skin dimpling.  There is some, at the time of the office visit, ecchymosis from recent biopsy.  There is no axillary adenopathy.  The remainder of the left breast is without abnormality.  The right breast is without abnormality.  The axillary areas are negative for adenopathy bilaterally.,ABDOMEN:  Soft, nontender without masses.  No gross organomegaly.  No CVA or flank tenderness.,EXTREMITIES:  Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy.  We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection.  The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient.  The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained.  Local numbness, paresthesias or chronic pain was explained.  The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers.  She was certainly encouraged to obtain further surgical medical opinions prior to proceeding.  I believe the patient has given full informed consent and desires to proceed with the above.
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DESCRIPTION: The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.

The situation involves a medical consultation for a patient diagnosed with breast cancer, discussing critical decisions regarding surgery and treatment options. Decisions in cancer treatment are inherently high-stakes because they directly affect the patient's health outcomes, quality of life, and survival. The stakes are heightened by the complexity of cancer treatment, the potential for serious side effects, and the psychosocial impact of the diagnosis. Therefore, the decision-making process and the consultation are high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Cholestasis Of Pregnancy

FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.
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DESCRIPTION: Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.

consult - history and phy., delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis

The situation described involves a complex pregnancy with complications such as cholestasis of pregnancy, fetal intolerance to labor, failure to progress, and subsequent delivery via cesarean section. While the procedure and postpartum recovery seem to have been handled appropriately, there are several risks involved, including significant blood loss and signs of early infection that required intervention with antibiotics. The overall situation is high-stakes due to the potential risks to both mother and child, particularly because of the challenging labor and need for surgical intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: Chest Wall Lump - Consult

CHIEF COMPLAINT:,  Lump in the chest wall.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient.  It is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.,CHRONIC/INACTIVE CONDITIONS,1.  Hypertension.,2.  Hyperlipidemia.,3.  Glucose intolerance.,4.  Chronic obstructive pulmonary disease?,5.  Tobacco abuse.,6.  History of anal fistula.,ILLNESSES:,  See above.,PREVIOUS OPERATIONS: , Anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery.,PREVIOUS INJURIES: , He had a broken ankle in the past.  They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major.  He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago.  He told me that he hit a moose once, but he does not remember hitting his chest.,ALLERGIES: , TO BACTRIM, SIMVASTATIN, AND CIPRO.,CURRENT MEDICATIONS,1.  Lisinopril.,2.  Metoprolol.,3.  Vitamin B12.,4.  Baby aspirin.,5.  Gemfibrozil.,6.  Felodipine.,7.  Levitra.,8.  Pravastatin.,FAMILY HISTORY: , Positive for hypertension, diabetes, and cancer.  Negative for heart disease, obesity or stroke.,SOCIAL HISTORY:  ,The patient is married.  He works as a truck driver and he drives in town.  He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Denies weight loss/gain, fever or chills.,ENMT:  Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision.,CV:  See history of present illness.  Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains.,RESPIRATORY:  He has a chronic cough.  Denies shortness of breath, wheezing, sputum production or bloody sputum.,GI:  Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation.,GU:  Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain.,MS:  Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness.,NEURO:  Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis.,PSYCH:  Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts.,INTEGUMENTARY:  Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL:  Blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds.  The patient is well developed, well nourished, and with fair attention to grooming.  The patient is moderately overweight.,NECK:  The neck is symmetric, the trachea is in the midline, and there are no masses.  No crepitus is palpated.  The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATION:  Normal respiratory effort.  There is no intercostal retraction or action by the accessory muscles.  Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.  There is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum.,CARDIOVASCULAR:  The PMI is palpable at the 5ICS in the MCL.  No thrills on palpation.  S1 and S2 are easily audible.  No audible S3, S4, murmur, click, or rub.  Carotid pulses 2+ without bruits.  Abdominal aorta is not palpable.  No audible abdominal bruits.  Femoral pulses are 2+ bilaterally, without audible bruits.  Extremities show no edema or varicosities.
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DESCRIPTION: Lump in the chest wall.   Probably an old fracture of the area with callus formation, need to rule out the possibility of a tumor.

The situation involves a 56-year-old male with a lump in the chest wall that has been enlarging and is painful. The physician is considering a differential diagnosis that includes ruling out a tumor. Given the patient's smoking history, family history of cancer, and the chronic nature of the complaint, this could potentially be a case of a malignant tumor or another serious underlying condition. The need to investigate the possibility of a tumor adds a significant level of urgency and seriousness to the assessment, making this a high-stakes medical evaluation that could impact the patient’s treatment and prognosis.


Medical Specialty: Consult - History and Phy.
Sample Name: Chest discomfort & palpitations - Consult.

CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn.
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DESCRIPTION: Patient with palpitations and rcent worsening of chronic chest discomfort.

