Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pacemaker (Dual Chamber)

CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.
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DESCRIPTION: Implantation of a dual chamber permanent pacemaker

cardiovascular / pulmonary, medtronic enrhythm, cephalic vein, dual chamber, dual chamber permanent pacemaker, dyspnea on exertion, echocardiogram, fatigue, hypertension, lightheadedness, normal sinus rhythm, pacemaker, permanent pacemaker, sinoatrial exit block, sinus bradycardia, valvular heart disease, bradycardia, medtronic, atrial,

The implantation of a dual chamber permanent pacemaker is a significant medical procedure intended to treat serious symptoms such as severe bradycardia, which can cause severe fatigue, lightheadedness, and dyspnea on exertion. If left untreated, these symptoms could severely impact the patient's quality of life and potentially lead to life-threatening situations. The successful execution of this procedure is crucial for stabilizing the patient's heart rhythm and ensuring her overall well-being. As there were no complications reported and the device functioned properly post-implantation, the immediate stakes are mitigated, but the initial high-stakes nature of requiring a pacemaker implantation remains.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Myocardial Perfusion Imaging - 1

MEDICATIONS: , Plavix, atenolol, Lipitor, and folic acid.,CLINICAL HISTORY:  ,This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION:  ,The patient exercised for a total of 12 minutes on the standard Bruce protocol.  The peak workload was 12.8 METS.  The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response.  The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90.  The test was stopped due to fatigue and leg pain.  EKG at rest showed normal sinus rhythm.  The peak stress EKG did not reveal any ischemic ST-T wave abnormalities.  There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen.  At peak, there was no chest pain noted.  The test was stopped due to fatigue and left pain.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was good.,2.  There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3.  The left ventricular cavity appeared normal in size.,4.  Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis.  Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,CONCLUSIONS:,1.  Good exercise tolerance.,2.  Less than adequate cardiac stress.  The patient was on beta-blocker therapy.,3.  No EKG evidence of stress induced ischemia.,4.  No chest pain with stress.,5.  Mild ventricular bigeminy with exercise.,6.  No diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7.  Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.
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DESCRIPTION: Myocardial perfusion imaging - patient with history of MI, stents placement, and chest pain.

cardiovascular / pulmonary, myocardial perfusion imaging, bruce protocol, cardiolite, ekg, mets, mi, spect, st-t, bigeminy, blood pressure, chest pain, exercise tolerance, myocardial perfusion, normal sinus rhythm, peak workload, sestamibi, stents, stress, tachycardia, ventricular, ventricular cavity, stress myocardial perfusion, perfusion imaging, myocardial, perfusion, mci, hypokinesis, imaging,

The medical situation involves a patient with a history of myocardial infarction (MI), stent placement, and ongoing chest pain who is undergoing myocardial perfusion imaging. This type of case is moderately high-stakes due to the risk factors involved with cardiovascular conditions, potential for ischemia, and the implications for the patient's health and management of their heart condition. The imaging results are crucial for evaluating the patient's current cardiac function and guiding potential interventions or adjustments in treatment. The stakes are heightened by the presence of ventricular bigeminy during exercise, hypokinesis, and a low-normal ejection fraction, which suggests possible underlying cardiac issues that need careful monitoring and management.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Multilobar Pneumonia

REASON FOR CONSULTATION: , Loculated left effusion, multilobar pneumonia.
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DESCRIPTION: Loculated left effusion, multilobar pneumonia.  Patient  had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency.

cardiovascular / pulmonary, neck bruits, nasal cannula, rhythm, pneumonia, chest tube, fluid collection, pleural effusion, multilobar pneumonia, pleural, loculations, multilobar,

The case involves a patient diagnosed with multilobar pneumonia, which is serious on its own, but it is compounded by additional health issues such as arrhythmia, heart failure, and renal insufficiency. These combinations of conditions make it a complex and potentially life-threatening situation, requiring urgent attention and management from the medical team. These conditions can significantly impact each other, increasing the risk for the patient.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Microlaryngoscopy

