Medical Specialty: Autopsy
Sample Name: Autopsy - 4

FINAL DIAGNOSIS: ,I. Ligature strangulation.,A. Circumferential ligature with associated ligature furrow of neck.,B. Abrasions and petechial hemorrhages, neck.,C. Petechial hemorrhages, conjunctival surfaces of eyes and skin of face.,II. Craniocerebral injuries.,A. Scalp contusion.,B. Linear, comminuted fracture of right side of skull.,C. Linear pattern of contusions of right cerebral hemisphere.,D. subarachnoid and subdural hemorrhage.,E. Small contusions, tips of temporal lobes.,III. Abrasion of right cheek.,IV. Abrasion/contusion, posterior right shoulder.,V. Abrasions of left lower back and posterior left lower leg.,VI. Abrasion and vancular congestion of vaginal mucosa.,VII. Ligature of right wrist.,TOXICOLOGIC STUDIES ,Blood ethanol - none detected.,Blood drug screen - no drugs detected.,CLINOCOPATHOLIGICAL CORRELATION:, Cause of death of this six year old female is asphyxia by strangulation associated with craniocerebral trauma. ,The body of this six year old female was first seen by me after I was called to an address XYZ, on 12/26/96. I arrived at the scene approximately 8 PM on 12/26 and entered the house where the decedent's body was located at approximately 8:20 PM. ,A brief examination of the body disclosed a ligature around the neck and a ligature around the right wrist. Also noted was a small area of abrasion or contusion below the right ear on the lateral aspect of the right cheek. A prominent dried abrasion was present on the lower left neck. After examining the body, I left the residence at approximately 8:30 PM. ,EXTERNAL EVIDENCE OF INJURY:, Located just below the right ear at the right angle of the mandible, 1.5 inches below the right external auditory canal is a 3/8 x 1/4 inch area of rust colored abrasion. In the lateral aspect of the left lower eyelid on the inner conjunctival surface is a 1 mm in maximum dimension petechial hemorrhage. Very fine, less than 1 mm petechial hemorrhages are present on the skin of the upper eyelids bilaterally as well as on the lateral left cheek. On everything the left upper eyelid there are much smaller, less than 1 mm petechial hemorrhages located on the conjunctival surface. Possible petechial hemorrhages are also seen on the conjunctival surfaces of the right upper and lower eyelids, but liver mortis on this side of the face makes definite identification difficult. ,A deep ligature furrow encircles the entire neck. The width of the furrow varies from one- eight of an inch to five/sixteenths of an inch and is horizontal in orientation, with little upward deviation. The skin of the anterior neck above and below the ligature furrow contains areas of petechial hemorrhage and abrasion encompassing an area measuring approximately 3 x 2 inches. The ligature furrow crosses the anterior midline of the neck just below the laryngeal prominence, approximately at the level of the cricoid cartilage. It is almost completely horizontal with slight upward deviation from the horizontal towards the back of the neck. The midline of the furrow mark on the anterior neck is 8 inches below the top of the head. The midline of the furrow mark on the posterior neck is 6.75 inches below the top of the head. ,The area of abrasion and petechial hemorrhage of the skin of the anterior neck includes on the lower left neck, just to the left of the midline, a roughly triangular, parchment-like rust colored abrasion which measures 1.5 inches in length with a maximum width of 0.75 inches. This roughly triangular shaped abrasion is obliquely oriented with the apex superior and lateral. The remainder of the abrasions and petechial hemorrhages of the skin above and below the anterior projection of the ligature furrow are nonpatterned, purple to rust colored, and present in the midline, right, and left areas of the anterior neck. The skin just above the ligature furrow along the right side of the neck contains petechial hemorrhage composed of multiple confluent very small petechial hemorrhages as well as several larger petechial hemorrhages measuring up to one-sixteenth and one-eight of an inch in maximum dimension. Similar smaller petechial hemorrhages are present on the skin below the ligature furrow on the left lateral aspect of the neck. Located on the right side of the chin is a three-sixteenths by one-eight of an inch area of superficial abrasion. On the posterior aspect of the right shoulder is a poorly demarcated, very superficial focus of abrasion/contusion which is pale purple in color and measures up to three-quarters by one-half inch in maximum dimension. Several linear aggregates of petechial hemorrhages are present in the anterior left shoulder just above deltopectoral groove. These measure up to one inch in length by one-sixteenth to one-eight of an inch in width. On the left lateral aspect of the lower back, approximately sixteen and one-quarter inches and seventeen and one-half inches below the level of the top of the head are two dried rust colored to slightly purple abrasions. The more superior of the two measures one-eight by one-sixteenth of an inch and the more inferior measures three-sixteenths by one-eight of an inch. There is no surrounding contusion identified. On the posterior aspect of the left lower leg, almost in the midline, approximately 4 inches above the level of the heel are two small scratch-like abrasions