Medical Specialty: Emergency Room Reports
Sample Name: Jaw Pain - ER Visit

CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS:  ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear.  Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began.  The patient denies any facial swelling.  No headache.  No swelling to the throat.  No sore throat.  No difficulty swallowing liquids or solids.  No neck pain.  No lymph node swelling.  The patient denies any fever or chills.  Denies any other problems or complaints.,REVIEW OF SYSTEMS:,  CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  HEENT:  No headache.  No neck pain.  No eye pain or vision change.  No rhinorrhea.  No sinus congestion, pressure, or pain.  No sore throat.  No throat swelling.  The patient does have the toothache on the left lower side that radiates towards his left ear as previously described.  The patient does not have ear pain or hearing change.  No pressure in the ear.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath.  GASTROINTESTINAL:  No nausea or vomiting.  No abdominal pain.  MUSCULOSKELETAL:  No back pain.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No speech change.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:,  None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana.  The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be healthy.  The patient is calm, comfortable in no acute distress, looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctivae bilaterally.  Nose, normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  Ears are normal without any sign of infection.  No erythema or swelling of the canals.  Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it.  MOUTH:  The patient has a dental fracture at tooth #18.  The patient states that the fracture is a couple of months old.  The patient does not have any obvious dental caries.  The gums are normal without any erythema, swelling, or evidence of infection.  There is no fluctuance or suggestion of abscess.  There is slight tenderness of the tooth #18.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion, or swelling.  Mucous membranes are moist.  Floor of the mouth is normal without any tenderness or swelling.  No suggestion of abscess.  There is no pre or post auricular lymphadenopathy either.  NECK:  Supple.  Nontender.  Full range of motion.  No meningismus.  No cervical lymphadenopathy.  No JVD.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to the back, arms, or legs.  The patient has normal use of the extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  No evidence of clinical intoxification.  HEMATOLOGIC/LYMPHATIC:  No lymphadenitis is palpated.,DIAGNOSES:,1.  ACUTE LEFT JAW PAIN.,2.  #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3.  ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation.  The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain.  The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain.  He was given precautions for drowsiness and driving with the use of this medication.  The patient was also given a prescription for pen V.  The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.
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DESCRIPTION: Patient started out having toothache, now radiating into his jaw and towards his left ear.  Ellis type II dental fracture.

emergency room reports, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,

The situation described doesn't indicate life-threatening symptoms such as chest pain, shortness of breath, or significant trauma. The patient's main issue is dental, involving a known tooth fracture, and the vital signs are relatively stable. While elevated blood pressure is noted, it is not at a critical level necessitating immediate intervention. The patient is discharged with clear follow-up instructions and pain management plan, indicating that the ER staff does not consider the condition to be urgent or life-threatening at this moment.


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

Medical Specialty: Emergency Room Reports
Sample Name: Penile Mass - Emergency Visit

CHIEF COMPLAINT: , "Bloody bump on penis.",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis.  The patient states that he has had a large bump on the end of his penis for approximately a year and a half.  He states that it has never bled before.  It has never caused him any pain or has never been itchy.  The patient states that he is sexually active, but has been monogamous with the same person for the past 13 years.  He states that he believes that his sexual partner is monogamous as well and reciprocates in this practice.  The patient does state that last night he was "trying to get some," meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis.  The patient said that there is a large amount of blood from this injury.  This happened last night, but he was embarrassed to come to the Emergency Department yesterday when it was bleeding.  The patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed.  The patient denies any drainage or discharge from his penis.  He denies fevers or chills recently.  He also denies nausea or vomiting.  The patient has not had any discharge from his penis.  He has not had any other skin lesions on his penis that are new to him.  He states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years.  The patient has never had these checked out.  He denies fevers, chills, or night sweats.  He denies unintentional weight gain or loss.  He denies any other bumps, rashes, or lesions throughout the skin on his body.,PAST MEDICAL HISTORY:  ,No significant medical problems.,PAST SURGICAL HISTORY: , Surgery for excision of a bullet after being shot in the back.,SOCIAL HABITS: , The patient denies illicit drug usage.  He occasionally smokes tobacco and drinks alcohol.,MEDICATIONS: , None.,ALLERGIES: , No known medical allergies.,PHYSICAL EXAMINATION:  ,GENERAL:  This is an African-American male who appears his stated age of 29 years.  He is well nourished, well developed, in no acute distress.  The patient is pleasant.  He is sitting on a Emergency Department gurney.,VITAL SIGNS:  Temperature 98.4 degrees Fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1, S2.  No murmur, rub, or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender, nondistended, and positive bowel sounds throughout.,GENITOURINARY:  The patient's external genitalia is markedly abnormal.  There is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus.  This pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter.  The patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well.  There are no open lesions at this point.  There is a small tear of the skin where the mass attaches to the glans near the urethral meatus.  Bleeding is currently stanch, and there is no sign of secondary infection at this time.  Bilateral testicles are descended and normal without pain or mass bilaterally.  There is no inguinal adenopathy.,EXTREMITIES:  No edema.,SKIN:  Warm, dry, and intact.  No rash or lesion.,DIAGNOSTIC STUDIES:  ,Non-emergency department courses.  It is thought that this patient should proceed directly with a referral to Urology for excision and biopsy of this mass.,ASSESSMENT AND PLAN: , Penile mass.  The patient does have a large pedunculated penile mass.  He will be referred to the urologist who is on-call today.  The patient will need this mass excised and biopsied.  The patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the ER.,
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DESCRIPTION: Patient presents to the Emergency Department with complaint of a bleeding bump on his penis.

