Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Angiography - 1

CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM:  ,Shortness of breath for two weeks and a history of pneumonia.  The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen.  Left lower lobe atelectasis is noted.  A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12).  A small left pleural effusion is noted.,Right lower lobe atelectasis is present.  There is a right pleural effusion, greater than as seen on the left side.  A right lower lobe pulmonary nodule measures 1.5 cm.  There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1.  Negative for pulmonary arterial embolism.,2.  Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3.  Cardiomegaly with mitral valvular calcifications.,4.  Postsurgical changes of a left upper lobectomy.,5.  Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6.  Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.
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DESCRIPTION: Shortness of breath for two weeks and a history of pneumonia.  CT angiography chest with contrast.  Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.

cardiovascular / pulmonary, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,

The situation involves analyzing a CT angiography with findings that suggest potential complications in a patient with respiratory complaints and a history of lung surgery. It points out possible pulmonary hypertension, cardiomegaly, pleural effusions, and presence of pulmonary nodules. These are significant medical findings, as they could indicate severe underlying health problems that require careful monitoring and potentially urgent treatment. While the situation is not immediately life-threatening, it involves important health risks that need to be addressed, making it relatively high-stakes from a medical perspective.


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Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Chest - 2

CLINICAL HISTORY: , A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.  Right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,TECHNIQUE: , Multiple transaxial images utilized in 10 mm sections were obtained through the chest.  Intravenous contrast was administered.,FINDINGS: , There is a large 3 x 4 cm lymph node seen in the right supraclavicular region.  There is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm.  A subcarinal lymph node is enlarged also.  It measures 6 x 2 cm.  Multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura.  There is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm.  There is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit.  The liver parenchyma is normal without evidence of any dominant masses.  The right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,IMPRESSION:,1.  Greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2.  Extensive mediastinal adenopathy as described above.,3.  No lesion seen within the left lung at this time.,4.  Supraclavicular adenopathy.
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DESCRIPTION: A 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  An abnormal chest radiograph shows right middle lobe infiltrate and collapse.  Patient needs staging CT of chest with contrast.

cardiovascular / pulmonary, supraclavicular, cervical adenopathy, pulmonary nodules, lymph node, adenopathy, pulmonary, chest,

This medical case involves a 68-year-old patient with adenocarcinoma, which is a type of cancer, and has findings of extensive metastasis as indicated by the lymph node enlargements and pulmonary nodules. The presence of metastases can suggest an advanced stage of cancer, which is typically considered a high-stakes situation due to the implications for treatment and prognosis. Diagnostic imaging, like a CT scan, is crucial for proper staging and subsequent treatment planning, impacting patient management significantly.

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Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 3

EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner.  Post-processing on a Vitrea workstation.  150 mL Ultravist 370 was utilized as the intravenous contrast agent.  Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque.  The distal LAD was unreadable while the proximal was normal.  The mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  The circumflex is diminutive in size along its proximal portion.  Distal is not readable.,Cardiac wall motion within normal limits.  No gross pulmonary artery abnormality however they are not well delineated.  A full report was placed on the patient's chart.  Report was saved to PACS.
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DESCRIPTION: Coronary Artery CTA with Calcium Scoring and Cardiac Function

cardiovascular / pulmonary, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography,

The patient has chest pain, is overweight, has high cholesterol, and a family history of related conditions, placing them at higher risk for cardiovascular issues. The CT angiography shows a moderate stenosis in the left anterior descending (LAD) artery and difficulties in viewing other parts due to artifacts. These findings suggest an elevated risk of a cardiac event, making this a moderately high-stakes situation. However, the stakes are not extremely high, as there is no immediate life-threatening condition indicated in the report, but further evaluation and monitoring are needed.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: COPD & Pneumonia - SOAP

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

cardiovascular / pulmonary, community acquired pneumonia, copd exacerbation, home o2, acute on chronic, pneumonia, exacerbation, copd

The situation involves a 97-year-old patient with a history of COPD who has been hospitalized for acute COPD exacerbation and community-acquired pneumonia. The patient is showing signs of improvement but experienced a fall due to weakness, leading to potential complications such as a subchondral fracture. Although the immediate conditions are resolving, there is an ongoing need to evaluate her safety, lifestyle adjustments, and potential transition to assisted living. The complexity of managing her health, potential changes to her living situation, and the inherent risks of her age and condition make this situation moderately high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary Angiography & Abdominal Aortography

