Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 4

PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Perclose to seal the right femoral arteriotomy.,INDICATIONS FOR PROCEDURE:, Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.,HEMODYNAMIC DATA:, The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,CORONARY ANGIOGRAM:, The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.,CONCLUSION:, Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.,The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.,ANGIOPLASTY CONCLUSION:, Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,RECOMMENDATIONS:, Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.,TOTAL MEDICATIONS DURING PROCEDURE:, Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.,CONTRAST ADMINISTERED:, 200 mL.,FLUOROSCOPY TIME:, 12.4 minutes.
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DESCRIPTION: Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.

cardiovascular / pulmonary, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arteriotomy, angiography, cardiac, circumflex, ostium, ventricular, femoral, percutaneous, catheterization,

The situation involves a complex cardiac catheterization procedure, which includes percutaneous coronary intervention (PCI) with stenting. Such procedures are inherently high-stakes due to the potential risks involved, such as bleeding, coronary artery damage, and the risk of myocardial infarction during or after the procedure. Furthermore, the patient has a history of coronary artery disease and a potentially recent non-ST elevation myocardial infarction, which increases the stakes. The use of anticoagulation and sedation adds further complexity. Monitoring and medication management post-procedure are crucial to ensure patient safety, highlighting the high-stakes nature of the case.


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Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 5

PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.,HEMODYNAMIC DATA:, Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.,CORONARY ANGIOGRAM:, The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.,CONCLUSION:, 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.,PLAN:, The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.,After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.
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DESCRIPTION: Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.

cardiovascular / pulmonary, catheterization, vein graft, angiography, angiogram, angio-seal, closure device, coronary atherosclerotic heart disease, saphenous vein graft, ventricular pressure, coronary artery, saphenous vein, atherosclerotic, coronary, artery, bifurcation, pda, ventricular, saphenous

The procedure described is a cardiac catheterization, which is a significant medical procedure used to diagnose and potentially treat conditions such as coronary artery disease. Given the patient's existing health risks (e.g., coronary disease, smoking, diabetes) and the discovery of a 100% occlusion in the proximal LAD, the stakes are relatively high. The procedure findings will directly influence the management of the patient's conditions, making it crucial for her ongoing treatment. However, the procedure itself was completed without immediate complications, and the plan involves continuation of medical therapy rather than immediate surgical intervention, which slightly reduces the immediate stakes.

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Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 12

PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed.  Coronary arteriography was performed with 6-French performed coronary catheters.  We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries.  After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery.  A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg.  On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  The aortic pressures were normal.  Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:,  Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  The mitral valve is competent and demonstrates normal mobility.  The left ventricular cavity is normal in size with excellent contractility.  Aneurysmal dilatation and/or dyskinesia absent.  The aortic valve is tricuspid and normal mobility.  The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  An abdominal aortic injection was performed.  Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  The abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  There is a normal left renal artery, normal right renal artery.  The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal.  The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:,  One notes ostial coronary calcification of the right coronary artery.  Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters.  Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually.  The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%.  There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  The distal portion of the vessel is free of disease.  The conus branch is seen arising right at the beginning part of the right coronary artery.  We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%.  At the ostium of the right coronary artery, calcification again is identified.  Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  There appears to be some mild stenosis of 10% in the proximal segment.  It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  The remaining portion of the left anterior descending artery is free of disease.  Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system.  There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well.  The catheter was removed.  Hemostasis was achieved.  The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1.  Excellent left ventricular contractility with normal left ventricular cavity size.,2.  Calcification of the mid abdominal aorta with wide patency of all vessels.  The left and right renal arteries are normal.  The external iliac arteries are normal.,3.  Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4.  Ostial stenosis of the right coronary artery that appears to be about 50% or greater.  The proximal right coronary artery has 50% stenosis as well.,5.  Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS:  ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  The ostial lesion of the right coronary artery may be severe.  It is at least 50%, but it could be worse.  Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery.  We will reevaluate her stress nuclear study as well.  Continue aggressive medical therapy.
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DESCRIPTION: Cardiac catheterization.   Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.

cardiovascular / pulmonary, intimal calcification, stenosis, coronary artery disease, mid abdominal aorta, coronary artery, cardiac catheterization, coronary arteries, descending artery, calcification, mid, proximal, aorta, catheterization, abdominal, cardiac, intimal, coronary, artery,