emergency room reports, bump on penis, bleeding bump, glans, urethral meatus, penile mass, emergency department, penis, penile, pedunculated, bump, mass,

The situation involves a patient presenting at the emergency department with a bleeding mass on the penis, which has been present for a significant amount of time. Although the bleeding has stopped and there is no acute distress or signs of infection, the presence of a mass, especially on a sensitive area like the genitals, can be concerning due to potential underlying conditions such as infections or malignancies. The need for a urologist to evaluate and possibly perform a biopsy indicates the importance of ruling out serious issues. While the immediate situation isn't life-threatening, the potential for serious underlying causes makes it somewhat high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Emergency Room Reports
Sample Name: Itchy Rash - ER Visit

CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.
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DESCRIPTION: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.

emergency room reports, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash,

The situation in the emergency room report involves a patient with an acute allergic reaction presenting with an itchy rash. The case is handled in the emergency room, and while the symptoms were concerning, they did not involve respiratory distress at the moment of examination. The provided medical intervention was effective, and the patient was discharged with instructions on what to do if symptoms worsen. As such, while this required attention and care in an emergency setting, the present risk was mitigated, and the patient is now stable. Potential risks exist if the condition were to escalate into anaphylaxis, but the current situation is relatively stable.


Medical Specialty: Emergency Room Reports
Sample Name: Hydrocarbon Aspiration - ER Visit

SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested "tiki oil" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,
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DESCRIPTION: The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.

The situation involves a 20-year-old male with hydrocarbon aspiration leading to significant respiratory symptoms, including dyspnea, pleuritic chest pain, and hemoptysis. His vital signs and laboratory results show severe issues such as high white blood cell count indicating infection or inflammation, and his arterial blood gases suggest respiratory issues. The fact that he requires ICU monitoring indicates that the situation is critical and potentially life-threatening. Additionally, the patient's asplenic status due to prior splenectomy can increase his risk of severe infections. Hence, this is a high-stakes medical situation that requires immediate and intensive care.


Medical Specialty: Emergency Room Reports
Sample Name: High PT-INR - ER Visit

REASON FOR THE VISIT:,  Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.  She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again.  I gave her the Coumadin as an outpatient and then the INR was found to be 12.  So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1.  Congestive heart failure.,2.  Renal insufficiency.,3.  Coronary artery disease.,4.  Atrial fibrillation.,5.  COPD.,6.  Recent pneumonia.,7.  Bladder cancer.,8.  History of ruptured colon.,9.  Myocardial infarction.,10.  Hernia repair.,11.  Colon resection.,12.  Carpal tunnel repair.,13.  Knee surgery.,MEDICATIONS:,1.  Coumadin.,2.  Simvastatin.,3.  Nitrofurantoin.,4.  Celebrex.,5.  Digoxin.,6.  Levothyroxine.,7.  Vicodin.,8.  Triamterene and hydrochlorothiazide.,9.  Carvedilol.,SOCIAL HISTORY:  ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,ASSESSMENT:,1.  Atrial fibrillation.,2.  Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12.  I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week.  I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  She is prone to a fall and this would be a big problem.  We will use one aspirin a day instead of the anticoagulation.  She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand.  We will see her as an outpatient.
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DESCRIPTION: Very high PT-INR.  she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.