NAME OF PROCEDURE,1.  Selective coronary angiography.,2.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3.  Abdominal aortography.,INDICATIONS:  ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain.  Thallium scan has been negative.  He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE:  ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine.  Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg.  Received additional Versed and fentanyl during the procedure.  Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed.  Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta.  Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch.  The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed.  This revealed a very high-grade lesion at the proximal right coronary artery.  This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed.  A 6-French sheath and a right Judkins guide was placed.  The patient was started on bivalarudin.  A BMW wire was easily placed across the lesion and into the distal right coronary artery.  A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres.  The intermediate result was improved with TIMI-3 flow to the terminus of the vessel.  Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres.  This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection.  This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres.  Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing.  The guiding catheter was withdrawn over wire and a pigtail was placed.  This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection.  The catheter was removed.  The bivalarudin was stopped at the termination of procedure.  A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein.  This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure.  Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel.  This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch.  It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals.  In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity.  After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow.  There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex.  The ramus intermedius is free of disease.  The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment.  This measures 25% to 30% at its worst point.  The circumflex is a large caliber vessel.  There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex.  Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation.  This may represent a small retrograde dissection as well.  There was some dye hang up in the wall.,IMPRESSION,1.  Successful stenting of subtotal stenosis of the proximal coronary artery.,2.  Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3.  Left to right collateral filling noted prior to coronary intervention.,4.  Small area of eccentric aneurysm formation in the abdominal aorta.
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DESCRIPTION: Selective coronary angiography.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.  Abdominal aortography.

cardiovascular / pulmonary, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal,

The scenario involves coronary angiography and stenting, which are critical procedures for a patient with signs of coronary artery disease and potential aortic complications. This is a high-stakes situation due to the potential for life-threatening conditions if not managed correctly, such as myocardial infarction or aortic aneurysm complications. The careful description of the procedure, hemodynamics, and intervention outcomes underscores the gravity of the patient's condition.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: COPD - Discharge Summary

HISTORY OF PRESENT ILLNESS:  ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.  He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD.  Unfortunately over the past few months he has returned to pipe smoking.  At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy.  COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click.  Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES:  ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7.  Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol.  The patient improved on this regimen.  Chest x-ray did not show any CHF.  The cortisone was tapered.  The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES:  ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge.  To follow up with me in the office in 4-5 days.
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DESCRIPTION: A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.

cardiovascular / pulmonary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd,

The patient is a 67-year-old male with a history of COPD and bronchospasm, admitted for acute asthmatic bronchitis. While COPD and bronchitis are serious concerns, especially in an older patient with a history of artificial heart valve and on anticoagulation therapy, the immediate life-threatening risk appears to have been managed with treatment during hospitalization. The patient has been discharged with a detailed plan, indicating that the condition has stabilized. The stakes are moderate as there is a need for careful follow-up and management to prevent relapse or complications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 1

HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS:  ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation.  Patient received oral Metoprolol 100 milligrams.  100 ml Ultravist 370 was utilized as the contrast agent.  0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age.  There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits.  Left ventricular ejection fraction calculated to be 82%.  End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins.  There is codominance between the right coronary artery and the circumflex artery.  There is mild to moderate stenosis of the proximal LAD with mixed plaque.  Mild stenosis mid LAD with mixed plaque.  No stenosis.  Distal LAD with the distal vessel becoming diminutive in size.  Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque.  Once again the distal vessel becomes diminutive in size.  Circumflex shows mild stenosis due to focal calcified plaque proximally.  No stenosis is seen involving the mid or distal circumflex.  The distal circumflex also becomes diminutive in size.  The left main shows small amount of focal calcified plaque without stenosis.  Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1.  Atherosclerotic coronary artery disease with values as above.  There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2.  Consider cardiology consult and further evaluation if clinically indicated.,3.  Full report was sent to the PACS.  Report will be mailed to Dr. ABC.
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DESCRIPTION: CCTA with cardiac function and calcium scoring.

cardiovascular / pulmonary, coronary ct angiography, vitrea workstation, cardiac wall motion, proximal lad, distal lad, focal calcified plaque, coronary artery disease, cardiac function, calcium scoring, wall motion, distal vessel, calcified plaque, distal circumflex, artery disease, mild stenosis, coronary artery, ccta, scoring, atherosclerotic, vessel, calcium, calcified, lad, circumflex, distal, plaque, coronary, artery, stenosis,

