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

CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with a history of gross hematuria.  The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.  Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen.  Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan.  This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement.  All of this workup was found to be grossly negative.  Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck.  At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis.  The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication.  The patient denies coronary artery disease.,PAST SURGICAL HISTORY:,  Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2.  The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1.  Metoprolol 100 mg b.i.d.,2.  Diltiazem 120 mg daily.,3.  Hydrocodone 10/500 mg p.r.n.,4.  Pravastatin 40 mg daily.,5.  Lisinopril 20 mg daily.,6.  Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints.  The patient states he has one uncle who died of lung cancer.  He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years.  He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month.  He denies any drug use.  He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL:  He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age.  VITAL SIGNS:  Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds.  HEAD AND NECK:  Normocephalic atraumatic.  LUNGS:  Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough.  HEART:  Regular rate and rhythm.  ABDOMEN:  Soft and nontender.  The liver and spleen are not palpably enlarged.  There is a large midline defect covered by skin, of which the fascia has numerous holes poking through.  These small hernias are of approximately 2 cm in diameter at the largest and are nontender.  GU:  The penis is circumcised and there are no lesions, plaques, masses or deformities.  There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place.  Testes are bilaterally descended and there are no masses or tenderness.  There is bilateral mild atrophy.  Epididymidis are grossly within normal limits bilaterally.  Spermatic cords are grossly within normal limits.  There are no palpable inguinal hernias.  RECTAL:  The prostate is mildly enlarged with a small focal firm area in the midline near the apex.  There is however no other focal nodules.  The prostate is grossly approximately 35 to 40 g and is globally firm.  Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault.  EXTREMITIES:  Demonstrate no cyanosis, clubbing or edema.  There is dark red urine in the Foley bag collection.,LABORATORY EXAM:,  Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42.  Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup.  CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam.  There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:,  Bladder cancer.,PLAN:  ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery.  Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop.  The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia.  The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging.  The patient understands these instructions and also agrees to quit smoking prior to his next visit.  This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.
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DESCRIPTION: Patient with a history of gross hematuria.  CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.

consult - history and phy., retrograde pyelogram, bladder biopsy, muscularis propria, bladder cancer, gross hematuria, bladder wall, ct scan, bladder, hematuria,

The situation involves a 68-year-old male with diagnosed high-grade bladder cancer, which is inherently a serious condition due to its potential to progress rapidly and impact vital functions. The patient has a significant tumor burden, raising stakes as it requires precise and aggressive treatment planning. Complications from the cancer or its surgical treatment could have severe health consequences. Furthermore, the patient's history of hypertension, diabetes, and other comorbidities increases the complexity of managing the condition, adding to the seriousness of the situation. The cancer's current non-operation status and the need for rigorous follow-up and potential smoking cessation also emphasize the high stakes, as these factors affect the patient's prognosis and quality of life.


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

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

REASON FOR VISIT: , This is a cosmetic consultation.,HISTORY OF PRESENT ILLNESS:,  The patient is a very pleasant 34-year-old white female who is a nurse in the operating room.  She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her.  She is very bright and well informed about cosmetic surgery.  She has recently had some neck surgery for a re-fusion of her neck and is currently on methadone for chronic pain regarding this.  Her current desires are that she obtain a breast augmentation and liposuction of her abdomen, and she came to me mostly because I offer transumbilical breast augmentation.  Her breasts are reportedly healthy without any significant problems.  Her weight is currently stable.,PAST MEDICAL AND SURGICAL HISTORY: ,  Negative.  Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02/05 and in 09/06.  She has had no previous cosmetic or aesthetic surgery.,FAMILY HISTORY AND SOCIAL HISTORY:,  Significant for Huntington disease in her mother and diabetes in her father.  Her brother has an aneurysm.  She does occasionally smoke and has been trying to quit recently.  She is currently smoking about a pack a day.  She drinks about once a week.  She is currently a registered nurse, circulator, and scrub technician in the operating room at Hopkins.  She has no children.,REVIEW OF SYSTEMS:  ,A 12-system review is significant for some musculoskeletal pain, mostly around her neck and thoracic region.  She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain.  She has considered difficult airway due to anterior cervical disk fusion and instability.  Her last mammogram was in 2000.  She has a size 38C breast.,MEDICATIONS: , Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed.,ALLERGIES: , None.,FINDINGS: , On exam today, the patient has good posture, good physique, good skin tone.  She is tanned.  Her lower abdomen has some excess adiposity.  There is some mild laxity of the lower abdominal skin.  Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation.  There was no piercing in that region.  Her breasts are C shaped.  They are not ptotic.  They have good symmetry with no evidence of tubular breast deformity.  She has no masses or lesions noted.  The nipples are of appropriate size and shape for a woman of her age.  Her scar on her neck from her anterior cervical disk fusion is well healed.  Hopefully, our scars would be similar to this.,IMPRESSION AND PLAN: , Hypomastia.  I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely.  This would make her fill out her clothes much better, and I think transumbilical technique in her is a good option.  I have discussed with her the other treatment options, and she does not want scars around her breasts if at all possible.  I think her lower abdominal skin is of good tone.  I think suction lipectomy in this region would bring down her size and accentuate her waist nicely.  I am a little concerned about the lower abdominal skin laxity, and I will discuss with her further that in the near future if this continues to be a problem, she may need a mini tummy tuck.  I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed.  I will try to set this up in the near future.  I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure.  Due to her neck issues, we may not be able to perform her surgery but I will check with Dr. X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused.
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DESCRIPTION: Hypomastia.   Patient wants breast augmentation and liposuction of her abdomen,

consult - history and phy., breast augmentation and liposuction, liposuction of her abdomen, transumbilical breast augmentation, cosmetic surgery, abdominal skin, breast augmentation, augmentation, liposuction, cosmetic, transumbilical, breast,

The situation involves a consultation for elective cosmetic surgery, which is generally not high-stakes in terms of immediate health risks, especially when compared to other medical procedures. However, there are some considerations, such as the patient's chronic pain and current medications that complicate anesthesia protocols. Moreover, the patient's medical history includes significant surgical procedures and a family history of serious health conditions, which add to the complexity but don't necessarily elevate it to high-stakes. However, due caution must be exercised to manage these complexities.

