Medical Specialty: General Medicine
Sample Name: HIV Followup

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old white male with a history of HIV disease.  His last CD4 count was 425, viral load was less than 50 in 08/07.  He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus.  He also has a history of hypertension and hypertriglyceridemia.  He had been having increased urination and thirst.  He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess.  The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide.  The patient reports that he has been taking the medication.  He is in general feeling better.  He says that his gluteal abscess is improving and he will be following up with Surgery today.,CURRENT MEDICATIONS:,1.  Gabapentin 600 mg at night.,2.  Metformin 1000 mg twice a day.,3.  Glipizide 5 mg a day.,4.  Flagyl 500 mg four times a day.,5.  Flexeril 10 mg twice a day.,6.  Paroxetine 20 mg a day.,7.  Atripla one at night.,8.  Clonazepam 1 mg twice a day.,9.  Blood pressure medicine, name unknown.,REVIEW OF SYSTEMS:,  He otherwise has a negative review of systems.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.)  HEENT:  Unremarkable except for some submandibular lymph nodes.  His fundi are benign.  NECK:  Supple.  LUNGS:  Clear to auscultation and percussion.  CARDIAC:  Reveals regular rate and rhythm without murmur, rub or gallop.  ABDOMEN:  Soft and nontender without organomegaly or mass.  EXTREMITIES:  Show no cyanosis, clubbing or edema.  GU:  Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions.,IMPRESSION:,1.  Human immunodeficiency virus disease with stable control on Atripla.,2.  Resolving left gluteal abscess, completing Flagyl.,3.  Diabetes mellitus, currently on oral therapy.,4.  Hypertension.,5.  Depression.,6.  Chronic musculoskeletal pain of unclear etiology.,PLAN: , The patient will continue his current medications.  He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter.  He has been encouraged to keep his appointment with his psychologist.
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DESCRIPTION: Human immunodeficiency virus disease with stable control on Atripla.  Resolving left gluteal abscess, completing Flagyl.  Diabetes mellitus, currently on oral therapy.  Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.

general medicine, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension,

This situation involves managing a patient with multiple chronic conditions, including HIV, diabetes mellitus, hypertension, and recent surgery for an abscess. Although the patient's HIV is stable and other conditions are under control with treatment, the complexity of managing these conditions, especially in a financially constrained context, does increase the stakes. The potential for complications arising from any of his medical conditions could have serious health implications. However, since the specific conditions are under control and the patient is following up on treatments, it isn't at the highest end of high-stakes situations.


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

Medical Specialty: General Medicine
Sample Name: Hypersensitivity to Coumadin

PROBLEM:,  Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty.  At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity.  However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels.  Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise.  Her prothrombin time is now 83.3 seconds with an INR of 6.52.  Hematology/Oncology consult was requested for recommendation regarding further evaluation and management.,SOCIAL HISTORY: , The patient is originally from Maine.  She has lived in Arizona for 4 years.  She has had 2 children; however, only one is living.  She had one child died from complications of ulcerative colitis.  She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.,CHILDHOOD HISTORY: , Negative for rheumatic fever.  The patient has usual childhood illnesses.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , The patient's mother died from gastric cancer.  She had a brother who died from mesothelioma.  He did have a positive asbestos exposure working in the shipyards.  The patient's father died from motor vehicle accident.  She had a sister who succumbed to pneumonia as a complication to Alzheimer disease.,HABITS: , No use of ethanol, tobacco, illicit, or recreational substances.,ADULT MEDICAL PROBLEMS: , The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X.  In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.,SURGERIES: , The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.,MEDICATIONS: , The patient's medications on admission include:,1.  Fosamax.,2.  TriCor.,3.  Gabapentin.,4.  Hydrochlorothiazide.,5.  Labetalol.,6.  Benicar.,7.  Crestor.,8.  Detrol.,REVIEW OF SYSTEMS: , Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time.  She is arousable, but not particularly conversant.,OBSERVATIONS:,GENERAL:  The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female.,HEENT:  Pupils were equal, round, and reactive to light and accommodation.  Extraocular muscles are grossly intact.  Oropharynx benign.,NECK:  Supple.  Full range of motion without bruits or thyromegaly.,LUNGS:  Clear to auscultation and percussion.,BACK:  Without spine or CVA tenderness.,HEART:  Regular rate and rhythm without murmurs, rubs, thrills, or heaves.,ABDOMEN:  Soft and nontender.  Positive bowel sounds without mass or visceromegaly.,LYMPHATIC:  No appreciable adenopathy.,EXTREMITIES:  The patient has some postoperative fullness involving her left knee.  She has a dressing over the left knee.,SKIN:  Without lesions.,NEURO:  Unable to assess in light of post morphine obtunded state.,ASSESSMENT: , Hypersensitivity to Coumadin.,PLAN: , Gave the patient vitamin K at this time.  Literature suggested oral vitamin K is actually more efficacious than parenteral.  However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion.  Repeat prothrombin time and INR in a.m.  Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively.
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DESCRIPTION: Probable Coumadin hypersensitivity.

Probable Coumadin hypersensitivity.

The situation involves a patient with probable hypersensitivity to Coumadin, leading to dangerously high levels of prothrombin time and INR, which poses a significant risk of bleeding. Given the patient's age and her postoperative status following major surgery, her condition requires close monitoring and intervention to prevent serious complications. The treatment plan involves administering vitamin K and switching anticoagulant therapy, which suggests the situation needs careful medical management to ensure patient safety.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: Headache - Office Visit

She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.
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DESCRIPTION: The patient with continued problems with her headaches.

general medicine, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran

The patient presents with a complex medical profile including poorly controlled diabetes, severe neuropathies, and a history of stroke, which are high-risk factors for complications. The stakes are heightened due to her diabetes being inadequately managed, with an A1c level of 10 indicating significant risk of further complications. Furthermore, her neural issues, such as severe ulnar neuropathy and carpal tunnel syndrome, present additional challenges that require specialist intervention. While the scenario isn't an immediate life-or-death situation, the ongoing management of these conditions is critical to avoid serious health deteriorations.