The situation describes an 81-year-old patient with a very high PT/INR due to Coumadin use, which poses a significant risk for bleeding complications. The patient has multiple comorbidities including congestive heart failure, atrial fibrillation, coronary artery disease, and a history of myocardial infarction, which heightens the complexity and risk of anticoagulation. The high INR and the decision to use vitamin K for reversal, as well as the shift from Coumadin to aspirin due to safety concerns, underscore the high-stakes nature due to the potential for life-threatening events such as bleeding or stroke.


Medical Specialty: Emergency Room Reports
Sample Name: Head Injury

CHIEF COMPLAINT:,  Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device.  She struck herself in the head with the flag.  There was no loss of consciousness.  She did feel dizzy.  She complained of a headache.  She was able to walk.  She continued to participate in her flag practice.  She got dizzier.  She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:,  DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home.  There is no smoking at home.  There is second-hand smoke exposure.,FAMILY HISTORY:  ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:,  She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS:  ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL:  She is supine awake, alert, cooperative, and active child.,HEENT:  Head atraumatic, normocephalic.  Pupils equal, round, reactive to light.  Extraocular motions intact and conjugate.  Clear TMs, nose and oropharynx.  Moist oral mucosa without noted lesions.,NECK:  Supple, full painless nontender range motion.,CHEST:  Clear to auscultation, equal, stable to palpation.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  No abdominal bruits are heard.,EXTREMITIES:  Equal femoral pulses are appreciated.  Equal radial and dorsalis pedis pulses are appreciated.  He moves all extremities without difficulty.  Nontender.  No deformity.  No swelling.,SKIN:  There was no significant bruising, lesions or rash about her abdomen.  No significant bruising, lesions or rash.,NEUROLOGIC:  Symmetric face and extremity motion.  Ambulates without difficulty.  She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:,  The differential entertained includes head injury, anxiety, and hypertensive emergency.  She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s.  Her laboratory data shows a mildly elevated creatinine of 1.3.  Urine is within normal.  Urinalysis showing no signs of infection.  Head CT read by staff has no significant intracranial pathology.  No mass shift, bleed or fracture per Dr. X.  A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90.  No significant ST-T wave changes.  No significant change from previous 09/2007 EKG.  Her headache has resolved.  She is feeling better.  I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home.  Follow up with her regular doctor.  Blood pressures have normalized for her.  She should return to emergency department on concern.  They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.
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DESCRIPTION: Head injury, anxiety, and hypertensive emergency.

This situation involves a 16-year-old patient presenting with a head injury after an accident during band practice, accompanied by dizziness and episodes of diplopia. Despite being initially serious enough to warrant an ambulance transport, her symptoms have largely resolved and significant problems have been ruled out with a head CT showing no intracranial pathology, and her vital signs returning to baseline. The main concerns are the head injury and her hypertensive state, which are being managed with a plan for follow-up rather than immediate critical intervention. While head injuries can be serious, in this case, the lack of ongoing symptoms and significant findings reduces the immediate stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Gastrointestinal Bleed - ER Visit

ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS:  ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  She states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  She noticed it was very dark and smelly.  She said she felt okay.  She got up.  She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools.  She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued.  She came to place her call, etc.  She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday.  She denies any nausea except for when she got weak.  She denies any vomiting or any other symptoms.,ALLERGIES:  ,She has no known drug allergies.,CURRENT MEDICATIONS:,1.  Lipitor, dose unknown.,2.  Paxil, dose unknown.,3.  Lasix, dose unknown.,4.  Toprol, dose unknown.,5.  Diphenhydramine p.r.n.,6.  Ibuprofen p.r.n.,7.  Daypro p.r.n.,PAST MEDICAL HISTORY:,1.  Non-insulin diabetes mellitus.,2.  History of congestive heart failure.,3.  History of hypertension.,4.  Depression.,5.  Arthritis.  She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6.  Hyperlipidemia.,7.  Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:,  She is a nonsmoker.  She occasionally has a drink every few weeks.  She is divorced.  She has 2 sons.  She is houseparent at Southern University.,REVIEW OF SYSTEMS:  ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE:  ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Currently was stable.  She is afebrile.,GENERAL:  She is alert, pleasant in no acute distress.  She does complain of some dizziness when she stands up.,HEENT:  Pupils equal, round and reactive to light.  Extraocular muscles intact.  Sclerae clear.  Oropharynx is clear.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR:  She is slightly tachycardic but otherwise normal.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.  She has no hepatomegaly.,EXTREMITIES:  No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:,  Her initial chem panel was within normal limits.  Her PT and PTT were normal.  Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  She is currently administered transfusion.  Platelet count was 125.  Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7.  PT and PTT were normal.  Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1.  Gastrointestinal bleed.
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DESCRIPTION: Gastrointestinal Bleed.  An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell.  She woke yesterday morning had a very dark and smelly bowel movement.

The situation involves an 81-year-old patient with a gastrointestinal bleed, which is a potentially life-threatening condition, especially considering the patient's advanced age and medical history, including ulcer disease and congestive heart failure. The dropping hematocrit and the need for a blood transfusion signify significant blood loss. These factors contribute to the high-stakes nature of the case since immediate medical intervention is crucial to prevent further deterioration and stabilize the patient.


Medical Specialty: Emergency Room Reports
Sample Name: Fall - ER Visit

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

The situation involves an 88-year-old patient with multiple significant injuries resulting from a fall: a proximal humerus fracture and a nondisplaced hip fracture. The patient has a complex medical history, including coronary artery disease and COPD, and is on medication (Plavix) that complicates surgical interventions. Additionally, she requires cardiology clearance for surgery, indicating the complexity and potential risks involved. These factors classify it as a high-stakes medical scenario due to the patient's age, medical history, and the nature of the injuries, which could have life-altering consequences if not managed properly.


Medical Specialty: Emergency Room Reports
Sample Name: Difficulty Breathing - ER Visit

HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.
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DESCRIPTION: The patient is 14 months old, comes in with a chief complaint of difficulty breathing.

The situation involves a 14-month-old child experiencing difficulty breathing and hypoxia, which are critical conditions requiring immediate medical attention. Considering the child's young age and the previous failure to respond adequately to outpatient treatment, the stakes are high. Timely intervention is crucial to prevent potential deterioration in the child's health. The decision to admit the child for continuous monitoring and treatment underscores the seriousness of the situation.


Medical Specialty: Emergency Room Reports
Sample Name: Dental Pain

CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.
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DESCRIPTION: This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.

emergency room reports, dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental,

The situation involves a 27-year-old female with dental pain and swelling, diagnosed as an acute dental abscess. While painful and potentially concerning if an abscess worsens or leads to systemic infection, the patient is stable, has received initial treatment, and is discharged in stable condition with a plan for outpatient follow-up. This is not considered a high-stakes emergency situation as her vital signs are stable, and there's no evidence of systemic infection at this time.


Medical Specialty: Emergency Room Reports
Sample Name: ER Report - Chest Pain

CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:, The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:, None. ,CURRENT MEDICATIONS:, Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:, The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: ,The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: ,The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: ,FINAL DIAGNOSIS: ,1. Evaluation of chest pain. ,2. Possible esophageal reflux.
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DESCRIPTION: Patient complains of chest pain - possible esophageal reflux

This situation is relatively high-stakes due to the patient's history of multiple myocardial infarctions and the presence of chest pain, a symptom often associated with cardiac issues. Despite the patient's current stable condition and normal test results, chest pain in someone with his medical history requires careful consideration and follow-up to rule out any potential cardiac events. Moreover, the potential misattribution of chest pain to esophageal reflux when a cardiac issue might exist can have serious consequences. Therefore, the stakes are elevated due to these factors.


