Medical Specialty: General Medicine
Sample Name: Dog Bite

CHIEF COMPLAINT:,  Dog bite to his right lower leg.,HISTORY OF PRESENT ILLNESS:,  This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to.  Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him.  He sustained a bite to his right lower leg.  Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that.  The dog has given no prior history of any reason to believe he is not a healthy dog.  The patient himself developed a puncture wound with a flap injury.  The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot.  It appears to be viable.  The wound is open about may be roughly a centimeter in the inside of the flap.  He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.,PAST MEDICAL HISTORY:  ,Significant for history of pulmonary fibrosis and atrial fibrillation.  He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.,ALLERGIES:  ,There are no known allergies.,MEDICATIONS:,  Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin.,FAMILY HISTORY: , Consistent with a sister of his has ovarian cancer and his father had liver cancer.  Heart disease in the patient's mother and father, and father also has diabetes.,SOCIAL HISTORY:,  He is a non-cigarette smoker.  He has occasional glass of wine.  He is married.  He has one biological child and three stepchildren.  He works for ABCD.,REVIEW OF SYSTEMS:,  He denies any chest pain.  He does admit to exertional shortness of breath.  He denies any GI or GU problems.  He denies any bleeding disorders.,PHYSICAL EXAMINATION,GENERAL:  Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3 or S4 gallop.  There is no obvious murmur.,ABDOMEN:  Soft.  It is nontender.  Bowel sounds are present.  There is no tenderness.,SKIN:  He does have like a Chevron incisional scar across his lower chest and upper abdomen.  It appears to be well healed and unremarkable.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  He has about 1+ pitting edema to both legs and they have been present since the surgery.  In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap.  The wound is spread apart about may be a centimeter all along that area and it is relatively clean.  There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate.  There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc.  The flap appeared to be viable.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.  He is on multiple medications and he is on chronic Bactrim.  We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult.  We will see him back in the office early next week to reassess his wound.  He is to keep the wound clean with the moist dressing right now.  He may shower several times a day.
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DESCRIPTION: A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago.

The situation involves a dog bite, which can be considered high-stakes due to the potential for infection, especially given that the patient is immunosuppressed due to his lung transplant and medication regimen. However, the wound is being properly managed, and the dog is known to have up-to-date vaccinations. The presence of a puncture and flap injury increases the stakes due to the risk of infection or complications. Overall, while the situation requires careful medical attention, it generally does not reach the highest level of stakes because there seems to be a plan in place to manage the risk of infection.


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

Medical Specialty: General Medicine
Sample Name: Fall - ER Visit

HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.  The patient states that she was on the ladder on Saturday and she stepped down after the ladder.  Felt some pain in her left hip.  Subsequently fell injuring her left shoulder.  It's unclear how long she was on the floor.  She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture.  Orthopedics was consulted.  Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only.  She presently is complaining of pain to the left shoulder.  She states she also has pain to the hip with motion of the leg.  She denies any numbness or paresthesias.  She states prior to this, she was relatively active within her home.  She does care for her daughter who has a mess.  The patient denies any other injuries.  Denies back pain.,PREVIOUS MEDICAL HISTORY:,  Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:,  Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1.  PENICILLIN.,2.  SULFA.,3.  ACE INHIBITOR.,PRESENT MEDICATIONS,1.  Lipitor 20 mg q.d.,2.  Metoprolol 25 mg b.i.d.,3.  Plavix 75 mg once a day.,4.  Aspirin 325 mg.,5.  Combivent Aerosol two puffs twice a day.,6.  Protonix 40 mg q.d.,7.  Fosamax 70 mg weekly.,8.  Multivitamins including calcium and vitamin D.,9.  Hydrocortisone.,10.  Nitroglycerin.,11.  Citalopram 20 mg q.d.,SOCIAL HISTORY:,  She denies alcohol or tobacco use.  She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:,  Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing.  She also has vision problems.  Denies headache syndrome.  Presently, denies chest pain or shortness of breath.  She denies abdominal pain.  Presently, she has left hip pain and left shoulder pain.  No urinary frequency or dysuria.  No skin lesions.  She does have swelling to both lower extremities for the last several weeks.  She denies endocrinopathies.  Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL:  The patient is alert and responsive.,EXTREMITIES:  The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment.  She is diffusely tender over the proximal humerus.  She is unable to actively elevate her arm due to pain.  The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse.  She does have chronic degenerative change to the MP and IP joints of both hands.  The left lower extremity, the thigh compartment is supple.  She has pain with log rolling tenderness over the greater trochanter.  The patient has pain with any attempt at hip flexion passively or actively.  The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism.  She has 2 to 3+ bilateral pitting edema pretibially and pedally.  The patient has a weak motor response to the left lower extremity.  She has a 1+ dorsalis pedis pulse.  Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:,  Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm.  There is no evidence of dislocation.  There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture.  There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine.  There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets.  Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62.  Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1.  This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip.  The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2.  Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:,  I have discussed this case with the emergency room physician as well as the patient.  Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation.  Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure.  She will need cardiology clearance, which would include an echo in advance of the procedure.  I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter.  She presently understands and agrees with the plan.
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DESCRIPTION: The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.

The situation involves an 88-year-old patient with a complex medical history who has suffered significant injuries (a proximal humerus fracture and a femoral neck fracture) due to a fall. The patient's medical history includes coronary artery disease, chronic obstructive pulmonary disease, and is on medications like Plavix, which complicates her case. The plan includes surgical intervention and necessary adjustments to her medication due to the risk of bleeding associated with surgery. Given her age, medical history, and the impact of her injuries on her mobility and well-being, the situation is high-stakes medically and for her quality of life.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 6