Medical Specialty: General Medicine
Sample Name: Headache - Emergency Visit

CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:,  This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache.  She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago.  Indicates pressure type of discomfort with throbbing component.  It is as high as a 9 on a 0 to 10 scale of intensity.  She denies having had similar discomfort in the past.  Denies any trauma.,Review of systems:  No fever or chills.  No sinus congestion or nasal drainage.  No cough or cold symptoms.  No head trauma.  Mild nausea.  No vomiting or diarrhea.  Other systems reviewed and are negative.,PMH: , Acne.  Psychiatric history is unremarkable.,PSH: , Right knee surgery.,SH: , The patient is single.  Living at home.  No smoking or alcohol.,FH: , Noncontributory.,ALLERGIES:  ,No drug allergies.,MEDICATIONS: , Accutane and Ovcon.,PHYSICAL EXAMINATION:,VITALS:  Temperature of 97.8 degrees F., pulse of 80, respiratory rate of 16, and blood pressure is 131/96.,GENERAL:  This is a 16-year-old white female.  She is awake, alert, and oriented x3.  She does appear bit uncomfortable.,HEAD:  Normocephalic and atraumatic.,EYES:  The pupils were equal and reactive to light.  Extraocular movements are intact.,ENT:  TMs are clear.  Nose and throat are unremarkable.,NECK:  There is no evidence of nuchal rigidity.  She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles.  Palpation clearly causes having exacerbation of her discomfort.,CHEST:  Thorax is unremarkable.,GI:  Abdomen is nontender.,MUSCLES:  Extremities are unremarkable.,NEURO:  Cranial nerves II through XII are grossly intact.  Motor and sensory are grossly intact.  ,SKIN:  Skin is warm and dry.,ED COURSE:,  The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.,DIAGNOSES:,1.  Muscle tension cephalgia.,2.  Right trapezius and rhomboid muscle spasm.,PLAN: , Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20.  She was instructed to apply warm compresses and perform gentle massage.  Follow up with regular provider as needed.  Return if any problems.
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DESCRIPTION: Muscle tension cephalgia.  Right trapezius and rhomboid muscle spasm.

The patient's symptoms, while severe, appear to be consistent with muscle tension cephalgia and muscle spasms, both of which are uncomfortable but generally not life-threatening. The patient received treatment with medication and instructions for follow-up care, and there is no indication of more serious underlying conditions such as neurological emergencies or signs of imminent complications. Therefore, while the situation required an emergency consultation due to the severity of pain, it does not indicate a high-stakes medical emergency.


Medical Specialty: General Medicine
Sample Name: Headache - Urgent Care Visit

CC: , Headache.,HPI: , This is a 15-year-old girl presenting with occipital headache for the last six hours.  She denies trauma.  She has been intermittently nauseated but has not vomited and has some photophobia.  Denies fever or change in vision.  She has no past history of headaches.  ,PMH: , None. ,MEDICATIONS:  ,Tylenol for pain.,ALLERGIES:,  None.,FAMILY HISTORY: , Grandmother died of cerebral aneurysm.  ,ROS:,  Negative.,PHYSICAL EXAM:  ,Vital Signs:  BP 102/60 P 70 RR 20 T 98.2 ,HEENT:  Throat is clear, nasopharynx clear, TMs clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender. ,Neck:  Supple without meningismus. ,Chest:  Lungs clear; heart regular without murmur.,COURSE IN THE ED: , The patient was seen in the urgent care and examined.  At this time, her photophobia and nausea make migraine highly likely.  She is well appearing and we'll try Tylenol with codeine for her pain.  One day off school and follow up with her primary doctor.  ,IMPRESSION: , Migraine headache.  ,PLAN: , See above.
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DESCRIPTION: Migraine headache - The patient was seen in the urgent care.

general medicine, photophobia, nausea, migraine headache, tylenol, migraine, headache,

This situation involves a 15-year-old girl presenting with her first episode of severe headache, which could potentially indicate a serious underlying condition. Her lack of headache history and a family history of cerebral aneurysm notably raises the stakes, as a first-time severe headache could sometimes denote an underlying serious condition. However, due to the absence of trauma, fever, or changes in vision and her well-appearing physical examination, the urgent care visit concludes with a benign diagnosis of a migraine. Her symptoms are managed conservatively, and she is advised to follow up with her primary care physician. While there is a potential risk due to family history of cerebral aneurysm, current findings and symptoms align more with a migraine. Thus, the situation does not seem extremely high-stakes, but it does warrant cautious monitoring.


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 7

CHIEF COMPLAINT:,  One-month followup.,HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old Caucasian female.  She comes here today with a friend.  The patient has no complaints.  She states she has been feeling well.  Her knees are not hurting her at all anymore and she is not needing Bextra any longer.  I think the last steroid injection that she had with Dr. XYZ really did help.  The patient denies any shortness of breath or cough.  Has no nausea, vomiting, abdominal pain.  No diarrhea or constipation.  She states her appetite is good.  She clears her plate at noon.  She has had no fevers, chills, or sweats.  The friend with her states she is doing very well.  Seems to eat excellently at noontime, despite this, the patient continues to lose weight.  When I asked her what she eats for breakfast and for supper, she states she really does not eat anything.  Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time.  She states she is really not hungry the rest of the time except at lunchtime.  She denies any fevers, chills, or sweats.  We did do some lab work at the last office visit and CBC was essentially normal.  Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3.  This is fairly stable for her.  Liver enzymes were normal.  TSH was normal.  Free albumin was normal at 23.  She is on different antidepressants and that may be causing some difficulties with unintentional weight loss.,MEDICATIONS:  ,Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.,SOCIAL HISTORY:,  The patient is widow.  She is a nonsmoker, nondrinker.  She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.,REVIEW OF SYSTEMS:,  As above in HPI.,PHYSICAL EXAM:,General:  This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face.  States are clothes are fitting more loosely.,Vital Signs:  Weight:  123, down 5 pounds from last month and down 11 pounds from May 2004.  Blood pressure:  128/62.  Pulse:  60.  Respirations:  20.  Temperature:  96.8.,Neck:  Supple.  Carotids are silent.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender, nondistended with positive bowel sounds.  No organomegaly or masses are appreciated.,Extremities:  Free of edema.,ASSESSMENT:,1.  Unintentional weight loss.  I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her.,2.  Depression, doing well.,3.  Paranoia, doing well.,4.  Dementia, stable.,5.  Osteoarthritis of the knees, pain is much improved.,PLAN:,1.  Continue on current medications.,2.  I did call and talk with doctor at hospital.  We discussed different options.  We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time.  Connie will weigh the patient once a week and I will go ahead and see the patient in one month.  We can see how she is doing at that time.  If she continues to lose weight despite eating better, then I think we will need to do further evaluation.
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DESCRIPTION: One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees.  Doing well.

The situation involves an 88-year-old patient with multiple medical conditions, including dementia, depression, paranoia, and osteoarthritis. While the assessment indicates that these conditions are relatively stable or improving, the unintentional weight loss is a concern, possibly related to her medications or inability to remember to eat. The follow-up plan includes dietary changes and monitoring, which if not addressed, could lead to more serious health issues. However, no immediate life-threatening condition is present, and the healthcare team is actively involved in managing her care.


