Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angiography & Catheterization - 1

INDICATION:,  Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him.  He understands.  All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:,  Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state.  Both groins were draped and sterilized in the usual fashion.  Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery.  Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery.  Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1.  Hemodynamics systemic blood pressure 140/70 mmHg.  LVEDP at the end of the procedure was 13 mmHg.,2.  The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery.  The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis.  The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium.  The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion.  There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3.  The right coronary artery is dominant.  It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI.  Angiomax bolus was started.  The ACT was checked.  It was higher in 300.  I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter.  I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support.  I was unable to cross with this lesion using a whisper wire.  I was unable to cross with this lesion using Cross-IT 100 wire.  I have also used second #6-French Amplatz right I guide catheter.  At one time, I have lost flow in the distal vessel.  The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel.  I have performed careful balloon angioplasty of the mid RCA.  I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon.  I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result.  Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing.  I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter.  The left ventricle is rather smaller in size.  The mid inferior wall is minimally hypokinetic, ejection fraction is 70%.  There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1.  Normal left ventricular size and function.  Ejection fraction is 65% to 70%.  No MR.,2.  Successful angioplasty and stenting of the subtotally closed mid RCA.  This was hard, organized thrombus, very difficult to penetrate.  I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result.  The RCA is dominant.,3.  No moderate disease in the distal left main.  Moderate disease in the ostium of the left circumflex artery.  Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation.  Continue aspirin lifelong and continue Plavix for at least 12 months.
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DESCRIPTION: Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.

cardiovascular / pulmonary, acute coronary syndrome, circumflex artery, ventricular catheterization, ventricular angiography, angioplasty, coronary artery, coronary angiography, arthrectomy, femoral angiography, perclose hemostasis, selective coronary angiography, angiographic stenosis, rca, coronary, catheterization, artery, angiography, hemostasis, wire, lad, femoral, angiographic, stenting, proximal,

The situation involves a cardiovascular procedure, specifically angiography and catheterization, which carries significant health risks such as death, myocardial infarction, and the need for emergent open heart surgery. The narrative describes a complex and challenging procedure with instances of complications (e.g., severe chest pain, ST-segment elevation, bradycardia, and hypotension) that required immediate intervention. Successfully completing such a procedure has immediate and long-term implications for the patient's health and survival, thereby making it high-stakes. This requires precise execution, immediate decision-making, and can have life-threatening consequences if not managed properly.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angina

ANGINA, is chest pain due to a lack of oxygen to the heart most often occurring in men age 35 or older and postmenopausal women.  It is usually located right under the breast bone.  Physical and emotional stress, as well as eating heavy meals, can bring it on.  In a healthy person, these stresses are easily handled.  In a person with an underlying heart condition like coronary artery disease, heart valve problem, arrhythmias or high blood pressure, the heart doesn't get enough blood (i.e. not enough oxygen to the heart muscles).  Other causes could be due to a hyperactive thyroid disorder or anemia.  People more likely to have angina may also have diabetes mellitus, be overweight, smoke, have a poor diet with lots of salt and fat, fail to exercise, have a stressful workload or have a family history of coronary artery disease.,SIGNS AND SYMPTOMS:,*  Pain in chest described as tightness, heavy pressure, aching or squeezing.,*  The pain sometimes radiates to the jaw, left arm, teeth and/or outer ear.,*  Possibly a left-sided numbness, tingling, or pain in the arm, shoulder, elbow or chest.,*  Occasionally a sudden difficulty in breathing occurs.,*  Pain may be located between the shoulder blades.,TREATMENT:,*  Nitroglycerin relieves the immediate symptoms of angina in seconds.  Carry it with you at all times.,*  Other medications may be prescribed for the underlying heart problems.  It is important to take them as prescribed by your doctor.,*  Surgery may be necessary to open the blocked coronary arteries (balloon angioplasty) or to bypass them.,*  Correct the contributing factors you have control over.  Lose weight, don't smoke, eat a low-salt, low-fat diet and avoid physical and emotional stresses that cause angina.  Such stressors include anger, overworking, going between extremes in hot and cold, sudden physical exertion and high altitudes (pressurized airplanes aren't a risk).  Practice relaxation techniques.,*  Exercise! Discuss first what you are able to do with your doctor and then go do it.,*  Even with treatment, angina may result in a heart attack, congestive heart failure or a fatal abnormal heartbeat.  Treatment decreases the odds that these will occur.,*  Let your doctor know if your angina doesn't go away after 10 minutes, even when you have taken a nitroglycerin tablet.  Call if you have repeated chest pains that awaken you from sleep regardless if the nitroglycerin helps.  If your pain changes or feels different, call your doctor or call 911 if the pain is severe.
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DESCRIPTION: A sample note on Angina.