Filled in based on scale_labels and scale_label_confidence


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

CHIEF COMPLAINT:,  The patient comes for bladder instillation for chronic interstitial cystitis.,SUBJECTIVE:,  The patient is crying today when she arrives in the office saying that she has a lot of discomfort.  These bladder instillations do not seem to be helping her.  She feels anxious and worried.  She does not think she can take any more pain.  She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help.  They seem to be intensifying her pain.  She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine.  So, she has to have somebody come with her and that is kind of troublesome to her.  We discussed this at length.  I did suggest that it was completely appropriate for her to decide.  She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality.  She had Hysterectomy in the past.,MEDICATIONS: , Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.,ALLERGIES:,  Compazine and Allegra.,OBJECTIVE:,Vital Signs:  Weight:  140 pounds.  Blood pressure:  132/90.  Pulse:  102.  Respirations:  18.  Age:  27.,PLAN:,  We discussed going for another evaluation by Dr. XYZ and seeking his opinion.  She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete.  The instillations give that a full trial and then he would be willing to see her back.  As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her.  She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend.  I thought that was reasonable and agreed that that would work out.,PROCEDURE:,:  She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine.  We waited about 20 minutes.  The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed.  The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder.  She seemed to tolerate it moderately well.  She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it.  If not, she will cancel and will start over next week or she will see Dr. Friesen.
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DESCRIPTION: Bladder instillation for chronic interstitial cystitis.

consult - history and phy., urethra, dmso, bladder, chronic interstitial cystitis, interstitial cystitis, bladder instillation, instillation, instillations,

The situation involves a patient with chronic interstitial cystitis experiencing significant emotional and physical distress due to ineffective treatment. This condition is severely affecting her daily life, functionality, and ability to care for her children. The stakes involve her quality of life and emotional well-being, as well as the potential need for alternative medical interventions. While it doesn't immediately threaten her life, it has a significant impact on her mental health and day-to-day functioning, making it moderately high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Bipolar Affective Disorder - Consult

IDENTIFYING DATA:  ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT:  ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior.  Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband.  She then turned on the oven and put her head in the oven and then tried to climb over the second storied  balcony.  All of these behaviors were interrupted by her husband who called 911.  He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,HISTORY OF PRESENT ILLNESS:  ,The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked.  After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium.  Her husband states that he restrained her from jumping, "so she would not kill herself," and this was taken as a statement in his affidavit.  The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital.  She arrives here and is today pacing on the unit and in and out of the large TV room area.  She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner.  She is highly tangential, delusional, and disorganized.  She refused to sign all admit papers and a considerable part of her immediate history is unknown.,PAST PSYCHIATRIC HISTORY:  ,The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009.  Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present.  She is currently treated by Dr. Y.  She has been involuntarily detained at least 7 times and revoked at least 6 times.  She was on XYZ Inpatient in 2001 and in 01/2009.  She states that she "feels invincible" when she becomes manic and this is also the description given by her husband.,MEDICAL HISTORY:  ,The patient has a history of a herniated disc in 1999.,MEDICATIONS: , Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o.  AM and 600 mg p.o. q.p.m., Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard.  She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc.  Of note, she also has a history of abusing Vicodin.,ALLERGIES:  ,Said to be PENICILLIN, LAMICTAL, and ZYPREXA.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with her husband.  There are no children.  She reportedly has a college education and has 2 brothers.,SUBSTANCE AND ALCOHOL HISTORY: , Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin.  The X Hospital tox screen of last night was positive for opiates.  Her lithium level per last night at X Hospital was 0.42 mEq/L.  She smokes nicotine, the amount is not known although she has asked and received Nicorette gum.,LEGAL HISTORY: , She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated.,MENTAL STATUS EXAM:,ATTITUDE: ,The patient's attitude is agitated when asked questions, loud and evasive.,APPEARANCE:,  Disheveled and moderately well nourished.,PSYCHOMOTOR: , Restless with erratic sudden movements.,EPS:,  None.,AFFECT: , Hyperactive, hostile, and labile.,MOOD: , Her mood is agitated, suspicious, and angry.,SPEECH:  ,Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,THOUGHT CONTENT: , Delusional, disorganized, psychotic, and paranoid.  Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,COGNITIVE ASSESSMENT:  ,The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital.  Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,JUDGMENT AND INSIGHT:,  Nil.  When asked, are there situations when you lose control, she refuses to answer.  When asked, are meds helpful, she refuses to answer.  She refuses to give her family information nor release of information to contact them.,ASSETS:,  The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,LIMITATIONS:,  The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,FORMULATION,:  The patient has bipolar affective disorder in a manic state at present.  She also may be depressed and is struggling with marital issues.,DIAGNOSES:
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DESCRIPTION: The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior.   Bipolar affective disorder, manic state.  Rule out depression.

The situation presented involves a patient with bipolar affective disorder who is currently in a manic and psychotic state, exhibiting dangerous behaviors such as attempting self-harm by placing her hand in a garbage disposal, trying to climb over a balcony, and putting her head in an oven. She has a history of suicide attempts and has not been compliant with her medication regimen, significantly increasing the risk of harm to herself and possibly others. The involvement of law enforcement and involuntary transfer to a hospital further underscore the severity of the situation. These factors highlight the immediate risk to her safety and the need for urgent medical and psychiatric intervention, making this a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Bariatric Consult - Surgical Weight Loss - 1

PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single.  She drinks alcohol once a week.  She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM:  ,This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear to auscultation bilaterally.  Cardiovascular is normal sinus rhythm.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN:  ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band.  ABC will be asking for a letter of medical necessity from Dr. XYZ.  She will also see my nutritionist and social worker and have an upper endoscopy.  Once this is completed, we will submit her to her insurance company for approval.
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DESCRIPTION: Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

consult - history and phy., elective surgical weight loss, surgical weight loss, weight loss, loss, weight, bmi, surgical, pounds,

The situation described involves a patient seeking a consult for elective surgical weight loss. Although the patient has a high BMI and a history of hypertension, this is a planned, elective procedure rather than an emergency one. While there are risks involved in bariatric surgery, the process includes thorough evaluations and insurance approval, suggesting that this is being managed systematically. The situation does not involve immediate life-threatening conditions, making it moderate in stakes but not extremely high-stakes.