The situation involves a cardiac catheterization procedure, which is a significant medical procedure used to diagnose and assess the severity of coronary artery disease. The findings include significant stenosis of the right coronary artery, indicating potential severe coronary artery disease, which is a serious condition that can lead to heart attacks or other complications if not monitored and managed properly. The procedure and subsequent recommendations for further evaluation, such as an IVUS analysis, indicate the potentially critical nature of the condition. However, the patient tolerated the procedure well and there is no immediate emergency or complication reported, hence it's not at the highest level of stakes, but still considerably high due to the implications of coronary artery disease.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 10

EXAM: , Left Heart Catheterization,REASON FOR EXAM:,  Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to the cath lab.  The right groin was draped in the usual sterile manner.  Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery.  A JL4 catheter was used to cannulate the left coronary arteries.  A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts.  The same catheter was used to cannulate the vein graft and also LIMA.  I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful.  A 6-French pigtail catheter was used to perform left ventriculography and pullback was done.  No gradient was noted.  Arterial sheath was removed.  Hemostasis was obtained with manual compression.  The patient tolerated the procedure very well without any complications.,FINDINGS:,1.  Native coronary arteries.  The left main is patent.  The left anterior descending artery is not clearly visualized.  The circumflex artery appears to be patent.  The proximal segment gives rise to small caliber obtuse marginal vessel.,2.  Right coronary artery is patent with mild distal and mid segment.  No evidence of focal stenosis or dominant system.,3.  Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site.  There appears to be possible _______ graft to the diagonal 1 vessel.  The distal LAD wraps around the apex.  No stenosis following the anastomotic site noted.,4.  Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5.  No other bypass grafts are noted by left ventriculography and also aortic root shot.,6.  Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1.  Left coronary artery disease native.,2.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  _______ graft to the diagonal 1 vessel.,3.  Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.
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DESCRIPTION: Left Heart Catheterization.  Chest pain, coronary artery disease, prior bypass surgery.  Left coronary artery disease native.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  Native right coronary artery is patent, mild disease.

cardiovascular / pulmonary, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft

The patient's procedure was a cardiac catheterization, which is a significant medical procedure generally used to diagnose or treat cardiovascular conditions. This patient has a history of coronary artery disease and prior bypass surgery, indicating a complex cardiovascular state. The stakes here are moderate to high because any complications can have serious health consequences for the patient. Furthermore, the procedure is invasive and requires precise execution, especially given the patient’s medical history of bypass surgery.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CAD - 6-Month Followup

REASON FOR VISIT:,  Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee.  He is also having trouble getting his nerves under control.  He is having stomach pains and occasional nausea.  His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.,MEDICATIONS:,  Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:,  BP:  140/78.  HR:  65.  WT:  260 pounds (which is up one pound).  There is no JVD.  No carotid bruit.  Cardiac:  Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border.  Lungs:  Clear.  Abdomen:  Mildly tender throughout the epigastrium.,Extremities:  No edema.,EKG:,  Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD):  Normal systolic and diastolic function.  Moderate LVH.  Possible gallstones seen.,IMPRESSION:,1.  CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD.  He has a stent in his LAD and his obtuse marginal.  Fairly stable.,2.  Dyspnea-Seems to be due to his weight and the disability from his knee.  His echocardiogram shows no systolic or diastolic function.,3.  Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4.  Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5.  Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6.  Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7.  Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1.  Discontinue Plavix.,2.  Aspirin reduced to 81 mg a day.,3.  Lorcet and Xanax prescriptions given.,4.  Refer over to Scotland Orthopedics.,5.  Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.
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DESCRIPTION: He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.  He has been having some chest pains, but overall he does not sound too concerning.  He does note some more shortness of breath than usual.  He has had no palpitations or lightheadedness.  No problems with edema.

The follow-up visit concerns a patient with coronary artery disease (CAD), a potentially serious condition. However, the situation is described as stable, with no alarming symptoms such as palpitations or lightheadedness. The presence of chest pains and increased shortness of breath require monitoring but are currently assessed as not overly concerning based on the context provided (e.g., stable cardiac evaluation and manageable symptoms). The decision to discontinue Plavix also suggests clinical stability, reducing the immediate medical risk perceived by the practitioner. Overall, there is an ongoing chronic background risk due to the history of CAD, but the current context indicates moderate stakes manageable within this setting.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CABG