which are dried and rust colored. They measure one-sixteenth by less than one- sixteenth of an inch and one-eight by less than one-sixteenth of an inch respectively. ,On the anterior aspect of the perineum, along the edges of closure of the labia majora, is a small amount of dried blood. A similar small amount of dried and semifluid blood is present on the skin of the fourchette and in the vestibule. Inside the vestibule of the vagina and along the distal vaginal wall is reddish hyperemia. This hyperemia is circumferential and perhaps more noticeable on the right side and posteriorly. The hyperemia also appears to extend just inside the vaginal orifice. A 1 cm red-purple area of abrasion is located on the right posterolateral area of the 1 x 1 cm hymeneal orifice. The hymen itself is represented by a rim of mucosal tissue extending clockwise between the 2 and 10:00 positions. The area of abrasion is present at approximately the 7:00 position and appears to involve the hymen and distal right lateral vaginal wall and possibly the area anterior to the hymen. On the right labia majora is a very faint area of violent discoloration measuring approximately one inch by three-eighths of an inch. Incision into the underlying subcutaneous tissue discloses no hemorrhage. A minimal amount of semiliquid thin watery red fluid is present in the vaginal vault. No recent or remote anal or other perineal trauma is identified. ,REMAINDER OF EXTERNAL EXAMINATION:, The unembalmed, well developed and well nourished Caucasian female body measures 47 inches in length and weighs an estimated 45 pounds. ,No scalp trauma is identified. The external auditory canals are patent and free of blood. The eyes are green and the pupils equally dilated. The sclerae are white. The nostrils are both patent and contain a small amount of tan mucous material. The teeth are native and in good repair. The tongue is smooth, pink-tan and granular. No buccal mucosal trauma is seen. The frenulum is intact. There is slight drying artifact of the tip of the tongue. On the right cheek is a pattern of dried saliva and mucous material which does not appear to be hemorrhagic. The neck contains no palpable adenopathy or masses and the trachea and larynx are midline. The chest is symmetrical. Breasts are prepubescent. The abdomen is flat and contains no scars. No palpable organomegaly or masses are identified. The external genitalia are that of a prepubescent female. No pubic hair is present. The anus is patent. Examination of the extremities is unremarkable. ,The fingernails of both hands are of sufficient length for clipping. Examination of the back is unremarkable. There is dorsal 3+ to 4+ livor mortis which is nonblanching. Livor mortis is also present on the right side of the face. At the time of the initiation of the autopsy there is mild 1 to 2+ rigor mortis of the elbows and shoulders with more advanced 2 to 3+ rigor mortis of the joints of the lower extremities. ,INTERNAL EXAM:, The anterior chest musculature is well developed. No sternal or rib fractures are identified. ,MEDIASTINUM: ,The mediastinal contents are normally distributed. The 21 gm thymus gland has a normal external appearance. The cut sections are finely lobular and pink-tan. No petechial hemorrhages are seen. The aorta and remainder of the mediastinal structures are unremarkable. ,BODY CAVITIES: ,The right and left thoracic cavities contain approximately 5 cc of straw colored fluid. The pleural surfaces are smooth and glistening. The pericardial sac contains 3-4 cc of straw colored fluid and the epicardium and pericardium are unremarkable. The abdominal contents are normally distributed and covered by a smooth glistening serosa. No intra-abdominal accumulation of fluid or blood is seen. ,LUNGS: ,The 200 gm right lung and 175 gm let lung have a normal lobar configuration. An occasional scattered subpleural petechial hemorrhage is seen on the surface of each lung. The cut sections of the lungs disclose an intact alveolar architecture with a small amount of watery fluid exuding from the cut surfaces with mild pressure. The intrapulmonary bronchi and vasculature are unremarkable. No evidence of consolidation is seen. ,HEART: ,The 100 gm heart has a normal external configuration. There are scattered subepicardial petechial hemorrhages over the anterior surface of the heart. The coronary arteries are normal in their distribution and contain no evidence of atherosclerosis. The tan- pink myocardium is homogeneous and contains no areas of fibrosis or infarction. The endocardium is unremarkable. The valve cusps are thin, delicate and pliable and contain no vegetation or thrombosis. The major vessels enter and leave the heart in the normal fashion. The foramen ovale is closed. ,AORTA AND VENA CAVA: ,The aorta is patent throughout its course as are its major branches. No atherosclerosis is seen. The Vena Cava is unremarkable. ,SPLEEN: ,The 61 gm spleen has a finely wrinkled purple capsule. Cut sections are homogeneous and disclose readily identifiable red and white pulp. No intrinsic abnormalities are identified. ,ADRENALS: ,The adrenal glands are of normal size and shape. A golden yellow cortex surmounts a thin brown-tan medullary area. No intrinsic abnormalities are identified.
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DESCRIPTION: Autopsy - Ligature strangulation and craniocerebral injuries.