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

REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath.  He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home.  His wife called paramedics and he was brought to the emergency room.,The patient has had a workup at this time which shows bilateral pulmonary infarcts.  He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.,The patient has no past history of any renal problems.  He feels that he has been in good health until this current episode.  His appetite has been good.  He denies swelling in his feet or ankles.  He denies chest pain.  He denies any problems with bowel habits.  He denies any unexplained weight loss.  He denies any recent change in bowel habits or recent change in urinary habits.,PHYSICAL EXAMINATION:,GENERAL:  A gentleman seen who appears his stated age.,VITAL SIGNS:  Blood pressure is 130/70.,CHEST:  Chest expands equally bilaterally.  Breath sounds are heard bilaterally.,HEART:  Had a regular rhythm, no gallops or rubs.,ABDOMEN:  Obese.  There is no organomegaly.  There are no bruits.  There is no peripheral edema.  He has good pulse in all 4 extremities.  He has good muscle mass.,LABORATORY DATA: , The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5.  On admission to the hospital, his creatinine on 6/27/2009 was 0.9.,The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.,IMPRESSION:,1.  Acute renal failure, probable renal vein thrombosis.,2.  Hypercoagulable state.,3.  Deep venous thromboses with pulmonary embolism.,DISCUSSION: , We are presented with a 36-year-old gentleman who has been in good health until this current event.  He most likely has a hypercoagulable state and has bilateral pulmonary emboli.  Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher.  Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.,The patient's urine output is about 30 to 40 mL per hour.,Several chemistries have been ordered.  A triple renal scan has been ordered.,I reviewed all of this with the patient and his wife.  Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis.  If not and his renal failure progresses, we are looking at dialytic intervention.  Both he and his wife were aware of this.  ,Thank you very much for asking to see this acutely ill gentleman in consultation with you.
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DESCRIPTION: Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.

consult - history and phy., urine output, deep venous thromboses, renal failure, pulmonary embolism, renal, azotemia, hypercoagulable, vein, thrombosis, pulmonary,

The situation involves a 36-year-old patient with acute renal failure and probable renal vein thrombosis, coupled with a hypercoagulable state and deep venous thromboses with pulmonary embolism. The patient has significant changes in BUN and creatinine levels, indicating potential renal failure progression which may result in the need for dialysis. This is a high-stakes medical situation because it involves multiple complex and potentially life-threatening conditions that require urgent and careful management. The involvement of pulmonary embolism and potential renal failure in a relatively young patient increases the complexity and urgency of care.


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

HISTORY OF PRESENT ILLNESS:,  I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history.  By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor.  She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension.  She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done.  She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg.  Other findings were not significantly changed including pericardial effusion description.  She has a history of longstanding hypertension.  She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion.  She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula.  She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1.  Norvasc 10 mg once a day.,2.  Aspirin 81 mg once a day.,3.  Colace 200 mg two at bedtime.,4.  Labetalol 100 mg p.o. b.i.d.,5.  Nephro-Vite one tablet p.o. q.a.m.,6.  Dilantin 100 mg p.o. t.i.d.,7.  Renagel 1600 mg p.o. t.i.d.,8.  Sensipar 120 mg p.o. every day.,9.  Sertraline 100 mg p.o. nightly.,10.  Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY:  ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY:  ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM:  ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%.  Height is 5 feet 1 inch, weight 147 pounds.  On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted.  HEENT shows the cranium is normocephalic and atraumatic.  She has moist mucosal membranes.  Neck veins are difficult to assess, but do not appear clinically distended.  No carotid bruits.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla.  No rub, no gallop.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  CVA is benign.  Extremities with no significant edema.  Pulses appear grossly intact.  She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change.  The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one.  Echocardiogram results as above.  Chest x-ray shows mild pulmonary vascular congestion.  BNP shows 3788.  Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90.  Troponin was 0.40 followed by 0.34.  INR 1.03 on 05/18/07.  White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time.  She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report.  One of the questions we were asked was whether the patient would be a candidate for Coumadin.  Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk.  If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year.  I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1.  Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin.  Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2.  The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3.  Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade.  I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification.  I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4.  Continue Norvasc for history of hypertension as well as labetalol.,5.  The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6.  Continue Dilantin for history of seizures.
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DESCRIPTION: A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.  The patient denies any chest pain nor clear shortness of breath.

The situation involves medical decision-making regarding a 74-year-old woman with complex health issues, including atrial fibrillation, fall risk, and anticoagulation therapy. Her medical history is significant for conditions such as end-stage renal disease, pulmonary hypertension, and previous strokes, making any intervention potentially high-risk. The decision to start anticoagulation (Coumadin) has significant implications for her risk of stroke and bleeding, particularly given her fall history. Such medical decisions can affect her overall health outcomes drastically, suggesting a high-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Asbestos Exposure - Hemoptysis

REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure.  The patient also has a very extensive cardiac history that would be outlined below.  He is being admitted with worsening shortness of breath and constipation.  He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1.  Benign prostatic hypertrophy.,2.  Peptic ulcer disease.,3.  Atrial fibrillation.,4.  Coronary artery disease.,5.  Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6.  ICD implantation.,7.  Peripheral vascular disease.,8.  CABG in 1991 and 1998.,9.  Congestive heart failure, EF 40%.,10.  Asbestos exposure.,MEDICATIONS,1.  Coumadin 6 mg alternating with 9 mg.,2.  Prevacid 30 mg once a day.,3.  Diovan 160 mg every day.,4.  Flomax 0.4 mg every day.,5.  Coreg 25 mg in the morning and 12.5 mg at night.,6.  Aldactone 25 mg a day.,7.  Lasix 20 mg a day.,8.  Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL:  The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT:  Significant for peripheral cyanosis.,NECK:  Supple.,LUNGS:  Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR:  Regular rate and rhythm with murmur and metallic click.,ABDOMEN:  Soft and benign.,EXTREMITIES:  1+ cyanosis.  No clubbing.  No edema.,LABORATORY DATA:,  Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000.  CK 266, PTT 37, PT 34, and INR 3.7.  Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1.  Hemoptysis.,2.  Acute bronchitis.,3.  Coagulopathy.,4.  Asbestos exposure.,5.  Left pleural effusion.,RECOMMENDATIONS,1.  Antibiotics.
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DESCRIPTION: Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.