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 5

S:,  The patient is here today with his mom for several complaints.  Number one, he has been having issues with his right shoulder.  Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder.  He has been having issues ever since.  He is having difficulties raising his arm over his head.  He does have some intermittent numbness in his fingers at night.  He is not taking any anti-inflammatories or pain relievers.  He is also complaining of a sore throat.  He did have some exposure to Strep and he has a long history of strep throat.  Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation.  He is also being seen for ADHD by Dr. B.  Adderall and Zoloft.  He takes these once a day.  He does notice when he does not take his medication.  He is doing well in school.  He is socializing well.  He is maintaining his weight and tolerating the medications.  However, he is having issues with anger control.  He realizes when he has anger outbursts that it is a problem.  His mom is concerned.  He actually was willing to go to counseling and was wondering if there was anything available for him at this time.,PAST MEDICAL/SURGICAL/SOCIAL HISTORY:,  Reviewed and unchanged.,O:,  VSS.  In general, patient is A&Ox3.  NAD.  Heart:  RRR.  Lungs:  CTA.  HEENT:  Unremarkable.  He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip.  Musculoskeletal:  Limited in range of motion, active on the right.  He stops at about 95 degrees.  No muscle weakness.  Neurovascularly intact.  Negative biceps tenderness.  Psych:  No suicidal, homicidal ideations.  Answering questions appropriately.  No hallucinations.
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DESCRIPTION: General Medicine SOAP note.  Patient with shoulder bursitis, pharyngitis, attention deficit disorder,

general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent

The patient in this SOAP note is experiencing multiple health concerns including shoulder bursitis, potential pharyngitis, and issues related to ADHD. While these conditions can affect quality of life and may require attention, they are not immediately life-threatening or associated with critical emergencies. The note mentions no suicidal or homicidal ideations and the patient does not appear to be in acute distress based on the examination findings. The situation requires management and support but does not present a high-stakes medical emergency.


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 4

S:,  ABC is in today for a followup of her atrial fibrillation.  They have misplaced the Cardizem.  She is not on this and her heart rate is up just a little bit today.  She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy.  She is very adamant that she wants to stop the Coumadin.  She is tired of blood draws.  We have had a difficult time getting her regulated.  No chest pains.  No shortness of breath.  She is moving around a little bit better.  Her arm does not hurt her.  Her back pain is improving as well.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple.  LUNGS are clear to auscultation.  HEART is irregularly irregular, mildly tachycardic.  ABDOMEN is soft and nontender.  EXTREMITIES:  No cyanosis, no clubbing, no edema.,EKG shows atrial fibrillation with a heart rate of 104.,A:,1.
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DESCRIPTION: General Medicine SOAP note.

General Medicine SOAP note.

general medicine, soap, alert and oriented, no acute distress, no cyanosis, atrial fibrillation, blood draw, dizziness, irregularly irregular, lightheadedness, no clubbing, no edema, shortness of breath, soft and nontender, vertigo, heart, fibrillation, coumadin, atrial,

The situation involves a follow-up appointment for a patient with atrial fibrillation, a common yet potentially serious condition requiring regular monitoring and medication management, in this case, blood thinners like Coumadin. The patient is experiencing dizziness and vertigo, which could indicate issues with their current medication or heart condition. They are also adamant about stopping Coumadin due to the inconvenience of blood draws, adding to the complexity as stopping blood thinners can increase the risk of stroke. Although there are no acute symptoms or distress, the management decisions and potential risks involved make this situation moderately high-stakes within general medicine.


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 10

SUBJECTIVE: , The patient has NG tube in place for decompression.  She says she is feeling a bit better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Pulse is 58 and blood pressure is 110/56.,SKIN:  There is good skin turgor.,GENERAL:  She is not in acute distress.,CHEST:  Clear to auscultation.  There is good air movement bilaterally.,CARDIOVASCULAR:  First and second sounds are heard.  No murmurs appreciated.,ABDOMEN:  Less distended.  Bowel sounds are absent.,EXTREMITIES:  She has 3+ pedal swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA:,  White count is down from 20,000 to 12.5, hemoglobin is 12, hematocrit 37, and platelets 199,000.  Glucose is 157, BUN 14, creatinine 0.6, sodium is 131, potassium is 4.0, and CO2 is 31.,ASSESSMENT AND PLAN:,1.  Small bowel obstruction/paralytic ileus, rule out obstipation.  Continue with less aggressive decompression.  Follow surgeon's recommendation.,2.  Pulmonary fibrosis, status post biopsy.  Manage as per pulmonologist.,3.  Leukocytosis, improving.  Continue current antibiotics.,4.  Bilateral pedal swelling.  Ultrasound of the lower extremity negative for DVT.,5.  Hyponatremia, improving.,6.  DVT prophylaxis.,7.  GI prophylaxis.
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DESCRIPTION: The patient has NG tube in place for decompression.

general medicine, small bowel obstruction, paralytic ileus, decompression, ng tube, pedal swelling, prophylaxis

This situation involves a patient with a small bowel obstruction or paralytic ileus, which requires careful observation and management, including decompression via NG tube and potential surgical consultation. The patient's vital signs and lab results are relatively stable, though they have notable conditions such as hyponatremia, pulmonary fibrosis, and leukocytosis. While the clinical situation necessitates medical attention and management, the patient's reported condition of feeling better and the plan to follow recommendations indicate it's not currently life-threatening. Additionally, since this is a routine update in a SOAP note intended for clinical use, it likely falls under moderate stakes without immediate high-risk decisions required.


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP

SUBJECTIVE: , This patient presents to the office today because he has not been feeling well.  He was in for a complete physical on 05/02/2008.  According to the chart, the patient gives a history of feeling bad for about two weeks.  At first he thought it was stress and anxiety and then he became worried it was something else.  He says he is having a lot of palpitations.  He gets a fluttering feeling in his chest.  He has been very tired over two weeks as well.  His job has been really getting to him.  He has been feeling nervous and anxious.  It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain.  These symptoms are not triggered by exertion.  He had similar symptoms about 9 or 10 years ago.  At that time he went through a full workup.  Everything ended up being negative and they gave him something that he took for his nerves and he says that helped.  Unfortunately, he does not remember what it was.  Also over the last three days he has had some intestinal problems.  He has had some intermittent nausea and his stools have been loose.  He has been having some really funny green color to his bowel movements.  There has been no blood in the stool.  He is not having any abdominal pain, just some nausea.  He does not have much of an appetite.  He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  There is no labored breathing.  Psychiatric:  He is alert and oriented times 3.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Eyes:  Pupils equal, round, and reactive to light bilaterally.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.,ASSESSMENT:  ,1.  Palpitations, possibly related to anxiety.,2.  Fatigue.,3.  Loose stools with some green color and also some nausea.  There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks.  He says his work is definitely contributing to some of his symptoms and he feels stressed.  He is leaving for a vacation very soon.  Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him.  My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis.  A 12-lead EKG was performed on him in the office today.  This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news.  I am going to send him to the lab from our office to get the following tests done:  Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray.  Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital.  We were able to squeeze him in.  His appointment is at 8:15 in the morning.  He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck.  I am not going to be here so he is going to see Dr. X.  Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ.  Certainly, if something comes up we may need to postpone his trip.  We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago.  In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety.  I talked about Ativan, how it works.  I talked about the side effects.  I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck.  I took him off of work today and tomorrow so he could rest.
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DESCRIPTION: Palpitations, possibly related to anxiety. Fatigue. Loose stools with some green color and also some nausea.

general medicine, palpitations, nausea, loose stools, fatigue, related to anxiety, stress test, anxiety,