This patient presents with symptoms that could indicate a potentially serious cardiac issue, such as worsening chest discomfort with palpitations and a history of mitral valve prolapse. These symptoms can be associated with serious conditions like coronary artery disease or arrhythmias, especially given the patient's family history of coronary artery disease. The decision to order further cardiac testing and prescribe medication aligns with the seriousness, though the patient is not currently in acute distress. Thus, while the situation may not be immediately life-threatening, it requires careful assessment due to the potential for severe outcomes if underlying conditions are not managed properly.


Medical Specialty: Consult - History and Phy.
Sample Name: Chronic Sinusitis

HISTORY:,  I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis.  As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.  She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics.  She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left.  She currently is not taking any medication for her sinuses.  She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness.  Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination.  She has tried topical nasal corticosteroid therapy without much improvement.  She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen.  She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears.  She denies any previous history of sinus surgery or nasal injury.  She believes she has some degree of allergy symptoms.,PAST MEDICAL HISTORY:  ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change.  She is currently 180 pounds.,PAST SURGICAL HISTORY:,  Lower extremity vein stripping, tonsillectomy and adenoidectomy.,FAMILY HISTORY: , Strong for heart disease and alcoholism.,CURRENT MEDICATIONS: , DynaCirc.,ALLERGIES: , Egg-based products cause hives.,SOCIAL HISTORY:  ,The patient used to smoke cigarettes for about 20 years, one-half pack a day.  She currently does not, which was encouraged to continue.  She rarely drinks any alcohol-containing beverages.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.  No nystagmus.,EARS:  During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position.  No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice.  No evidence of any orthostatic hypotension was noted during the exam.  Tympanic membranes were noted to be intact.  No signs of middle ear effusion or ear canal inflammation.,NOSE:  The patient appears congested.  Turbinate hypertrophy is noted.  There are no signs of any acute sinusitis.  Septum is midline, slightly deviated to the left.,THROAT:  There is clear postnasal drip.  Oral hygiene is good.  No masses or lesions noted.  Both vocal cords move well to midline.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,IMPRESSION:  ,1.  Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2.  Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3.  Inferior turbinate hypertrophy.,4.  Nasal septum deformity.,RECOMMENDATIONS:,  An ENG was ordered to evaluate vestibular function.  She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening.  A Medrol Dosepak was prescribed as directed.  The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended.  After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations.  In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,Thank you for allowing me to participate with the care of your patient.
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DESCRIPTION: Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.

The situation involves a medical evaluation for chronic sinusitis, which is impacting the patient's quality of life due to associated symptoms like facial discomfort, nasal congestion, and dizziness. While these symptoms are concerning and require careful management to prevent complications, they do not represent an immediately life-threatening condition. The medical team is conducting appropriate diagnostic tests and treatments, and the patient has been advised on what to do if symptoms escalate. However, the potential for unexpected complications from dizziness or other symptoms related to the ear or vestibular system adds a layer of concern that cannot be ignored.


Medical Specialty: Consult - History and Phy.
Sample Name: Cervical Cord Lesion - Consult

HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was "rebuilt." He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.
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DESCRIPTION: Patient reports a six to eight-week history of balance problems with later fatigue and weakness.

The situation described involves a 58-year-old male with neurological symptoms such as balance problems, fatigue, weakness, and recent falls. The concern is a cervical cord lesion with a differential diagnosis considering severe conditions like transverse myelitis, tumor, or ischemia. This is a potentially serious medical condition that can lead to significant morbidity if not diagnosed and treated promptly. The potential for a progressive neurological decline or failure of adaptive functioning increases the stakes significantly.


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: Breast Calcifications - Preop Consult