This case involves an elderly male with hemoptysis and a complex medical history, including asbestos exposure, coagulopathy, and existing heart conditions. Hemoptysis can be a sign of serious underlying conditions, such as lung cancer or pulmonary embolism, and the patient's pleural effusion and coagulopathy add complexity to his condition. The patient's history of asbestos exposure increases the risk of serious respiratory conditions, further elevating the stakes. Prompt and accurate diagnosis and management are critical to prevent potentially life-threatening complications and improve the patient's quality of life.


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

REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema.  She follows up at the wound care center at Hospital.  Her lower extremity edema is being managed there.  She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her.  As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management.  She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas.  Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,PAST MEDICAL HISTORY:,  Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities.  She has had a hysterectomy and a cholecystectomy in the remote past.,SOCIAL HISTORY: , The patient lives by herself and has three pet cats.  She is an ex-smoker, quit smoking about five years ago.  She occasionally drinks a glass of wine.  She denies any other recreational drugs use.  She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.,FAMILY HISTORY: , Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia.  One of her uncles was diagnosed with leukemia.,ALLERGIES: , ADHESIVE TAPE ALLERGIES.,REVIEW OF SYSTEMS:,  At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left.  She denies any nausea, vomiting or diarrhea.  She denies any pain, tenderness, increased warmth or drainage from the lower extremities.  Denies chest pain, cough or phlegm production.  All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General:  A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.,Vital signs:  Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  Head is normocephalic and external ear exam is normal.,Neck:  Supple.  There is no palpable lymphadenopathy.,Cardiovascular system:  Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.  Heart sounds are little distant secondary to thick chest wall.,Lungs:  Clear to auscultation and percussion bilaterally.,Abdomen:  Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus.  There is no evidence of cutaneous candidiasis in the inguinal folds.  There is no palpable lymphadenopathy in the inguinal and femoral areas.,Extremities:  Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis.  There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area.  It has minimal serosanguineous drainage and there is no surrounding erythema.  Therefore, in my opinion, there is no current evidence of cellulitis or wound infection.  There is no cyanosis or clubbing.  There is no peripheral stigmata of endocarditis.,Central nervous system:  The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.,LABORATORY DATA: , White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils.  The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5.  Liver function tests are also within normal limits.,The nasal screen for MRSA is negative.  Urine culture is negative so far from admission.  Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,IMPRESSION AND PLAN:,  A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema.  Admitted for inpatient management of bilateral lower extremity lymphedema.  I have been consulted to rule out possibility of active cellulitis and wound infection.,At present, I do not find evidence of active cellulitis that needs antibiotic therapy.  In my opinion, lymphedema wraps could be initiated.  We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week.  If she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,Her stage II ulcer on the right leg does not look infected.  I would recommend continuation of wound care along with lymphedema wraps.,Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.  Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.,I appreciate the opportunity of participating in this patient's care.  If you have any questions, please feel free to call me at any time.  I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.
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DESCRIPTION: Questionable need for antibiotic therapy for possible lower extremity cellulitis.

The situation involves deciding whether antibiotic therapy is necessary for a 51-year-old patient with a history of recurrent cellulitis and several other medical conditions. Although it is important to ensure appropriate treatment, the clinical assessment suggests there is no current need for antibiotics as there is no active cellulitis detected. The stakes involve ensuring the patient does not receive unnecessary antibiotics while not missing a serious infection. However, there is a clear plan for monitoring and response if the condition changes, reducing the immediate urgency of the decision.


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

REASON FOR CONSULTATION: , Antibiotic management for a right foot ulcer and possible osteomyelitis.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with past medical history of diabetes mellitus.  He was doing fairly well until last week while mowing the lawn, he injured his right foot.  He presented to the Hospital Emergency Room.  Cultures taken from the wound on 06/25/2008, were reported positive for methicillin-sensitive Staphylococcus aureus (MSSA).  The patient was started on intravenous antibiotic therapy with Levaquin and later on that was changed to oral formulation.  The patient underwent debridement of the wound on 07/29/2008.  Apparently, MRI and a bone scan was performed at that facility, which was reported negative for osteomyelitis.  The patient was then referred to the wound care center at General Hospital.  From there, he has been admitted to Long-Term Acute Care Facility for wound care with wound VAC placement.  On exam, he has a lacerated wound on the plantar aspect of the right foot, which extends from the second metatarsal area to the fifth metatarsal area, closed with the area of the head of these bones.  The wound itself is deep and stage IV and with exam of her gloved finger in my opinion, the third metatarsal bone is palpable, which leads to the clinical diagnosis of osteomyelitis.  The patient has serosanguineous drainage in this wound and it tracks under the skin in all directions except distal.,PAST MEDICAL HISTORY: , Positive for:,1.  Diabetes mellitus.,2.  Osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back.,FAMILY HISTORY: , Positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that.  One of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: , Positive findings of the foot that have been mentioned above.  All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General:  A 68-year-old Caucasian male who was not in any acute hemodynamic distress at present.,Vital Signs:  Show a maximum recorded temperature of 98, pulse is rating between 67 to 80 per minute, respiratory rate is 20 per minute, blood pressure is varying between 137/63 to 169/75.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements intact.  Head is normocephalic.  External ear exam is normal.,Neck:  Supple.  There is no palpable lymphadenopathy.,Cardiovascular:  Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.,Lungs:  Clear to auscultation and percussion bilaterally.,Abdomen:  Soft, nontender, and nondistended without any organomegaly and bowel sounds are positive.  There is no palpable lymphadenopathy in the inguinal and femoral area.,Extremities:  There is no cyanosis, clubbing or edema.  There is no peripheral stigmata of endocarditis.  On the plantar aspect of the distal part of the right foot, the patient has a lacerated wound, which extends from the second metatarsal area to the fifth metatarsal area.  Tracking under the skin is palpable with a gloved finger in all direction except the distal one.  On the proximal tracking, the area of the wound, the third metatarsal bone is palpable.  Therefore, clinically, the patient has diagnoses of osteomyelitis.,Central nervous system:  The patient is alert, oriented x3.  Cranial nerves II through XII are intact.  There is no focal deficit appreciated.,LABORATORY DATA:,  No laboratory or radiological data is available at present in the chart.,IMPRESSION/PLAN: , A 68-year-old Caucasian male with history of diabetes mellitus who had an accidental lawn mower-associated injury on the right foot.  He has undergone debridement on 07/29/2008.  Culture results from the debridement procedure are not available.  Wound cultures from 07/25/2008 showed methicillin-sensitive Staphylococcus aureus.,From the Infectious Disease point of view, the patient has the following problems, and I would recommend following treatments strategy.,1.  Right foot infected ulcer with clinical evidence of osteomyelitis.  Even if the MRI and bone scan are negative, the treatment should be guided with diagnosis on clinical counts in my opinion.  Cultures have been reported positive for methicillin-sensitive Staphylococcus aureus.  Therefore, I would discontinue the current antibiotic regimen of oral Levaquin, Zyvox, and intravenous Zosyn, and start the patient on intravenous Ancef 2 g q.8 h.  We will need to continue this treatment for 6 weeks for treatment of osteomyelitis and deep wound infection.  I would also recommend continuation of wound care and wound VAC placement that would start tomorrow.  We will get a PICC line placed to complete the 6-week course of intravenous antibiotic therapy.,2.  We would check labs including CBC with differential, chemistry 7 panel, LFTs, ESR, and C-reactive protein levels every Monday and chemistry 7 panel and CBC every Thursday for the duration of antibiotic therapy.,3.  I will continue to monitor wound healing 2 to 3 times a week.  Wound care will be managed by the wound care team at the Long-Term Acute Care Facility.,4.  The treatment plan was discussed in detail with the patient and his daughter who was visiting him when I saw him.,5.  Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.,6.  I appreciate the opportunity of participating in this patient's care.  If you have any questions please feel free to call me at any time.  I will continue to follow the patient along with you for the next few days during this hospitalization.  We would also try to get the results of the deep wound cultures from 07/29/2008, MRI, and bone scan from Hospital.
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DESCRIPTION: Antibiotic management for a right foot ulcer and possible osteomyelitis.