The situation involves the interpretation of a Coronary CT Angiography (CCTA) report, indicating the presence of coronary artery disease with mild to moderate stenosis. The medical context is inherently high-stakes due to the potential implications for the patient's cardiovascular health and the need for possible interventions to prevent serious events like heart attacks. However, the condition seems to be in an early stage (mild to moderate stenosis) and is not immediately life-threatening, hence a consult with a cardiologist is suggested for further evaluation. While it is a serious situation, it's not an emergency, which somewhat mitigates the stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Atrial Fibrillation

REASON FOR CONSULTATION:,  Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.  Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke.  She was found to have confusion while in her facility.  She then came to the emergency room and found to have a right sided acute stroke.  12-lead EKG performed on August 10, 2009, found to have atrial fibrillation.  Telemetry also revealed atrial fibrillation with rapid ventricular response.  Currently, the telemetry is normal sinus rhythm.  Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian.  She did not recall why she is in the hospital, she said she had a stroke.  She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post bypass grafting surgery.  Unable to obtain the place, location, anatomy, and the year it was performed.,2.  Carotid artery stenosis status post right carotid artery stenting.  Again, the time was unknown.,3.  Diabetes.,4.  Hypertension.,5.  Hyperlipidemia.,6.  History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  The patient is a resident of Lake Harris Port Square.  She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air.  Temperature 99, respiratory rate 16.,GENERAL:  The patient is sitting in the chair at bedside.  Appears comfortable.  Left facial droop.  Left side hemiplegia.,HEAD AND NECK:  No JVP seen.  Right side carotid bruit heard.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI not displaced, regular rhythm.  Normal S1 and S2.  Positive S4.  There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN:  Soft.,EXTREMITIES:  Not edematous.,DATA:,  A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute.  Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7.  The patient's hemoglobin was 8.2 a few days ago before blood transfusion.  Chemistry-7 within normal limits.  Lipid profile:  Triglycerides 64, total cholesterol 106, HDL 26, LDL 17.  Liver function tests are within normal limits.  INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%.  Mild apical hypokinesis.  Mild dilated left atrium.  Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation.  No intracardiac masses or thrombus were noted.  The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1.  Paroxysmal atrial fibrillation.  It is unknown if this is a new onset versus a paroxysmal atrial fibrillation.  Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated.  However, given the patient's current neurologic status, the safety of falling is unclear.  We need to further discuss with the patient's primary care physician, probably rehab physician.  If the patient's risk of falling is low, then Coumadin is indicated.  However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended.  Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management.  Therefore, I will not recommend transesophageal echocardiogram at this point.  Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2.  Carotid artery stenosis.  The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery.  It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting.  If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency.  However, given the patient's current acute stroke, revascularization is not indicated at this time.,3.  Coronary artery disease.  Clinically stable.  No further test is indicated at this time.
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DESCRIPTION: Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.

The situation involves a medical consultation for a patient with atrial fibrillation, a history of coronary artery disease, previous strokes, and a potential new acute stroke, which are all serious medical conditions. The decision regarding anticoagulation treatment is also significant due to the patient's risk factors and current health status. The assessment involves balancing the risk of stroke against the risk of falls due to anticoagulation. These decisions can have a major impact on the patient's health outcomes. Therefore, this medical consultation scenario is high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Complex Cyanotic Congenital Heart Disease

HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.
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DESCRIPTION: A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.

The situation involves managing a complex congenital heart condition in a pediatric patient, specifically with asplenia syndrome and various cardiac anomalies including cyanotic heart disease. The detailed history and procedural notes indicate multiple previous surgeries and interventions, significant current cardiovascular abnormalities, and ongoing surgical considerations. This context underscores the high stakes, as it involves life-threatening conditions requiring careful planning and execution of medical interventions. The management of these congenital defects is critical for the patient's life and health outcomes. Additionally, the cardiovascular specialty and the invasive procedures described, such as catheterization and stenting, support a high stakes assessment.