PREOPERATIVE DIAGNOSIS:,  Airway obstruction secondary to laryngeal subglottic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Airway obstruction secondary to laryngeal subglottic stenosis and tracheal stenosis.,OPERATION PERFORMED: , Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.,INDICATIONS FOR SURGERY:  ,The patient is a 56-year-old white female with a history of relapsing polychondritis, which resulted in saddle nose deformity in glottic and subglottic stenosis for which she has undergone number of procedures in the past to the upper airway.  She currently is trach dependent for her airway because of glottic and subglottic stenosis, but she is having no significant problems breathing and talking around her trach tube and came for further evaluation.  Endoscopic reevaluation of her tube and nature of the proposed procedure done.  Risk and complications of bleeding, infection, alteration of with speech or swallowing, failure to improve her airway, and loss of voice.  Cardiorespiratory anesthetic results were discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room and placed in the supine position.  Under adequate general endotracheal anesthesia, the patient's #5 metal tracheostomy tube was removed and a #5 laser-safe endotracheal tube was inserted.  The patient was then prepared for endoscopy.  The Kantor laryngoscope was then inserted.  Oral cavity, hypopharynx, larynx, and nasal cavity showed good dentition with good tongue, buccal cavity, and mucosa without lesions.  Larynx was then ***** short epiglottis.  Larynx was suspended with significant scarring beginning in the supraglottic area with loss of laryngeal contour beginning in the supraglottis with extensive scar tissue at the level of the false cord obliteration of ventricles and true cords.  This appeared to be stable, and airway was patent at the supraglottic and glottic level with some narrowing at the subglottic level with mild-to-moderate subglottic stenosis, otherwise this appeared to be stable.  However, distally, the level of the trach site examined with the microscope and 0 and 30-degree telescopes.  The patient noted to have marked narrowing with dense scarring posterolaterally on the left securing good visualization of the trach tube.  The laryngoscope was removed, and a 5 x 30 pediatric rigid bronchoscope was then passed.  The LP contact tip laser was utilized to vaporize the scar tissue and release the scar banding following which the scope was passed and further dilation carried out.  Mid and distal trachea were widely patent.  Trachea and mainstem bronchi were patent without obvious disease.  The patient did not appear to have any relapsing polychondritis with progressive scar tissue at the level of the trach site and the posterior trachea wall was significant.  This was further dilated and following which was removed and a new #5 metal tracheostomy tube inserted.  The patient tolerated the procedure well without complications and was taken to recovery room in satisfactory condition.
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DESCRIPTION: Suspension microlaryngoscopy, rigid bronchoscopy, dilation of tracheal stenosis.

cardiovascular / pulmonary, airway obstruction, oral cavity, bronchoscopy, buccal cavity, hypopharynx, laryngeal, larynx, microlaryngoscopy, nasal cavity, polychondritis, subglottic, tracheal stenosis, tracheostomy tube, scar tissue, subglottic stenosis, tracheal, airway, cavity, tube, scarring, stenosis,

The case involves a major surgical procedure addressing severe airway obstruction due to laryngeal and tracheal stenosis, which are high-risk conditions. The patient also has a history of relapsing polychondritis, complicating the situation. The surgery carries potential risks such as bleeding, infection, and loss of voice, and it demands careful anesthetic management, indicating a high-stakes medical scenario that requires significant expertise and carries potential life-threatening risks if not managed properly.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mesothelioma - Consult

REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization.  He has also been seen by me in the clinic in the last few weeks.  He was admitted on January 18, 2008, with recurrent malignant pleural effusion.  On the same day, he underwent VATS and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by Dr. X.  He was found to have 2.5L of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma.  His hospital course here has been significant for dyspnea, requiring ICU stay.  He also had a chest tube, which was taken out few days ago.  He has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist.  The biopsy from the pleural nodule done on the right on January 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma.  Immunohistochemical staining showed tumor cells positive for calretinin and focally positive for D2-40, MOC-31.  Tumor cells are negative for CDX-2, and monoclonal CEA.,The patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days.  He does have edema in his lower extremities.  He is currently on 4L of oxygen.  He denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia.  No neurological or musculoskeletal signs or symptoms.  He reports that he is able to ambulate to the bathroom, but gets short of breath on exertion.  He denies any other complaints.,PAST MEDICAL HISTORY:,  Left ventricular systolic dysfunction as per the previous echocardiogram done in December 2007, history of pneumonia in December 2007, admitted to XYZ Hospital.  History of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in XYZ Hospital.,ALLERGIES:,  No known drug allergies.,CURRENT MEDICATIONS:  ,In the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, Zosyn, p.r.n. acetaminophen, and hydrocodone.,SOCIAL HISTORY: , The patient is married and lives with his spouse.  He has history of tobacco smoking and also reports history of alcohol abuse.  No history of illicit drug abuse.,FAMILY HISTORY:  ,Significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,REVIEW OF SYSTEMS: , As stated above.  He denies any obvious asbestos exposure, as far as he can remember.,PHYSICAL EXAMINATION,GENERAL:  He is awake, alert, in no acute distress.  He is currently on 4L of oxygen by nasal cannula.,VITAL SIGNS:  Blood pressure 97/65 mmHg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees Fahrenheit.,HEENT:  No icterus or sinus tenderness.  Oral mucosa is moist.,NECK:  Supple.  No lymphadenopathy.,LUNGS:  Clear to auscultation except few diffuse wheezing present bilaterally.,CARDIOVASCULAR:  S1 and S2 normal.,ABDOMEN:  Soft, nondistended, and nontender.  No hepatosplenomegaly.  Bowel sounds are present in all four quadrants.,EXTREMITIES:  Bilateral pedal edema is present in both the extremities.  No signs of DVT.,NEUROLOGICAL:  Grossly nonfocal.,INVESTIGATION:,  Labs done on January 28, 2008, showed BUN of 23 and creatinine of 0.9.  Liver enzymes checked on January 17, 2008, were unremarkable.  CBC done on January 26, 2008, showed WBC of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000.  Chest x-ray from yesterday shows right-sided Port-A-Cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,ASSESSMENT,1.  Mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2.  Chronic obstructive pulmonary disease.,3.  Paroxysmal atrial fibrillation.,4.  Malignant pleural effusion, status post surgery as stated above.,5.  Anemia of chronic disease.,RECOMMENDATIONS,1.  Compare the slides from the previous biopsy done in December at XYZ Hospital with recurrent pleural nodule biopsy slides.  I have discussed regarding this with Dr. Y in Pathology here at Methodist XYZ Hospital.  I will try to obtain the slides for comparison from XYZ Hospital for comparison and immunohistochemical staining.,2.  I will also discuss with Dr. X and also with intervention radiologist at XYZ Hospital regarding the exact sites of the two biopsies.,3.  Once the results of the above are available, I will make further recommendations regarding treatment.  The patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to Triumph Hospital for rehab, which I agree with.,4.  Continue present care.,Discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction.  They clearly understand the above.  They also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this.
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DESCRIPTION: Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.