DISCHARGE DATE:  MM/DD/YYYY,HISTORY OF PRESENT ILLNESS:  Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.  He underwent a resection there.  He was to be admitted to the Day Hospital for cystectomy.  He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE:  Mr. ABC presented to the Day Hospital in anticipation for Urology surgery.  On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained.  A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia.  In addition, inducible ischemia seen in the inferior lateral septum.  Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease.  The RCA, proximal was 95% stenosed and the distal 80% stenosed.  The mid LAD was 85% stenosed and the distal LAD was 85% stenosed.  There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%.  Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ.  Mr. ABC had a noncomplicated post-intervention hospital course.  He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS:  Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Obese, soft, nontender.  Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN:  Dry and intact, no bruit, no ecchymosis, no hematoma.  Distal pulses are intact.,DISCHARGE LABS:  CBC:  White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1.  BMP:  Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211.  Lipid profile:  Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1.  On MM/DD/YYYY, cardiac MRI adenosine stress.,2.  On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS:  Mr. ABC is discharged home.  He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet.  He should follow post-coronary artery intervention restrictions.  He should not lift greater than 10 pounds for seven days.  He should not drive for two days.  He should not immerse in water for two weeks.  Groin site care reviewed with patient prior to being discharged home.  He should check groin for bleeding, edema, and signs of infection.  Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him.  He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1.  Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2.  Bladder cancer.,3.  Diabetes.,4.  Dyslipidemia.,5.  Hypertension.,6.  Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7.  Multiple resections of the bladder tumor.,8.  Distant history of appendectomy.,9.  Distant history of ankle surgery.
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DESCRIPTION: A white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital.

general medicine, coronary artery disease, heart catheterization, artery disease, bare metal, metal stents, artery intervention, bladder cancer, coronary artery, veteran, surgery, cardiac, inducible, catheterization, ischemia, cancer, urology, stenosed, bladder, heart, artery, coronary,

The discharge summary includes details of a patient with significant comorbid conditions, including coronary artery disease, bladder cancer, diabetes, and hypertension, among others. The high-stakes aspect comes from the fact that proper post-discharge care is critical to prevent complications such as cardiac events or issues related to recent interventions. However, since the surgical and immediate hospital course was non-complicated, the immediate risk is somewhat mitigated, although the potential consequences of non-compliance with discharge instructions remain significant. Proper follow-up and self-monitoring are essential for the patient's ongoing health.


Medical Specialty: General Medicine
Sample Name: Disseminated Intravascular Coagulation

DIAGNOSES:,1.  Disseminated intravascular coagulation.,2.  Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.  At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer.  At this time, I am being consulted for further evaluation and recommendations for treatment.  The nurses report that she has actually improved clinically over the last 24 hours.  Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion.  There is no prior history of coagulopathy.,PAST MEDICAL HISTORY:  ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY:  ,There were possible illicit drugs.  Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY:  ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL:  She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS:  She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT:  Her sclerae showed conjunctival hemorrhage.  There are no petechiae.  Her nasal vestibules are clear.  Oropharynx has ET tube in place.,NECK:  No jugular venous pressure distention.,CHEST:  Coarse breath sounds bilaterally.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender with good bowel sounds.  There was some oozing around the site of her central line.,EXTREMITIES:  No clubbing, cyanosis, or edema.  There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES:  ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN:  ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease.  My recommendation for the patient is to continue factor replacement as you are.  It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time.  There is no indication at this point for Xigris.  However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions.  I will repeat her laboratory studies in the morning and give more recommendations at that time.
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DESCRIPTION: Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis.  Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.

general medicine, intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated,

This case involves a 20-year-old female with disseminated intravascular coagulation resulting from sepsis due to Streptococcal pneumonia, requiring intensive care and intubation. DIC is a severe condition with possible life-threatening complications, as it indicates severe systemic illness alongside bleeding and clotting issues. The patient is intubated, indicating severe respiratory distress, and the presence of sepsis further complicates the situation. While the report mentions some clinical improvement, the need for ongoing aggressive treatment, including factor replacement and close monitoring, reflects the high-stakes nature of the scenario. The healthcare provider is considering additional interventions if the patient's condition doesn't continue to improve, emphasizing the need to carefully manage a potentially volatile situation.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 9

DISCHARGE DIAGNOSIS:,1.  Epigastric pain.  Questionable gastritis, questionable underlying myocardial ischemia.,2.  Congestive heart failure exacerbation.,3.  Small pericardial effusion with no tamponade.,4.  Hypothyroidism.,5.  Questionable subacute infarct versus neoplasm in the pons.,6.  History of coronary artery disease, status post angioplasty and stent.,7.  Hypokalemia.,CLINICAL RESUME: , This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.  She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago.  She has had abdominal CAT scan and gastric emptying studies which was normal.,A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon.  Otherwise unremarkable.  The patient follows with Dr. XYZ as an outpatient.  The patient had some worsening of her symptoms over the last few days and then came to the ER.  She was admitted.  Please refer to Dr. XYZ initial H&P for complete details.,HOSPITAL COURSE:,1.  Epigastric pain, nausea, and vomiting.  The patient was restituted with antiemetics and her symptoms improved.  It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin.  A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct.  However, brain neoplasm could not be excluded.  Other workup including a CT angio did not show any evidence of acute pulmonary emboli.  It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion.  The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive.  She refused to complete the stress test.  She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2.  Congestive heart failure exacerbation.  The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved.  An echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade.  There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV.,3.  Small pericardial effusion.  The patient did not have any clinical or echocardiographic evidence of tamponade.,4.  Hypothyroidism.  TSH was quite elevated at 19.,5.  Questionable subacute infarct versus neoplasm in the pons on an MRI of the head.,6.  History of coronary artery disease/angioplasty and stents.,7.  Hyperkalemia.,8.  Patient was doing well.  She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,MEDICATIONS AND ADVICE ON DISCHARGE:,1.  She is to continue taking Coreg 12.5 mg p.o. b.i.d.,2.  Cozaar 50 mg p.o. daily.,3.  Aldactone 25 mg p.o. daily.,4.  Synthroid 0.075 mg p.o. daily.,5.  Carafate 1 gram p.o.  4 times a day.,6.  Claritin 10 mg p.o. daily.,7.  Lasix 20 mg p.o. daily.,8.  K-Dur 20 mEq p.o. daily.,9.  Prilosec 40 mg p.o. daily.,10.  Zofran 4 mg p.o. q.4-6 hourly p.r.n.,She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time.  She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time.  She is to follow up with Dr. XYZ from GI as scheduled.  The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient.  She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time.  She will also need repeat echocardiogram done in one month for a pericardial effusion.  This can be arranged by her primary care physician.  Repeat TSH to be done in 6 weeks' time.,Over 35 minutes were spent in the patient discharged.
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DESCRIPTION: A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.