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: Cardiovascular / Pulmonary
Sample Name: Chest Pain - Office Note

DISCHARGE DIAGNOSES:,1.  Chest pain.  The patient ruled out for myocardial infarction on serial troponins.  Result of nuclear stress test is pending.,2.  Elevated liver enzymes, etiology uncertain for an outpatient followup.,3.  Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia.  The patient ruled out for myocardial infarction with serial troponins.  Nuclear stress test has been done, results of which are pending.  The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations.  He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks.  Discharge medications will depend on results of nuclear stress test.
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DESCRIPTION: Patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain

cardiovascular / pulmonary, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test

The context indicates a concern for potential cardiovascular issues, given the family history of premature coronary artery disease and the patient's symptoms of chest pain. While the patient has been ruled out for myocardial infarction via serial troponins, the nuclear stress test results are still pending, which could significantly influence the patient's care and medication adjustments. The stakes are heightened by the possibility of serious cardiovascular implications if the nuclear stress test results indicate any issues. The need for careful monitoring and follow-up with specialists also highlights the critical nature of this scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest discomfort & palpitations - Consult.

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

The situation involves a patient with a history of mitral valve prolapse and presenting with symptoms such as palpitations and severe chest discomfort, which has been worsening. These symptoms can be indicative of potentially serious cardiovascular conditions. The patient's family history of coronary artery disease (CAD) further elevates the risk. Given the cardiovascular specialty, these are considered critical symptoms that require thorough evaluation and management to prevent severe events like a heart attack. The testing and change in medication indicate the practitioner's concern for the patient's cardiovascular health. Therefore, this consult is high-stakes due to the potential for significant health complications and the necessity for precise medical intervention.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Pain - Cardiac Consult

REASON FOR REFERRAL:,  Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy.  Since then she just says "things have changed".  She just does not want to go out anymore and just does not feel the same.  Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband.  Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel "like cramps" and sometimes like a dull ache, which will last all day long.  She is also tender in the left breast area and gets numbness in her left hand.  She has also had three spells of "falling", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  Twice it happened, when getting up quickly at night and another time in the grocery store.  She suffered no trauma.  She has no remote history of syncope.  Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:,  Sulfa.,SOCIAL HISTORY: , She does not smoke or drink.  She is married with two children.,REVIEW OF SYSTEMS:,  Otherwise unremarkable.,PEX:,  BP:  130/70 without orthostatic changes.  PR:  72.  WT:  206 pounds.  She is a healthy young woman.  No JVD.  No carotid bruit.  No thyromegaly.  Cardiac:  Regular rate and rhythm.  There is no significant murmur, gallop, or rub.  Chest:  Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  Lungs:  Clear.  Abdomen:  Soft.  Moderately overweight.  Extremities:  No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1.  Syncopal spells - These do sound, in fact, to be syncopal.  I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good.  I have asked her to drink plenty of fluids and to not to get up suddenly at night.  I think this should take care of the problem.  I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2.  Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1.  Reassurance that her cardiac checkup looks excellent, which it does.,2.  Drink plenty of fluids and arise slowly from bed.,3.  Flexeril 10 mg q 6 p.r.n.,4.  I have asked her to return should the syncopal spells continue.
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DESCRIPTION: Chest pain, possible syncopal spells.  She has been having multiple cardiovascular complaints including chest pains, which feel like cramps and sometimes like a dull ache, which will last all day long.

cardiovascular / pulmonary, chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest,

The situation involves a 31-year-old woman experiencing chest pain and possible syncopal spells, which have been characterized as likely due to simple orthostasis or vasovagal syncope based on the normal results from an EKG and echocardiogram. However, chest pains in patients can sometimes be misleading in their presentation and can occasionally mask more serious underlying cardiac issues. The doctor has evaluated the situation and concluded the condition appears to be musculoskeletal in nature due to stress, with recommendations provided for reassurance and managing symptoms. While the case does not appear to present any immediate life-threatening condition based on the evaluations, chest pain and syncope in general carry a potential risk for more serious conditions thus warrant a moderate level of concern and monitoring.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid & Cerebral Arteriograms

EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1.  Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2.  Mild stenosis of the right internal carotid artery measured at 20%.,3.  Patent bilateral vertebral arteries.,4.  No significant disease was identified of the anterior cerebral vessels.,DISCUSSION:  ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped.  Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic.  A 19-French needle was then advanced into the common femoral artery and a wire was advanced.  Over the wire, a sheath was placed.  A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire.  Flushed arteriogram was performed.  Arteriogram demonstrated no significant disease of the great vessels at their origins.  There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.  The vertebral arteries were widely patent.  Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed.  Carotid and cerebral arteriograms were performed.  The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable.  The external carotid artery on the right is quite tortuous in its appearance.  The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%.  Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal.  No significant stenosis identified.  There is complete cross-filling into the left brain via the right.  No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well.  No complications occurred during or immediately after the procedure.  Stasis was achieved of the puncture site using a VasoSeal.  The patient will be observed for at least 2-1/2 hours prior to being discharged to home.
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DESCRIPTION: Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.