TITLE OF PROCEDURE:  ,Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.  Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  The ascending aorta was crossclamped.  Cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia.  The obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened.  End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed through the left internal mammary artery with running 8-0 Prolene suture.  The mammary pedicle was sutured to the heart with interrupted 5-0 Prolene suture.  A warm antegrade and retrograde cardioplegia were given.  The aortic crossclamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventricular and atrial pacing wires were placed.  The patient was fully warmed and weaned from cardiopulmonary bypass.  The patient was decannulated in the routine fashion and Protamine was given.  Good hemostasis was noted.  A single mediastinal and left pleural chest tube were placed.  The sternum was closed with interrupted wire, linea alba with running 0 Prolene, the sternal fascia was closed with running 0 Prolene, the subcutaneous tissue with running 2-0 Dexon and the skin with running 3-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.
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DESCRIPTION: Coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection.

cardiovascular / pulmonary, cabg, cardioplegia, potassium, cardiopulmonary, coronary artery, marginal, obtuse, myocardial, autogenous, coronary artery bypass grafting, running prolene suture, saphenous vein, ascending aorta, prolene suture, artery, coronary, bypassNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Coronary Artery Bypass Grafting (CABG) is a major surgical procedure used to improve blood flow to the heart in patients with severe coronary artery disease. It involves significant risks, including bleeding, infection, myocardial infarction, or even death. The procedure is complex and requires careful pre-operative and post-operative management. The stakes are high due to the potential for serious complications and the critical condition of the patients who typically need this surgery.


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

PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE:  ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring devices were placed.  The chest, abdomen and legs were prepped and draped in the sterile fashion.  The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood.  Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The pericardium was opened.  The pericardial cradle was created.  The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet.  An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene.  Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped.  Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route.  This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg.  The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length.  Cold antegrade and retrograde potassium cardioplegia were given.  The mammary artery was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified and opened.  End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed.  The partial occlusion clamp was placed.  Aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  A partial occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Ventilation was commenced.  The patient was fully warm and the patient was then wean from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.
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DESCRIPTION: Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.

cardiovascular / pulmonary, coronary occlusive disease, coronary bypass graft, cabg, myocardial, mammary artery, obtuse marginal, cardiopulmonary bypass, potassium cardioplegia, prolene suture, bypass, artery, anastomosis, autogenous, obtuse, marginal, cardiopulmonary, potassium, retrograde, cardioplegia, antegrade, coronary

The situation describes a Coronary Artery Bypass Grafting (CABG) procedure, which is a significant surgical intervention aimed at treating severe coronary occlusive disease. It's a high-stakes situation given the potential risks associated with any major cardiac surgery, including complications from anesthesia, infection, and issues related to the heart and circulatory system function during the procedure. The patient's health condition, such as severe coronary occlusive disease and the need for cardiopulmonary bypass adds to the stakes. The procedural complexity further underscores the high-stakes nature.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - Pediatric

FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.
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DESCRIPTION: Flexible Bronchoscopy (pediatric)

Flexible Bronchoscopy (pediatric)

cardiovascular / pulmonary, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

A bronchoscopy in pediatric patients involves direct examination of the airways using a flexible scope. While it is generally a safe procedure, the risks include respiratory depression from sedation, bleeding, contamination, and pneumothorax. These risks, although small, can be serious, especially in a pediatric setting. Therefore, the procedure is associated with moderate to high importance due to the vulnerability of pediatric patients, and the potential for serious complications, requiring careful consideration and parental consent.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 5

PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.
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DESCRIPTION: Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.

cardiovascular / pulmonary, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic,

The situation described involves complex medical procedures for a patient with significant airway obstruction due to a stent complication and associated granulation tissue. The procedures required, including bronchoscopy, excision, dilation, and coagulation, indicate a critical and high-stakes situation. The patient's airway was severely compromised, with a high-grade tracheal and bronchial obstruction, and the medical team had to remove the stent piecemeal, a challenging procedure. Proper management was crucial to prevent further complications such as respiratory distress or failure, which could be life-threatening. Therefore, the stakes were high given the potential risks and the need for precise execution of the procedures to ensure the patient's safety and improved airway function.