The situation involves a patient experiencing palpitations potentially linked to anxiety, fatigue, and gastrointestinal issues which might require medical evaluation before he leaves for a trip. The presence of palpitations and chest pain can be concerning, but an EKG has already been performed with no significant changes noted. Immediate follow-up with stress testing has been arranged to rule out any serious cardiac issues before his travel. However, the patient's condition does not appear to be life-threatening at present, which reduces the stakes somewhat. Additionally, the stress-inducing work context and the plan to manage anxiety reduce immediate concerns. Therefore, while the situation requires prompt medical attention, it is not considered extremely high-stakes.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 10

CHIEF COMPLAINT:,  The patient is here for two-month followup.,HISTORY OF PRESENT ILLNESS:,  The patient is a 55-year-old Caucasian female.  She has hypertension.  She has had no difficulties with chest pain.  She has some shortness of breath only at walking up the stairs.  She has occasional lightheadedness only if she bends over then stands up quickly.  She has had no nausea, vomiting, or diarrhea.  She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year.  The patient is wanting to lose weight before her surgery.  She is concerned about possible coronary disease or stroke risk.  She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable.  She has had fairly normal lipid panel, last being checked on 11/26/2003.  Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129.  The patient is a nonsmoker.  Her fasting glucose in November 2003 was within normal limits at 94.  Her fasting insulin level was normal.  Repeat nonfasting glucose was 109 on 06/22/2004.  She does not have history of diabetes.  She does not exercise regularly and is not able to because of knee pain.  She also has had difficulties with low back pain.  X-ray of the low back did show a mild compression fracture of L1.  She has had no falls that would contribute to a compression fracture.  She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan.  She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.,CURRENT MEDICATIONS:,  Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n.,ALLERGIES:  ,Bactrim, which causes nausea and vomiting, and adhesive tape.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Depression.,3.  Myofascitis of the feet.,4.  Severe osteoarthritis of the knee.,5.  Removal of the melanoma from the right thigh in 1984.,6.  Breast biopsy in January of 1997, which was benign.,7.  History of Holter monitor showing ectopic beat.  Echocardiogram was normal.  These were in 1998.,8.  Compression fracture of L1, unknown cause.  She had had no injury.  Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting.,SOCIAL HISTORY:,  The patient is married.  She is a nonsmoker and nondrinker.,REVIEW OF SYSTEMS:,  As per the HPI.,PHYSICAL EXAMINATION:,General:  This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.,Vital signs:  Weight:  Refused.  Blood pressure:  148/82, on recheck by myself with a large cuff, it was 125/60.  Pulse:  64.  Respirations:  20.  Temperature:  96.3.,Neck:  Supple.  Carotids are silent.,Chest:  Clear to auscultation.,Cardiovascular:  Revealed a regular rate and rhythm without murmur, S3, or S4.,Extremities:  Revealed no edema.,Neurologic:  Grossly intact.,RADIOLOGY:  EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads.,ASSESSMENT:,1.  Hypertension, well controlled.,2.  Family history of cerebrovascular accident.,3.  Compression fracture of L1, mild.,4.  Osteoarthritis of the knee.,5.  Mildly abnormal chest x-ray.,PLAN:,1.  We will get a C-reactive protein cardiac.,2.  We discussed weight loss options.  I would recommend Weight Watchers or possibly having her see a dietician.  She will think about these options.  She is not able to exercise regularly right now because of knee pain.,3.  We would recommend a screening colonoscopy.  She states that we discussed this in the past and she canceled her appointment to have that done.  She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.,4.  We will start Fosamax 70 mg once weekly.  She is to take this in the morning on an empty stomach with full glass of water.  She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.,5.  I would like to see her back in one to two months.  At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing.  One would also consider preoperative beta-blocker for cardiac protection.
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DESCRIPTION: Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.

The situation involves a routine two-month follow-up for a 55-year-old female patient with several health concerns, including hypertension, osteoarthritis, and a compression fracture. The patient is planning an upcoming surgery for knee replacement, and there are discussions on weight loss and osteoporosis prevention. Though there's a consideration of her mildly abnormal EKG for preoperative cardiac testing, the issues being managed are typical for her age and appear to be stable. Therefore, while important for her management, the follow-up itself doesn't seem to involve immediate life-threatening concerns. Overall, this scenario seems to be low to moderate stakes since it involves chronic condition management and pre-operative planning rather than urgent or life-threatening interventions.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 8

SUBJECTIVE:,  The patient comes in today for a comprehensive evaluation.  She is well-known to me.  I have seen her in the past multiple times.,PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: , Noted and reviewed today.  They are on the health care flow sheet.  She has significant anxiety which has been under fair control recently.  She has a lot of stress associated with a son that has some challenges.  There is a family history of hypertension and strokes.,CURRENT MEDICATIONS:,  Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.,REVIEW OF SYSTEMS:,  Significant for occasional tiredness.  This is intermittent and currently not severe.  She is concerned about the possibly of glucose abnormalities such diabetes.  We will check a glucose, lipid profile and a Hemoccult test also and a mammogram.  Her review of systems is otherwise negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness.,BREAST EXAM:  No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Soft, nontender, bowel sounds normoactive.  No masses or organomegaly.,GU:  External genitalia without lesions.  BUS normal.  Vulva and vagina show just mild atrophy without any lesions.  Her cervix and uterus are within normal limits.  Ovaries are not really palpable.  No pelvic masses are appreciated.,RECTAL:  Negative.,BREASTS:  No significant abnormalities.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  Pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy.,ASSESSMENT:,  Generalized anxiety and hypertension, both under fair control.,PLAN:,  We will not make any changes in her medications.  I will have her check a lipid profile as mentioned, and I will call her with that.  Screening mammogram will be undertaken.  She declined a sigmoidoscopy at this time.  I look forward to seeing her back in a year and as needed.
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DESCRIPTION: Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.

The patient's anxiety and hypertension are under fair control, and there is no indication of immediate life-threatening conditions in the current examination. Although there is concern about glucose levels and potential diabetes, these issues will be addressed through routine testing. The overall evaluation shows stable health with no urgent or critical interventions required at this time. The absence of severe symptoms or immediate medical threats indicates this is not a high-stakes situation.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 9

SUBJECTIVE:,  The patient is well-known to me.  He comes in today for a comprehensive evaluation.  Really, again he borders on health crises with high blood pressure, diabetes, and obesity.  He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc.  He knows better and has been through some diabetes training.  In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004.  Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days.  He has had elevated blood pressure.  His other concerns include allergic symptoms.  He has had irritable bowel syndrome with some cramping.  He has had some rectal bleeding in recent days.  Also once he wakes up he has significant difficulty in getting back to sleep.  He has had no rectal pain, just the bleeding associated with that.,MEDICATIONS/ALLERGIES:,  As above.,PAST MEDICAL/SURGICAL HISTORY: , Reviewed and updated - see Health Summary Form for details.,FAMILY AND SOCIAL HISTORY:,  Reviewed and updated - see Health Summary Form for details.,REVIEW OF SYSTEMS:,  Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions:  None.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, well-developed, obese male who is in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness or breast enlargement.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Significantly obese without any discernible organomegaly.  GU:  Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.,RECTAL:  Smooth, nonenlarged prostate with just some irritation around the rectum itself.  No hemorrhoids are noted.,EXTREMITIES:  Some slow healing over the tibia.  Without clubbing, cyanosis, or edema.  Peripheral pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy noted.,BACK:  He has pain in his back in general.,ASSESSMENT/PLAN:,1.  Diabetes and hypertension, both under less than appropriate control.  In fact, we discussed increasing the Lantus.  He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control.  He knows what needs to be done with the absence of carbohydrates, and especially simple sugar.  He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile.  I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range.  He has allergic rhinitis for which Zyrtec can be used.,2.  He has irritable bowel syndrome.  We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened.  For the bleeding I would like to obtain a sigmoidoscopy.  It is bright red blood.,3.  For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene.  I will look forward to seeing him back in a month.  I will call him with the results of his lab.  His medications were made out.  We will use some Elocon cream for his seborrheic dermatitis of the face.  Zyrtec and Flonase for his allergic rhinitis.
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DESCRIPTION: Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.