This consultation involves a 73-year-old patient with a complex medical history, including a confirmed diagnosis of malignant mesothelioma, a serious and aggressive cancer often linked to asbestos exposure. The patient also has multiple other serious conditions, such as malignant pleural effusion, paroxysmal atrial fibrillation, and COPD, each of which can significantly impact quality of life and prognosis. The ongoing assessment and management of potentially life-threatening conditions, especially in the context of making treatment decisions regarding possible lung carcinoma and complex pharmacological management, make this a high-stakes medical situation. The potential outcomes significantly affect the patient's health and survival, requiring close coordination between specialists and careful deliberation of treatment options.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lung Biopsy Pathology Report

CLINICAL HISTORY:,  A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.  The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter.  The patient was referred for surgical treatment.,SPECIMEN:,A.  Lung, wedge biopsy right lower lobe,B.  Lung, resection right upper lobe,C.  Lymph node, biopsy level 2 and 4,D.  Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A.  Wedge biopsy of right lower lobe showing:  Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B.  Right upper lobe lung resection showing:  Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin.  Two (2) hilar lymph nodes with no metastatic tumor.,C.  Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D.  Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT:  ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe.  This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces.  Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule.  The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,
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DESCRIPTION: Lung, wedge biopsy right lower lobe and resection right upper lobe.  Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.

cardiovascular / pulmonary, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node

The situation involves a detailed pathology report for a patient with lung masses suspected to be cancerous. The potential diagnosis of adenocarcinoma and the surgical intervention discussed indicate serious health implications. Given that the patient has multiple masses in the lung, with one showing transbronchial spread, the stakes are high. This is crucial for treatment decisions and the patient's overall prognosis. The outcome can significantly impact the patient's quality of life and survival, thus making this a high-stakes situation. The coordination of surgical interventions and potential cancer treatments adds to the complexity and weight of the situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lobectomy & Lymphadenectomy

PREOPERATIVE DIAGNOSIS:  ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1.  Right thoracotomy.,2.  Extensive lysis of adhesions.,3.  Right lower lobectomy.,4.  Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position.  After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion.  Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue.  The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly.  The chest was entered through the fifth intercostal space.  A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection.  The right lower lobe was identified.  There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not.  Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe.  Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected.  The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected.  Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected.  The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis.  The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free.  The mediastinum was then explored.  No nodes were identified around the pulmonary ligament or around the esophagus.  Subcarinal nodes were dissected, and hemostasis was obtained with clips.  The space below and above the osseous was opened, and the station R4 nodes were dissected.  Hemostasis was obtained with clips and with electrocautery.  All nodal tissue were sent to Pathology as permanent specimen.  Following this, the chest was thoroughly irrigated and aspirated.  Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures.  Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches.  The incision was then closed with interrupted #2-0 Vicryl pericostal stitches.  A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin.  A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:,  None.,COMPLICATIONS:,  None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.
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DESCRIPTION: Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.

cardiovascular / pulmonary, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest

The situation described involves a complex surgical procedure to remove a section of a patient's lung that is affected by non-small cell carcinoma, a type of cancer. This type of surgery, a lobectomy, involves significant surgical risk, requires precision, and can be associated with postoperative complications despite the current condition being satisfactory. The stakes are particularly high because it involves a diagnosis of cancer and is intended to treat a potentially life-threatening condition. Additionally, the procedure involves the thoracic cavity and requires general anesthesia and intensive postoperative care. Therefore, the stakes are high not only due to the complexity of the surgery but also because of the implications for the patient's long-term health outcome.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lightheaded & Dizziness