A sample note on Angina.

cardiovascular / pulmonary, lack of oxygen, heart valve, arrhythmias, blood pressure, heart, tightness, nitroglycerin, coronary artery disease, oxygen, angina, coronary, chest,

The description of angina presents a serious medical condition with potential life-threatening implications, such as heart attack, congestive heart failure, or fatal arrhythmias. The condition requires immediate attention when symptoms persist despite taking nitroglycerin, emphasizing the high stakes involved in managing this medical issue. It carries a significant risk to patient health, especially for those with underlying heart conditions.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Acute Inferior Myocardial Infarction

CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".,The patient is diabetic and has a prior history of coronary artery disease.  The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  The severity of the pain has progressively increased.  He describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  He ranks the pain a 7 on a scale of 1-10.  He admits some shortness of breath & diaphoresis.  He states that he has had nausea & 3 episodes of vomiting tonight.  He denies any fever or chills.  He admits prior episodes of similar pain prior to his PTCA in 1995.  He states the pain is somewhat worse with walking and seems to be relieved with rest.  There is no change in pain with positioning.  He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  The patient ranks his present pain a 4 on a scale of 1-10.  The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:,  All other systems reviewed & are negative.,PAST MEDICAL HISTORY:,  Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs.  Smokes 2 packs of cigarettes per day.  Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay.  Humulin N. insulin 50 units in a.m.  HCTZ 50 mg QDay.  Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General:  The patient is moderately obese but he is otherwise well developed & well nourished.  He appears in moderate discomfort but there is no evidence of distress.  He is alert, and oriented to person place and circumstance.  There is no evidence of respiratory distress.  The patient ambulates
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DESCRIPTION: Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.

The case involves a 40-year-old male patient presenting with classic symptoms of an acute myocardial infarction (heart attack), including chest pain radiating to the neck and arm, shortness of breath, diaphoresis, and a significant cardiac history. The patient has serious risk factors such as diabetes, hypertension, significant smoking history, and family history of coronary artery disease. These combined factors indicate it is a high-stakes scenario as myocardial infarctions can be life-threatening and require immediate medical intervention.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Abnormal Stress Test

HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.  He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI.  I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded.  The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1.  Aspirin 325 mg once a day.,2.  Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3.  Nexium 40 mg once a day.,4.  Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation.  I see that his LDL was 136 on May 3, 2002.,5.  Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION:  ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.
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DESCRIPTION: Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.

cardiovascular / pulmonary, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress

The situation involves a 60-year-old patient with a significantly abnormal stress test result, indicating serious cardiovascular issues. A cardiac catheterization revealed severe coronary artery disease, specifically a 99% blockage in one artery, making it a critical condition requiring intervention through PCI (Percutaneous Coronary Intervention). Given the severity of the patient's condition and the decision to transfer him for immediate medical intervention, the stakes are high as untreated or delayed treatment could lead to serious complications including a heart attack.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Abnormal Echocardiogram