The situation involves a patient with multiple chronic health conditions such as diabetes, hypertension, obesity, and irritable bowel syndrome. These conditions are critical as they require ongoing management and can lead to serious health complications if not properly controlled. The patient's decision to change his lifestyle to improve his health indicates a pivotal moment in care management. While the current situation isn't immediately life-threatening, it has significant long-term implications for the patient's health, thus making it reasonably high-stakes.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 42

HISTORY AND CLINICAL DATA:  ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues.  He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,He reports no clear-cut chest discomfort or difficulty with angina.  He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.,REVIEW OF SYSTEMS:,  General review of system is significant for difficulty with intermittent constipation, which has been problematic recently.  He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.,PAST MEDICAL HISTORY:,  Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,SOCIAL HISTORY: , Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,MEDICATIONS AT HOME:,  Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily.,ALLERGIES:  ,He has known history of allergy to clonidine, Medifast does fatigue.,DIAGNOSTIC AND LABORATORY DATA: , Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes.  Low voltage in the limb leads.,WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000.  Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179.  Low total protein 5.7.  Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200.,PHYSICAL EXAMINATION:  ,He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular.  JVD difficult to assess.  Normal carotids with obvious bruits.  Conjunctivae pink.  Oropharynx clear.  Mild kyphosis.  Diffusely depressed breath sounds halfway up both posterior lung fields.  No active wheezing.  Cardiac Exam:  Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base.  Abdomen:  Soft, nontender, protuberant, benign.  Extremities:  2+ bilateral pitting edema to the level of the knees.  Neuro Exam:  Appears alert, oriented x3.  Appropriate manner and affect, exceedingly hard of hearing.,OVERALL IMPRESSION:,  An 88-year-old white male with the following major medical issues:,1.  Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2.  Hypertension with suboptimal controlled currently.,3.  Diabetes.,4.  Prostate CA, status post radium seed implant.,5.  COPD, on metered-dose inhaler.,6.  CLL followed by Dr. Y.,7.  Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8.  Hearing loss, anxiety.,9.  Significant degenerative joint disease.,PLAN:,1.  Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2.  Strict I&O, Foley catheter has already been placed.,3.  Daily BMP.,4.  Two-dimensional echocardiogram to assess left ventricular systolic function.  Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event.  Further recommendations will be forthcoming pending his clinical course and hospital.
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DESCRIPTION: Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea.  Medifast does fatigue

The situation involves an elderly patient with multiple significant health issues, including congestive heart failure, COPD, diabetes, and cancer. The patient is experiencing acute symptoms of heart failure, which requires hospitalization and specialized care, making it a potentially life-threatening condition. Although the patient appears stable and not in acute distress at the moment, the nature of his medical problems and potential complications, like heart failure progressing or worsening, or new cardiac events, make this high-stakes.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 40

CHIEF COMPLAINT:, Altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. When asked why he came to the emergency room, the patient replies that it started about 2 PM yesterday. However, he is unable to tell me exactly what started at 2 PM yesterday. The patient's speech is clear, but he speaks nonsensically using words in combinations that don't make any sense. No other history of present illness is available.,PAST MEDICAL HISTORY:, Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia.,PAST SURGICAL HISTORY:, Unknown.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, The patient denies smoking and drinking.,MEDICATIONS:, Per the emergency room record, medications are Lotensin 20 mg daily, Toprol 50 mg daily, Plavix 75 mg daily and aspirin 81 mg daily.,ALLERGIES:, UNKNOWN.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature: 97.9. Pulse: 79. Respiratory rate: 20. Blood pressure: 117/84.,GENERAL: Well-developed, well-nourished male in no acute distress.,HEENT: Eyes: Pupils are equal, round and reactive. There is no scleral icterus. Ears, nose and throat: His oropharynx is moist. His hearing is normal.,NECK: No JVD. No thyromegaly.,CARDIOVASCULAR: Irregular rhythm. No lower extremity edema.,RESPIRATORY: Clear to auscultation bilaterally with normal effort.,ABDOMEN: Nontender. Nondistended. Bowel sounds are positive.,MUSCULOSKELETAL: There is no clubbing of the digits. The patient's strength is 5/5 throughout.,NEUROLOGICAL: Babinski's are downgoing bilaterally. Deep tendon reflexes are 2+ throughout.,LABORATORY DATA:, By report, head CT from the outlying facility was negative. An EKG showed atrial fibrillation with a rate of 75. There is no indication of any acute cardiac ischemia. A chest x-ray shows no acute pulmonary process, but does show cardiomegaly.,Labs are as follows: White count 9.4, hemoglobin 17.2, hematocrit 52.5, platelet count 219. PTT 24, PT 13, INR 0.96. Sodium 135, potassium 3.6, chloride 99, bicarb 27, BUN 13, creatinine 1.4, glucose 161, calcium 9, magnesium 1.9, total protein 7, albumin 3.7, AST 22, ALT 41, alkaline phosphatase 85, total bilirubin 0.7, total cholesterol 193. Cardiac isoenzymes are negative times one with a troponin of 0.09.,ASSESSMENT AND PLAN:,1. Probable stroke. The patient has an expressive aphasia. He does not have dysarthria, however. Also, his strength is not affected. I suspect that the patient has had strokes or TIAs in the past because he was taking aspirin and Plavix at home. Head CT is reportedly negative. I will ask our radiologist to re-read the head CT. I will also order MRI and MRA, carotid Doppler ultrasound and echocardiogram in addition to a fasting lipid profile. I will consult neurology to evaluate and continue his aspirin and Plavix.,2. Atrial fibrillation. The patient's rate is controlled currently. I will continue him on his amiodarone 200 mg twice daily and consult CHI to evaluate him.,3. Hypertension. I will continue his home medications and add clonidine as needed.,4. Hyperlipidemia. The patient takes no medications for this currently. I will check a fasting lipid profile.,5. Hyperglycemia. It is unknown whether the patient has a history of diabetes. His glucose is currently 171. I will start him on sliding scale insulin for now and monitor closely.,6. Renal insufficiency. It is also unknown whether the patient has a history of this and what his baseline creatinine might be. Currently he has only mild renal insufficiency. This does not appear to be prerenal. Will monitor for now.
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DESCRIPTION: Patient with a diagnosis of stroke.