REASON FOR CONSULTATION: , Lightheaded, dizziness, and palpitation.,HISTORY OF PRESENT ILLNESS: , The patient is a 50-year-old female who came to the Emergency Room.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.  The patient had some cardiac workup in the past, results are as mentioned below.  Denies any specific chest pain.  Activities fairly stable.  She is actively employed.  No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,CORONARY RISK FACTORS: , No history of hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol normal.  No history of established coronary artery disease and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Tubal ligation.,MEDICATIONS: , On pain medications, ibuprofen.,ALLERGIES:,  SULFA.,PERSONAL HISTORY: , She is a nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , History of chest pain in the past.  Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal.  Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal.  An echocardiogram at that time was also normal.  At this time, presentation with lightheaded, dizziness, and palpitation.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No carotid bruits.  No thyromegaly.  No lympyhadenopathy.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI normal.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Benign.,PSYCHOLOGICAL:  Normal.,MUSCULOSKELETAL:  Nonsignificant.,EKG: , Normal sinus rhythm, incomplete right bundle-branch block.,LABORATORY DATA:,  H&H stable.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.  Chest x-ray unremarkable.,IMPRESSION:,1.  Lightheaded, dizziness in a 50-year-old female.  No documented arrhythmia with the symptoms of palpitation.,2.  Normal cardiac structure by echocardiogram a year and half ago.,3.  Normal cardiac catheterization in 11/07.,4.  Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile.
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DESCRIPTION: Lightheaded, dizziness, and palpitation.  This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  During the episode, the patient describes symptoms of palpitation and fluttering of chest.  She relates the heart was racing.  By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm.  No evidence of arrhythmia.

The patient's symptoms of lightheadedness, dizziness, and palpitations could potentially be linked to cardiovascular issues, but previous tests including EKG and cardiac catheterization have not shown significant abnormalities. The absence of arrhythmia and negative cardiac enzyme tests reduce immediate high-risk concerns for acute cardiac events. However, due to the nature of cardiovascular symptoms and the patient's age, further monitoring or follow-up may be necessary to rule out underlying conditions. While not immediately life-threatening, such symptoms need attention, but the currently available data does not suggest a high-stakes scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Laryngoscopy

PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis.  She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007.  She returns with some increasing shortness of breath and dyspnea on exertion.  Endoscopic reevaluation is offered to her.  The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms.  An endoscopic treatment was offered to her.  Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position.  Following adequate general anesthesia, the patient was prepared for endoscopy.  The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition.  Tongue and buccal cavity mucosa were without ulcers, masses, or lesions.  The oropharynx was clear.  The larynx was then manually suspended.  Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent.  The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds.  At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred.  Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated.  Remainder of the bronchi was then examined.  The mid and distal trachea were widely patent.  Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring.  The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out.  Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished.  Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia.  The patient tolerated the procedure well without complication.
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DESCRIPTION: Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.

cardiovascular / pulmonary, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent,

This medical procedure involves direct laryngoscopy, rigid bronchoscopy, and dilation of subglottic upper tracheal stenosis, a serious medical condition affecting the airway. The stakes are relatively high, given the patient's age, the complexity of the airway involved, and potential risks including bleeding, infection, and airway obstruction possibly requiring a tracheostomy. Additionally, the condition has recurred after previous interventions, highlighting its challenging nature. While the procedure is common, the risks associated with respiratory complications and the patient's symptoms of dyspnea add to its seriousness.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Immunohistochemical Study

CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma.  During her preop evaluation it was noted that she had a lesion on her chest x-ray.  CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:,  Tumor cells show no reactivity with cytokeratin AE1/AE3.  No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen.  Tumor cells show partial reactivity with cytokeratin-7.  PAS with diastase demonstrates no convincing intracytoplasmic mucin.  No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains.  Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody.  No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A.  Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1).  The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type:  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size:  2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement:  The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion:  Present.,Margins:  Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes:  Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage:  pT1N1MX.
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DESCRIPTION: Specimen - Lung, left lower lobe resection.  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.  The tumor closely approaches the pleural surface but does not invade the pleura.

cardiovascular / pulmonary, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor,

The situation involves a detailed pathological report of a complex oncological condition. The presence of sarcomatoid carcinoma, especially with pleomorphic/giant cell and spindle cell components, indicates a serious medical condition that can significantly impact the patient's prognosis. The findings suggest vascular invasion and metastasis to lymph nodes, which are critical factors in treatment planning and prognosis. Such situations are typically high-stakes because they involve life-threatening conditions requiring precise and timely medical interventions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Hypertension & Cardiomyopathy

PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.
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DESCRIPTION: Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.

cardiovascular / pulmonary, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,