The situation involves the autopsy of a six-year-old female victim who suffered a violent death by ligature strangulation accompanied by craniocerebral injuries. This case likely relates to a criminal investigation, given the details of asphyxia and trauma. The high-stakes nature arises from the need for precise forensic analysis to determine the circumstances of the death, which can have significant legal implications, including potential homicide charges. The sensitivity is heightened by the victim's age and the nature of the injuries.


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

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

consult - history and phy., allergic rhinitis, nasal drainage, stuffiness, congestion, drainage,

The situation involves a routine pediatric consultation for allergic rhinitis, which is commonly seen in young children. The child's symptoms are being managed with medication, and there are no immediate life-threatening conditions described. Though her allergy to eggs prevents her from receiving the flu shot, this does not significantly elevate the stakes in terms of immediate health risks. The primary issues are managing her current mild symptoms and allergies, which the proposed treatment plan addresses. As such, the situation does not involve any critical or urgent medical concerns.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 10

PREOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal fusion.,5.  Two previous C-sections.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,POSTOPERATIVE DIAGNOSES:,1.  36th and 4/7th week, intrauterine growth rate.,2.  Charcot-Marie-Tooth disease.,3.  Previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  Previous spinal effusion.,5.  Two previous C-section.  The patient refuses trial labor.  The patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6.  Adhesions of bladder.,7.  Poor fascia quality.,8.  Delivery of a viable female neonate.,PROCEDURE PERFORMED:,1.  A repeat low transverse cervical cesarean section.,2.  Lysis of adhesions.,3.  Dissection of the bladder of the anterior abdominal wall and away from the fascia.,4.  The patient also underwent a bilateral tubal occlusion via Hulka clips.,COMPLICATIONS: , None.,BLOOD LOSS:,  600 cc.,HISTORY AND INDICATIONS:  ,Indigo Carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus.  The uterus appeared to be intact.  This patient is a 26-year-old Caucasian female.  The patient is well known to the OB/GYN clinic.  The patient had two previous C-sections.  She appears to be in probably early labor.  She had an amniocentesis early today.  She is contracting regularly about every three minutes.  The contractions are painful and getting much more so since the amniocentesis.  The patient had fetal lung maturity noted.  The patient also has probable IUGR as none of her babies have been over 4 lb.  The patient's baby appears to be somewhat small.  The patient suffers from Charcot-Marie-Tooth disease, which has left her wheelchair bound.  The patient has had a spinal fusion, however, family planning is definitely complete per the patient.  The patient refuses trial labor.  The patient and I discussed the consent.  She understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery.  Her questions were answered.  The patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy.  The patient understands this and would like to try our best.,PROCEDURE:  ,The patient was taken back to the operative suite.  She was given general anesthetic by Department of Anesthesiology.  Once again, in layman's terms, the patient understands the risks.  The patient had the informed consent reviewed and understood.  The patient has had a Pfannenstiel incision, which was slightly bent towards the right side favoring the right side.  The patient had the first knife went through this incision.  The second knife was used to go to the level of fascia.  The fascia was very thin, ruddy in appearance, and with abundant scar tissue.  The fascia was incised.  Following this, we were able to see the peritoneum.  There was really no obvious rectus abdominal muscles noted.  They were very weak, atrophic, and thin.  The patient has the peritoneum tented up.  We entered the abdominal cavity.  The bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia.  The bladder flap was then entered into the uterus as well.  There are some bladder adhesions.  We removed these adhesions and we removed the bladder of the fascia.  We dissected the bladder of the lower segment.  We made a small nick on the lower segment.  We were able to utilize the blunt end of the knife to enter into the uterine cavity.  The baby was in occiput transverse position with the ear being cocked at such a position as well.  The patient's baby was delivered without difficulty.  It was a 4 lb and 10 oz baby girl who vigorously cried well.  There was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection.  The patient's placenta was delivered.  There was no retained placenta.  The uterine incision was closed with two layers of #0 Vicryl, the second layer imbricating over the first.  The patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized.  Then we ligated this as there was bleeding and oozing.  The patient had the Indigo Carmine instilled into the bladder with some saline about 300 cc.  The 400 cc was instilled.  The bladder appears to be intact.  The bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment.  There was some oozing around the area of the bladder.  We placed an Avitene there.  The two Hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx.  The patient has two clips on each side.  There was excellent tubal occlusion and placement.  The uterus was placed back into the abdominal cavity.  We rechecked again.  The tubal placement was excellent.  It did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx.  The patient then underwent further examination.  Hemostasis appeared to be good.  The fascia was reapproximated with short running intervals of #0 Vicryl across the fascia.  We took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible.  The Scarpa's fascia was reapproximated with #0 gut.  The skin was reapproximated then as well via subcutaneous closure.  The patient's sponge and needle counts found to be correct.  Uterus appeared to be normal prior to closure.  Bladder appeared to be normal.  The patient's blood loss is 600 cc.
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DESCRIPTION: A repeat low transverse cervical cesarean section, Lysis of adhesions, Dissection of the bladder of the anterior abdominal wall and away from the fascia, and the patient also underwent a bilateral tubal occlusion via Hulka clips.

surgery, intrauterine growth rate, charcot-marie-tooth disease, amniocentesis, c-sections, trial labor, low transverse cervical cesarean section, lysis of adhesions, dissection, bladder, abdominal wall, fascia, hulka clips, bilateral tubal occlusion, intrauterine, transverse, uterus, abdominal,

The situation involves a surgical procedure for a patient with a complex medical history including previous C-sections, Charcot-Marie-Tooth disease, and spinal fusion. The surgery itself involves multiple procedures including a repeat C-section, bladder dissection, and tubal occlusion. The presence of conditions like Charcot-Marie-Tooth disease, past surgeries, and current active labor increase the complexity and potential risk of complications. Although the procedure completed successfully without immediate complications, the stakes remain high due to the potential for future complications and the irreversible nature of some aspects of the surgery, such as the tubal occlusion with intention for sterilization. There is also inherent high-stakes involvement given that this is an obstetric procedure where both maternal and fetal health are critical considerations.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mayoview - 1