Medical Specialty: Emergency Room Reports
Sample Name: ER Report - Rib Cage Pain

HISTORY:,  The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today.  He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had "rib cage pain" for the last few days.  He denies any history of trauma.  He does have increased pain with laughing.  Per the patient, he also claims to have an elevated temperature yesterday of 101.  Apparently, the patient did go to the emergency room at ABCD yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to Children's.,PAST MEDICAL HISTORY: , The patient has a medical history significant for "Staphylococcus infection" that was being treated with antibiotics for 10 days.,CURRENT MEDICATIONS: , He states that he is currently taking no medications.,ALLERGIES:  ,He is not allergic to any medication.,PAST SURGICAL HISTORY: , He denies any past surgical history.,SOCIAL HISTORY: , The patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago.  He also has a history of marijuana used approximately 1 year ago.  He currently states that he is in a rehab program.,FAMILY HISTORY:,  Unknown by the patient.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,GENERAL:  He is alert and appeared to be in no acute distress.  He had normal hydration.,HEENT:  His pupils were equal, round, reactive.  Extraocular muscles intact.  He had no erythema or exudate noted in his posterior oropharynx.,NECK:  Supple with full range of motion.  No lymphadenopathy noted.,RESPIRATORY:  He had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,CARDIOVASCULAR:  Regular rate and rhythm.  Positive S1, S2.  No murmurs, rubs, or gallops noted.,GI:  Nontender, nondistended with normoactive bowel sounds.  No masses noted.,SKIN:  Appeared normal except on the left anterior tibial area where the patient had a healing skin lesion.  There were no vesicles, erythema or induration noted.,MUSCULOSKELETAL:  Nontender with normal range of motion.,NEURO/PSYCHE:  The patient was alert and oriented x3 with nonfocal neurological exam.,ASSESSMENT: , This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,PLAN: , Due to the fact that this patient is an adult male, we will transfer him to XYZ Medical Center for further evaluation.  I have spoken with XYZ Medical Center Dr. X who has accepted the patient for transfer.  He was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress.  Dr. X was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork.  The plan was explained in detail to the patient who stated that he understood and would comply.  The appropriate paperwork was created and one copy was given to the patient.,CONDITION ON DISCHARGE: , At the time of discharge, he was stable, vital signs stable, in no acute distress.
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DESCRIPTION: This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.

The situation involves a young adult with rib cage pain, a minor persistent fever, and no signs of acute distress according to the physical exam. Although not immediately life-threatening, the pain and fever from an unknown source and the patient's recent visit to the ER warrant further investigation. However, the patient's stable condition suggests this is a moderate-stakes situation needing outpatient follow-up, rather than emergency intervention. The transfer to another medical center in a private vehicle rather than ambulance further suggests lower urgency.


Medical Specialty: Emergency Room Reports
Sample Name: Consult - ICU Management

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

The described case involves a critically ill patient in the Intensive Care Unit (ICU) with life-threatening conditions such as mesenteric ischemia, septic shock, acute renal insufficiency, adrenal insufficiency, and a hypercoagulable syndrome. The patient requires continuous monitoring, aggressive management, and possible reoperation. Given the immediate risk to the patient's life and the complexity of their care, this is an extremely high-stakes situation.


Medical Specialty: Emergency Room Reports
Sample Name: Consult/ER Report - OB/GYN

The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,
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DESCRIPTION: A female with unknown gestational age who presents to the ED after a suicide attempt.

The situation involves a potential pregnancy with an unknown gestational age following a suspected miscarriage and a suicide attempt. This is high-stakes due to the immediate concern for the patient's mental health and potential risks to the fetus if the pregnancy is ongoing. Immediate and careful management is required to ensure the safety and health of both the patient and the potential pregnancy.


Medical Specialty: Emergency Room Reports
Sample Name: Chest Tube Insertion in ER

PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.
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DESCRIPTION: Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.

emergency room reports, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,

The situation involves an emergency medical procedure to address a life-threatening condition—spontaneous pneumothorax, respiratory failure, and pneumonia with sepsis. These conditions are critical and require immediate intervention to prevent worsening of the patient's state or potential death. The mention of 'informed consent not obtained' further emphasizes the urgency, and the procedure was conducted under emergency consent due to the patient's condition. In an ER setting, this represents a high-stakes scenario due to the immediate risk to the patient's life.