Patient with a diagnosis of stroke.

The situation involves an elderly male patient with a probable stroke, altered mental status, and several comorbidities including atrial fibrillation, hypertension, hyperlipidemia, hyperglycemia, and renal insufficiency. Strokes can lead to significant morbidity or mortality if not promptly and adequately managed, especially considering the patient's history and ongoing symptoms such as expressive aphasia. The need for extensive diagnostic work, consultation with specialists, and management of multiple health concerns indicates a high-stakes situation within the medical context.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 4

CHIEF COMPLAINT:,  Jaw pain this morning.,BRIEF HISTORY OF PRESENT ILLNESS:,  This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease.  The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day.  Also, history of chronic diverticulitis with recent bouts.  The patient has been doing well, seen in my office at the end of December for complete physical examination.  I had ordered a stress test for him, then delayed due to a family illness.  However, denies any chest pain or chest tightness with exertion.  The patient was doing well.  He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand.  He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain.  He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event.  The patient's pain resolved.  He was given nitroglycerin in the emergency room drawing his blood pressure 67/32.  Blood pressure quickly came back to normal with the patient's reverse Trendelenburg.,FAMILY HISTORY: , Strongly positive for heart disease in his father.  He had a bypass at age 60.  Both parents are alive.  Both have dementia.  His father has history of coronary artery disease and multiple vascular strokes.  He is in his 80s.  His mother is 80, also with dementia.  The patient does not smoke or drink.,PAST MEDICAL HISTORY:,  Remarkable for tonsillectomies.,MEDICATIONS:,  Synthroid and Lipitor.,ALLERGIES:,  PENICILLIN AND BIAXIN.,REVIEW OF SYSTEMS:,  Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18.  He is afebrile.,GENERAL:  He is well-developed, well-nourished white male, in no acute distress.,HEENT:  Pupils equal, round, and reactive to light and accommodation.  Extraocular movements were intact.  Throat was clear.,NECK:  Supple.  There is no organomegaly or thyromegaly.  Carotids are +2 without bruits.,CHEST:  Lungs are clear to auscultation and percussion.,CV:  Without any murmurs or gallops.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.  Bowel sounds are active.  No tenderness.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Peripheral pulses 2+.,NEUROLOGICAL:  Intact.  Motor exam is 5/5.,LABORATORY STUDIES:,  EKG is within normal limits, good sinus rhythm.  His axis is somewhat leftward.  CBC and BMP were normal and cardiac enzymes were negative x1.,IMPRESSION:,1.  Jaw pain, sounds musculoskeletal.  We will rule out angina equivalent.,2.  Hypercholesterolemia.,3.  Hypothyroidism.,PLAN: , Lipitor and thyroid have been ordered.  His chest pain unit protocol for the stress thallium that will be done in the morning.  If test is negative, we will discharge home.  If positive, we will consult Cardiology.  The patient requests Dr. ABC.
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DESCRIPTION: Consultation for jaw pain.

Consultation for jaw pain.

The situation involves a 53-year-old male with jaw pain who was admitted to rule out myocardial infarction (MI) or coronary artery disease. Considering the potential for a cardiac event given the patient's history of hypercholesterolemia and a family history of heart disease, this scenario has significant potential health implications. However, the fact that the patient currently denies any chest pain and the initial cardiac tests were negative indicates a lower immediate risk. Nevertheless, the possibility of an underlying cardiac issue necessitates careful monitoring and further testing, which slightly elevates the stakes.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 33

MEDICAL PROBLEM LIST:,1.  Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.,2.  Dementia and depression.,3.  Hypertension.,4.  History of atrial fibrillation.  The patient has been in sinus rhythm as of late.  The patient is not anticoagulated due to fall risk.,5.  Glaucoma.,6.  Degenerative arthritis of her spine.,7.  GERD.,8.  Hypothyroidism.,9.  Chronic rhinitis (the patient declines nasal steroids).,10.  Urinary urge incontinence.,11.  Chronic constipation.,12.  Diabetes type II, 2006.,13.  Painful bunions on feet bilaterally.,CURRENT MEDICINES: , Aspirin 81 mg p.o. daily, Cymbalta 60 mg p.o. daily, Diovan 80 mg p.o. daily, felodipine 5 mg p.o. daily, omeprazole 20 mg daily, Toprol-XL 100 mg daily, Levoxyl 50 mcg daily, Lantus insulin 12 units subcutaneously h.s., simvastatin 10 mg p.o. daily, AyrGel to both nostrils twice daily, Senna S 2 tablets twice daily, Timoptic 1 drop both eyes twice daily, Tylenol 1000 mg 3 times daily, Xalatan 0.005% drops 1 drop both eyes at bedtime, and Tucks to rectum post BMs.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  ACE INHIBITOR MAY HAVE CAUSED A COUGH.,CODE STATUS:,  Do not resuscitate, healthcare proxy, palliative care orders in place.,DIET:,  No added salt, no concentrated sweets, thin liquids.,RESTRAINTS:,  None.  The patient has declined use of chair check and bed check.,INTERVAL HISTORY: , Overall, the patient has been doing reasonably well.  She is being treated for some hemorrhoids, which are not painful for her.  There has been a note that she is constipated.,Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188.  I see a couple in the 150s.  However, I also see one that is in the one teens and a couple in the 120s range.,She is not bothered by cough or rib pain.  These are complaints, which I often hear about.,Today, I reviewed Dr. Hudyncia's note from psychiatry.  Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year.,She is not having problems with breathing.  No neurologic complaints or troubles.  Pain is generally well managed just with Tylenol.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is pleasant and cooperative.  She is in no apparent distress.  Her lungs are clear to auscultation and percussion.  Heart sounds regular to me.  Abdomen:  Soft.  Extremities without any edema.  At the rectum, she has a couple of large hemorrhoids, which are not thrombosed and are not tender.,ASSESSMENT AND PLAN:,1.  Hypertension, good control, continue current.,2.  Depression, well treated on Cymbalta.  Continue.,3.  Other issues seem to be doing pretty well.  These include blood pressure, which is well controlled.  We will continue the medicines.  She is clinically euthyroid.  We check that occasionally.  Continue Tylenol.,4.  For the bowels, I will increase the intensity of regimen there.  I have a feeling she would not tolerate either the FiberCon tablets or Metamucil powder in a drink.  I will try her on annulose and see how she does with that.
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DESCRIPTION: Patient with hypertension, dementia, and depression.

This situation involves a patient with multiple chronic health conditions, including a history of strokes, dementia, depression, hypertension, atrial fibrillation, diabetes, and others. The patient has a 'Do Not Resuscitate' (DNR) order and is under palliative care. These factors indicate a complex and delicate healthcare situation where careful management and monitoring of various conditions are necessary to maintain quality of life. While the current status suggests that most conditions are well-managed, the presence of a DNR order and palliative care involvement suggest a high-stakes situation with significant implications for the patient's health and well-being.