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

DIAGNOSES:,1.  Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2.  Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion.  She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis.  She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness.  She was treated per pathway orders.  However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission.  There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained.  We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe.  However, the rest of the lungs were normal and the heart was also normal.  There were no complications during her hospitalization and she continued to be stable and eating better.  On day 2 of the admission, it was decided she was okay to go home.  Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this.  During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care.  The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Vital signs were stable within normal limits on room air.,GENERAL:  She is sleeping and in no acute distress.,HEENT:  Her anterior fontanelle was soft and flat.  She does have some upper airway congestion.,CARDIOVASCULAR:  Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES:  Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS:  Her lungs did show some slight coarseness, but good air movement with equal breath sounds.  She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases.  She did not have any respiratory distress while she was asleep.,ABDOMEN:  Normal bowel sounds.  Soft and nondistended.,GENITOURINARY:  She is Tanner I female.,DISCHARGE WEIGHT:,  Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY:  No one should smoke near The patient.  She should also avoid all other exposures to smoke such as from fireplaces and barbecues.  She is to avoid contact with other infants since she is sick and they are to limit travel.  There should be frequent hand washings.,DIET:  Regular diet.  Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS:  She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:,  Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,
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DESCRIPTION: Bronchiolitis, respiratory syncytial virus positive; improved and stable.  Innocent heart murmur, stable.

cardiovascular / pulmonary, bronchiolitis, respiratory syncytial virus, bulb suctioning, innocent heart murmur, chest x ray, syncytial virus, heart murmur, respiratory distress, lungs,

The patient, a child with bronchiolitis due to RSV, was hospitalized primarily for observation due to age and the nature of the illness, which can worsen around the third or fourth day. The child's condition improved and criteria for discharge were met, with detailed instructions provided to the parents regarding monitoring symptoms of respiratory distress. Given that the child was stable at discharge and that the parents were instructed on specific symptoms to watch for and actions to take, the situation is moderately serious but not critical. The stakes are not extremely high as the child is being discharged in stable condition and the parents seem well-prepared for outpatient care; however, RSV in infants always requires vigilance due to potential complications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 3

PROCEDURE: , Fiberoptic bronchoscopy.,PREOPERATIVE DIAGNOSIS:,  Right lung atelectasis.,POSTOPERATIVE DIAGNOSIS:,  Extensive mucus plugging in right main stem bronchus.,PROCEDURE IN DETAIL:,  Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots.  The patient was breathing supplemental nasal and mask oxygen throughout the procedure.  Saturations and vital signs remained stable throughout.  A flexible fiberoptic bronchoscope was passed through the right naris.  The vocal cords were visualized.  Secretions in the larynx were as aspirated.  As before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening.  The ports were anesthetized and the trachea entered.  There was no cough reflex helping explain the propensity to aspiration and mucus plugging.  Tracheal secretions were aspirated.  The main carinae were sharp.  However, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina.  This was gradually lavaged clear.  Saline and Mucomyst solution were used to help dislodge remaining plugs.  The airways appeared slightly friable, but were patent after the airways were suctioned.  O2 saturations remained in the mid-to-high 90s.  The patient tolerated the procedure well.  Specimens were submitted for microbiologic examination.  Despite his frail status, he tolerated bronchoscopy quite well.
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DESCRIPTION: Fiberoptic bronchoscopy for diagnosis of right lung atelectasis and extensive mucus plugging in right main stem bronchus.

cardiovascular / pulmonary, bronchoscopy, fiberoptic, mucomyst, atelectasis, bronchoscope, bronchus, carinae, larynx, main stem, mucus, nasal, plugging, trachea, fiberoptic bronchoscopy, mucus plugging, secretionsNOTE

The procedure described is a fiberoptic bronchoscopy conducted to diagnose and treat serious respiratory conditions such as right lung atelectasis and extensive mucus plugging in the right main stem bronchus. While the procedure itself is fairly routine in medical settings, it involves a vulnerable patient in the ICU with stabilized vital signs, indicating a moderate level of risk. Moreover, the intervention is critical for maintaining airway patency and thus has substantial implications for the patient's immediate respiratory health. The stakes are relatively high due to the potential complications associated with respiratory failure if the mucus plugging is not addressed adequately.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Atrial Flutter - Progress Note

HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day.  This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52.  Dr. X was again consulted from the bedside.  We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful.  In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care.  Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS:  T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL:  The patient is much more alert appearing than my last examination of approximately 3 weeks ago.  He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES:  Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR:  Reveals an irregularly irregular rhythm.,LUNGS:  Have diminished breath sounds but are clear anteriorly.,ABDOMEN:  Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES:  Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL:  The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday.  Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000.  INR 1.4.  Transaminases are continuing to trend upwards of SGOT 546, SGPT 256.  Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1.  Hypotension.  I would aggressively try and fluid replete the patient giving him another liter of fluids.  If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  Increased transaminases.  Presumably this is from increased congestion.  This is certainly concerning.  We will continue to follow this.  Ultrasound of the liver was apparently negative.,3.  Fever and elevated white count.  The patient does have a history of pneumonia and empyema.  We will continue current antibiotics per infectious disease and continue to follow the patient's white count.  He is not exceptionally toxic appearing at this time.  Indeed, he does look improved from my last examination.,4.  Ventilatory-dependent respiratory failure.  The patient has received a tracheostomy since my last examination.  Vent management per PMA.,5.  Hypokalemia.  This has resolved.  Continue supplementation.,6.  Hypernatremia.  This is improving somewhat.  I am hoping that with increased fluids this will continue to do so.,7.  Diabetes mellitus.  Fingerstick blood glucoses are reviewed and are at target.  We will continue current management.  This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  Total critical care time spent today 37 minutes.
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DESCRIPTION: A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.

cardiovascular / pulmonary, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter,

The situation is highly complex, involving a critically ill patient with multiple organ dysfunctions, including cardiovascular, hepatic, and respiratory issues. The patient has hypotension, atrial flutter, signs of worsening renal function, and elevated transaminases, among other concerns. Immediate, coordinated interventions are required, and there is mention of possible pressure support and fluid management to stabilize the patient. Therefore, the situation is high-stakes due to the critical nature of the patient's condition, the decisions to be made regarding treatment and intervention, and the potential impact on the patient's survival and quality of life.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Ash Split Venous Port

ASH SPLIT VENOUS PORT,PROCEDURE DETAILS:  ,The patient was taken to the operating room and placed in supine position and monitored anesthesia care provided by the anesthetist.  The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.  Xylocaine 1% was infiltrated in the supraclavicular area and anterior chest along the planned course of the catheter.  The patient was placed into Trendelenburg position.,The right internal jugular vein was accessed by a supraclavicular 19-gauge, thin-walled needle as demonstrated by easy withdrawal of venous blood on the first pass of the needle.  Under fluoroscopic control, a J-wire was advanced into the right atrium.  The needle was removed and the skin puncture site enlarged to about 8 mm with the scalpel.  A second incision was made 5 cm inferior to the right midclavicular line, through which an Ash split catheter was advanced, using the tunneling rod, in a gently curving pass to exit the skin of the neck incision.  The tunneling needle was removed and the catheter split up to the marker as indicated in the recommended use of the catheter.,Sequential dilators were advanced over the J-wire under fluoroscopic control to dilate the subcutaneous tunnel followed by advancement of a dilator and sheath into the right superior vena cava under fluoroscopic control.  The dilator and wire were removed, leaving the sheath in position, through which a double-lumen catheter was advanced into the central venous system.  The sheath was peeled away, leaving the catheter into position.  Each port of the catheter was flushed with dilute heparinized saline.,The patient was returned to the flat position.  The catheter was secured to the skin of the anterior chest using 2-0 Ethilon suture placed through the suture "wings.",The neck incision was closed with 3-0 Vicryl subcuticular closure and pressure dressing applied.  Fluoroscopic examination of the chest revealed no evidence of pneumothorax upon completion of the procedure and the catheter was in excellent position.,The patient was returned to the recovery room for postoperative care.
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DESCRIPTION: Ash split venous port insertion. The right anterior chest and supraclavicular fossa area, neck, and left side of chest were prepped with Betadine and draped in a sterile fashion.

cardiovascular / pulmonary, ash split venous port, venous port, anterior chest, incision, dilators, sheath, port, supraclavicular, needle, fluoroscopic, venous, insertion, catheter

The situation describes a medical procedure involving the insertion of an Ash split venous port, which is a routine yet critical procedure often used for patients requiring long-term venous access. This procedure requires careful handling to avoid complications such as pneumothorax, infection, or incorrect catheter placement, each of which could have serious consequences for the patient. However, it is a common procedure in medical practice for experienced practitioners. Therefore, while there are risks involved, the situation is not uncommon in medical contexts and is typically well-handled by trained professionals.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bilateral Carotid Angiography

PROCEDURE PERFORMED:,1.  Selective ascending aortic arch angiogram.,2.  Selective left common carotid artery angiogram.,3.  Selective right common carotid artery angiogram.,4.  Selective left subclavian artery angiogram.,5.  Right iliac angio with runoff.,6.  Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure.  Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:,  400 ml.,SPECIMENS REMOVED:,  Not applicable.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile fashion.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication.  Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed.  Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed.  Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1.  Type 2 aortic arch.,2.  Left subclavian artery was patent.,3 Left vertebral artery was patent.,4.  Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5.  Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6.  Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:,  Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.
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DESCRIPTION: Carotid artery angiograms.