This situation involves a patient with multiple serious cardiovascular and pulmonary conditions, including nonischemic cardiomyopathy, branch vessel coronary artery disease, and congestive heart failure classified as NYHA Class III. Additionally, the patient has a history of not adhering to medication adjustments following a recent hospitalization and also tested positive for cocaine during a previous stay. The patient is at significant risk of deterioration due to non-compliance with treatment regimens, volume overload, and complex medical history, with lack of insurance complicating care. These factors together make this a high-stakes medical scenario as it directly impacts the patient's health and survival.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Holter Monitor Report - 2

INDICATION: , Syncope.,HOLTER MONITOR SUMMARY ANALYSIS: , Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.  Total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m.  Average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m.  Total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions.  No significant ST elevation noted and ST depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm.,IMPRESSION OF THE FINDINGS: , Predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and Mobitz type 1 Wenckebach, several episodes, Mobitz type II, 3 to 2 AV conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted.  No significant pauses noted.
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DESCRIPTION: Holter monitoring for syncope.  Analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.

cardiovascular / pulmonary, artefact, ventricular contraction, holter monitor, premature contractions, mobitz type, holter, beatsNOTE

The Holter monitor report analyzed the subject's heart activity, indicating issues like premature ventricular contractions and occasional atrial premature contractions. It also noted conditions such as Mobitz type II AV conduction disease, which can be potentially concerning because it may lead to significant arrhythmias or indicate underlying heart disease that could further complicate the patient's syncope (fainting) episodes. This suggests a situation that requires careful monitoring and possible intervention, as untreated issues could lead to severe health outcomes. Therefore, the stakes are fairly high as this could significantly impact the patient's health and quality of life.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 10

PROCEDURE: , Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,PROCEDURE IN DETAIL:  ,The patient was brought to the Catheterization Laboratory.  After informed consent, he was medicated with Versed and fentanyl.  The right groin was prepped and draped, and infiltrated with 2% Xylocaine.  Percutaneously, #6-French arterial sheath was placed.  Selective native left and right coronary angiography was performed followed by left ventricular angiography.  The patient had a totally occluded right coronary.  We initially started with a JR4 guide.  We were able to a sport wire through the total occlusion and saw a very tight stenosis.  We were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  We then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  We then switched to an AL1 guide and that too did not enable us to get anything to cross this lesion.  We finally had to go an AL2 guide, we were concerned that this could cause some proximal dissection.  That guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  The surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  We then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm Vision stent, where the lesion was and post-dilated it to 18 atmospheres.  Routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 Vision balloon and dilate the area and re-establish flow to the small segment.  We then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm Vision stent at 18 atmospheres.  Final angiography showed resolution of the dissection.  We could see a little staining extrinsic to the stent.  No perforation and excellent flow.  During the intervention, we did give a bolus and drip of Angiomax.  At the end of the procedure, we stopped the Angiomax and gave 600 mg of Plavix.  We did a right femoral angiogram; however, the Angio-Seal plug could not take, so we used manual pressure and a Femostop.  We transported the patient to his room in stable condition.,ANGIOGRAPHIC DATA:,  Left main coronary is normal.  Left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the LAD before it bifurcates into diagonal.  The diagonal does appear to have about 50% osteal stenosis.  There is a lot of plaquing further down the diagonal, but good flow.  The rest of the LAD looked good pass the proximal 60% stenosis and after the diagonal branch.  Circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  The first obtuse marginal had a long 50% narrowing and then the AV groove branch was free of any disease.  Some mild collaterals to the right were seen.  Right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  After we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  Following the balloon angioplasty, we established good flow down the distal vessel.  We still had about residual 70% stenosis.  When we had to go back with the AL2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  We re-dilated and then deployed.  Repeat angiography now did show some hang up off dye distally.  We never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  After deploying the stent, we had total resolution of the original lesion.  We then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large PDA.  The posterolateral branch appeared to be occluded in its mid portion.  We got a wire through and dilated this.  We then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  Repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  There were no filling defects in the stent and excellent flow.  The distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,IMPRESSION: , Atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  Minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.
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DESCRIPTION: Left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.

cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography

The procedure described is a complex and invasive intervention involving the heart's blood vessels, specifically dealing with significant stenosis and occlusions of coronary arteries. Such procedures are generally high-stakes due to the critical nature of heart function and the risks associated with potential complications such as perforation, dissection, or thrombosis during the intervention. Moreover, decisions and actions taken during the procedure can have immediate life-threatening consequences if not managed properly. Therefore, it requires skilled execution by the medical team and careful post-operative monitoring to ensure patient stability.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Angiography - 2

PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter.  The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to manifold and flushed.  The catheter did slip into the left ventricle.  During the rotation, the LVEDP was then measured.  The ostium of the right coronary artery was then engaged.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was then removed.  The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally.  The distal portion was diffusely diseased.  The proximal portion otherwise shows minor luminal irregularities.  The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch.  The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion.  The dominant coronary artery gives off the posterior descending artery and posterolateral artery.  The left ventricular end-diastolic pressure was approximately 22 mmHg.  It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1.  Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting.  These findings and plan were discussed in detail with the patient and the patient's family.  The patient is agreeable.,2.  The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy.  The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting.  In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.
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DESCRIPTION: Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.

cardiovascular / pulmonary, non-st elevation, coronary angiography, ventriculogram, heart catheterization, bypass grafting, catheterization, coronary, artery, angiography, luminal, branch, descending, circumflex, vessel, guidewire,

The described medical procedure and findings involve a critical case of three-vessel coronary artery disease. This condition poses significant risks to the patient's health, including potential heart attacks or other serious cardiac events. The fact that surgical intervention (likely PCI and possible coronary artery bypass grafting) is being planned, and the need for aggressive medical therapy, highlight the seriousness of the situation. Additionally, the decisions about medication take into account the patient's medical history, indicating the complexity and potential risk in treatment decisions. These elements collectively make this a high-stakes medical scenario.


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

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

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

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


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization

PROCEDURES:,1.  Right and left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculography.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  Patient was prepped and draped in sterile fashion.  Via modified Seldinger technique, the right femoral vein was punctured and a 6-French sheath was placed over a guide wire.  Via modified Seldinger technique, right femoral artery was punctured and a 6-French sheath was placed over a guide wire.  The diagnostic procedure was performed using the JL-4, JR-4, and a 6-French pigtail catheter along with a Swan-Ganz catheter.  The patient tolerated the procedure well and there were immediate complications were noted.  Angio-Seal was used at the end of the procedure to obtain hemostasis.,CORONARY ARTERIES:,LEFT MAIN CORONARY ARTERY:  The left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  No significant stenotic lesions were identified in the left main coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:  The left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  No significant stenotic lesions were identified in the left anterior descending coronary artery system.,CIRCUMFLEX ARTERY:  The circumflex artery is a moderate sized vessel.  The vessel is a stenotic lesion.  After the right coronary artery, the RCA is a moderate size vessel with no focal stenotic lesions.,HEMODYNAMIC DATA: , Capital wedge pressure was 22.  The aortic pressure was 52/24.  Right ventricular pressure was 58/14.  RA pressure was 14.  The aortic pressure was 127/73.  Left ventricular pressure was 127/15.  Cardiac output of 9.2.,LEFT VENTRICULOGRAM: , The left ventriculogram was performed in the RAO projection only.  In the RAO projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  Severe mitral regurgitation was also noted.,IMPRESSION:,1.  Left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2.  Severe mitral regurgitation.,3.  No significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,
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DESCRIPTION: Right and left heart catheterization, coronary angiography, left ventriculography.

cardiovascular / pulmonary, ventriculography, catheterization, seldinger, hypokinesis, estimated ejection fraction, severe mitral regurgitation, descending coronary artery, coronary artery, aortic pressure, heart catheterization, stenotic lesions, coronary, artery, heart, angiography, anterior, ventricular, ventriculogram, lesions

The procedure involves diagnostic heart catheterization, which is an invasive procedure used to diagnose and assess heart conditions. The findings indicate left ventricular dilatation, global hypokinesis, and severe mitral regurgitation, which are significant cardiac issues but no significant coronary artery disease was found. The findings could have implications for treatment decisions and patient management, which can affect a patient's long-term health outcomes. However, since there were no complications during the procedure and no significant coronary artery lesions were found, the immediate stakes are moderate rather than critical.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Elevated BNP - Consult

REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:,  The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested.  The patient denies any chest pain or shortness of breath.  Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At this time, he is on:,1.  Atrovent and albuterol nebulizers.,2.  Azithromycin.,3.  Potassium chloride 10 mEq p.o. daily.,4.  Furosemide 20 mg IV daily.,5.  Enoxaparin 40 mg daily.,6.  Lisinopril 10 mg p.o. daily.,7.  Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:,  History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke.  Drinks occasionally.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea.  He has cough.  No fever.  No abdominal pain.  No syncope, near-syncope, or palpitation.  All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable, not in distress.,VITAL SIGNS:  His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT:  Atraumatic, normocephalic.  Eyes PERRLA.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Clear.,HEART:  S1 and S2, regular.  No S3.  No S4.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,DIAGNOSTIC DATA:,  EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay.  CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe.  Loculated pleural effusion in the left upper lobe.  No PE.  Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05.  White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1.  Pneumonia.,2.  Diastolic heart failure, not contributing to his present problem.,3.  Hypertension, controlled.,4.  History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics.  No further cardiac workup at this time.
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DESCRIPTION: Elevated BNP.  Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.