MYOVIEW NUCLEAR STRESS STUDY,REASON FOR THE TEST:,  Angina, coronary artery disease.,FINDINGS: , The patient exercised according to the Lexiscan nuclear stress study, received a total of 0.4 mg of Lexiscan.  At peak hyperemic effect, 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview injected for the resting and the usual SPECT and gated SPECT protocol was followed in the rest-stress sequence.,The data analyzed using Cedars-Sinai software.,The resting heart rate was 49 with the resting blood pressure of 149/86.  Maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,EKG at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted T-wave in 1, 2, and aVL as well as from V4 to V6 with LVH.  Maximal stress test EKG showed no change from baseline.,IMPRESSION:  ,Maximal Lexiscan stress test with abnormal EKG at baseline maximal stress test, please refer to the Myoview interpretation.,MYOVIEW INTERPRETATIONS,FINDINGS: , The left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced LV function with akinesis of the inferior and inferoseptal wall.  EF was calculated at 32%, estimated 35% to 40%.,Cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall.  Both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical MI.  No reversible defects indicative of myocardium at risk.  The lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,IMPRESSION:,1.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.,2.  No reversible ischemia identified.,3.  Moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.
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DESCRIPTION: Myoview nuclear stress study.  Angina, coronary artery disease.  Large fixed defect, inferior and apical wall, related to old myocardial infarction.

cardiovascular / pulmonary, myoview, myoview interpretations, spect, gated spect protocol, myoview nuclear stress study, nuclear stress study, stress study, stress test, stress, lexiscan, ekg, inferoapical, angina, wall, resting,

The Myoview nuclear stress study reveals several critical findings, such as a large fixed defect related to an old myocardial infarction, moderately reduced left ventricular function, and an abnormal EKG. These findings suggest the patient has significant cardiovascular issues that can heavily impact their health if not managed properly. The potential for worsening heart conditions or sudden cardiac events further heightens the stakes of the situation, impacting medical decision-making and patient outcomes.


Medical Specialty: Neurology
Sample Name: Craniotomy - Occipital

PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:,  Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:,  Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:,  The patient was placed in the prone position after general endotracheal anesthesia was administered.  The scalp was prepped and draped in the usual fashion.  The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  The bone flap was elevated.  The ultrasound was then used.  The ultrasound showed the tumors directly I believe are in the interhemispheric fissure.  We noticed that the dura was quite tense despite that the patient had slight hyperventilation.  We gave 4 ounce of mannitol, the brain became more pulsatile.  We then used the stealth to perform a ventriculostomy.  Once this was done, the brain began to pulsate nicely.  We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus.  After having done this we then used operating microscope and slight self-retaining retraction was used.  We obtained access to the tumor.  We biopsied this and submitted it.  This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total.  After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates.  The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  The next step was to close the wound after reapproximating the bone flap.  The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  The sterile dressings were applied to the scalp.  The patient returned to the recovery room in satisfactory condition.  Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.
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DESCRIPTION: Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.

neurology, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain,

The procedure described is a complex neurosurgical operation involving the removal of brain tumors. Such surgeries carry significant risks, including potential complications like infection, bleeding, and neurological deficits. The stakes are further heightened by the patient's condition, which involves multiple brain tumors and metastasis from breast cancer, indicating a serious and life-threatening medical situation. The operation's success is critical for the patient's immediate well-being and long-term health outcomes. Therefore, the situation is high-stakes both medically and personally for the patient.


Medical Specialty: Orthopedic
Sample Name: Dorsal Extensor Compartment Release

PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:,  Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , Bier block.,TOURNIQUET TIME: , 30 minutes.,COMPLICATIONS: , None.,INDICATIONS:  ,The above patient is a 47-year-old right hand dominant black female who has signs and symptomology of de Quervain's stenosing tenosynovitis.  She was treated conservatively with steroid injections, splinting, and nonsteroidal anti-inflammatory agents without relief.  She is presenting today for release of the first dorsal extensor compartment.  She is aware of the risks, benefits, alternatives and has consented to this operation.,PROCEDURE: , The patient was given intravenous prophylactic antibiotics.  She was taken to the operating suite under the auspices of Anesthesiology.  She was given a left upper extremity bier block.  Her left upper extremity was then prepped and draped in the normal fashion with Betadine solution.  Afterwards, a transverse incision was made over the extensor retinaculum of the first dorsal extensor compartment.  Dissection was carried down through the dermis into the subcutaneous tissue.  The dorsal radial sensory branches were kept out of harm's way.  They were retracted gently to the ulnar side of the wrist.  The retinaculum was incised with a #15 scalpel blade in the longitudinal fashion and the retinaculum was released completely both proximally and distally.  Both the extensor pollices brevis and abductor pollices longus tendons were identified.  There was no pathology noted within the first dorsal extensor compartment.  The wound was irrigated.  Hemostasis was obtained with bipolar cautery.  The wound was infiltrated with _0.25% Marcaine solution and then closure performed with #6-0 nylon suture utilizing a horizontal mattress stitch.  Sterile occlusive dressing was applied along with the thumb spica splint.  The tourniquet was released and the patient was transported to the recovery area in stable and satisfactory condition.
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DESCRIPTION: Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.  Release of first dorsal extensor compartment.

orthopedic, dorsal extensor compartment, de quervain tendonitis, dorsal, extensor, quervain, tendonitis, retinaculum, tenosynovitis, tourniquet,

The procedure described is a surgical intervention aimed at relieving symptoms of de Quervain's stenosing tenosynovitis. While any surgical procedure holds some intrinsic risk, this particular operation is commonly performed and usually not considered as high-risk or high-stakes. There are no reported complications in this case, and the patient was transported to recovery in stable condition. The condition treated, while uncomfortable and impairing, is not life-threatening, making the overall stakes relatively low.