REASON FOR CONSULTATION:  ,Abnormal echocardiogram findings and followup.  Shortness of breath, congestive heart failure, and valvular insufficiency.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools.  The patient has colitis and also diverticulitis, undergoing treatment.  During the hospitalization, the patient complains of shortness of breath, which is worsening.  The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.  This consultation is for further evaluation in this regard.  As per the patient, she is an 86-year-old female, has limited activity level.  She has been having shortness of breath for many years.  She also was told that she has a heart murmur, which was not followed through on a regular basis.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY:  ,Nonsignificant.,PAST SURGICAL HISTORY: , No major surgery.,MEDICATIONS: , Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.,ALLERGIES:  ,AMBIEN, CARDIZEM, AND IBUPROFEN.,PERSONAL HISTORY:,  She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:  ,Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of cataract, blurred vision, and hearing impairment.,CARDIOVASCULAR:  Shortness of breath and heart murmur.  No coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and severe muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGICAL:  As above.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.,HEENT/NECK:  Head is atraumatic and normocephalic.  Neck veins flat.  No significant carotid bruits appreciated.,LUNGS:  Air entry bilaterally fair.  No obvious rales or wheezes.,HEART:  PMI displaced.  S1, S2 with systolic murmur at the precordium, grade 2/6.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Chronic skin changes.  Feeble pulses distally.  No clubbing or cyanosis.,DIAGNOSTIC DATA: , EKG:  Normal sinus rhythm.  No acute ST-T changes.,Echocardiogram report was reviewed.,LABORATORY DATA:,  H&H 13 and 39.  BUN and creatinine within normal limits.  Potassium within normal limits.  BNP 9290.,IMPRESSION:,1.  The patient admitted for gastrointestinal pathology, under working treatment.,2.  History of prior heart murmur with echocardiogram findings as above.  Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.,RECOMMENDATIONS:,1.  From cardiac standpoint, conservative treatment.  Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.,2.  After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.,3.  Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares.  She has a normal LV function.
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DESCRIPTION: Abnormal echocardiogram findings and followup.  Shortness of breath, congestive heart failure, and valvular insufficiency.   The patient complains of shortness of breath, which is worsening.  The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.

The situation involves a complex medical assessment of an elderly patient with significant cardiovascular issues, such as severe mitral regurgitation and congestive heart failure. These conditions require careful management and can lead to serious health consequences if not properly addressed. The high BNP level indicates significant heart stress, and the patient's age and the complexity of her medical conditions elevate the stakes. However, the decision to avoid invasive procedures due to the patient's condition and wishes slightly lessens the immediacy of surgical intervention risks. Overall, the situation has high-stakes implications for the patient's health outcomes.


Medical Specialty: Bariatrics
Sample Name: Gastric Bypass - Preop Eval

REASON FOR VISIT:,  Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3.  Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds.  Abdomen:  Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:,  The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks.  Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection.  Questions regarding hospital course and recovery were addressed.  We will continue on the Medifast diet until the time of surgery and cleared for surgery.
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DESCRIPTION: Preop evaluation regarding gastric bypass surgery.

bariatrics, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass,

This preoperative evaluation is crucial for determining if the patient is ready for a significant surgery such as gastric bypass, which inherently comes with considerable risks. The stakes are high due to potential complications that can arise during or after surgery, such as death, pulmonary embolism, and infection, making the decision impactful on the patient's health and life. Additionally, gastric bypass surgery is a life-changing procedure for the patient tackling morbid obesity, complicating factors like the psychological and nutritional pre-op clearances underscore the importance of the decision at hand.


Medical Specialty: Autopsy
Sample Name: Autopsy - 5

MANNER OF DEATH: , Homicide.,CAUSE OF DEATH:,
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DESCRIPTION: Autopsy - Homicide - evidence of exsanguination - multiple stab wounds.

The situation involves an autopsy for a homicide case, which is inherently high-stakes as it involves legal and criminal implications. The findings could influence the judicial process and have significant consequences for the perpetrators, victims' families, and the community. The accuracy and details of the autopsy report can impact the outcome of a criminal investigation and court proceedings.