cardiovascular / pulmonary, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire,

The situation involves a medical diagnostic procedure that is critical for assessing a patient's vascular health. The detection of complete occlusion in the left common carotid artery and mild stenosis in the right internal carotid artery indicates significant concerns related to blood flow to the brain, which could lead to severe outcomes such as a stroke. Although the patient's procedure was well-tolerated without immediate complications, the findings are inherently high-stakes due to the severity of potential consequences if untreated or not monitored closely.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Central Venous & Arterial  Line

INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room.  Antibiotic prophylaxis with cephazolin and gentamicin were already given.  A strict aseptic technique was used including use of gowns, mask, and gloves, etc.  The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:,  Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin.  A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened.  Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery.  There was good venous blood return on the first try.  Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm.  It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact.  There was good blood return from both lumens, which were flushed with heparinized saline.  The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:,  Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:,  Attention was directed to the left wrist, which was placed on wrist rest.  The Allen test was normal.  A Cook 2.5-French 5 cm long arterial catheter kit was opened.  A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return.  Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact.  There was pulsatile blood return and the catheter was flushed with heparinized saline solution.  It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure.  The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure.  There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion.  Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance.  There was good visualization of the heart.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  The probe was removed at the end.  There was no trauma and there was no blood tingeing.,
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DESCRIPTION: Insertion of central venous line and arterial line and transesophageal echocardiography probe.

cardiovascular / pulmonary, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter

The situation involves three critical medical procedures conducted on a patient under general anesthesia in preparation for open-heart surgery. These procedures—central venous line insertion, arterial line insertion, and transesophageal echocardiography probe insertion—are integral to the successful monitoring and management of a patient undergoing major cardiovascular surgery. Any complications during these procedures could significantly impact surgical outcomes. Therefore, the situation is high-stakes due to its direct impact on the patient's condition and the complexity of the upcoming surgery.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Central Line Insertion

PREOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,PROCEDURE:,  Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  The catheter was fixed to the skin with sutures.  The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.
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DESCRIPTION: Central line insertion.  Empyema thoracis and need for intravenous antibiotics.

cardiovascular / pulmonary, thoracis, intravenous, central line insertion, empyema, catheter,

Central line insertion is a common medical procedure that, while routine, is still significant given it requires precision to avoid complications such as pneumothorax, infection, or bleeding. The patient has empyema thoracis and requires intravenous antibiotics, indicating a serious infection. However, the procedure was completed without complications, and a chest x-ray confirmed the catheter's correct position. In the context of medical procedures, this was conducted smoothly, suggesting a moderate level of stakes given the potential risks involved in central line insertion and the patient's need for urgent treatment.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiology Progress Note

SUBJECTIVE:,  The patient is a 78-year-old female with the problem of essential hypertension.  She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure.  She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.,OBJECTIVE:,  Heart rate is 80 and blood pressure is 130/70.  Head and neck are unremarkable.  Heart sounds are normal.  Abdomen is benign.  Extremities are without edema.,ASSESSMENT AND PLAN:,  The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past.  I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc.  So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4.  In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.
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DESCRIPTION: Problem of essential hypertension.  Symptoms that suggested intracranial pathology.

cardiovascular / pulmonary, cardiology, ekg, k-dur, progerss note, soap, ankle swelling, blood pressure, chest x-ray, echocardiogram, essential hypertension, heart attack, hydrochlorothiazide, hypertension, pathology, chest, heart, intracranial,

The situation involves an elderly patient with essential hypertension and a significant past medical event—a suspected massive heart attack that requires evaluation. However, her current condition is stable with controlled blood pressure and no acute symptoms. The physician's plan includes routine follow-up and further investigations to confirm past events, making it a moderate-stakes situation due to the potential implications of undiagnosed cardiac damage.