Medical Specialty: Radiology
Sample Name: Three Views - Ankle

EXAM: , Three views of the right ankle.,INDICATIONS:  ,Pain.,FINDINGS: , Three views of the right ankle are obtained.  There is no evidence of fractures or dislocations.  No significant degenerative changes or destructive osseous lesions of the ankle are noted.  There is a small plantar calcaneal spur.  There is no significant surrounding soft tissue swelling.,IMPRESSION:  ,Negative right ankle.
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DESCRIPTION: Pain.  Three views of the right ankle.  Three views of the right ankle are obtained.

radiology, three views, calcaneal, plantar, spur, osseous, ankle

The provided medical scenario involves interpreting radiology results for an ankle examination. The findings indicate there are no fractures, dislocations, or significant degenerative changes, and the overall impression is a negative right ankle. While the presence of a small calcaneal spur is noted, such findings are relatively common and typically not emergency situations. The primary concern expressed is pain, which, without further abnormalities, suggests this is a low-stakes situation focused on routine diagnostic assessment rather than an immediate or life-threatening condition.


Medical Specialty: Consult - History and Phy.
Sample Name: Iliopsoas Hematoma - 2

CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.
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DESCRIPTION: Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.

consult - history and phy., cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac,

The situation described involves a patient who experienced a life-threatening cardiac event, requiring advanced emergency interventions including defibrillation and cardiac catheterization. Complications included renal and liver failure, and the patient eventually required the implantation of an internal cardiac defibrillator. There are also issues with neurological function due to anoxic injury and permanent weakness in the right lower extremity due to iliopsoas hematoma and severe axonal degeneration. These medical scenarios indicate a high-stakes situation as they involve life-preserving measures, complex care management, and significant long-term health implications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Cath & Coronary Angiography

PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.  It was accompanied by diaphoresis and shortness of breath.  The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain.  He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5.  Stress images revealed left ventricular dilatations suggestive of multivessel disease.  He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing.  The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed.  The right inguinal area was sterilely cleansed with a Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin.  The needle was removed and a pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed and the sheath was flushed.  A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis.  The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter.  The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views.  This catheter was removed.  The sheath was flushed the final time.  The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,  This vessel is seen to be heavily calcified throughout its course.  Begins as a moderate caliber vessel.  There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  This vessel is heavily calcified in its proximal portion.  It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex.  There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches.  There is sequential 80% and 90% stenosis in the mid-portion of the vessel.  Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY:  ,This vessel is also calcified in its proximal portion.  There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery.  There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system.  There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1.  Three-vessel coronary artery disease as described above.,2.  Moderate mitral regurgitation per TEE.,3.  Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4.  Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.
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DESCRIPTION: Left heart catheterization and bilateral selective coronary angiography.   The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.

cardiovascular / pulmonary, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire,

The situation involves a 65-year-old patient with significant cardiac concerns, including severe coronary artery disease detected through heart catheterization and angiography. The findings indicate a three-vessel coronary artery disease with high-grade stenosis in important coronary arteries, suggesting a high risk of serious cardiac events such as a heart attack. Additionally, the patient presents with moderate mitral regurgitation and other complicating medical history. The proposed plan involves significant interventions like coronary artery bypass grafting (CABG) and potentially mitral valve surgery to address these issues. These procedures are complex and carry significant risks, making this situation high-stakes given the potential impact on the patient's health and survival.


Medical Specialty: Discharge Summary
Sample Name: Laryngitis - Discharge

DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY:  ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene.  The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions.  The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,SHORT-TERM GOALS:,1.  To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2.  He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3.  We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4.  To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation.  However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1.  The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2.  The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.
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DESCRIPTION: Chronic laryngitis, hoarseness.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.

discharge summary, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis

This situation involves the discharge summary of a patient with chronic laryngitis who has successfully completed speech therapy and achieved the goals of returning to normal vocal function. While important for the patient's ongoing health and quality of life, this situation does not carry significant immediate risks or life-threatening consequences that would classify it as high-stakes. The patient has been discharged with a home program to maintain their progress, indicating resolution and low complexity of the current issue.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cineangiography

PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Cineangiography of SVG to OM.,4.  Cineangiography of LIMA to LAD.,5.  Left ventriculogram.,6.  Aortogram.,7.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,NARRATIVE:,  After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac catheterization suite.  The right groin was prepped in the usual sterile fashion.  Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta.  Next, Judkins left catheter was used to engage the left coronary system.  Cineangiography was recorded in multiple views.  Next, Judkins right catheter was used to engage the right coronary system.  Cineangiography was recorded in multiple views.  Next, the Judkins right catheter was used to engage the SVG to OM.  Cineangiography was recorded.  Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views.  Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressures were measured.  LV gram was done and a pullback gradient across the aortic valve was done and recorded.  Next, an aortogram was done and recorded.  At this point, I decided to proceed with percutaneous intervention of the left circumflex.  Therefore, AVA 3.5 guide was used to engage the left coronary artery.  Angiomax bolus and drip was started.  Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres.  Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent.  Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion.  We next attempted a cutting balloon.  Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire.  Again, we were unable to cross the lesion with the stent.  We then try to cross with a noncompliant balloon, which we were unsuccessful.  We also try to cutting balloon again, we were unsuccessful.  Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted.  Final images showed no evidence of dissection, perforation, or further complication.  The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results.  The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,DIAGNOSTIC FINDINGS,1.  The LV.  LVEDP was 4.  LVES is approximately 50%-55% with inferobasal hypokinesis.  No significant MR. No gradient across the aortic valve.,2.  Aortogram.  The ascending aorta shows no significant dilatation or evidence of dissection.  The valve shows no significant aortic insufficiencies.  The abdominal aorta and distal aorta shows significant tortuosities.,3.  The left main.  The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.,4.  Left circumflex.  The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch.  The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis.  The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5.  LAD.  The LAD is a totally 100% occluded vessel.  The LIMA to LAD is patent with only a small-to-moderate caliber LAD.  There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%.  The diagonal shows proximal 80% stenosis.,6.  The right coronary artery:  The right coronary artery is 100% occluded.  There are retrograde collaterals from left to right to the distal PDA and PLV branches.  The SVG to OM is 100% occluded at its take off.  The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7.  LIMA to LAD is widely patent.,ASSESSMENT AND PLAN: , Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon.  Final images showed some improvement, however, continued residual stenosis.  At this point, the patient will be transferred back to telemetry floor and monitored.  We can attempt future intervention or continue aggressive medical management.  The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch.  Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.
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DESCRIPTION: Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD.  Left ventriculogram and aortogram.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.