The discharge summary details a complex medical case involving an 83-year-old woman with multiple serious health conditions, including congestive heart failure exacerbation, potential myocardial ischemia, and a questionable cerebral infarct versus neoplasm. While she is currently in a stable condition and being discharged, the potential risks associated with her conditions, such as cardiac events or neurological issues, are significant. Her discharge plan involves close outpatient follow-up with multiple specialists, indicating a high need for ongoing medical attention. Further testing is required to rule out severe complications. The stakes are relatively high due to her age, the seriousness of her conditions, and the potential for rapid deterioration without proper follow-up.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - Migraine

ADMITTING DIAGNOSIS: , Intractable migraine with aura.,DISCHARGE DIAGNOSIS:,  Migraine with aura.,SECONDARY DIAGNOSES:,1.  Bipolar disorder.,2.  Iron deficiency anemia.,3.  Anxiety disorder.,4.  History of tubal ligation.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  CT of the head with and without contrast, which was negative.,2.  An MRA of the head and neck with and without contrast also negative.,3.  The CTA of the neck also read as negative.,4.  The patient also underwent a lumbar puncture in the Emergency Department, which was grossly unremarkable though an opening pressure was not obtained.,HOME MEDICATIONS:,1.  Vicodin 5/500 p.r.n.,2.  Celexa 40 mg daily.,3.  Phenergan 25 mg p.o. p.r.n.,4.  Abilify 10 mg p.o. daily.,5.  Klonopin 0.5 mg p.o. b.i.d.,6.  Tramadol 30 mg p.r.n.,7.  Ranitidine 150 mg p.o. b.i.d.,ALLERGIES:,  SULFA drugs.,HISTORY OF PRESENT ILLNESS: , The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008.  She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma.  The patient also perceived some swelling in her face.  Once in the Emergency Department, the patient underwent a very thorough evaluation and examination.  She was given the migraine cocktail.  Also was given morphine a total of 8 mg while in the Emergency Department.  For full details on the history of present illness, please see the previous history and physical.,BRIEF SUMMARY OF HOSPITAL COURSE:  ,The patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail.  The patient was brought up to 4 or more early in the a.m. on the August 1, 2008 and was given the dihydroergotamine IV, which did allow some minimal resolution in her headache immediately.  At the time of examination this morning, the patient was feeling better and desired going home.  She states the headache had for the most part resolved though she continues to have some diffuse trigger point pain.,PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: , General physical exam was unremarkable.  HEENT:  Pupils were equal and respond to light and accommodation bilaterally.  Extraocular movements were intact.  Visual fields were intact to confrontation.  Funduscopic exam revealed no disc pallor or edema.  Retinal vasculature appeared normal.  Face is symmetric.  Facial sensation and strength are intact.  Auditory acuities were grossly normal.  Palate and uvula elevated symmetrically.  Sternocleidomastoid and trapezius muscles are full strength bilaterally.  Tongue protrudes in midline.  Mental status exam: revealed the patient alert and oriented x 4.  Speech was clear and language is normal.  Fund of knowledge, memory, and attention are grossly intact.  Neurologic exam:  Vasomotor system revealed full power throughout.  Normal muscle tone and bulk.  No pronator drift was appreciated.  Coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement.  No tremor or dysmetria.  Excellent sensory.  Sensation is intact in all modalities throughout. The patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum.  Gait was assessed, the patient's routine and tandem gait were normal.  The patient is able to balance on heels and toes.  Romberg is negative.  Reflexes are 2+ and symmetric throughout.  Babinski reflexes are plantar.,DISPOSITION:,  The patient is discharged home.,INSTRUCTIONS FOR FOLLOWUP:  ,The patient is to followup with her primary care physician as needed.
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DESCRIPTION: Intractable migraine with aura.  The patient is discharged home.  Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.

The discharge summary provides a comprehensive overview of the patient's condition and treatments received during hospitalization. The primary condition, an intractable migraine with aura, has been sufficiently managed with treatments, and the patient has been cleared for discharge. While there are secondary diagnoses (bipolar disorder, iron deficiency anemia, anxiety disorder), the patient was stable during the hospital stay and has been instructed to follow up with a primary care physician. This indicates that the situation is not immediately life-threatening or critical, but does require careful outpatient management.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 19