Medical Specialty: Bariatrics
Sample Name: Bariatric Consult - Surgical Weight Loss - 4

HISTORY OF PRESENT ILLNESS:,  Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.  The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss.  At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46.  She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:,  Significant for hypertension, for which the patient takes Norvasc and Lopressor for.  She also suffers from high cholesterol and is on lovastatin for this.  She has depression, for which she takes citalopram.  She also stated that she had a DVT in the past prior to her hysterectomy.  She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones.  She also had a hysterectomy in 1994 secondary to hemorrhage.  The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker.  She is married, with 2 children aged 22 and 28.  She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY:  ,Significant for high blood pressure and diabetes as well as cancer on her father side.  He did pass away from congestive heart failure.  Mother suffers from high blood pressure, cancer, and diabetes.  Her mother has passed away secondary to cancer.  She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling.  The patient also wears glasses for vision and has dentures.  She does complain of shortness of breath with exertion.  She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain.  The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease.  She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION:  ,The patient is a well-nourished, well-developed female, in no distress.  Eye Exam:  Pupils equal and reactive to light.  Extraocular motions are intact.  Neck Exam:  No cervical lymphadenopathy.  Midline trachea.  No carotid bruits.  Nonpalpable thyroid.  Neuro Exam:  Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted.  Lung Exam:  Clear breath sounds without rhonchi or wheezes.  Cardiac Exam:  Regular rate and rhythm without murmur or bruits.  Abdominal Exam:  Positive bowel sounds.  Soft, nontender, obese, and nondistended abdomen.  Lap cholecystectomy scars noted.  No obvious hernias.  No organomegaly appreciated.  Lower extremity Exam:  Edema 1+.  Dorsalis pedis pulses 2+.,ASSESSMENT:  ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery.  The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels.  I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy.  Also the patient will meet with the dietitian and psychologist as per her usual routine.  I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.
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DESCRIPTION: Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.

bariatrics, jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,

The situation involves Ms. A, a 55-year-old female, who is being considered for laparoscopic Roux-en-Y gastric bypass surgery due to long-term obesity and associated comorbidities. The procedure is significant as it aims to address her severe obesity (BMI of 46) and improve her hypertension, hypercholesterolemia, depression, and other health issues. Bariatric surgery is a major and potentially life-changing surgical intervention. Its success and outcome can significantly impact the patient's quality of life and longevity. However, it requires careful pre-operative evaluation and lifestyle changes. While important, this scenario does not present immediate life-threatening conditions, but carries substantial implications for her long-term health, making it a moderately high-stakes situation.