cardiovascular / pulmonary, coronary system cineangiography, svg to om, lima to lad, ventriculogram, aortogram, percutaneous intervention, circumflex, obtuse marginal branch, balloon angioplasty, coronary artery, balloon, cineangiography, lad,

The case involves complex cardiovascular procedures, including multiple cineangiographies and an attempted percutaneous intervention of a heavily stenosed left circumflex artery. The fact that the stent could not be passed and the procedure had to be aborted suggests critical artery blockage, affecting the heart’s function. Given these circumstances, the high potential risk for the patient, and continuous monitoring requirements, it indicates a high-stakes medical scenario. The need for future intervention or aggressive medical management further indicates the significance of the case.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 6

SUBJECTIVE:,  This 3-year-old male is brought by his mother with concerns about his eating.  He has become a very particular eater, and not eating very much in general.  However, her primary concern was he was vomiting sometimes after particular foods.  They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit.  After this occurred several times, they stopped giving him carrots.  Last week, he ate some celery and the same thing happened.  They had not given him any of that since.  He eats other foods without any apparent pain or vomiting.  Bowel movements are normal.  He does have a history of reactive airway disease, intermittently.  He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:,  He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight:  31.5 pounds, which is an increase of 2.5 pounds since May.  Temperature is 97.1.  He certainly appears in no distress.  He is quite interested in looking at his books.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Cardiac:  Regular rate and rhythm without murmurs.,Abdomen:  Soft without organomegaly, masses, or tenderness.,ASSESSMENT:,  Report of vomiting and abdominal pain after eating raw carrots and celery.  Etiology of this is unknown.,PLAN:,  I talked with mother about this.  Certainly, it does not suggest any kind of an allergic reaction, nor obstruction.  At this time, they will simply avoid those foods.  In the future, they may certainly try those again and see how he tolerates those.  I did encourage a wide variety of fruits and vegetables in his diet as a general principle.  If worsening symptoms, she is welcome to contact me again for reevaluation.
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DESCRIPTION: A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.

soap / chart / progress notes, eating, foods, vomiting, reactive airway disease, raw carrots, carrots,

The case involves a 3-year-old boy experiencing vomiting and abdominal pain after consuming specific foods such as raw carrots and celery. While concerning, the symptoms are limited to these foods, and there is no indication of a severe allergic reaction or obstruction. The child is otherwise healthy with normal bowel movements and has gained weight. The plan is to avoid these foods and monitor symptoms, which suggests a cautious but not urgent approach. The stakes are relatively low as long-term effects or immediate severe health risks seem unlikely based on the current information.


Medical Specialty: Radiology
Sample Name: MRI Brain - Memory Loss

FINDINGS:,There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant).,There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.,Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain.,There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended.,There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis.,There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.,Normal flow within the carotid arteries and circle of Willis.,Normal calvarium, central skull base and temporal bones.  There is no demonstrated calvarium metastases.,IMPRESSION:,Severe generalized cerebral atrophy.,Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended.,Remote lacunar infarction in the right cerebellar hemisphere.,Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.,No demonstrated calvarial metastases.
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DESCRIPTION: A middle-aged female with memory loss.

A middle-aged female with memory loss.

radiology, white matter ischemic, remote lacunar infarction, memory loss, matter ischemic, remote lacunar, cerebellar hemisphere, lacunar infarction, brachium pontis, white matter, basilar, calvarium, ischemic, enhancement, cerebellar, hemispheres, hyperintensity, infarction, brachium,

The findings from the MRI and impression indicate severe generalized cerebral atrophy and extensive chronic white matter ischemic changes. These findings are concerning and could explain the memory loss in the middle-aged female patient. The possibility of a round morphology lesion raises further concern, and a reassessment is recommended, which adds to the seriousness of the situation. While there is no immediate life-threatening condition like calvarial metastases, the neurologic implications are significant and warrant further investigation and management. Therefore, given the potential implications for the patient's brain health and cognitive function, this situation is considered high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Limbic Encephalitis