The situation involves a 95-year-old patient with elevated BNP and a diagnosis of pneumonia, which can be serious for someone of advanced age. He also has a history of hypertension and current treatments include diuretics and antibiotics. Although the high BNP could indicate heart failure, the cardiology assessment deems it not contributing to the current problem, focusing instead on managing pneumonia and potential heart failure. The patient's stable condition, absence of severe symptoms like chest pain or shortness of breath, and the decision not to pursue further cardiac workup at this time suggest the situation is not immediately life-threatening. However, given his age and complex medical background, the situation still requires careful monitoring, making it moderate to high-stakes.


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

EXAM:,  Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode.  Cardiac chamber dimensions, left atrial enlargement 4.4 cm.  Left ventricle, right ventricle, and right atrium are grossly normal.  LV wall thickness and wall motion appeared normal.  LV ejection fraction is estimated at 65%.  Aortic root and cardiac valves appeared normal.  No evidence of pericardial effusion.  No evidence of intracardiac mass or thrombus.  Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal.  There is mild tricuspid regurgitation.  Calculated pulmonary systolic pressure 42 mmHg.,ECHOCARDIOGRAPHIC DIAGNOSES:,1.  LV Ejection fraction, estimated at 65%.,2.  Mild left atrial enlargement.,3.  Mild tricuspid regurgitation.,4.  Mildly elevated pulmonary systolic pressure.
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DESCRIPTION: Echocardiogram was performed including 2-D and M-mode imaging.

cardiovascular / pulmonary, lv ejection fraction, ejection fraction, tricuspid regurgitation, systolic pressure, valves, atrial, echocardiogram,

The echocardiogram results indicate some mild abnormalities: mild left atrial enlargement, mild tricuspid regurgitation, and mildly elevated pulmonary systolic pressure. However, the left ventricular ejection fraction is normal at 65%, and no immediate, severe complications like intracardiac mass, thrombus, or significant valve dysfunctions are noted. These findings suggest a situation that requires monitoring and potentially some intervention to prevent future issues, but it is not immediately life-threatening. Thus, while it's important to follow up, it's not presently high stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dual Chamber Generator Replacement

REFERRAL INDICATIONS,1.  Pacemaker at ERI.,2.  History AV block.,PROCEDURES PLANNED AND PERFORMED:,  Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Versed 2 mg.,3.  Fentanyl 50 mcg.,CLINICAL HISTORY:  ,The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to generator replacement have been discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF OPERATION: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area of the previous incision.  A transverse incision was made through the skin and subcutaneous tissue.  Hemostasis was achieved with electrocautery.  Using blunt dissection, pacemaker, and leads were removed from the pocket.  Leads were disconnected from the pulse generator and interrogated.  The pocket was washed with antibiotic impregnated saline.  The new pulse generator was obtained and connected securely to the leads and placed back in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.,2.  New pulse generator Medronic, product # ADDR01, serial # ABCD1234.,3.  Right atrial lead, product # 4068, serial # ABCD1234.,4.  Right atrial lead, product # 4068, serial # ABCD1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 572 ohms.  P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.,2.  Right ventricular lead impedance 365 ohms.  No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.,CONCLUSIONS,1.  Successful dual chamber generator replacement.,2.  No acute complications.,PLAN,1.  She will be monitored for 3 hours and then dismissed home.,2.  Resume all medications.  Ex-home dismissal instructions.,3.  Doxycycline 100 mg one p.o. twice daily for 7 days.,4.  Wound check in 7-10 days.,5.  Continue followup in device clinic.
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DESCRIPTION: Dual chamber generator replacement.  The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.

The situation involves a medical procedure for replacing a dual chamber pacemaker generator, which is a critical device for managing heart rhythm disorders in patients with a history of AV block. While the procedure is routinely performed and is reported to have been completed successfully with no complications, it involves significant risks, such as bleeding and infection, and is crucial for the patient's cardiac health. The importance of the pacemaker for the patient's condition, combined with the potential complications from the procedure, make this a moderately high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dual Chamber ICD Implantation

PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.
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DESCRIPTION: Dual Chamber ICD Implantation, fluoroscopy,  defibrillation threshold testing, venography.

cardiovascular / pulmonary, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire,

The procedure described is a dual chamber implantable cardioverter-defibrillator (ICD) implantation, which is a significant medical intervention. ICDs are used to prevent sudden cardiac death in patients at risk of ventricular arrhythmias. This surgical procedure involves fluoroscopy, venography, and defibrillation threshold testing, each of which carries inherent risks, such as bleeding, infection, or complications from anesthesia. These factors contribute to the high-stakes nature of the procedure, as it involves the heart and major blood vessels, which are vital to a patient's health. The outcome of this procedure critically impacts the patient's ability to avoid life-threatening arrhythmias.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Difficulty Breathing - ER Visit