The situation involves the management of a diabetic patient's foot ulcer, which is at high risk of developing into or is already exhibiting signs of osteomyelitis. Given the patient's diabetes, there is an increased risk of complications, potential for chronic wounds, and the eventual threat of more severe outcomes such as amputation if not managed properly. This makes it a high-stakes medical situation due to the potential severe impacts on the patient's health and quality of life.


Medical Specialty: Consult - History and Phy.
Sample Name: Arm Pain - Neuro Consult

HISTORY OF PRESENT ILLNESS:  ,The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain.  He states that a little less than a year ago he developed pain in his right arm.  It is intermittent, but has persisted since that time.  He describes that he experiences a dull pain in his upper outer arm.  It occurs on a daily basis.  He also experiences an achy sensation in his right hand radiating to the fingers.  There is no numbness or paresthesias in the hand or arm.,He has had a 30-year history of neck pain.  He sought medical attention for this problem in 2006, when he developed ear pain.  This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes.  He was then referred to Dr. X for treatment of neck pain.  He has been receiving epidural injections under the care of Dr. X since 2007.  When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain.  He also has taken several Medrol dose packs, which has caused his blood sugars to increase.  He is taking multiple other pain medications.  The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,PAST MEDICAL HISTORY: , He has had diabetes since 2003.  He also has asthma, hypertension, and hypercholesterolemia.,CURRENT MEDICATIONS: , He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral.  He also uses Lidoderm patches and multiple eye drops and creams.,ALLERGIES:,  He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.,FAMILY HISTORY:,  His father died from breast cancer.  He also had diabetes.  He has a strong family history of diabetes.  His mother is 89.  He has a sister with diabetes.  He is unaware of any family members with neurological disorders.,SOCIAL HISTORY:,  He lives alone.  He works full time in Human Resources for the State of Maryland.  He previously was an alcoholic, but quit in 1984.  He also quit smoking cigarettes in 1984, after 16 years of smoking.  He has a history of illicit drug use, but denies IV drug use.  He denies any HIV risk factors and states that his last HIV test was over two years ago.,REVIEW OF SYSTEMS: , He has intermittent chest discomfort.  He has chronic tinnitus.  He has urinary dribbling.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  HR 72. RR 16.,General Appearance:  Patient is well appearing, in no acute distress.,Cardiovascular:  There is a regular rhythm without murmurs, gallops, or rubs.  There are no carotid bruits.,Chest:  The lungs are clear to auscultation bilaterally.,Skin:  There are no rashes or lesions.,NEUROLOGICAL EXAMINATION:,Mental Status:  Speech is fluent without dysarthria or aphasia.  The patient is alert and oriented to name, place, and date.  Attention, concentration, registration, recall, and fund of knowledge are all intact.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Optic discs are normal.  Visual fields are full.  Extraocular movements are intact without nystagmus.  Facial sensation is normal.  There is no facial, jaw, palate, or tongue weakness.  Hearing is grossly intact.  Shoulder shrug is full.,Motor:  There is normal muscle bulk and tone.  There is no atrophy or fasciculations.  There is no action or percussion myotonia or paramyotonia.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,Sensory:  Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense.  Romberg is absent.,Coordination:  There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,Deep Tendon Reflexes:  Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles.  Plantar reflexes are flexor.  There are no finger flexors, Hoffman's sign, or jaw jerk.,Gait and Stance:  Casual gait is normal.  Heel, toe, and tandem walking are all normal.,RADIOLOGIC DATA:,  MRI of the cervical spine, 05/19/08:  I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.,IMPRESSION:  ,The patient is a 58-year-old gentleman with one-year history of right arm pain.  He also has a longstanding history of neck pain.  His neurological examination is normal.  He has an MRI that shows some degenerative changes.  I do believe that his symptoms are probably referable to his neck.  However, I do not think that they are severe enough for him to undergo surgery at this point in time.  Perhaps another course of physical therapy may be helpful for him.  I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal.  We could still try to treat him with neuropathic pain medications.,RECOMMENDATIONS:,1.  I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.,2.  I gave him a prescription for Neurontin.  I discussed the side effects of the medication with him.,3.  We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations.
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DESCRIPTION: Patient experiences a dull pain in his upper outer arm.  It occurs on a daily basis.  He also experiences an achy sensation in his right hand radiating to the fingers.  There is no numbness or paresthesias in the hand or arm.