PRIMARY DISCHARGE DIAGNOSES:,1.  Urinary tract infection.,2.  Gastroenteritis with nausea and vomiting.,3.  Upper gastrointestinal bleed likely secondary to gastritis.,4.  Right hip osteoarthritic pain.,SECONDARY DISCHARGE DIAGNOSES:,1.  Hypertension.,2.  Gastroesophageal reflux disease.,3.  Chronic atrial fibrillation.,4.  Osteoporosis.,5.  Valvular heart disease.,HOSPITAL COURSE SUMMARY: , The patient is 93-year-old Caucasian female with a past medical history of hypertension, chronic atrial fibrillation, gastroesophageal reflux disease, osteoporosis and chronic right hip pain after total hip arthroplasty was admitted to our hospital for complaints of nausea and vomiting and urinary tract infection.  Over the course of her hospitalization, the patient was started on antibiotic regimen and proton pump inhibitors for an episode of coffee-ground emesis.  The patient was managed conservatively and was also provided with physical therapy for chronic right hip pain.,At the time of discharge, the patient continues to complain of right hip pain impairing ability to walk.  The patient denies any chest pain, nausea, vomiting, fever, chills, shortness of breath, abdominal pain or any urine or bowel problems.,PAST MEDICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PAST SURGICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  At the time of discharge temperature 36.6 degree Celsius, pulse rate of 77 per minute, respiratory rate 20 per minute, blood pressure 115/63, and oxygen saturation of 94% on room air.,GENERAL:  The patient is a thin built Caucasian female with no pallor, cyanosis or icterus.  She is alert and oriented x3.,HEENT:  No carotid bruits, JVD, lymphadenopathy or thyromegaly.  Pupils are equally reactive to light and accommodation.,BACK AND EXTREMITY:  Bilateral pitting edema and peripheral pulses are palpable.  The patient has right hip brace/immobilizer.,HEART:  Irregularly irregular heart rhythm, grade 2-3/6 systolic ejection murmur best heard over the aortic area and normal S1 and S2.,CHEST:  Auscultation revealed bibasilar crackles.,ABDOMEN:  Soft, nontender, no organomegaly and bowel sounds are present.,CNS:  Nonfocal.,LABORATORY STUDIES: , WBC 6.5, hemoglobin 12.5, hematocrit 38.9, platelet count 177,000, INR 1.2, sodium 141, potassium 3.6 and serum creatinine of 0.8.  Liver function tests were normal.  The patient's troponin was elevated at 0.05 at the time or presentation, but it trended down to 0.04 on the third set.  Urinalysis revealed trace protein, trace blood, and 10-20 WBCs.  Blood culture showed no growth till date.  Urine culture grew 50-100,000 colonies of Enterococcus susceptible to ampicillin and nitrofurantoin.,Chest x-ray showed enlarged heart with large intrathoracic hiatal hernia.  Lung parenchyma was otherwise clear.,Right hip x-ray showed that the prosthesis was in satisfactory position.  There was small gap between the cancellous bone and the long stem femoral component of the prosthesis, which is within normal limits.,DISCHARGE MEDICATIONS:,1.  Aspirin 81 mg orally once daily.,2.  Calcium with vitamin D two tablets orally once daily.,3.  Nexium 40 mg orally once daily.,4.  Multivitamins with minerals one capsule once daily.,5.  Zoloft 25 mg orally once daily.,6.  Norco 325/10 mg every 6-8 hours as needed for pain.,7.  Systane ophthalmic solution two drops in both eyes every two hours as needed.,8.  Herbal __________ by mouth everyday.,9.  Macrodantin 100 mg orally every six hours for seven days.,ALLERGIES:,  Penicillin.,PROGNOSIS: , Improved.,ASSESSMENT AND DISCHARGE PLAN:  ,The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.,PROBLEM #1:
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DESCRIPTION: The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.

This situation involves a 93-year-old patient with multiple medical issues, including a recent hospitalization for urinary tract infection, gastroenteritis, upper gastrointestinal bleed, and hip pain. While these conditions are serious, the patient has been managed and stabilized enough for discharge. The ongoing issues, such as chronic right hip pain and atrial fibrillation, require careful outpatient management. Although her age and combination of medical conditions increase the stakes to a degree, she is currently stable, and there are no immediate life-threatening conditions reported at discharge.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 1

DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient.,3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids.,4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses.,4. IV contrast CT scan of the head is unremarkable.,5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary.,6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.,7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left.,HISTORY AND PHYSICAL: ,This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery.,The patient was admitted to the MICU.,HOSPITAL COURSE PER PROBLEM LIST:,1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT, OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.,2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.,3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.,4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.,CONDITION ON DISCHARGE:, Stable.,ACTIVITY: ,As tolerated.,DIET:, Low-fat, low-salt, cardiac diet.,DISCHARGE INSTRUCTIONS:,1. Take medications regularly.,2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital.,3. Continue Cipro for an additional two days for his UTI.,DISCHARGE MEDICATIONS:,1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.,2. Aggrenox, one tablet p.o. b.i.d.,3. Docusate sodium 100 mg, one cap p.o. b.i.d.,4. Zocor 20 mg, one tablet p.o. at bedtime.,5. Prevacid 30 mg p.o. once a day.,FOLLOW UP:,1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.,2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance.
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DESCRIPTION: Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.

The situation described involves a patient who has experienced an acute cerebrovascular accident (stroke), hypertension, a urinary tract infection, and hypercholesterolemia. The nature of a stroke automatically elevates this scenario to high-stakes because it involves potential risks to critical bodily functions and long-term health consequences. The patient's immediate treatment and rehabilitation are crucial to managing symptoms and preventing further complications, thus requiring careful medical management. Furthermore, the persistent issues such as recurrent stroke risk and the need for rehabilitation increase the stakes. However, the patient is stable upon discharge, which slightly mitigates the immediacy of high-stake concerns.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 14

HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.  She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission.  Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis.  Biopsies were done.  The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender.  Lungs clear.  Blood pressure 129/69 on admission.  At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3.  Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema.  This was done and did not really show what the cecum on the barium enema.  There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon.  She did have some enemas.  She had persistent nausea, headache, neck pain throughout this hospitalization.  Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS:  ,Migraine headache.,COMPLICATIONS:  ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN:  ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications.  Diet and activity as tolerated.
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DESCRIPTION: The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.

general medicine, diarrhea, nausea, inability to eat, egd, colonoscopy, biopsies, barium enema, cecum, barium, admission,

The discharge summary indicates that the patient has been experiencing serious symptoms such as daily diarrhea, nausea, and abdominal pain for several months, as well as recurrent headaches. Although the immediate situation is managed, the underlying cause of her condition is uncertain, and her discharge condition is described as 'guarded,' indicating ongoing concerns. The stakes are moderate as these symptoms can significantly impact quality of life, and there is potential for serious underlying health issues that need timely follow-up. However, since she is not in immediate danger and a follow-up plan has been set, the situation is not extremely high-stakes.


Medical Specialty: General Medicine
Sample Name: Consult - Hypertension

HISTORY OF PRESENT ILLNESS:,  The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s.  Her lisinopril was increased to 40 mg daily.  She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure.  Denies any physical complaints at the present time.  Denies having any renal problems in the past.,PAST MEDICAL HISTORY:,  As above plus history of anemia treated with Procrit.  No smoking or alcohol use and lives alone.,FAMILY HISTORY:,  Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain.  No palpitations.  Pulmonary:  No shortness of breath, cough, or wheezing.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  GU:  No nocturia.  Denies having gross hematuria.  Salt intake is minimal.  Neurological:  Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78.  Examination of the head is unremarkable.  Neck is supple with no JVD.  Lungs are clear.  There is no abdominal bruit.  Extremities 1+ edema bilaterally.,LABORATORY DATA:,  Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital.  The creatinine is 0.8.  Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:,  Accelerated hypertension.  No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA.  I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension.  She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  At this point, I would not pursue a diagnosis of renal artery stenosis.  Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor.  I will continue HCTZ at 24 mg daily.  The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure.  The patient was told to be stick with her salt intake.  She will report to me in 10 days with the result of her blood pressure.  She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.
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DESCRIPTION: Patient with a past medical history of hypertension for 15 years.