CC:, Rapidly progressive amnesia.,HX: ,This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally. There was no mass affect. The areas mildly enhanced with gadolinium.,PMH:, 1) CAD; MI x 2 (1978 and 1979). 2) PVD; s/p aortic endarterectomy (3/1991). 3)HTN. 4)Bilateral inguinal hernia repair.,FHX/SHX:, Mother died of a stroke at age 58. Father had CAD and HTN. The patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. He had been a feed salesman all of his adult life.,ROS:, Unremarkable. No history of cancer.,EXAM:, BP 136/75 HR 73 RR12 T36.6,MS: Alert but disoriented to person, place, time. He could not remember his birthdate, and continually asked the interviewer what year it was. He could not remember when he married, retired, or his grandchildren's names. He scored 18/30 on the Follutein's MMSE with severe deficits in orientation and memory. He had moderate difficulty naming. He repeated normally and had no constructional apraxia. Judgement remained good.,CN: unremarkable.,Motor: Full strength throughout with normal muscle tone and bulk.,Sensory: Intact to LT/PP/PROP,Coordination: unremarkable.,Station: No pronator drift, truncal ataxia or Romberg sign.,Gait: unremarkable.,Reflexes: 3+ throughout with downgoing plantar responses bilaterally.,Gen Exam: unremarkable.,STUDIES:, MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor. EEG was normal awake and asleep. Antineuronal antibody screening was unremarkable. CSF studies were unremarkable and included varicella zoster, herpes zoster, HIV and HTLV testing, and cytology. The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes, but no organism or etiology was concluded. TFT, B12, VDRL, ESR, CRP, ANA, SPEP and Folate studies were unremarkable. Neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,IMPRESSION:, Limbic encephalitis secondary to cancer of unknown origin.,He was last seen 7/26/96. MMSE 20/30 and category fluency 20 . Disinhibited affect. Mild right grasp reflex. The clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .
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DESCRIPTION: Patient with a 1-year history of progressive anterograde amnesia

consult - history and phy., mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory,

The case involves a patient with severe memory impairments due to limbic encephalitis, a condition that can be associated with underlying malignancies. This situation is high-stakes medically due to the significant impact on the patient's quality of life and the potential underlying causes that could be life-threatening. Memory loss suggests serious neurological involvement. However, the clinical course seems to be benign and non-progressive at the moment, providing some reassurance, but the potential for underlying cancer of unknown origin remains a serious concern.


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

SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.
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DESCRIPTION: A white female presents for exam and Pap.

The situation is a routine medical consultation involving a gynecological exam and Pap smear, with additional minor health concerns like rhinitis and dermatitis. These issues are common and not life-threatening. The consultation includes preventive care recommendations such as nutrition and exercise advice. The stakes are typical for a standard medical check-up with no indication of urgent or severe health issues.


Medical Specialty: Consult - History and Phy.
Sample Name: Neuropsychological Evaluation - 4

REASON FOR REFERRAL:,  The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the "early stages of a likely dementia" and was thereafter terminated from her position as a psychiatric nurse.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION:  ,Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:,  The patient reported that she had worked as a nurse supervisor for Hospital Center for four years.  She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work.  She continues to receive some compensation through FMLA hours.  She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services.  She said that these 90 days are up around the end of November.  She said the reason for her dismissal was performance complaints.  She said that they began "as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  She described it as a very chaotic and hectic work environment in which she was often putting in extra time.  She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D.  He completed a Comprehensive Independent Medical Evaluation on 08/14/2009.  She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  Please note that we do not have copies of any of her work-related correspondence.  The patient never received a copy of the neuropsychological evaluation because she was told that it was "too derogatory."  A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  To summarize, the results indicated "diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  This suggests that her intellectual functioning has declined."  It concluded that "results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits.  His neurological examination on 09/23/2009 was unremarkable.  The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting.  A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING:  ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  She also denied any problems with attention and concentration or forgetfulness or memory problems.  She continues to independently perform all activities of daily living.  She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  She reported that if her children had noticed anything they definitely would have brought it to her attention.  She said that she does not currently have a lawyer and does not intend to return to her previous physician.  She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  Other current symptoms include excessive fatigue.  She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  She also reported having fallen approximately five times within the past year.  She said that this typically occurs when she is climbing up steps and is usually related to her right foot "like dragging."  Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal.  She denied any significant medical conditions during childhood.  As mentioned, she now has a history of fibromyalgia.  She also experiences some restriction in the range of motion with her right arm.  MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7.  MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  As mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:,  NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  She drinks two to four cups of coffee per day.,SOCIAL HISTORY:  ,The patient was born and raised in North Carolina.  She was the sixth of nine siblings.  Her father was a chef.  He completed third grade and died at 60 due to complications of diabetes.  Her mother is 93 years old.  Her last job was as a janitor.  She completed fourth grade.  She reported that she has no cognitive problems at this time.  Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  The patient completed a Bachelor of Science in Nursing through State University in 1979.  She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  She was married for two years.  Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  She has two children ages 43 and 30.  Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York.  In school, the patient reported obtaining primarily A's and B's.  She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  The patient worked for Hospital Center for four years.  Prior to that, she worked for an outpatient mental health center for 2-1/2 years.  She was reportedly either terminated or laid off and was unsure of the reason for that.  Prior to that, she worked for Walter P. Carter Center reportedly for 21 years.  She has also worked as an OB nurse in the past.  She reported that other than the two instances reported above, she had never been terminated or fired from a job.  In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  She was also taking Prozac during that time.  She then began taking Prozac again when she started working at secondary to stress with the work situation.  She reported a chronic history of mild sadness or depression, which was relatively stable.  When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test
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DESCRIPTION: The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.