The situation involves a medical evaluation for persistent arm pain, likely related to degenerative cervical spine changes. Although the patient has multiple chronic conditions (e.g., diabetes, hypertension), the immediate concern of the arm pain is described as minimal and does not significantly interfere with the patient's quality of life. The pain does not necessitate urgent or surgical intervention, and non-invasive treatments are being considered. Therefore, while it requires medical attention, it is not immediately life-threatening or critical.


Medical Specialty: Consult - History and Phy.
Sample Name: Abnormal Stress Test

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

consult - history and phy., standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress

The situation involves a patient with significant cardiac concerns, specifically severe coronary artery disease evidenced by a markedly abnormal stress test and severe chest pain. The stress test results indicate serious heart ischemia and potentially life-threatening conditions. The patient requires transfer for percutaneous coronary intervention (PCI), which is a critical procedure aimed at opening narrowed coronary arteries to improve blood flow to the heart. Given these factors, this is indeed a high-stakes medical situation because it involves the potential risk of acute myocardial infarction or other cardiac events if not timely and correctly handled.


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

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

The patient, an 86-year-old female, is experiencing worsening shortness of breath due to severe mitral regurgitation and pleural effusion, alongside a history of heart murmur and congestive heart failure. These are serious cardiac issues, particularly given her age and the presence of other health conditions like colitis and diverticulitis. The situation is high-stakes as it involves potentially life-threatening cardiovascular findings, though immediate surgical intervention is not planned due to her age and the patient's reluctance. The management plan involves medical treatment with careful monitoring, which underscores the seriousness of her condition.


Medical Specialty: Chiropractic
Sample Name: Wrist Pain

CHIEF COMPLAINT:,  Left wrist pain.,HISTORY OF PRESENT PROBLEM:,
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DESCRIPTION: Consultation for wrist pain.

Consultation for wrist pain.

chiropractic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,

The situation involves a consultation for wrist pain, which is typically not life-threatening but can affect quality of life and daily functioning. In a chiropractic context, it usually involves addressing musculoskeletal issues. While important, it is lower-stakes compared to situations involving severe or potentially life-threatening conditions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Ventricular Ectopy - Consult

REASON FOR CONSULTATION:,  Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS:  ,I am seeing the patient upon the request of Dr. Y.  The patient is a very well known to me.  He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.  The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath.  The patient was admitted and being treated for pneumonia, according to him.  The patient denies any chest pain, chest pressure, or heaviness.  Denies any palpitations, fluttering, or awareness of heart activity.  However, on monitor, he was noticed to have PVCs random.  He had run off three beats consecutive one time at 12:46 p.m. today.  The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY:  Cough and shortness of breath.,MUSCULOSKELETAL:  Positive for arthritis and neck pain.,GU:  Unremarkable.,NEUROLOGIC:  Otherwise unremarkable.,ENDOCRINE:  Otherwise unremarkable.,HEMATOLOGIC:  Otherwise unremarkable.,ALLERGIC:  Otherwise unremarkable.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease since 2002.,2.  History of peripheral vascular disease for over 10 years.,3.  COPD.,4.  Hypertension.,PAST SURGICAL HISTORY:,  Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1.  Aspirin 81 mg daily.,2.  Clopidogrel 75 mg daily.,3.  Allopurinol 100 mg daily.,4.  Levothyroxine 100 mcg a day.,5.  Lisinopril 10 mg a day.,6.  Metoprolol 25 mg a day.,7.  Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION.  HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:,  No history of premature coronary artery disease.  One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired.  He has nine children, 25 grandchildren.  He smokes one pack per day.  He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT:  Normocephalic and atraumatic.  No thyromegaly or lymphadenopathy.,NECK:  Supple.,CARDIOVASCULAR:  Upstroke is normal.  Distal pulse symmetrical.  Heart regular with a normal S1 with normally split S2.  There is an S4 at the apex.,LUNGS:  With decreased air entry.  No wheezes.,ABDOMINAL:  Benign.  No masses.,EXTREMITIES:  No edema, cyanosis, or clubbing.,NEUROLOGIC:  Awake, alert, and oriented x3.  No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.
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DESCRIPTION: Ventricular ectopy and coronary artery disease.   He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.

The patient has a complex cardiac history including coronary artery disease, peripheral vascular disease, and a recent episode of ventricular ectopy. Although the immediate presentation involves symptoms of a possible respiratory infection, the presence of ventricular ectopy and his risk factors elevate the stakes. These issues, if unaddressed, could potentially lead to severe cardiac events given his reduced ejection fraction and other complicating cardiac conditions. Therefore, the situation has significant medical implications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Trouble breathing

CHIEF COMPLAINT:, "Trouble breathing.",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:,  Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.,PAST SURGICAL HISTORY:,  IVC filter placement 1999.
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DESCRIPTION: Patient with worsening shortness of breath and cough.

This situation involves a patient with a significant and worsening respiratory issue, alongside a past medical history of pulmonary embolism and recurrent venous thromboembolism. Given her symptoms and medical history, the potential risk factors for life-threatening conditions such as a new pulmonary embolism or heart failure are substantial. Her current state of being short of breath at rest and unable to complete sentences suggests a high level of respiratory distress, making this a high-stakes medical situation that requires urgent attention and intervention.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Ultrasound - Carotid - 1

RIGHT:,1.  Mild heterogeneous plaque seen in common carotid artery.,2.  Moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3.  Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%.  ,4.  Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5.  Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,LEFT: , ,1.  Mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2.  Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3.  Peak systolic velocity is normal in common carotid artery and in the bulb.,4.  Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,VERTEBRALS:,  Antegrade flow seen bilaterally.
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DESCRIPTION: Right and Left carotid ultrasound

Right and Left carotid ultrasound

cardiovascular / pulmonary, carotid ultrasound, antegrade flow, peak systolic velocity, bulb, carotid artery, homogeneous plaque, plaque, spectral broadening, bulb and internal carotid, velocity is normal, common carotid artery, internal carotid artery, external carotid artery, internal carotid, external carotid, peak systolic, systolic velocity, artery, carotid, ultrasound, velocity, heterogeneous,