Medical Specialty: Emergency Room Reports
Sample Name: Cut on Foot - ER Visit

CHIEF COMPLAINT:,  Cut on foot.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old male who had a piece of glass fall on to his right foot today.  The patient was concerned because of the amount of bleeding that occurred with it.  The bleeding has been stopped and the patient does not have any pain.  The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort.  The patient denies any injuries to any other portion of his body.  He has not had any recent illness.  The patient has no other problems or complaints.,PAST MEDICAL HISTORY:,  Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16.  Oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well-nourished, well-developed, the patient appears to be healthy.  The patient is calm and comfortable in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear conjunctiva and cornea bilaterally.  NECK:  Supple with full range of motion.  CARDIOVASCULAR:  Peripheral pulse is +2 to the right foot.  Capillary refills less than two seconds to all the digits of the right foot.  RESPIRATIONS:  No shortness of breath.  MUSCULOSKELETAL:  The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot.  There is no palpable foreign body, no foreign body is visualized.  There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels.  It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home.  The patient does not have any tenderness to the foot.  The patient has full range of motion to all the joints, all the toes, as well as the ankles.  The patient ambulates well without any difficulty or discomfort.  There are no other injuries noted to the rest of the body.  SKIN:  The 4-mm partial thickness laceration to the right foot as previously described.  No other injuries are noted.  NEUROLOGIC:  Motor is 5/5 to all the muscle groups of the right lower extremity.  Sensory is intact to light touch to all the dermatomes of the right foot.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No active bleeding is occurring at this time.  No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:,  The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1.  A 4-MM LACERATION TO THE RIGHT FOOT.,2.  ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  To home.  The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection.  The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.
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DESCRIPTION: Patient had a piece of glass fall on to his right foot.  A 4-mm laceration.  Acute foot pain, now resolved.   The patient was given discharge instructions on wound care.

emergency room reports, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body,

The situation presented involves a 32-year-old male who sustained a laceration on his right foot from a piece of glass without any immediate complications or severe pain. The cut resulted in initial bleeding, which has been controlled, and the patient is experiencing no pain or impairment in function. While there remains a minor risk of infection or the presence of a small piece of retained glass, the patient was sufficiently stable to be discharged with instructions for at-home care. The patient's condition does not appear life-threatening or in need of urgent intervention. Therefore, it is considered a low-stakes medical situation.


Medical Specialty: Emergency Room Reports
Sample Name: Altered Mental Status - ER Visit

CHIEF COMPLAINT: , Altered mental status.,HISTORY OF PRESENT ILLNESS: , This is a 6-year-old white male, who was sent from the Emergency Room with the diagnosis of intracranial bleeding.  The patient was found by the 8-year-old sister in the bathroom.  He was laying down on one side, and he was crying and moaning.  The sibling went and told the parents.  The parents rushed to the bathroom, they found him crying, and he was not moving the left side of his body.  He was initially alert, but his alertness diminished.  They decided to take him to the emergency room in Hospital, where a CT was done on his head, which showed a 4 x 4 x 2.5 cm bleed.  The emergency physician called our emergency room, and I decided to involve Neurosurgery, Mr. X, the physician assistant, who is on call for the Neurosurgery Services.  Collectively, they have made arrangements with the ICU attendings to have the child transported to our emergency room.  For a small stop, I am obtaining an MRI and then admitting to the ICU.  History was taken from the parents.  He had a history of gastroesophageal reflux disease, otherwise, a healthy child.,MEDICATIONS: , None.,ALLERGIES:,  No known drug allergies.,PAST SURGICAL HISTORY: , He had only tympanostomy tubes placed.,FAMILY MEDICAL HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  He was brought by our transport team.  While en route, he was not as alert as he was.  He was still oriented.  He had to be stimulated via sternal rub to wake up, and saturation went down to the 80s, and he was started on nasal cannula, and code 3 was initiated, and he was rushed to our emergency room.  When I saw him, he was lethargic, but arousable.  He could recognize where he was, and he could recognize also his parents well.,HEENT:  Pupils are 4 mm reactive to direct and indirect light.  No signs of trauma is seen on the head.  Throat is clear.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft.,NEUROLOGIC:  He has left-sided weakness, but his cranial nerves II through XII are grossly intact.,EMERGENCY DEPARTMENT COURSE: , In the emergency room, at the time when I saw him, Dr. Y and Dr. Z were from the ICU and Anesthesia Services arrived also, and they evaluated the patient with me and pretty much they took care of the patient.  They decided to give him a dose of IV mannitol.  I ordered his labs, type and cross.  CBC is 15.6 white blood cell count, hemoglobin 12.8.  PT/PTT were ordered due to the bleed, which was seen intracerebrally.  They were 13.1 and 24.5 respectively.  Blood gas, I-STAT pH 7.36, pCO2 is 51.  This was a venous specimen.  The ICU attendings decided to do a rapid sequence intubation.  This was done in our emergency room by Dr. Y and Dr. Z.  The patient was sent to the MRI, and from where he was going to be admitted to the ICU in critical condition.,DIFFERENTIAL DIAGNOSES: , Arteriovenous malformation, stroke, traumatic injury.,IMPRESSION: , Intracerebral hemorrhage of uncertain etiology to be determined while inpatient.,TIME SPENT:,  I spent 30 minutes critical care time with the patient excluding any procedures.,
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DESCRIPTION: A 6-year-old was laying down on one side, and he was crying and moaning, sent from the Emergency Room with the diagnosis of intracranial bleeding.