Medical Specialty: Autopsy
Sample Name: Autopsy - 1

EXTERNAL EXAMINATION - SUMMARY,The body is presented in a black body bag. At the time of examination, the body is clothed in a long-sleeved red cotton thermal shirt, khaki twill cargo pants, and one black shoe.,The body is that of a normally developed, well nourished Caucasian female measuring 63 inches in length, weighing 114 pounds, and appearing generally consistent with the stated age of thirty-five years. The body is cold and unembalmed with declining rigor. Pronounced unblanching lividity is present on the posterior of the body in the regions of the feet; the upper thighs, particularly on the right side; the lower back, particularly on the right side; the right arm; and the neck.,The scalp is covered by long (16 inches) brown hair. The body hair is female and average. The skull is symmetric and evidences extensive trauma in the occipital region. The eyes are open and the irises are blue. Pupils are asymmetrically dilated. The teeth are natural and well maintained. The anterior chest is of normal contour and is intact. The breasts are female and contain no palpable masses. The abdomen is flat and the pelvis is intact. The external genitalia are female and unremarkable. The back is symmetrical and intact. The upper and lower extremities are symmetric, normally developed and intact. The hands and nails are clean and evidence no injury.,There are no residual scars, markings or tattoos.,INTERNAL EXAMINATION - SUMMARY,CENTRAL NERVOUS SYSTEM: ,The brain weighs 1,303 grams and is within normal limits. ,SKELETAL SYSTEM:, Subdural hematoma and comminuted fractures of the occipital bone are observed. Numerous bone fragments from the fractures penetrated the brain tissue. ,RESPIRATORY SYSTEM--THROAT STRUCTURES: ,The oral cavity shows no lesions. The mucosa is intact and there are no injuries to the lips, teeth or gums. There is no obstruction of the airway. The mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. No injuries are seen and there are no mucosal lesions. The lungs weigh: right, 355 grams; left 362 grams. The lungs are unremarkable. ,CARDIOVASCULAR SYSTEM:, The heart weighs 253 grams, and has a normal size and configuration. No evidence of atherosclerosis is present. ,GASTROINTESTINAL SYSTEM: ,The mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. The gastric mucosa is intact and pink without injury. Approximately 125 ml of partially digested semisolid food is found in the stomach. The mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. ,URINARY SYSTEM:, The kidneys weigh: left, 115 grams; right, 113 grams. The kidneys are anatomic in size, shape and location and are without lesions. ,FEMALE GENITAL SYSTEM: ,The structures are within normal limits. Examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. Vaginal fluid samples are removed for analysis. ,DESCRIPTION OF INJURIES - SUMMARY,Blunt force traumatic injury with multiple cranial fractures resulting in craniocerebral injury. Wound measures approximately 4 inches high x 5 1/2 inches wide. Subdural hematoma and comminuted fractures of the occipital bone are observed. Numerous bone fragments from the fractures penetrated the brain tissue. Depths of penetration range from 1/2-inch to 3 inches. Injury appears to have resulted from a single blow administered to the posterior of the head, delivered at an approximate 90º angle to the occipital bone.,LABORATORY DATA,CEREBROSPINAL FLUID CULTURE AND SENSITIVITY:,Gram stain: Unremarkable,Culture: No growth after 72 hours,CEREBROSPINAL FLUID BACTERIAL ANTIGENS:,Hemophilus influenza B: Negative,Streptococcus pneumoniae: Negative,N. Meningitidis: Negative,Neiserria meningitidis B/E. Coli K1: Negative ,PRELIMINARY TOXICOLOGICAL RESULTS:,BLOOD  -  ETHANOL  -  NEG ,BLOOD  -  CANNABINOIDS-ETS  -  INC,BLOOD  -  COCAINE-ETS  -  INC,BLOOD  -  OPIATES-ETS  -  INC,BLOOD  -  AMPHETAMINE-ETS  -  INC,BLOOD  -  BARBITURATE -ETS  -  INC,BLOOD  -  BENZODIAZEPINE-ETS  -  INC,BLOOD  -  METHADONE-ETS  -  INC,BLOOD  -  PCP-ETS  -  INC,BLOOD  -  CARBON MONOXIDE  -  NEG,Urine Drugs: Initial test results inconclusive. Further tests pending. ,EVIDENCE COLLECTED,1. Samples of Blood (type O+), Urine, Bile, and Tissue (heart, lung, brain, kidney, liver, spleen). ,2. Thirteen autopsy photographs. ,3. Two postmortem x-rays. ,Clothing transferred to ABC Lab for further analysis.
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DESCRIPTION: Autopsy - Homicide - Blunt force cranial trauma

The situation involves an autopsy following a suspected homicide, indicated by blunt force cranial trauma and multiple substances found in preliminary toxicological results. Autopsies in homicide cases are critical for legal proceedings, as they help determine cause of death and potential involvement of substances or other factors. The outcome of the autopsy will have significant legal and investigational implications, possibly affecting the prosecution of a crime. Therefore, the stakes can be considered high due to the impact on justice and potential legal consequences.


Medical Specialty: Bariatrics
Sample Name: Bariatric Consult - Surgical Weight Loss - 2

PAST MEDICAL HISTORY:  ,She had a negative stress test four to five years ago.  She gets short of breath in walking about 30 steps.  She has had non-insulin dependent diabetes for about eight years now.  She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married.  She is an office manager for a gravel company.  Her spouse is also overweight.  She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time.  She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:,  Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:,  She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass.  ABC will be asking for a letter of medical necessity from XYZ.  She will also need an EKG and clearance for surgery.  She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.
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DESCRIPTION: Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.

bariatrics, elective surgical weight loss, surgical weight loss, weight loss, lap band, gastric bypass, loss, weight, lap, band, lost, gained, diabetes, gastric, bypass, overweight, surgical

The situation involves a medical evaluation for elective bariatric surgery. Although bariatric surgery is an elective procedure, it is still a significant surgical intervention with potential risks. The patient's existing medical conditions such as diabetes, obesity, and her social habits add complexity to the case. However, since it is elective and non-emergent, it is not extremely high-stakes like life-saving emergency surgeries. The stakes are moderate due to the possible health improvements from the surgery versus the surgical risks and preparation process.