REASON FOR HOSPITALIZATION:  ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08.  That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position.  Additional imaging studies confirmed the suspicious nature of these calcifications.  The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08.  The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis.  No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast.  She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy.  I was called to see the patient in the emergency consultation in the breast center.  At the same time, Dr. Y was consulted in Interventional Radiology.  Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material.  This resulted in immediate occlusion of the false aneurysm.  The patient was seen in my office for followup appointment on 06/24/08.  At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy.  There was, however, no evidence of reforming of the false aneurysm.  There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,I discussed the issues with the patient and her husband.  The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings.  For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization.  Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months.  The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04.  This revealed benign histologic findings.  The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40.  Other than her age, the patient has no other risk factors for development of breast cancer.  She is not receiving any hormone replacement therapy.  She has had five children with the first pregnancy occurring at the age of 24.  Other than her daughter, there are no other family members with breast cancer.  There are no family members with a history of ovarian cancer.,PAST MEDICAL HISTORY: , Other hospitalizations have occurred for issues with asthma and pneumonia.,PAST SURGICAL HISTORY: , Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,CURRENT MEDICATIONS:,1.  Plavix.,2.  Arava.,3.  Nexium.,4.  Fosamax.,5.  Advair.,6.  Singulair.,7.  Spiriva.,8.  Lexapro.,DRUG ALLERGIES:,  ASPIRIN, PENICILLIN, IODINE AND CODEINE.,FAMILY HISTORY:, Positive for heart disease, hypertension and cerebrovascular accidents.  Family history is positive for colon cancer affecting her father and a brother.  The patient has a daughter who was diagnosed with breast cancer at age 40.,SOCIAL HISTORY: , The patient does not smoke.  She does have an occasional alcoholic beverage.,REVIEW OF SYSTEMS:  ,The patient has multiple medical problems, for which she is under the care of Dr. X.  She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease.  There is a history of anemia and there is a history of sciatica, which has been caused by arthritis.  The patient has had skin cancers, which have been treated with local excision.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly aged female who is alert and in no distress.,HEENT:  Head, normocephalic.  Eyes, PERRL.  Sclerae are clear.  Mouth, no oral lesions.,NECK:  Supple without adenopathy.,HEART:  Regular sinus rhythm.,CHEST:  Fair air entry bilaterally.  No wheezes are noted on examination.,BREASTS:  Normal topography bilaterally.  There are no palpable abnormalities in either breast mound.  Nipple areolar complexes are normal.  Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses.  The previous tissue changes from the stereotactic core needle biopsy have resolved.  Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,ABDOMEN:  Obese.  No masses.  Normal bowel sounds are present.,BACK:  No CVA tenderness.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT:,1.  Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2.  Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3.  History of chronic obstructive lung disease and asthma, controlled with medications.,4.  History of gastroesophageal reflux disease, controlled with medications.,5.  History of transient ischemic attack managed with medications.,6.  History of osteopenia and osteoporosis, controlled with medications.,7.  History of anxiety controlled with medications.,PLAN: , Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.  This will be performed on an outpatient basis.
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DESCRIPTION: Suspicious calcifications upper outer quadrant, left breast.  Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.

The case involves a 78-year-old woman with a suspicious finding in her breast requiring a biopsy, alongside complications from a previous procedure that caused a false aneurysm. While breast cancer is a potentially life-threatening condition, the current situation does not involve an immediate risk to life and can be managed with planned surgical intervention. The decision to postpone surgery suggests this is not an emergency, indicating a moderate level of stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Breast Reconstruction

REASON FOR CONSULTATION:,  Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year.  She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer.  This apparently was positive in two separate locations within the suspicious area.  She also underwent MRI, which suggested that there was significant size to the area involved.  Her contralateral left breast appeared to be uninvolved.  She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications.  She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight.  Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps.  There are no any significant scars on the right breast as she has only undergone needle biopsy at this point.  Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:,  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.  We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction.  I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim.  A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy.  I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration.  I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure.  We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant.  In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery.  Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed.  In any case, she does prefer this option in order to avoid the need for an implant.  We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen.  We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction.  At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy.  For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days.  We may cancel this if the chance of postoperative irradiation is high.  If this is the case, I think we can do a better job on the reconstruction if we defer it.  The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist.
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DESCRIPTION: Breast reconstruction post mastectomy.  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.

consult - history and phy., breast reconstruction, mastectomy, lump, breast, mammogram, needle biopsy, breast cancer, hypertrophy, tram flap, latissimus dorsi,

Breast reconstruction following mastectomy is a high-stakes medical situation as it involves complex surgical procedures and significant decisions regarding the patient's post-cancer treatment and quality of life. The considerations about immediate versus delayed reconstruction, the potential for complications like infection or necrosis, and the impact of radiation therapy on reconstruction outcomes make it a critical decision. Moreover, the potential physical and emotional impacts underscore the importance of making informed choices. This consultation involves weighing benefits and risks that can significantly affect the patient's health and recovery.


Medical Specialty: Consult - History and Phy.
Sample Name: Bladder Tumor

CHIEF COMPLAINT:,  Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.  The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006.  This was followed by bladder instillation of BCG.  At this time, the patient denies any voiding symptoms or hematuria.  The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health.  No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented.  Her lungs are clear.  Heart, regular sinus rhythm.  Back, no CVA tenderness.  Abdomen, soft and nontender.  No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.
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DESCRIPTION: Recurrent bladder tumor.  The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.

consult - history and phy., bladder neck, voiding symptoms, hematuria, transitional cell carcinomas, ureteric orifice, bladder tumor, bladder, cystoscopy, papillomatosis, transitional, carcinomas, orifice,

The situation involves a recurrent bladder tumor in a 79-year-old woman who previously had transitional cell carcinomas of the bladder neck. The patient has undergone treatment before with TUR and BCG therapy. The recurrence of cancerous tumors in an elderly patient can have serious implications on her health, potentially affecting her bladder function and overall quality of life. This requires careful monitoring, further diagnostic evaluations, and possibly more invasive interventions. Although the patient is in good health otherwise, the situation still poses significant health risks and requires careful management by her healthcare providers.