The situation involves a 58-year-old female patient who was dismissed from her role due to cognitive issues suspected to be early dementia, impacting her livelihood and quality of life. This evaluation determines her cognitive status, potentially influencing her future employment, disability application, and treatment. The stakes are high as the evaluation outcomes will impact her career, finances, and healthcare decisions significantly.


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

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

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


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: Gardnerella Bacterial Vaginosis

CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  The patient states that she has also had frequency of urination.  The patient denies any burning with urination.  She states that she is sexually active and does not use condoms.  She does have three sexual partners.  The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  The patient does state that she has never had HIV testing.  The patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  The patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  The patient also denies skin rashes or lesions.  She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  The patient is G2 P2.  She has had some irregular Pap smears in the past.  Her last Pap smear was approximately 6 to 12 months ago.  The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1.  Bronchitis.,2.  Urinary tract infections.,3.  Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day.  She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:,  No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is an African-American female who appears her stated age of 25 years.  She is well nourished, well developed, and in no acute distress.  The patient is pleasant.,VITAL SIGNS:  Afebrile.  Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.,ABDOMEN:  Soft, nontender, nondistended.  Positive bowel sounds throughout.,SKIN:  Warm, dry and intact.  No rash or lesion.,PSYCH:  Alert and oriented to person, place, and time.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.,GENITOURINARY:  The pelvic exam done shows external genitalia without abnormalities or lesions.  There is a white-to-yellow discharge.  Transformation zone is identified.  The cervix is mildly friable.  Vaginal vault is without lesions.  There is no adnexal tenderness.  No adnexal masses.  No cervical motion tenderness.  Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's.  No squamous epithelial cells and no other signs of infection.  There is no glucose.  The patient's cervical swabs and cultures are obtained and there are positive clue cells.  Negative Trichomonas.  Negative fungal elements and Chlamydia and gonorrhea are pending at this time.  Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  The patient will follow up with her primary care provider.,
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DESCRIPTION: Vaginal discharge with a foul odor.

Vaginal discharge with a foul odor.

The primary issue in this case is the diagnosis of Gardnerella bacterial vaginosis, a common and typically non-severe condition. The patient is not in acute distress and her vital signs are stable. The treatment plan with metronidazole is standard and the condition is generally manageable with antibiotics. There are no immediate life-threatening complications, and although there is a potential for further complications like pelvic inflammatory disease if left untreated, this does not make the current situation high-stakes. Additionally, pending results for other possible infections such as Chlamydia and gonorrhea will be managed as needed, but at present, there is no indication of an emergency.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dilated Cardiomyopathy - Consult

REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital.  He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure.  He feels in general "OK," but is stressed and fatigued.  He works hard running 3 companies.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.  There has been some PND, but he sleeps on 1 pillow.  He has no edema now, but has had some mild leg swelling in the past.  There has never been any angina and he denies any palpitations, syncope or near syncope.  When he takes his pulse, he notes some irregularity.  He follows no special diet.  He gets no regular exercise, although he has recently started walking for half an hour a day.  Over the course of the past year, these symptoms have been slowly getting worse.  He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982.  He had trauma to his right thumb.  There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife.  He has a lot of stress in his life.  He does not smoke, but does drink.  He has high school education.,On family history, mother is alive at age 89.  Father died at 72 of heart attack.  He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction.  He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds.  His blood pressure is 120/70 in each arm seated.  His pulse is 80 beats per minute and regular.  He is breathing 1two times per minute and that is unlabored.  Eyelids are normal.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  Neck is supple and symmetrical without adenopathy or thyromegaly.  Jugular venous pressure is normal.  Carotids are brisk without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is regular.  The first and second heart sounds are normal.  He does have a fourth heart sound and a soft systolic murmur.  The precordial impulse is enlarged.  Abdomen is soft without hepatosplenomegaly or masses.  He has no clubbing, cyanosis or peripheral edema.  Distal pulses are normal throughout both arms and both legs.  On neurologic examination, his mentation is normal.  His mood and affect are normal.  He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate.  His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33.  His glucose is 97 and creatinine 0.9.  Potassium is 4.3.  He is not anemic.  Urinalysis was normal.,I reviewed his echocardiogram personally.  This shows a dilated cardiomyopathy with EF of 15%.  The left ventricular diastolic dimension is 6.8 cm.  There are no significant valvular abnormalities.,He had a stress thallium.  His heart rate response to stress was appropriate.  The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate.  There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy.  We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged.  The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES:  ,1.  Dilated cardiomyopathy.,2.  Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily.  The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily.  In addition, he could benefit from a loop diuretic such as furosemide.  I did not start this as he is planning to go back home to San Salvador tomorrow.  I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening.  All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing.  There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here.  He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later.  If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:,  See the above.
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DESCRIPTION: A 63-year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure.  He has noted shortness of breath with exertion and occasional shortness of breath at rest.

The situation involves a patient with newly diagnosed dilated cardiomyopathy, which is a serious heart condition that causes heart failure symptoms. The patient's ejection fraction is notably low at 15%, indicating severe heart impairment. The management involves starting and up-titrating important heart medications, and close follow-up is planned. While he does not currently need a defibrillator, this could change depending on his response to treatment, indicating potential future high-risk interventions. The condition is serious and impacts his overall health and life expectancy, making the situation high-stakes from a medical perspective.