Medical Specialty: Autopsy
Sample Name: Autopsy - 7

EXTERNAL EXAMINATION: , The body is that of a 62-inch, 112-pound white female who appears the recorded age of 41 years.  The body is clad in a pink and white gown.  Three pillows and a blanket are also received with the body.  The scalp is covered in thick brown hair with flecks of gray.  The irides are brown.  There is bilateral tache noire.  The eyelids are yellow and dry.  The eyes have a sunken appearance.  The ears and nose are normally developed.  The mouth has partial natural dentition.  The left upper first bicuspid through the molars are absent.  The left lower bicuspid is absent.  The right upper second molar is capped.  The left lower first molar appears decayed.  The teeth are otherwise in good repair.  The lips and buccal mucosa have no trauma.  The neck is unremarkable except for a 2.5 cm tracheostomy scar just above the suprasternal notch.  The posterior portion of the neck is unremarkable and free of scars.  An obliquely oriented 6 cm surgical scar is on the anterior left chest with an underlying, implanted, medical device.  The breasts are pendulous and otherwise unremarkable.  There is white powder underneath the breasts.  A round, 8 mm scar is on the upper central abdomen.  A horizontally oriented 2.5 cm linear scar is on the central upper abdomen.  A faint, approximately 1 cm scar is on the right mid lateral abdomen.  There are a few striae on the hips and lower abdomen.  The external genitalia are normally developed and white powder covers the perineum.  The labia are dry.  The urethral meatus is visible and 3.5 mm in diameter.  No objects or substances are in the vagina other than a slight amount of yellow-white discharge.  The anus is patent and unremarkable.  Faint, pink-white, flat, 1-2 cm scars are just above the superior portion of the gluteal cleft.  A 2.5 cm, somewhat square shaped, brown macule is on the left buttock.  There are no open and active decubitus ulcers.  The upper extremities have flexion contractures with striae on the medial portions of the upper arms.  The muscles of the extremities are atrophic.  The lower extremities are partially shaved.  The left fifth toe is absent.  The skin on the back is intact.  The spine has accentuated thoracic kyphosis and lumbar lordosis.  The skin demonstrates tenting,RADIOGRAPHS: , Postmortem radiographs show radiopaque shadows extending from the periosteum of the femurs, left tibia, and right ischial tuberosity.  Diffuse, severe osteoporosis is present.  The 11th thoracic vertebral body has an endplate fracture.  Degenerative joint changes are noted in the acromioclavicular joints, hips, right knee, left foot, and pelvis.  The left fifth toe is amputated along with the distal portion of the left fifth metatarsal.  Radiographs of anterior neck structures and iliac wings are not remarkable.  Calculi are seen in the urinary tract.  Staples are in the gallbladder bed.,INTERNAL EXAMINATION: , The muscles of the chest and abdominal wall are normally developed.  The subcutaneous tissues are dry.  The panniculus is 2.5-3 cm.  In the left chest wall is an implanted medical device with a wire extending through subcutaneous tissues of the left neck and into the left scalp.  A flat, four-prong electrical device is in the subgaleal area of the left scalp.  A wire then further extends into the cranial cavity.  The peritoneal cavity is unremarkable and dry.  There are no intraperitoneal adhesions except for an adhesion of the anterior portion of the stomach to the anterior abdominal wall in the area of the previously described round abdominal scar.  The organs are in the usual anatomic relations.  The pleural cavities are dry.  The lungs are well aerated.  The pericardial sac is remarkable for a 1 cm focal area of anterior pericardial adhesion to the anterior portion of the right ventricle.  There is some lateral adhesion of the right ventricle to the right lateral portion of the pericardial sac.  No other adhesions are noted.  The pericardial sac is dry.  The diaphragm is intact.  The sternum is unremarkable.  The ribs have no trauma and are normally developed with somewhat prominent costochondral junctions.,CARDIOVASCULAR SYSTEM: , The pericardial sac is remarkable as previously described.  The epicardial fat of the 255 gram heart is otherwise unremarkable.  The root of the aorta has no atherosclerosis.  The arch and descending aorta have minimal atherosclerosis (see attached CV pathology report).,RESPIRATORY SYSTEM: , The right and left lungs are 260 and 245 grams, respectively.  The lungs have a normal number of lobes and have light pink-red outer surfaces.  The bronchi are unobstructed.  The well-aerated lung parenchyma is pink-red.  There are no anthracosis, tumors, cysts, or infarcts.  The upper lobe bronchi contain a scant amount pearlescent fluid.  The proximal bronchi contain yellow pearlescent fluid.  The lower lobe distal bronchi contain some scattered areas of yellow pearlescent fluid.  The alveoli otherwise contain foamy, reddish-white fluid.  The pulmonary arteries contain no emboli.  The lower lobes have firm areas of partial consolidation with yellow-green pearlescent fluid.  The firm area of the left lower lobe is ,4 x 4 x 3 cm.  The right lung has scattered firm areas (<lcm).,HEMOLYMPHATIC SYSTEM: , The 215 gram spleen is covered in an intact, gray, somewhat wrinkled capsule.  There are two hilar accessory spleens (1.4 and 1 cm in diameter).  