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Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiology Office Visit - 2

HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension.  Patient has severe backache secondary to disc herniation.  Patient has seen an orthopedic doctor and is scheduled for surgery.  Patient also came to my office for surgical clearance.  Patient had cardiac cath approximately four years ago, which was essentially normal.  Patient is documented to have morbid obesity and obstructive sleep apnea syndrome.  Patient does not use a CPAP mask.  Her exercise tolerance is eight to ten feet for shortness of breath.  Patient also has two-pillow orthopnea.  She has intermittent pedal edema.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Blood pressure is 135/70.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Weight 258 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Clear. ,CARDIOVASCULAR:  There is no murmur or gallop heard over the precordium. ,ABDOMEN:  Soft.  There is no hepatosplenomegaly. ,EXTREMITIES:  The patient has no pedal edema.  ,MEDICATIONS:  ,1.  BuSpar 50 mg daily.,2.  Diovan 320/12.5 daily.,3.  Lotrel 10/20 daily.,4.  Zetia 10 mg daily.,5.  Ambien 10 mg at bedtime.,6.  Fosamax 70 mg weekly.,DIAGNOSES:,1.  Controlled hypertension.,2.  Morbid obesity.,3.  Osteoarthritis.,4.  Obstructive sleep apnea syndrome.,5.  Normal coronary arteriogram.,6.  Severe backache.,PLAN:,1.  Echocardiogram, stress test.,2  Routine blood tests.,3.  Sleep apnea study.,4.  Patient will be seen again in my office in two weeks.
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DESCRIPTION: Cardiology office visit sample note.

Cardiology office visit sample note.

The situation involves a 57-year-old female with a complex medical history including controlled hypertension, morbid obesity, obstructive sleep apnea, and a pending surgery for severe backache. The context is a routine cardiology office visit for surgical clearance, which is critical but not immediately life-threatening. The patient has a history of a cardiac catheterization that was normal and is managing multiple chronic conditions. The stakes are moderate due to the need to clear the patient for surgery and assess cardiac risk, but there is no indication of an immediate life-threatening condition in the current evaluation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardioversion

HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress.  Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation.  I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure.  After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday.  The patient declined.  I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,PROCEDURE NOTE: , The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff.  The patient participated actively in this.  She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect.  She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm.  This was confirmed on 12 lead EKG.,IMPRESSION/PLAN: , Successful resumption of normal sinus rhythm from recurrent atrial fibrillation.  The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress.  She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted.  She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.,This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.
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DESCRIPTION: Cardioversion.  An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation

cardiovascular / pulmonary, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial,

The situation is considered high-stakes because it involves performing a medical procedure, cardioversion, on an elderly patient with a complex medical history, including past aortic valve replacement and paroxysmal atrial fibrillation. Cardioversion is a procedure used to restore a normal heart rhythm, which is critical in managing atrial fibrillation. The patient also has complicating factors like hypokalemia, incomplete compliance with obstructive sleep apnea therapy, and stress. Performing this procedure successfully is crucial to the patient's recovery and ongoing health management. Given these complexities and potential risks, the stakes are high.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiology Office Visit - 1

HISTORY OF PRESENT ILLNESS:,  This 66-year-old white male was seen in my office on Month DD, YYYY.  Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia.  Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  His exercise tolerance is about two to three yards for shortness of breath.  The patient stopped taking Coumadin for reasons not very clear to him.  He was documented to have recent atrial fibrillation.  Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation.  Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 120/60.  Respirations 18 per minute.  Heart rate 75-85 beats per minute, irregular.  Weight 207 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Severe inspiratory and expiratory wheezing heard throughout the lung fields.  Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR:  PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.,EXTREMITIES:  Patient has 1+ pedal edema.,MEDICATIONS: , ,1.  Ambien 10 mg at bedtime p.r.n.,2.  Coumadin 7.5 mg daily.,3.  Diovan 320 mg daily.,4.  Lantus insulin 50 units in the morning.,5.  Lasix 80 mg daily.,6.  Novolin R p.r.n.,7.  Toprol XL 100 mg daily.,8.  Flovent 100 mcg twice a day.,DIAGNOSES:,1.  Atherosclerotic coronary vascular disease with old myocardial infarction.,2.  Moderate to severe LV systolic dysfunction.,3.  Diabetes mellitus.,4.  Diabetic nephropathy and renal failure.,5.  Status post ICD implantation.,6.  New onset of atrial fibrillation.,7.  Chronic Coumadin therapy.,PLAN:,1.  Continue present therapy.,2.  Patient will be seen again in my office in four weeks.
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DESCRIPTION: Sample cardiology office visit note.