The findings in the ultrasound report indicate varying levels of plaque in the carotid arteries, with some areas showing severe stenosis. Carotid artery stenosis can significantly increase the risk of strokes or cardiovascular events. The mention of a 70% stenosis in the external carotid artery is concerning and suggests a potentially high-stakes scenario as it may require medical intervention to prevent a stroke or other complications.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Ultrasound - Carotid - 2

EXAM: , Ultrasound carotid, bilateral.,REASON FOR EXAMINATION: , Pain.,COMPARISON:,  None.,FINDINGS: , Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery.  There are no different colors or spectral Doppler waveform abnormalities.,PARAMETRIC DATA:,  Right CCA PSV 0.72 m/s.  Right ICA PSV is 0.595 m/s.  Right ICA EDV 0.188 m/s.  Right vertebral 0.517 m/s. Right IC/CC is 0.826. Left CCA PSV 0.571 m/s, left ICA PSV 0.598 m/s.  Left ICA EDV 0.192 m/s.  Left vertebral 0.551 m/s.  Left IC/CC is 1.047.,IMPRESSION:,1.  No evidence for clinically significant stenosis.,2.  Minimal, predominantly soft plaquing.,
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DESCRIPTION: Bilateral carotid ultrasound to evaluate pain.

cardiovascular / pulmonary, carotid, cca psv, doppler, ic/cc, ica edv, ica psv, ultrasound, arteries, calcific plaquing, common carotid, internal carotid artery, spectral, stenosis, waveform, ultrasound carotid bilateral, ultrasound carotid, plaquing,

The situation involves a medical examination using an ultrasound to evaluate the condition of the carotid arteries due to patient-reported pain. The findings show minimal plaquing without clinically significant stenosis. While it is essential to monitor and potentially manage carotid artery conditions to prevent future complications like stroke, the current test results show no immediate high-risk problem. Therefore, the stakes, though relevant to long-term health, are not immediately critical based on the provided ultrasound results.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram - 3

REASON FOR EXAM: , Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS:  ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:,  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable.  No dissection.,IMPRESSION:,1.  Mildly dilated left atrium.,2.  Mild-to-moderate regurgitation.,3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended.
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DESCRIPTION: Transesophageal echocardiographic examination report.   Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.

cardiovascular / pulmonary, aortic valve replacement, stenotic valve, thrombus, stenosis, ventricular, esophageal, peak velocity, valve replacement, aortic valve, aortic, transesophageal, valve, oropharynx, atrium, interrogation, atrial, moderate,

The situation involves a patient undergoing a transesophageal echocardiogram to assess the condition of a recently replaced aortic valve. It identifies issues such as moderate aortic valve stenosis and mild mitral regurgitation but does not indicate immediate life-threatening conditions or emergencies. While understanding dysfunction in heart valves is critical for overall management and planning, the findings suggest that the patient's current condition is manageable. Furthermore, the recommendation is for a follow-up in two to three years, which suggests stability rather than an urgent issue. Therefore, the stakes are moderate but not critically high.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram - 4

PROCEDURE NOTE:,  The patient was brought to the transesophageal echo laboratory after informed consent was obtained.  The patient was seen by Anesthesia for MAC anesthesia.  The patient's posterior pharynx was anesthetized with local Cetacaine spray.  The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,FINDINGS: ,1.  Left ventricle is normal in size and function; ejection fraction approximately 60%.,2.  Right ventricle is normal in size and function.,3.  Left atrium and right atrium are normal in size.,4.  Mitral valve, aortic valve, tricuspid valve, and pulmonic valve with no evidence of vegetation.  Aortic valve is only minimally thickened.,5.  Mild mitral regurgitation and mild tricuspid regurgitation.,6.  No left ventricular thrombus.,7.  No pericardial effusion.,8.  There is evidence of patent foramen ovale by contrast study.,The patient tolerated the procedure well and is sent to recovery in stable condition.  He should be n.p.o. x4 hours, then liquid, then increase as tolerated.  Once his infection is cleared, he should follow up with us with regard to followup of patent foramen ovale.
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DESCRIPTION: Transesophageal echocardiogram.   The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.

cardiovascular / pulmonary, ventricle, atrium, mitral valve, aortic valve, tricuspid valve, pulmonic valve, regurgitation, transesophageal probe, transesophageal echocardiogram, posterior pharynx, transesophageal, valve

A transesophageal echocardiogram, while technically demanding and requiring sedation, is a routine procedure used to evaluate heart function and structure. The findings suggest mostly normal cardiac function with mild regurgitations and the presence of a patent foramen ovale, a common congenital condition. The patient tolerated the procedure well and is stable. The situation involves some risk due to anesthesia and the nature of the procedure, but it is generally considered low stakes compared to many other cardiovascular interventions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram - 5

CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed.  Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained.  There were no complications.  The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1.  Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp.  The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2.  Mitral valve is calcified and thick.  No vegetation seen.  There is mild-to-moderate MR present.  There is mild AI present also.,3.  Tricuspid valve and pulmonary valve are structurally normal.,4.  There is a mild TR present.,5.  There is no clot seen in the left atrial appendage.  The velocity in the left atrial appendage was 0.6 m/sec.,6.  Intraatrial septum was intact.  There is no clot or mass seen.,7.  Normal LV and RV systolic function.,8.  There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1.  There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis.  Calculated aortic valve area was 0.6 sq. cm.,2.  Normal LV systolic function.,
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DESCRIPTION: Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.

cardiovascular / pulmonary, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal

The clinical scenario involves a patient with severe aortic stenosis, aortic valve vegetation, and MRSA bacteremia, likely indicating an endocarditis diagnosis. These conditions are severe and can lead to life-threatening complications if not managed properly. Aortic stenosis with vegetations suggests potential obstruction and risk of embolic events, while bacteremia can spread to other areas or lead to systemic infection. This makes the situation high-stakes as it requires timely medical intervention to prevent serious outcomes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Tilt Table Test - 1