The splenic parenchyma is dark red-maroon and unremarkable.  There is no interstitial fibrosis, tumors, cysts or infarcts.  No enlarged lymph nodes are noted.  The bone marrow of the lumbar vertebral bodies is red and soft.,GENITOURINARY SYSTEM:,  The right and left kidneys are 100 and 130 grams, respectively.  The right kidney has a central, 2-2.5 cm, obliquely oriented cleft/scar extending from the central renal pelvis to the upper lateral cortex.  The brown-tan outer surfaces are otherwise slightly lobular and granular.  The pelvis of the right kidney is mildly dilated.  A 1 x 0.6 x 0.7 cm, green-brown stone is in the pelvis of the right kidney.  The left renal pelvis has an approximately 0.5 x 0.6 x 1 cm, green-brown stone.  The corticomedullary ratios are reduced.  The pelvic fat is increased.  The left ureter contains pearlescent fluid.  The urinary bladder contains ,6 cc of brown-yellow fluid.  A 3.8 x 1.2 x 1 cm, white-yellow, somewhat crescent shaped stone is within the lumen of the bladder.  The uterus is present and has a normal shape.  The cervix is normally developed.  The cervical os is large (coned) and contains mucoid fluid.  There are a few minute nabothian cysts (<2 mm).  A 2 cm, spherical leiomyoma is in the posterior portion of the uterine corpus.  The endometrial cavity contains 3 to 4 mm thick, tan endometrium.  The ovaries are present, firm and otherwise grossly unremarkable.  The fallopian tubes are unremarkable except for a few adhesions of the fimbriated ends.,GASTROINTESTINAL SYSTEM:,  The stomach contains 60 cc of green-brown fluid without any solid food fragments.  The gastric mucosa is flat, congested, and green-gray.  The gastric mucosa is congested.  No ulcerations are noted.  There are a few congested vessels with minute petechiae around the previously healed ostomy site.  An 8 mm blood clot is on the gastric mucosa near the healed/healing gastrostomy site.  The wall of the stomach is thin (<3mm).  No perforations are noted.  The esophagus is not remarkable with gray/pink mucosa.  The bowel contains progressively formed feces with the rectum containing hard stool.  The appendix is present, but is atrophic/small.  The bowel has no perforations.  An abundant amount of greenish liquid is in the duodenum.  No foreign objects are noted.,HEPATOBILIARY SYSTEM:,  The outer surface of the 965 gram liver is covered in a transparent intact capsule.  There are very few inferior hepatic adhesions associated with an absent gallbladder.  Surgical staples are imbedded in the area of the cystic duct.  The hepatic parenchyma is brown-green with a slight pattern of congestion.  The bile ducts and portal veins appear grossly unremarkable.  No fibrosis, cysts or infarcts are noted.  A yellow-white, round, 2 mm nodule is in the anterior portion of the right lobe of the liver.,ENDOCRINE SYSTEM: , The adrenals and pancreas are present and grossly unremarkable.  The thyroid is mildly atrophic without nodules.,MUSCULOSKELETAL SYSTEM: , The upper and lower extremities are atrophic as previously described.  The trunk musculature is atrophic.  A 1 x 1.5 x ,1 cm area of induration/calcification extends from the anterior surface of the right femur.  The anterior/lateral cortical surface of the distal right femur metaphysis is rough and irregular.  The cortical bone of the lumbar and thoracic vertebral bodies is thin and soft.  The iliac wings have no trauma or deformity.,NECK: , The strap muscles of the anterior neck have intact musculature with atrophy of the musculature on the right side.  The right sternocleidomastoid is moderately atrophic.  There are no hemorrhages.  The larynx and piriform recesses contain yellow-tan, mucoid fluid.  There is yellow-green, mucoid fluid on the base of the tongue and epiglottis.  The larynx contains a scant amount of fluid.  The thyroid and cricoid cartilages are intact.  The hyoid bone is intact.  The tongue is atrophic.  There is a yellow-green dry crusted material on the surface of the tongue.  The posterior pharyngeal musculature appears atrophic.  There are no hemorrhages.  A healed tracheostomy site is on the anterior trachea.  The carotid arteries and jugular veins are not remarkable.  The muscles and cervical vertebral bodies of the posterior neck are not remarkable.  The spinal cord and column have no trauma.  The posterior laminae are soft.,CENTRAL NERVOUS SYSTEM: , See neuropathology report,MICROSCOPIC EXAMINATION: , (Also see neuropathology and cardiovascular pathology reports),LUNGS, LOWER LOBES:  Widespread bronchopneumonia.  Intraalveolar debris and bacteria.,Intraalveolar foamy macrophages.  Congestion.  Edema.,UTERUS:  Late proliferative endometrium leiomyoma.,ACCESSORY SPLEEN:  Not remarkable.,COLON:  Autolysis.  Melanosis.,URINARY BLADDER:  Chronic inflammation.,OVARIES:  Corpora albicantia.  Follicular cyst.,FALLOPIAN TUBES:  Paratubal cyst.  Congestion.,VAGINA:  Vascular congestion.,ADRENAL GLANDS:  Mild congestion.,STOMACH, GASTROSTOMY:  Clotted blood.,LIVER:  Focal nodular hyperplasia (single focus).  Centrilobular congestion with steatosis,KIDNEYS:  Tubular necrosis.  Mild vascular congestion.,THYROID:  Not remarkable.,PANCREAS:  Early autolysis.  Mild interstitial fibrosis.,EPIGLOTTIS:  Focal ulceration with acute inflammation.,LARYNX, RIGHT ARYEPIGLOTTIC FOLD:  Not remarkable.
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DESCRIPTION: Cause of death - Anoxic Encephalopathy