general medicine, hypertension, ace inhibitor, accelerated hypertension, hctz, mra of the renal arteries, procrit, sma7, anemia, beta-blocker, doxorubicin, hemiparesis, history of cva, hyperkalemia, no abdominal bruit, uterine cancer, renal artery stenosis, artery stenosis, blood pressure, blood, pressure, renal,

The situation involves managing a 74-year-old woman with a complex medical history, including hypertension, a past cerebrovascular accident, and uterine cancer with metastatic disease. Her case is complicated by recent worsening hypertension despite medication adjustments. While hypertension is a common condition, it can lead to life-threatening complications if not managed properly, especially in patients with significant comorbidities like this one. Testing and medication adjustments are underway to control her blood pressure, indicating the need for careful monitoring and timely intervention. However, it doesn't appear immediately life-threatening at the moment, since there are no acute symptoms reported. Nonetheless, the potential consequences of uncontrolled hypertension and existing health conditions make it a moderately high-stakes situation.


Medical Specialty: General Medicine
Sample Name: Diabetes Mellitus - SOAP Note - 1

CHIEF COMPLAINT:  ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:,  Patient is a 34-year-old male with significant diabetic neuropathy.  He has been off on insurance for over a year.  Has been using NPH and Regular insulin to maintain his blood sugars.  States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago.  Reports that his blood sugar dropped too low which caused the accident.  Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time.  Reports that he had some indications of kidney damage when first diagnosed.  His urine microalbumin today is 100.  His last hemoglobin A1C drawn at the end of December is 11.9.  Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7.  His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker.  Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today.  Patient also has a history of gastroparesis and impotence.  Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.  , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head.  Was not wearing a helmet.  Reports that he did not go to the emergency room and had a headache for several days after this incident.  Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room.  Patient did not comply.  Reports that the headache has resolved.  Denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,PHYSICAL EXAMINATION: , WD, WN.  Slender, 34-year-old white male.  VITAL SIGNS:  Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16.  Microalbumin 100. SKIN:  There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long.  No signs of infection.  Wound is closed with new granulation tissue.  Appears to be healing well.  HEENT:  Normocephalic.  PERRLA.  EOMI.  TMs pearly gray with landmarks present.  Nares patent.  Throat with no redness or swelling.  Nontender sinuses.  NECK:  Supple.  Full ROM.  No LAD. CARDIAC:
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DESCRIPTION: Followup diabetes mellitus, type 1.

Followup diabetes mellitus, type 1.

general medicine, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars

The situation involves a patient with type 1 diabetes mellitus who is not adequately managing his condition due to fear of hypoglycemia and lack of insurance. His last hemoglobin A1C is significantly high at 11.9, indicating poor blood sugar control, which increases the risk of complications such as diabetic neuropathy, kidney damage, and potential cardiovascular issues. Additionally, the patient experienced a head injury in a recent accident, and although he is currently asymptomatic, he did not seek immediate medical attention when advised, which could have been dangerous. These factors collectively present a moderately high-stakes scenario in terms of potential health risks that require careful management and follow-up. However, the immediate situation does not indicate an urgent life-threatening condition, thus not placing it at the highest level of stakes.


Medical Specialty: General Medicine
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 situation involves a patient with multiple significant medical conditions and a history of coronary artery disease, which is a serious condition given the patient's age and the need for continual monitoring of symptoms and management of risk factors. While the patient's primary symptoms seem to be aligned with fatigue and tiredness, there is a history of potential cardiac issues and recent complications such as a urinary tract infection post-procedure, adding complexity to his care. The stakes are moderate to high due to the potential impact on the patient's overall health and the need for careful medical management.


Medical Specialty: General Medicine
Sample Name: COPD & Pneumonia - SOAP

SUBJECTIVE: , Review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation.  The patient does have a longstanding history of COPD.  However, she does not use oxygen at her independent assisted living home.  Yesterday, she had made improvement since being here at the hospital.  She needed oxygen.  She was tested for home O2 and qualified for it yesterday also.  Her lungs were very tight.  She did have wheezes bilaterally and rhonchi on the right side mostly.  She appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,Overnight, the patient needed to use the rest room.  She stated that she needed to urinate.  She awoke, decided not to call for assistance.  She stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  She attempted to walk to the rest room on her own.  She sustained a fall.  She stated that she just felt weak.  She bumped her knee and her elbow.  She had femur x-rays, knee x-rays also.  There was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  This morning, she denied any headache, back pain or neck pain.  She complained mostly of right anterior knee pain for which she had some bruising and swelling.,OBJECTIVE:,VITAL SIGNS:  The patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  She is 95% on 2 L via nasal cannula.,HEART:  Regular rate and rhythm without murmur, gallop or rub.,LUNGS:  Reveal no expiratory wheezing throughout.  She does have some rhonchi on the right mid base.  She did have a productive cough this morning and she is coughing green purulent sputum finally.,ABDOMEN:  Soft and nontender.  Her bowel sounds x4 are normoactive.,NEUROLOGIC:  She is alert and oriented x3.  Her pupils are equal and reactive.  She has got a good head and facial muscle strength.  Her tongue is midline.  She has got clear speech.  Her extraocular motions are intact.  Her spine is nontender on palpation from neck to lumbar spine.  She has good range of motion with regard to her shoulders, elbows, wrists and fingers.  Her grip strengths are equal bilaterally.  Both elbows are strong from extension to flexion.  Her hip flexors and extenders are also strong and equal bilaterally.  Extension and flexion of the knee bilaterally and ankles also are strong.  Palpation of her right knee reveals no crepitus.  She does have suprapatellar inflammation with some ecchymosis and swelling.  She has got good joint range of motion however.,SKIN:  She did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently Steri-Stripped and wrapped with Coban and is not actively bleeding.,ASSESSMENT:,1.  Acute on chronic COPD exacerbation.,2.  Community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.,3.  Generalized weakness and deconditioning secondary to the above.  Also sustained a fall secondary to instability and not using her walker or calling for assistance.  The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,PLAN:,1.  I will have PT and OT evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  Myself and one of her daughter's spoke today about the fact that she generally lives independently at the Brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2.  We will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.
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DESCRIPTION: Acute on chronic COPD exacerbation and community acquired pneumonia both resolving.  However, she may need home O2 for a short period of time.

general medicine, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd

The situation involves a high-stakes decision-making process for a 97-year-old patient with multiple health conditions, including acute COPD exacerbation, pneumonia, and the repercussions of a fall. The stakes are high due to the patient's age, the complexity of her conditions, and the need to balance her desire for independence with ensuring her safety and appropriate level of care (e.g., assisted living, PT/OT involvement). Managing such a case can significantly impact the patient's quality of life and long-term health outcomes.