emergency room reports, arteriovenous malformation, stroke, traumatic injury, intracerebral hemorrhage, altered mental status, crying and moaning, mental status, intracranial bleeding, icu attendings, emergency, intracranial, neurosurgery, gastroesophageal, intracerebrally, bleeding, icu,

The situation involves a 6-year-old child with altered mental status due to intracranial bleeding, which is considered a medical emergency. This condition required an evaluation by both emergency room and neurosurgery specialists, rapid intubation, and immediate transfer to the ICU in critical condition. The child's life is potentially at risk, as intracranial hemorrhages can lead to significant morbidity or mortality if not promptly addressed. Therefore, the stakes are very high due to the potential for severe outcomes and the need for immediate and coordinated medical intervention.


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

Medical Specialty: Emergency Room Reports
Sample Name: Agitation - ER Visit

HISTORY OF PRESENT ILLNESS:  This is a 91-year-old female who was brought in by family.  Apparently, she was complaining that she felt she might have been poisoned at her care facility.  The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now.  The patient apparently had a little bit of dry heaves, but no actual vomiting.  She had just finished eating dinner.  No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries.  She has a pacemaker.  She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS:  Very difficult to get from the patient herself.  She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her.  She initially stated that everything was wrong, but could not specify any specific complaints.  Denies chest pain, back pain, or abdominal pain.  Denies any extremity symptoms or complaints.,SOCIAL HISTORY:  The patient is a nonsmoker.  She is accompanied here with daughter who brought her over here.  They were visiting the patient when this episode occurred.,MEDICATIONS:  Please see list.,ALLERGIES:  NONE.,PHYSICAL EXAMINATION:  VITAL SIGNS:  The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air.  GENERAL:  The patient is an elderly frail looking little lady lying on the gurney.  She is awake, alert, and not really wanted to answer most of the questions I asked her.  She does have a tremor with her mouth, which the daughter states has been there for "many years".  HEENT:  Eye exam is unremarkable.  Oral mucosa is still moist and well hydrated.  Posterior pharynx is clear.  NECK:  Supple.  LUNGS:  Actually clear with good breath sounds.  There are no wheezes, no rales, or rhonchi.  Good air movement.  CARDIAC:  Without murmur.  ABDOMEN:  Soft.  I do not elicit any tenderness.  There is no abdominal distention.  Bowel sounds are present in all quadrants.  SKIN:  Skin is without rash or petechiae.  There is no cyanosis.  EXTREMITIES:  No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE:  I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly.  After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better.  Family states she seems more calm.  They do not want to pursue any further workup at this time.,IMPRESSION:  ACUTE EPISODE OF AGITATION.,PLAN:  At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode.  The patient herself has good vital signs.  She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient.  Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC.  She is discharged in stable condition.
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DESCRIPTION: Acute episode of agitation.  She was complaining that she felt she might have been poisoned at her care facility.

emergency room reports, acute episode of agitation, agitation,

This situation involves a 91-year-old patient experiencing an acute episode of agitation and concerns about possible poisoning. While the family's report suggests a non-critical perspective and the patient responds well to a small dose of medication, the elderly age of the patient and the mention of possible poisoning initially elevate the stakes, as these can be serious issues. However, medical evaluation and family decision led to a stable discharge with no immediate concerns, suggesting the stakes are not very high at this moment.