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

The situation described involves a 14-month-old child with significant respiratory distress, indicative of status asthmaticus and hypoxia. The child has a history of reactive airway disease and requires continuous nebulization and IV steroids. Given the child's age, the failure of outpatient therapy, repeated ER visits, and requirement for hospital admission, this is a high-stakes medical situation. Pediatric respiratory distress can escalate quickly and requires careful monitoring and intervention to prevent further complications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CyberKnife Treatment - Followup

HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting.  She continues to have pain with deep inspiration and resolving dysphagia.  She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP:  122/86.  Temp:  96.8.  HR:  79.  RR:  26.  RAS:  100%.,HEENT:  Normocephalic.  Pupils are equal and reactive to light and accommodation.  EOMs intact.,NECK:  Supple without masses or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally,CARDIAC:  Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES:  No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT.
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DESCRIPTION: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.

cardiovascular / pulmonary, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife,

The situation involves a follow-up visit after CyberKnife treatment for early-stage lung cancer. While the cancer treatment seems to have gone well, ongoing symptoms like pain with deep inspiration can be concerning and warrant monitoring. Additionally, follow-up in cancer patients is crucial to ensure no recurrence or complications arise. The stakes are moderate because although the immediate threat is low due to successful initial treatment, vigilant monitoring is essential.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cystic Fibrosis

INTERVAL HISTORY:,  ABC who is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit.  He was accompanied by his adopted mother.  He is attending the fourth grade and has not missed significant days for illness.  He has a chronic cough that has been slightly increased for the prior 4 days.  Sputum is not produced.  Sinuses are described as clear.  He is an eager eater, eating a regular diet of increased calorie and protein.  He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half.  Belly complaints are denied.  He has 2 to 3 bowel movements per day.  He does need a flu vaccine.,MEDICATIONS: , Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks,  A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Respiratory rate 20 and pulse 91.  Temperature is 100.0 per tympanic membrane.  Oximetry is 98% on room air.  Height is 128 cm, which is an increase of 1.0 cm from prior visit.  Weight is 24.5 kg, which is an increase of 500 grams from prior visit.,GENERAL:  He is a cooperative school-aged boy in no apparent distress.,HEENT:  Tympanic membranes clear, throat with minimal postnasal drip.,CHEST:  Significant for 1+ hyperinflation.  Lungs are auscultated with good air entry and clear breath sounds.,CARDIAC:  Regular sinus rhythm without murmur.,ABDOMEN:  Palpated as soft, without hepatosplenomegaly.,EXTREMITIES:  Not clubbed.,CHART REVIEW: , This chart was thoroughly reviewed prior to this conference by X, RN, BSN.  Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.,DISCUSSION:  PHYSICIAN: , X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons.  He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis.  This situation will be looked into with the hope of restarting soon.  Other than that the patient seems to be doing well.  A flu shot was given.,NURSE: , X, RN, BSN, did note that the patient was doing quite well.  Reinforcement of current medication regime was supplied.  No other needs identified at this time.,RESPIRATORY CARE: , X, RCP, did review appropriate sequencing of medications with the patient and family.  Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues.  At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.,DIETICIAN: , X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines.  This is despite the fact that he has an excellent appetite.  Mom reports he is taking his enzymes consistently as well as vitamins.  He does have problems meeting his goal for resource drinks per day.  Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely.  A variety of additional high calorie items were discussed with mom.,SOCIAL WORK: , X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital.  The patient is doing well in school.  With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.,IMPRESSION: , ,1.  Cystic fibrosis.,2.  Poor nutritional status.,PLAN:  ,1.  Give flu vaccine 0.5 mg IM now, this was done.,2.  Continue all other medications and treatment.,3.  Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.,4.  Needs to augment current high-calorie diet to give more nutrition.  To follow advice by a dietician.,5.  Continue all the medication treatments before.,6.  To continue off and ongoing psychosocial nutritional counseling as necessary.
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DESCRIPTION: A 10 years of age carries a diagnosis of cystic fibrosis

The situation involving a 10-year-old with cystic fibrosis is serious because the condition is chronic and requires careful, ongoing medical management to prevent complications. The patient is dealing with multiple issues, including respiratory symptoms and poor nutritional status. Additionally, there are some logistical challenges regarding medication access due to CCS authorization issues. However, it's worth noting that the patient is not in acute distress and is being seen for a routine follow-up visit. Therefore, the situation requires close attention and proactive management but is not immediately life-threatening.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 4

COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE:  The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:,  Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:,  The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right.
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DESCRIPTION: A 51-year-old male with chest pain and history of coronary artery disease.

This situation involves a medical evaluation of a patient with a history of coronary artery disease, who is currently undergoing a Coronary CT Angiography (CCTA) due to chest pain. The findings indicate the presence of calcific plaque and possible flow-limiting lesions, but no high-grade stenosis. The stakes are high because coronary artery disease can lead to severe outcomes such as myocardial infarction if not managed properly. It requires careful assessment and potentially urgent medical intervention, making it critical for the patient's health.