Medical Specialty: General Medicine
Sample Name: Consult - Vomiting & Nausea

CHIEF COMPLAINT:,  Vomiting and nausea.,HPI: , The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.  She states she has it at least once a day.  It can be any time, but can also be postprandial.  She states she will vomit up some dark brown-to-green fluid.  There has been no hematemesis.  She states because of the nausea and vomiting, she has not been able to take much in the way of PO intake over the past week.  She states her appetite is poor.  The patient has lost 40 pounds of weight over the past 16 months.  She states for the past few days, she has been getting severe heartburn.  She used Tums over-the-counter and that did not help.  She denies having any dysphagia or odynophagia.  She is not having any abdominal pain.  She has no diarrhea, rectal bleeding, or melena.  She has had in the past, which was remote.  She did have some small amounts of rectal bleeding on the toilet tissue only if she passed a harder stool.  She has a history of chronic constipation for most of her life but she definitely has a bowel movement every 3 to 4 days and this is unchanged.  The patient states she has never had any endoscopy or barium studies of the GI tract.,The patient is anemic and her hemoglobin is 5.7 and she is thrombocytopenic with the platelet count of 34.  She states she has had these abnormalities since she has been diagnosed with breast cancer.  She states that she has metastatic breast cancer and that is in her rib cage and spine and she is getting hormonal chemotherapy for this and she is currently under the care of an oncologist.  The patient also has acute renal failure at this point.  The patient said she had a PET scan done about a week ago.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to her rib cage and spine, hypothyroidism, anemia, thrombocytopenia, hypertension, Bells palsy, depression, uterine fibroids, hysterectomy, cholecystectomy, breast lumpectomy, and thyroidectomy.,ALLERGIES: , No known drug allergies.,MEDICINES:,  She is on Zofran, Protonix, fentanyl patch, Synthroid, Ativan, and Ambien.,SOCIAL HISTORY:  ,The patient is divorced and is a homemaker.  No smoking or alcohol.,FAMILY HISTORY:,  Negative for any colon cancer or polyps.  Her father died of mesothelioma, mother died of Hodgkin lymphoma.,SYSTEMS REVIEW: , No fevers, chills or sweats.  She has no chest pain, palpitations, coughing or wheezing.  She does get shortness of breath, no hematuria, dysuria, arthralgias, myalgias, rashes, jaundice, bleeding or clotting disorders.  The rest of the system review is negative as per the HPI.,PHYSICAL EXAM: , Temperature 98.4, blood pressure 95/63, heart rate 84, respiratory rate of 18, and weight is 108 kg.  GENERAL APPEARANCE:  The patient was comfortable in bed.  Skin exam is negative for any rashes or jaundice.  LYMPHATICS:  There is no palpable lymphadenopathy of the cervical or the supraclavicular area.  HEENT:  She has some mild ptosis of the right eye.  There is no icterus.  The patient's conjunctivae and sclerae are normal.  Pupils are equal, round, and reactive to light and accommodation.  No lesions of the oral mucosa or mucosa of the pharynx.  NECK:  Supple.  Carotids are 2+.  No thyromegaly, masses or adenopathy.  HEART:  Has regular rhythm.  Normal S1 and S2.  She has a 2/6 systolic ejection murmur.  No rubs or gallops.  Lungs are clear to percussion and auscultation.  Abdomen is obese, it may be mildly distended.  There is no increased tympany.  The patient does have hepatosplenomegaly.  There is no obvious evidence of ascites.  The abdomen is nontender, bowel sounds are present.  The extremities show some swelling and edema of the ankle regions bilaterally.  Legs are in SCDs.  No cyanosis or clubbing.  For the rectal exam, it shows brown stool that is very trace heme positive at most.  For the neuro exam, she is awake, alert, and oriented x3.  Memory intact.  No focal deficits.  Insight and judgment are intact.,X-RAY AND LABORATORY DATA:  ,She came in, white count 9.2, hemoglobin 7.2, hematocrit 22.2, MCV of 87, platelet count is 47,000.  Calcium is 8.1, sodium 134, potassium 5.3, chloride 102, bicarbonate 17, BUN of 69, creatinine of 5.2, albumin 2.2, ALT 28, bilirubin is 2.2, alkaline phosphatase is 359, AST is 96, and lipase is 30.  Today, her hemoglobin is 5.7, TSH is 1.1, platelet count is 34,000, alkaline phosphatase is 303, and bilirubin of 1.7.,IMPRESSION,1.  The patient has one week of nausea and vomiting with decreased p.o. intake as well as dehydration.  This could be on the basis of her renal failure.  She may have a viral gastritis.  The patient does have a lot of gastroesophageal reflux disease symptoms recently.  She could have peptic mucosal inflammation or peptic ulcer disease.,2.  The patient does have hepatosplenomegaly.  There is a possibility she could have liver metastasis from the breast cancer.,3.  She has anemia as well as thrombocytopenia.  The patient states this is chronic.,4.  A 40-pound weight loss.,5.  Metastatic breast cancer.,6.  Increased liver function tests.  Given her bone metastasis, the elevated alkaline phosphatase may be from this as opposed to underlying liver disease.,7.  Chronic constipation.,8.  Acute renal failure.,PLAN:  ,The patient will be on a clear liquid diet.  She will continue on the Zofran.  She will be on IV Protonix.  The patient is going to be transfused packed red blood cells and her hemoglobin and hematocrit will be monitored.  I obtained the result of the abdominal x-rays she had done through the ER.  The patient has a consult pending with the oncologist to see what her PET scan show.  There is a renal consult pending.  I am going to have her get a total abdominal ultrasound to see if there is any evidence of liver metastasis and also to assess her kidneys.  Her laboratory studies will be followed.  Based upon the patient's medical condition and including her laboratory studies including a platelet count, we talked about EGD versus upper GI workup per upper GI symptoms.  I discussed informed consent for EGD.  I discussed the indications, risks, benefits, and alternatives.  The risks reviewed included, but were not limited to an allergic reaction or side effect to medicines, cardiopulmonary complications, bleeding, infection, perforation, and needing to get admitted for antibiotics or blood transfusion or surgery.  The patient voices her understanding of the above.  She wants to think about what she wants to do.  Overall, this is a very ill patient with multiorgan involvement.
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DESCRIPTION: A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.