Sample cardiology office visit note.

This is a high-stakes situation given the patient's complex medical history, including severe orthopnea, paroxysmal nocturnal dyspnea, longstanding ischemic heart disease, end-stage LV systolic dysfunction, recent atrial fibrillation, and chronic conditions like diabetes mellitus and nephropathy. The report indicates that the patient has recently had pneumonia, which can complicate his existing conditions. The patient also stopped taking Coumadin, a crucial anticoagulant therapy, increasing the risk of thromboembolic events. These factors indicate a need for careful management and follow-up to prevent potentially life-threatening exacerbations.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation - 7

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me.  He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation.  There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission.  He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy.  The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation.  The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Type I diabetes mellitus.,2.  Hyperlipidemia.,3.  Hypertension.,4.  Morbid obesity.,5.  Sleep apnea syndrome.,6.  Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General:  Unremarkable.,Cardiopulmonary:  No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal:  Unremarkable.,Genitourinary:  See above.,Musculoskeletal:  Unremarkable.,Neurologic:  Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease.  His mother has congestive heart failure.,SOCIAL HISTORY:  ,The patient is married.  He lives with his wife.  He is employed as a barber.  He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1.  Clonidine 0.3 mg b.i.d.,2.  Atenolol 50 mg daily.,3.  Simvastatin 80 mg daily.,4.  Furosemide 40 mg daily.,5.  Metformin 1000 mg b.i.d.,6.  Hydralazine 25 mg t.i.d.,7.  Diovan 320 mg daily.,8.  Lisinopril 40 mg daily.,9.  Amlodipine 10 mg daily.,10.  Lantus insulin 50 units q.p.m.,11.  KCl 20 mEq daily.,12.  NovoLog sliding scale insulin coverage.,13.  Warfarin 7.5 mg daily.,14.  Levothyroxine 0.2 mg daily.,15.  Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General:  A well-appearing, obese black male.,Vital Signs:  BP 140/80, HR 88, respirations 16, and afebrile.,HEENT:  Grossly normal.,Neck:  Normal.  Thyroid, normal.  Carotid, normal upstroke, no bruits.,Chest:  Midline sternotomy scar.,Lungs:  Clear.,Heart:  PMI fifth intercostal space mid clavicular line.  Normal S1 and prosthetic S2.  No murmur, rub, gallop, or click.,Abdomen:  Soft and nontender.  No palpable mass or hepatosplenomegaly.
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DESCRIPTION: The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.

The patient has significant cardiovascular history with aortic valve replacement, paroxysmal atrial fibrillation, congestive heart failure, and a previous transient ischemic attack. He is undergoing management for postoperative bleeding from a surgery requiring discontinuation of anticoagulation, which poses high risk due to his cardiovascular conditions. The combination of these factors suggests a high-stakes scenario, specifically due to balancing bleeding risk versus thromboembolic risk in a patient with complex cardiovascular history. Further, Type I diabetes mellitus, hypertension, and other chronic conditions complicate the clinical picture, increasing the stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation - 2

CHIEF REASON FOR CONSULTATION:,  Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:,  This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  During this time, patient felt extremely short of breath and dizzy.  Palpitations lasted for about five to ten minutes without any recurrence.  Patient also gives history of having tightness in the chest after she walks briskly up to a block.  Chest tightness starts in the retrosternal area with radiation across the chest.  Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  Patient gives history of having hypertension for the last two months.  Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1.  Astelin nasal spray.,2.  Evista 60 mg daily.,3.  Lopressor 25 mg daily.,4.  Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:,  The patient underwent right foot surgery and C-section.,FAMILY HISTORY:,  The patient is married, has six children who are doing fine.  Father died of a stroke many years ago.  Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks.  ,ALLERGIES:,  THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:,  Otherwise negative.  ,PHYSICAL EXAMINATION: , ,GENERAL:  Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS:  Blood pressure is 160/80.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Patient weighs 133 pounds, height 64 inches.  BMI is 22.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good.,NECK:  Supple.  No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries.  Trachea in midline. Thyroid not enlarged.  JVP flat at 45°.,CHEST:  Chest is symmetrical on both sides, moves well with respirations.  Vesicular breath sounds heard over the lung fields.  No wheezing, crepitation, or pleural friction rub heard.  ,CARDIOVASCULAR SYSTEM:  PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.  There is no diastolic murmur or gallop heard.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or ascites.  No bruit heard over the aorta or renal vessels.,EXTREMITIES:  No pedal edema.  Femoral arterial pulsations are 3+, popliteal 2+.  Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO:  Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes.  Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,
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DESCRIPTION: To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.