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

Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 24

CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.,Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.,On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.,Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.,Past Medical History:, HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.,PAST SURGICAL HISTORY:, Excisional lymph node biopsy (9/03).,FAMILY HISTORY:, There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,SOCIAL HISTORY:, Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .,MEDICATION:, Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,ALLERGIES:, ,  Sulfa (rash).,REVIEW OF SYSTEMS:, The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.,Ht: 5'9" Wt: 159 lbs.,GEN: Well developed man in no apparent distress. Alert and Oriented X 3.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.,NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally.,CV: Regular rate and rhythm. No murmurs, gallops, rubs.,ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES:,C-spine/lumbosacral spine (11/30):  Within normal limits.,CXR (12/8):  Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.,CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,HOSPITAL COURSE:,  The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.
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DESCRIPTION: Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.

This case involves a patient with a complex medical history, including AIDS with a low CD4 count, making him highly vulnerable to opportunistic infections and other complications. The patient is experiencing severe headaches, neck pain, and back pain. His symptoms, combined with his recent medical history of a motor vehicle accident, his non-compliance with HAART, and the potential for serious conditions such as hydrocephalus (as suggested by the CT scans and elevated opening pressure from lumbar puncture), escalate the severity. These factors place this situation in a higher stakes category due to the potential for critical health implications such as meningitis, neurological complications, or other opportunistic infections.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 21

SUBJECTIVE:,  The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage.  She does take Zyrtec on a fairly regular basis.  Mom is having some allergy trouble herself right now.  She does not know her colors.  She knows some of her shapes.  She speaks in sentences.  She is not showing much interest in the potty.  She is in the 80th percentile for height and weight, and still over 95th percentile for head circumference.  Mom has no other concerns.,ALLERGIES:,  Eggs and peanuts.,OBJECTIVE:,General:  Alert, very talkative little girl.,HEENT:  TMs clear and mobile.  Eyes:  PERRL.  Fundi benign.  Pharynx clear.  Mouth moist.  Nasal mucosa is pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Clear.  No tachypnea, wheezing, rales or retractions.,Abdomen:  Soft and nontender without mass or organomegaly.,GU:  Normal female genitalia.  Tanner stage I.,Extremities:  No clubbing, cyanosis or edema.  Pulses 2+ and equal.,Hips:  Intact.,Neurological:  Normal.  DTRs are 2+.  Gait was normal.,Skin:  Warm and dry.  No rashes noted.,ASSESSMENT:,  Allergic rhinitis.  Otherwise healthy 2-year-old young lady.,PLAN:,  In addition to her Zyrtec, I put her on Nasonex spray one spray each nostril daily.  If this works for her, certainly she can do it through the ragweed season.  Otherwise she is doing well.  I talked about ways to improve her potty training.  She is a very good eater.  I will see her yearly or p.r.n.  Unfortunately she is not able to get the flu shot due to her egg allergy.
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DESCRIPTION: A 2-year-old little girl with stuffiness, congestion, and nasal drainage. - Allergic rhinitis

general medicine, allergic rhinitis, nasal drainage, stuffiness, congestion, drainage,

The situation involves a routine medical examination of a 2-year-old girl experiencing typical allergy symptoms that are being managed with medication. There are no indications of emergency or serious medical conditions. The case is well within the capabilities of general medical practice, and no immediate risks or severe health concerns are present. Furthermore, the patient is otherwise healthy and developing normally for her age.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 2

HISTORY OF PRESENT ILLNESS:, This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye.  He states that he was doing his normal job when he felt a foreign body sensation.  He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day.  He has no significant blurriness of vision or photophobia.
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DESCRIPTION: Initial clinic visit for foreign body in left eye.

The situation involves a foreign body in the eye, which is a common but potentially serious issue. While there is no blurriness or photophobia, the persistent and worsening pain suggests that the foreign body may cause further complications if not addressed promptly. Eye injuries can become high-stakes if they threaten vision, but based on the current information, the risk appears moderate. The stakes are higher due to the risk of vision damage, but not extremely high since there are no immediate symptoms of vision loss.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 19

SUBJECTIVE:,  This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.  The patient is in foster care, has a long history of the prematurity, born at 22 weeks.  She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic.  She is on 2-1/2 liters of oxygen and does require that.  Her diet has been fluctuating.  They have been trying to figure out what works best with her.  She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her.  They have been doing more pureed foods and that seems to loosen her up, so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure.  She was hospitalized a couple of weeks back for the distension she had in the abdomen.  Dr. XYZ has been working with her G-tube, increasing her Mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her G-tube site is looking.  She also has been seen Dr. Eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.,CURRENT MEDICATIONS:,  Flagyl, vitamins, Zyrtec, albuterol, and some Colace.,ALLERGIES TO MEDICINES: , None.,FAMILY SOCIAL HISTORY:,  As mentioned, she is in foster care.  Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient.  Biological Mom and Grandma do visit on Thursdays for about an hour.,REVIEW OF SYSTEMS:,  The patient has been eating fairly well, sleeping well, doing well with her sprints.  A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.,PHYSICAL EXAMINATION:,Vital Signs:  She is 28 pounds 8 ounces today, 33-1/2 inches tall.  She is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.,HEENT:  Sclerae and conjunctivae are clear.  TMs are clear.  Nares are patent.  Oropharynx is clear.  Trach site is clear of any signs of infection.,Chest:  Coarse.  She has got little bit of wheezing going on, but she is moving air fairly well.,Abdomen:  Positive bowel sounds and soft.  The G-tube site looks fairly clean today and healthy.  No signs of infection.  Her tone is good.  Capillary refill is less than three seconds.,ASSESSMENT:,  A 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.,PLAN:,  At this point is to continue with the Isomil and pureed baby foods, a little bit of Pediasure.  They are going to see Dr. XYZ towards the end of this month and follow up with Dr. Eisenbaum.  I would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand.  She is just doing wonderful progression on her development.  Each time I see her, I am very impressed, that relayed to foster mom.  Approximately 25 minutes spent with the patient, most of it counseling.
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DESCRIPTION: 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.

general medicine, chronic lung disease, signs of infection, breathing status, foster mom, foster care, pediasure

The case involves a 2-year-old patient with complex medical issues, including chronic lung disease and nutrition challenges due to prematurity. The medical team is frequently reassessing the patient's needs and adapting her care plan, indicating ongoing management of potentially fragile health. While there is no immediate acute crisis mentioned, the close monitoring required and the dependency on respiratory support make it a significantly involved situation. The stakes aren't life-threatening at this moment, but careful management is crucial to avoid deterioration in health.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 18