This patient presents with several critical medical issues, including metastatic breast cancer, acute renal failure, severe anemia with a hemoglobin level of 5.7, and hepatosplenomegaly. These conditions, especially in combination, indicate a very high-stakes situation. Acute renal failure, severe anemia requiring transfusion, and the potential for liver metastasis are life-threatening if not managed carefully. Additionally, the fact that she has been unable to maintain adequate oral intake and has lost a significant amount of weight over a prolonged period complicates her overall health status. Multinational involvement and ongoing treatments further increase the complexity and severity of her condition.


Medical Specialty: General Medicine
Sample Name: Consult - Syncope

REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.  No palpitation.  Presently, he is comfortable, lying in the bed.  As per the patient, no prior cardiac history.,CORONARY RISK FACTORS: , History of hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is borderline elevated.  No history of established coronary artery disease.  Family history noncontributory.,PAST MEDICAL HISTORY:  ,Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation.,PAST SURGICAL HISTORY: ,Back surgery, shoulder surgery, and appendicectomy.,FAMILY HISTORY: , Nonsignificant.,MEDICATIONS:,1.  Pain medications.,2.  Thyroid supplementation.,3.  Lovastatin 20 mg daily.,4.  Propranolol 20 b.i.d.,5.  Protonix.,6.  Flomax.,ALLERGIES:,  None.,PERSONAL HISTORY:,  He is married.  Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  No weakness, fatigue, or tiredness.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  No congestive heart failure.  No arrhythmias.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGIC:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.  No significant carotid bruits.,LUNGS:  Air entry is bilaterally decreased.,HEART:  PMI is displaced.  S1 and S2 are regular.,ABDOMEN:  Soft and nontender.  Bowel sounds are present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.  The patient is moving all extremities; however, the patient has tremors.,RADIOLOGICAL DATA: , EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors.,LABORATORY DATA: , H&H stable.  White count of 14.  BUN and creatinine are within normal limits.  Cardiac enzyme profile is negative.  Ammonia level is elevated at 69.  CT angiogram of the chest, no evidence of pulmonary embolism.  Chest x-ray is negative for acute changes.  CT of the head, unremarkable, chronic skin changes.  Liver enzymes are within normal limits.,IMPRESSION:,1.  The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.
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DESCRIPTION: Patient was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.

The patient, a 69-year-old male, experienced syncope (fainting) and possibly a seizure, which are significant medical events, especially given his age and known medical conditions such as hypertension and Parkinson's disease. Although there are no immediate indications of a life-threatening event, the consultation aims to rule out potential causes such as cardiac or neurological issues. Despite stable vital signs and negative cardiac enzyme profile, the elevated ammonia level and past tremor activity add complexity to the case, necessitating further investigation.


Medical Specialty: General Medicine
Sample Name: Consult - Chest Pain - 1

REASON FOR CONSULTATION:,  Chest pain.,HISTORY OF PRESENT ILLNESS: , The patient is a 37-year-old gentleman admitted through emergency room.  He presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region.  Also, shortness of breath is noted without any diaphoresis.  Symptoms on and off for the last 3 to 4 days especially when he is under stress.  No relation to exertional activity.  No aggravating or relieving factors.  His history is significant as mentioned below.  His workup so far has been negative.,CORONARY RISK FACTORS:,  No history of hypertension or diabetes mellitus.  Active smoker.  Cholesterol status, borderline elevated.  No history of established coronary artery disease.  Family history positive.,FAMILY HISTORY: , His father died of coronary artery disease.,SURGICAL HISTORY: , No major surgery except for prior cardiac catheterization.,MEDICATIONS AT HOME:,  Includes pravastatin, Paxil, and BuSpar.,ALLERGIES:,  None.,SOCIAL HISTORY: , Active smoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hyperlipidemia, smoking history, and chest pain.  He has been, in October of last year, hospitalized.  Subsequently underwent cardiac catheterization.  The left system was normal.  There was a question of a right coronary artery lesion, which was thought to be spasm.  Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal.  The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed.  No relation to exertional activity.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurring vision, or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute.,HEENT:  Head is atraumatic and normocephalic.  Neck veins flat.,LUNGS:  Clear.,HEART:  S1 and S2, regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Benign.,PSYCHOLOGICAL:  Normal.,MUSCULOSKELETAL:  Within normal limits.,DIAGNOSTIC DATA: , EKG, normal sinus rhythm.  Chest x-ray unremarkable.,LABORATORY DATA: , First set of cardiac enzyme profile negative.  H&H stable.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Chest pain in a 37-year-old gentleman with negative cardiac workup as mentioned above, questionably right coronary spasm.,2.  Hyperlipidemia.,3.  Negative EKG and cardiac enzyme profile.,RECOMMENDATIONS:
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DESCRIPTION: A 37-year-old admitted through emergency, presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region.  Also, shortness of breath is noted without any diaphoresis.  Symptoms on and off for the last 3 to 4 days especially when he is under stress.  No relation to exertional activity.  No aggravating or relieving factors.

The situation involves a patient with chest pain, which can be indicative of a life-threatening condition such as a heart attack. However, the patient's current diagnostic tests, such as EKG and cardiac enzyme profile, are negative. Despite this, the patient has several coronary risk factors, including being an active smoker, borderline cholesterol, and a family history of coronary artery disease, which increase the stakes. Given these factors, while the immediate tests are negative, the risk of a more serious underlying condition cannot be entirely dismissed, making it a moderately high-stakes situation.