Medical Specialty: Discharge Summary
Sample Name: Urology Discharge Summary

PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.  Physical examination revealed normal heart and lungs.  Abdomen was negative for abnormal findings.  ,LABORATORY DATA:, BUN 19 and creatinine 1.1.  Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1.  Discharge  hemoglobin 11.4, and hematocrit 33.3.  Chest x-ray calcified old granulomatous disease, otherwise normal.  EKG was normal.  ,COURSE IN THE HOSPITAL:, The patient had a cysto and TUR of the prostate.  Postoperative course was uncomplicated. The pathology report is pending at the time of dictation.  He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet.  ,DISCHARGE DIAGNOSIS: , Enlarged prostate with benign bladder neck obstruction.  ,To be followed in my office in one week and by Dr. ABC next available as an outpatient.
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DESCRIPTION: Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction.

discharge summary, tur, bun, cystourethroscopy, difficulty voiding, bladder neck obstruction, creatinine, cysto, enlarged prostate, transurethral resection of prostate, urinary stream, bladder neck, neck obstruction, prostate

The situation described in the discharge summary involves the routine management of a common urological condition (enlarged prostate and bladder neck obstruction). The patient underwent a standard procedure (cystourethroscopy and transurethral resection of the prostate), experienced no complications, and is being discharged in satisfactory condition. Given these factors, the scenario is not high-stakes since it indicates a typical postoperative recovery without significant complications or life-threatening issues. The follow-up care is routine, with monitoring by specialists. The stakes are relatively low in the context of medical assessments as it does not involve immediate life-threatening conditions or complex post-operative challenges.


Medical Specialty: Discharge Summary
Sample Name: Speech Therapy - Discharge Summary - 1

HISTORY: , The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.  At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3.6/100 based on the Western Aphasia Battery.  Since the initial evaluation, the patient has attended 60 outpatient speech therapy sessions, which have focussed on her receptive communication, expressive language, multimodality communication skills, and swallowing function and safety.,SHORT-TERM GOALS:,1.  The patient met 3 out of 4 original short-term therapy goals, which were to complete a modified barium swallow study, which she did do and which revealed no aspiration.  At this time, the patient is eating and drinking and taking all medications by mouth; however, her G-tube is still present.  The patient was instructed to talk to the primary care physician about removal of her feeding tube.,2.  The patient will increase accuracy of yes-no responses to greater than 80% accuracy.  She did accomplish this goal.  The patient is also able to identify named objects with greater than 80% accuracy.,ADDITIONAL GOALS: , Following the completion of these goals, additional goals were established.  Based on reevaluation, the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90% accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80% accuracy independently.  The patient continues to have difficulty stating verbally, yes or no, to questions as well as accurately using head gestures and to respond to yes-no questions.  The patient continues to have marked difficulty with her expressive language abilities.  She is able to write simple words to help express her basic wants and needs.  She has made great strides; however, with her receptive communication, she is able to read words as well as short phrases and able to point to named objects and answer simple-to-moderate complex yes-no questions.  A reevaluation completed on 12/01/08, revealed an aphasia quotient of 26.4.  Once again, she made significant improvement and comprehension, but continues to have unintelligible speech.  An alternative communication device was discussed with the patient and her husband, but at this time, the patient does not want to utilize a communication device.  If, in the future, the patient continues to struggle with her expressive communication, an alternative augmented communication device would be a benefit to her.  Please reconsult at that time if and when the patient is ready to use a speech generating device.  The patient is discharged from my services at this time due to a plateau in her progress.  Numerous home activities were recommended to allow her to continue to make progress at home.
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DESCRIPTION: The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.

discharge summary, communication skills, g-tube, aphasia, language evaluation, western aphasia battery, skilled speech therapy, swallowing function, speech therapy, therapy, swallowing, aspiration, speech, communication,

The situation involves a patient's discharge from speech therapy, where significant progress has been made, yet some communication challenges persist. While communication and aspiration risks can be critical, the patient has shown improvement and is discharged due to plateaued progress. The stakes primarily involve the patient's quality of life and communication abilities, not immediate life-threatening conditions. The risk is moderate but not urgent or life-threatening, as there are long-term solutions and plans, like considering an augmentative communication device if needed.