Cause of death - Anoxic Encephalopathy

The situation involves an autopsy report providing detailed anatomical and pathological findings, culminating in the cause of death as anoxic encephalopathy. The stakes can be considered moderate due to the medical-legal implications of autopsy results, which might be associated with legal inquiries, familial closure, or public health data. However, it does not involve immediate life-and-death decisions or urgent interventions, which are typically associated with the highest stakes in medical settings.


Medical Specialty: Allergy / Immunology
Sample Name: Evaluation of Allergies

HISTORY:,  A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies.  Please refer to chart for history and physical and review of systems and detailed medical history.,IMPRESSION:  ,1.  Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.,2.  History of fibromyalgia.,3.  History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.,4.  History of chronic fatigue.,5.  History of hypothyroidism.,6.  History of depression.,7.  History of dysphagia.,RECOMMENDATIONS: , RAST allergy testing was ordered for food allergy evaluation.  The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested.  The patient will follow up after RAST allergy testing for further treatment recommendations.  At this point, no changes in her medication were prescribed until her followup visit.
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DESCRIPTION: Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.

allergy / immunology, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy

This patient has multiple health issues including potential allergies, asthma, and other chronic conditions which could compound her health complications. The stakes are moderate because the patient's symptoms—like potential food allergies and chronic conditions—require careful management to prevent further health deterioration or complications. However, since immediate life-threatening risks are not explicitly mentioned, the stakes are not at the highest level. The follow-up treatments and tests are planned, indicating ongoing care rather than urgent intervention.