Medical Specialty: General Medicine
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 patient with a lump in the chest wall that has been growing and is tender. This raised concern for a possible tumor, which can be a significant medical condition. Given the patient's history, including smoking and familial cancer history, further evaluation for a potentially serious condition like cancer is warranted. Thus, this medical consult is relatively high-stakes as it may involve diagnosing and managing a life-threatening condition.


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

Medical Specialty: General Medicine
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 situation involves medical concerns related to potential breast cancer, given the suspicious calcifications observed in the patient's left breast. The patient's age, family history of breast cancer, and presence of new symptoms following a biopsy necessitate a thorough examination and further surgical intervention. The stakes are elevated due to the potential for a cancer diagnosis, which requires careful management and timely biopsy to rule out malignancy. Although the surgery will be performed on an outpatient basis, the underlying issue could have significant implications for the patient's health.


Medical Specialty: General Medicine
Sample Name: Asbestos Exposure - Hemoptysis

REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure.  The patient also has a very extensive cardiac history that would be outlined below.  He is being admitted with worsening shortness of breath and constipation.  He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1.  Benign prostatic hypertrophy.,2.  Peptic ulcer disease.,3.  Atrial fibrillation.,4.  Coronary artery disease.,5.  Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6.  ICD implantation.,7.  Peripheral vascular disease.,8.  CABG in 1991 and 1998.,9.  Congestive heart failure, EF 40%.,10.  Asbestos exposure.,MEDICATIONS,1.  Coumadin 6 mg alternating with 9 mg.,2.  Prevacid 30 mg once a day.,3.  Diovan 160 mg every day.,4.  Flomax 0.4 mg every day.,5.  Coreg 25 mg in the morning and 12.5 mg at night.,6.  Aldactone 25 mg a day.,7.  Lasix 20 mg a day.,8.  Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL:  The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT:  Significant for peripheral cyanosis.,NECK:  Supple.,LUNGS:  Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR:  Regular rate and rhythm with murmur and metallic click.,ABDOMEN:  Soft and benign.,EXTREMITIES:  1+ cyanosis.  No clubbing.  No edema.,LABORATORY DATA:,  Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000.  CK 266, PTT 37, PT 34, and INR 3.7.  Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1.  Hemoptysis.,2.  Acute bronchitis.,3.  Coagulopathy.,4.  Asbestos exposure.,5.  Left pleural effusion.,RECOMMENDATIONS,1.  Antibiotics.
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DESCRIPTION: Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.

This situation is high-stakes due to the combination of the patient's age, complex medical history, and current symptoms. The patient's asbestos exposure increases the risk of serious lung conditions, including cancer, and the presence of hemoptysis (coughing up blood) suggests significant respiratory pathology. Furthermore, the patient's history of multiple cardiac issues, including coronary artery disease and aortic valve replacement, along with current coagulopathy, increases the overall medical risk. The pleural effusion noted in the diagnostic studies could indicate a potential worsening or complication related to his respiratory status. Immediate and appropriate medical intervention is critical to manage these complex issues and prevent potentially life-threatening outcomes, such as significant bleeding, worsening respiratory failure, or cardiac complications.


Medical Specialty: General Medicine
Sample Name: Antibiotic Therapy Consult

REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema.  She follows up at the wound care center at Hospital.  Her lower extremity edema is being managed there.  She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her.  As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management.  She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas.  Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,PAST MEDICAL HISTORY:,  Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities.  She has had a hysterectomy and a cholecystectomy in the remote past.,SOCIAL HISTORY: , The patient lives by herself and has three pet cats.  She is an ex-smoker, quit smoking about five years ago.  She occasionally drinks a glass of wine.  She denies any other recreational drugs use.  She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.,FAMILY HISTORY: , Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia.  One of her uncles was diagnosed with leukemia.,ALLERGIES: , ADHESIVE TAPE ALLERGIES.,REVIEW OF SYSTEMS:,  At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left.  She denies any nausea, vomiting or diarrhea.  She denies any pain, tenderness, increased warmth or drainage from the lower extremities.  Denies chest pain, cough or phlegm production.  All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General:  A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.,Vital signs:  Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  Head is normocephalic and external ear exam is normal.,Neck:  Supple.  There is no palpable lymphadenopathy.,Cardiovascular system:  Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.  Heart sounds are little distant secondary to thick chest wall.,Lungs:  Clear to auscultation and percussion bilaterally.,Abdomen:  Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus.  There is no evidence of cutaneous candidiasis in the inguinal folds.  There is no palpable lymphadenopathy in the inguinal and femoral areas.,Extremities:  Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis.  There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area.  It has minimal serosanguineous drainage and there is no surrounding erythema.  Therefore, in my opinion, there is no current evidence of cellulitis or wound infection.  There is no cyanosis or clubbing.  There is no peripheral stigmata of endocarditis.,Central nervous system:  The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.,LABORATORY DATA: , White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils.  The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5.  Liver function tests are also within normal limits.,The nasal screen for MRSA is negative.  Urine culture is negative so far from admission.  Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,IMPRESSION AND PLAN:,  A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema.  Admitted for inpatient management of bilateral lower extremity lymphedema.  I have been consulted to rule out possibility of active cellulitis and wound infection.,At present, I do not find evidence of active cellulitis that needs antibiotic therapy.  In my opinion, lymphedema wraps could be initiated.  We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week.  If she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,Her stage II ulcer on the right leg does not look infected.  I would recommend continuation of wound care along with lymphedema wraps.,Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.  Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.,I appreciate the opportunity of participating in this patient's care.  If you have any questions, please feel free to call me at any time.  I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.
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DESCRIPTION: Questionable need for antibiotic therapy for possible lower extremity cellulitis.

The consultation involves assessing whether a patient requires antibiotic therapy for possible cellulitis, a common but potentially serious skin infection. While cellulitis can lead to complications if left untreated, the current assessment suggests there is no active infection requiring antibiotics at the moment. The patient is in a controlled hospital setting where she is being monitored closely, and there is no immediate evidence of infection. Therefore, while the situation needs attention and is significant due to the patient's medical history, it is not high-stakes in terms of immediate life-threatening risk.