SUBJECTIVE:,  This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks.  Started off as a congestion but then he started coughing about a week ago.  Cough has gotten worsen.  Mother was also worried.  He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened.  He is not running any fevers.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Fairly healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  The sister is in today with clinical sinusitis.  Mother and father have been healthy.,REVIEW OF SYSTEMS:,  He has been congested for about three weeks ago.  Coughing now but no fevers.  No vomiting.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed male in no acute distress, afebrile.,Vital Signs:  Weight:  22 pounds 6 ounces.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular muscles are intact.  TMs are clear.  Nares are very congested.  Oropharynx has drainage in the back of the throat.  Mucous membranes are moist.  Mild erythema though.,Neck:  Some shotty lymphadenopathy.  Full range of motion.  Supple.,Chest:  Clear.  No crackles.  No wheezes.,Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  Clear.  Tone is good.  Capillary refill less than 3 seconds.,RADIOLOGY:,  Chest x-ray:  No foreign body noted as well.  No signs of pneumonia.,ASSESSMENT:,  Clinical sinusitis and secondary cough.,PLAN:,  Amoxicillin a teaspoon twice daily for 10 days.  Plenty of fluids.  Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving.
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DESCRIPTION: 1-year-old male who comes in with a cough and congestion.  Clinical sinusitis and secondary cough.

general medicine, congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis,

The situation involves a medical consultation for a 1-year-old child experiencing cough and congestion likely related to sinusitis. The mother expressed concern about a potential foreign body ingestion, but there is no evidence supporting this on the chest X-ray. The child is otherwise in no acute distress and afebrile, indicating stable health. The prescribed treatment is standard and non-emergent. Although the situation involves a very young child, which can increase concern, it is managed with routine care and does not indicate an immediate life-threatening condition.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 12

CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.
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DESCRIPTION: Feeling weak and shaky - Dyspnea on exertion and history of diabetes

The situation involves a 75-year-old patient with increasing symptoms of weakness and shortness of breath on exertion. She has multiple risk factors and a complex medical history, including heart disease, hypertension, type II diabetes, and a past pulmonary embolism, as well as a family history of coronary artery disease and heart failure. There is uncertainty about her medication regimen and past medical history. Given these factors, it's crucial to determine if there is an acute medical issue, such as coronary artery disease or unmanaged diabetes, that needs immediate attention. The patient's medical complexity and potential cardiovascular risks make this a moderately high-stakes situation.


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

REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain.  The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  The patient has had pain in the abdomen and across the back for the last four to five days.  The patient has some nausea and vomiting.  The patient wants something done for the stone.  The patient denies any hematuria, dysuria, burning or pain.  The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY:  ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000.  The patient's creatinine is 0.92.,ASSESSMENT:,1.  Left flank pain.,2.  Left ureteral stone.,3.  Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow.  Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  The patient has a pretty enlarged stone.  Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  The patient understood all the risk, benefits of the procedure and wanted to proceed.  Need for stent was also discussed with the patient.  The patient will be scheduled for surgery tomorrow.  Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.
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DESCRIPTION: Left flank pain, ureteral stone.

Left flank pain, ureteral stone.

general medicine, flank pain, ureteral stone, shockwave lithotripsy, shockwave, nausea, vomiting, lithotripsy, ureteral, stone,

The situation involves a 76-year-old female with a ureteral stone causing significant discomfort and requiring surgical intervention. While the procedure is generally considered routine and the patient is stable with no immediate life-threatening symptoms like fever or severe infection, her age and the size of the stone add complexity. The potential complications from the procedure and the potential need for additional interventions if this one is unsuccessful add a moderate level of stakes. However, it is not extremely high-stakes as the condition is being actively managed with a surgical plan in place.


Medical Specialty: General Medicine
Sample Name: Feeling Dizzy - ER Visit

REASON FOR CONSULTATION:,  This is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,PAST MEDICAL HISTORY: , Hypertension.  The patient noncompliant,HISTORY OF PRESENT COMPLAINT: , This 66-year-old patient has history of hypertension and has not taken medication for several months.  She is a smoker and she drinks alcohol regularly.  She drinks about 5 glasses of wine every day.  Last drink was yesterday evening.  This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room.  On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83.  The patient received 5 mg of metoprolol IV, after which heart rate was reduced to the 70 and blood pressure was well controlled.  On direct questioning, the patient said she had been drinking a lot.  She had not had any withdrawal before.  Today is the first time she has been close to withdrawal.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies chest pain.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria.  No hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems is not remarkable.,SOCIAL HISTORY:  ,The patient is a smoker and drinks alcohol daily in considerable amounts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a 66-year-old lady with telangiectasia of the face.  She is not anxious at this moment and had no tremors.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  Chest is tympanitic to percussion.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.  No clubbing.  No cyanosis.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,DIAGNOSTIC DATA: , EKG shows sinus tachycardia, no acute ST changes.,LABORATORY DATA: , White count is 6.3, hemoglobin is 12.4, hematocrit 38, and platelets 488,000.  Glucose is 124, BUN is 18, creatinine is 1.07, sodium is 146, and potassium is 3.4.  Liver enzymes are within normal limits.  TSH is normal.,ASSESSMENT AND PLAN:,1.  Uncontrolled hypertension.  We will start the patient on beta-blockers.  The patient is to see her primary physician within 1 week's time.,2.  Tachycardia, probable mild withdrawal to alcohol.  The patient is stable now.  We will discharge home with diazepam p.r.n.  The patient had been advised that she should not take alcohol if she takes the diazepam.,3.  Tobacco smoking disorder.  The patient has been counseled.  She is not contemplating quitting at this time.,DISPOSITION: , The patient is discharged home.,DISCHARGE MEDICATIONS:,1.  Atenolol 50 mg p.o. b.i.d.,2.  Diazepam 5 mg tablet 1 p.o. q.8h. p.r.n., total of 5 tablets.,3.  Thiamine 100 mg p.o. daily.
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DESCRIPTION: A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.

The situation involves a 66-year-old woman with uncontrolled hypertension and probable mild alcohol withdrawal, leading to tachycardia and dizziness. While she was stabilized in the ER and discharged with medication and instructions, this is a potentially dangerous combination of factors that, if not managed properly, could result in high-risk cardiovascular events. Additionally, her noncompliance with hypertension medication and significant alcohol consumption add complexity and potential for future crises. However, because she stabilized and was discharged with a clear management plan, the situation is not immediately life-threatening.


Medical Specialty: General Medicine
Sample Name: Female Exam & ROS

GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vitals:  Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  Bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Breasts:  Bilaterally symmetrical without tenderness, masses.  No axillary tenderness or masses.,Pelvic examination:  Revealed normal external genitalia.  Pap smear obtained without difficulty.  Bimanual examination revealed no pelvic tenderness or masses.  No uterine enlargement.  Rectal examination revealed normal sphincter tone, no rectal masses.  Stool is Hemoccult negative.
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DESCRIPTION: Sample female exam and review of systems.

general medicine, female exam, extremities, hemoccult, musculoskeletal, neurologic examination, pelvic examination, back pain, bone pain, chills, cough, cranial nerves ii through xii, fevers, heart rate, joint pain, paresis, paresthesias, polydipsia, regular rhythm, weight gain, wheezing, examination revealed, pelvic, rectal, heartburn, symmetrical, tenderness, indigestion, masses,

The description provided is a routine medical examination and review of systems for a female patient in a general medicine context. The examination findings are normal, with no significant medical concerns or symptoms reported. Routine check-ups and screening exams are typically low-stakes situations unless there are unusual findings or symptoms suggestive of a serious condition. The context here is a professional medical setting, but the examination itself does not suggest any immediate or serious concerns needing urgent attention.