The consultation is needed to evaluate a combination of potentially serious cardiovascular symptoms: exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG findings. These symptoms, particularly in a 72-year-old patient with a history of hypertension, may indicate significant cardiovascular issues such as angina or coronary artery disease. The presence of a systolic murmur and the family history of stroke further raise concerns. The stakes are high as these symptoms and findings could indicate a risk of major cardiac events if not promptly investigated and managed.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 8

PROCEDURE PERFORMED:,1.  Right femoral artery access.,2.  Selective right and left coronary angiogram.,3.  Left heart catheterization.,4.  Left ventriculogram.,INDICATIONS FOR PROCEDURE:,  A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%.  This was a sharp decline from a previous LVEF of 50% to 55%.  We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  The right groin was prepped and draped in the usual sterile manner.  2% Lidocaine was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery.  6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram.  A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11.  There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1.  The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  The left main coronary artery is free of any disease.,3.  The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  The left anterior descending artery has a patent stent in the proximal LAD.  The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  The diagonal branches are free of any disease.,6.  The right coronary artery is a dominant vessel and has mild luminal irregularities.  Its midsegment has a focal area of 30% narrowing as well.  The rest of the right coronary artery is free of any disease.,7.  The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy.  Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram.  The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.
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DESCRIPTION: Left heart cardiac catheterization.

Left heart cardiac catheterization.

cardiovascular / pulmonary, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending

The situation involves a cardiac catheterization procedure and analysis of findings in a patient with significant coronary artery disease history. The patient has a marked decline in left ventricular systolic function, causing concern and prompting a detailed investigation. This places the patient's health at serious risk if not managed properly, making it a higher-stakes situation. Decisions about further treatment, such as continuing medical management or considering additional interventions, have important implications for the patient's outcome.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 7

INDICATIONS FOR PROCEDURE:, The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,ESTIMATED CONTRAST:, Less than 150 mL.,PROCEDURES PERFORMED:, Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.,OPERATIVE TECHNIQUE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. One percent Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was then placed in the right common femoral artery by the modified Seldinger technique.,SELECTIVE CORONARY ARTERIOGRAPHY:, Next, right and left Judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views.,LEFT VENTRICULOGRAM:, Next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. Next, an LV-gram was then performed with a hand injection of 50 mL of contrast. Next, pull-back pressure was measured across the aortic valve.,AORTA ARCH ANGIOGRAM:, Next, aortic arch angiogram was then performed with injection of 50 mL of contrast at a rate of 20 mL/second to maximum pressure of 750 PSI performed in the 40-degree LAO view.,Next, right iliofemoral angiogram was performed in the 20-degree RAO view. Next Angio-Seal was applied successfully.,The patient left the cath lab without problems or issues.,DIAGNOSES:, Left ventricular end-diastolic pressure was 18 mmHg. There was no gradient across the aortic valve. The central aortic pressure was 160 mmHg.,LEFT VENTRICULOGRAM:, The left ventriculogram demonstrated normal LV systolic function with estimated ejection fraction greater than 50%.,AORTIC ARCH ANGIOGRAM: ,The aortic arch angiogram demonstrated normal aortic arch. No aortic regurgitation was seen.,SELECTIVE CORONARY ARTERIOGRAPHY:, The right coronary artery is large and dominant.,The left main is patent.,The left anterior descending is patent.,The left circumflex is patent.,IMPRESSION:, This study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. In addition, the aortic root is normal.
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DESCRIPTION: Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.

The procedure detailed is a cardiac catheterization, which is a highly specialized and complex medical procedure used to diagnose and potentially treat cardiovascular conditions. Though no complications were encountered and the results were normal indicating no immediate life-threatening issues, the nature of the procedure itself involves significant risk due to the cardiac system's critical role in maintaining life. Further, the context in which these procedures are performed, often due to serious cardiac symptoms, increases the stakes. While the patient experienced no complications and results were favorable, the inherent risks involved in the procedure such as potential for myocardial infarction, stroke, or vascular injury make it high-stakes. The information provided in the query also supports this categorization as interventional cardiology deals directly with the heart.