INDICATIONS: , The patient is a 22-year-old female with past medical history of syncope.  The patient is also complaining of dizziness.  She was referred here by Dr. X for tilt table.,TECHNIQUE: , Risks and benefits explained to the patient.  Consent obtained.  She was lying down on her back for 20 minutes and her blood pressure was 111/75 and heart rate 89.  She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120/80.  Then, the patient received sublingual nitroglycerin 0.4 mg.  The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110/50.  The patient felt nauseous and felt hot at that time.  She did not pass out.,COMPLICATIONS:,  None.,Tilt table was then terminated.,SUMMARY:,  Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure.,RECOMMENDATIONS: , I recommend followup in the office in one week and she will need Toprol-XL 12.5 mg every day if symptoms persist.
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DESCRIPTION: Tilt table test.  A patient with past medical history of syncope.  The patient is also complaining of dizziness.

cardiovascular / pulmonary, vasovagal syncope, tilt table test, blood pressure, heart rate, dizziness,

The tilt table test is performed to diagnose the cause of syncope, which can be a serious condition due to the risk of fainting and injury. However, the test itself is routine and the patient did not experience major complications during the procedure. While it is important for the patient's diagnosis and subsequent treatment, the immediate situation does not carry life-threatening stakes. The follow-up and recommendations ensure that the condition is managed. Therefore, while important, it is not highly urgent or dangerous.


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

PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS:  ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube.  The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined.  The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring.  The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000.  A #67 blade was used to perform the incision.  Electrocautery was used to remove excess fat tissue to expose the strap muscles.  The strap muscles were grasped and divided in the midline with a cutting electrocautery.  Sharp dissection was used to expose the anterior trachea and cricoid cartilage.  The thyroid isthmus was identified crossing just below the cricoid cartilage.  This was divided in the midline with electrocautery.  Blunt dissection was used to expose adequate cartilaginous rings.  A 4.0 silk was used for stay sutures to the midline of the cricoid.  Additional stay sutures were placed on each side of the third tracheal ring.  Thin DuoDerm was placed around the stoma.  The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings.  The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl.  A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties.  A flexible scope was passed through the tracheotomy tube.  The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube.  Ventilation was confirmed.  There was good chest rise and no appreciable leak.  The procedure was terminated.  The patient was in stable condition.  Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.
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DESCRIPTION: Tracheotomy for patient with respiratory failure.

cardiovascular / pulmonary, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal,

The situation involves a medical procedure, specifically a tracheotomy, being performed on a patient with respiratory failure—a potentially life-threatening condition. The success and precision of this procedure directly impact the patient's ability to breathe and their overall survival, indicating that this is a high-stakes situation within the medical context.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Toronto Porcine Valve Insertion

PREOPERATIVE DIAGNOSIS:,  Aortic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Aortic stenosis.,PROCEDURES PERFORMED,1.  Insertion of a **-mm Toronto stentless porcine valve.,2.  Cardiopulmonary bypass.,3.  Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  , 300 cc.,INTRAVENOUS FLUIDS:  , 1200 cc of crystalloid.,URINE OUTPUT:  , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the neck, chest and legs were prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make a midline median sternotomy incision.  Dissection was carried down to the left of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw.  The chest retractor was positioned.  Next, full-dose heparin was given.  The pericardium was opened.  Pericardial stay sutures were positioned.  After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass.  A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta.  Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine.  Next a 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine.  A 4-0 U-stitch was placed in the right atrium.  A retrograde cardioplegia catheter was positioned at this site.  Next, scissors were used to dissect out the right upper pulmonary vein.  A 4-0 Prolene pursestring was placed in the right upper pulmonary vein.  Next, a right-angle sump was placed at this position.  We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit.  Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery.  The aorta was completely encircled.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  We then prepared to cross-clamp the aorta.  We went down on our flows and cross-clamped the aorta.  We backed up our flows.  We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart.  The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit.  Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures.  In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view.  Next, scissors were used to excise the diseased aortic valve leaflets.  Care was taken to remove all the calcium from the aortic annulus.  We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve.  We prepared the valve.  Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus.  We started with our individual commissural stitches.  They were connected to our valve sewing ring.  Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position.  After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve.  The valve was lowered into place and all of the sutures were tied.  Next, we gave another round of cold blood antegrade and retrograde cardioplegia.  Next, we sewed our distal suture line.  We began with the left coronary cusp of the valve.  We ran a 5-0 RB needle up both sides of the valve.  Care was taken to avoid the left coronary ostia.  This procedure was repeated on the right cusp of the stentless porcine valve.  Again, care was taken to avoid any injury to the coronary ostia.  Lastly, we sewed our non-coronary cusp.  This was done without difficulty.  At this point we inspected our aortic valve.  There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open.  We gave another round of cold blood antegrade and retrograde cardioplegia.  The antegrade portion was given in a direct ostial fashion once again.  We now turned our attention to closing the aorta.  A 4-0 Prolene double row of suture was used to close the aorta in a running fashion.  Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia.  At this point, we removed our aortic cross-clamp.  The heart gradually regained its electromechanical activity.  We placed 2 atrial and 2 ventricular pacing wires.  We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle.  We removed our retrograde cardioplegia catheter.  We oversewed that site with a 5-0 Prolene.  By now, the heart was de-aired and resumed normal electromechanical activity.  We began to wean the patient from cardiopulmonary bypass.  We then removed our venous cannula and suture ligated that site with a #2 silk.  We then gave full-dose protamine.  After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula.  We buttressed that site with a 4-0 Prolene on an SH needle.  We placed a mediastinal chest tube and brought it out through the skin.  We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions.  They were brought out through the skin.  The sternum was closed with #7 wires in an interrupted figure-of-eight fashion.  The fascia was closed with #1 Vicryl.  We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.
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DESCRIPTION: Aortic stenosis.   Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.

cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,

The procedure described in the report involves aortic stenosis treatment through the insertion of a porcine valve, requiring cardiopulmonary bypass and cardioplegia. This is a high-stakes situation because it involves major heart surgery with several critical phases such as the arrest and restart of the heart, bypass, and potential complications associated with anesthesia, bleeding, and infection. Furthermore, the successful replacement of the aortic valve is vital for the patient's survival and quality of life, indicating that the stakes are high.