Carotid artery angiograms.

cardiovascular / pulmonary, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram,

The procedure entails detailed diagnostic imaging of the carotid arteries to assess stenosis, which is critical for patients with symptoms like TIA and aortic stenosis. The situation is moderately high-stakes because improper management of carotid artery stenosis can lead to serious consequences such as stroke. The procedure's complexity and the patient's condition further raise the stakes. However, there is a clear follow-up plan, which slightly mitigates the immediate risk, but due to its nature, it is still significant.


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

SUBJECTIVE: , The patient states that she feels better.  She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia.  Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen.  There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center.  The aortic stenosis was secondary to a congenital bicuspid valve, by her description.  She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition.  She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days.  Last night, she had a prolonged episode for which she contacted EMS.  Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day.  She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively.  She states that she has been taking her aspirin at 325 mg q.a.m.  She remains on Zyrtec 10 mg q.a.m.  Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS:  Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60.  The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL:  She is alert and in no apparent distress.,HEENT:  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK:  Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:  Lungs are clear bilaterally to auscultation.  The incision is well healed and without evidence of significant cellulitis.,HEART:  Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub.  There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN:  Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES:  Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC:  Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function.  Gait and station were not tested.,MENTAL STATUS:  Shows the patient to be alert, coherent with full capacity for decision making.,BACK:  Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000.  INR 1.0.  Electrolytes are normal with exception potassium 3.3.  GFR is decreased at 50 with creatinine of 1.1.  Glucose was 119.  Magnesium was 2.3.  Phosphorus 3.8.  Calcium was slightly low at 7.8.  The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge.  Troponin is negative x2 from 2100 and repeat at 07:32.  This morning, her BNP was 163 at admission.  Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion.  Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds.  Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient.  I contacted Dr. Varner and we reviewed the patient's managed to this point.  All combined impression is that the patient was likely to not have had actual ventricular tachycardia.  This is based on her EP study from October showing her to be non-inducible.  In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease.  What is most likely that the patient has postoperative atrial fibrillation.  Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely.  At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period.  I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated.  Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1.  Atrial fibrillation with rapid ventricular response.,2.  Wolff-Parkinson White Syndrome.,3.  Recent aortic valve replacement with bioprosthetic Medtronic valve.,4.  Hyperlipidemia.
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DESCRIPTION: Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.

cardiovascular / pulmonary, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic,

The patient is in a post-operative state following an aortic valve replacement, has a history of Wolff-Parkinson-White Syndrome, and is experiencing atrial fibrillation with a rapid ventricular response. While currently stable and showing no signs of distress, the complexity of these cardiac issues makes the situation relatively high-stakes. Complications or mismanagement could lead to significant health consequences, such as heart failure, stroke, or other cardiac events. The need for coordinated care, including medication adjustments and follow-up procedures, also contributes to the stakes involved.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortogram - Leg claudication.

PREPROCEDURE DIAGNOSIS:,  Left leg claudication.,POSTPROCEDURE DIAGNOSIS: ,  Left leg claudication.,OPERATION PERFORMED: , Aortogram with bilateral, segmental lower extremity run off.,ANESTHESIA: , Conscious sedation.,INDICATION FOR PROCEDURE:  ,The patient presents with lower extremity claudication.  She is a 68-year-old woman, who is very fearful of the aforementioned procedures.  Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence.  She appears to understand and agrees to proceed.,DESCRIPTION OF PROCEDURE: , The patient was taken to the Angio Suite, placed in a supine position.  After adequate conscious sedation, both groins were prepped with Chloraseptic prep.  Cloth towels and paper drapes were placed.  Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed.  Guidewire was threaded followed by a ,4-French sheath.  Through the 4-French sheath a 4-French Omni flush catheter was placed.  The glidewire was removed and contrast administered to identify the level of the renal artery.  Using power injector an aortogram proceeded.,The catheter was then pulled down to the aortic bifurcation.  A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach.  The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery.  The Omni flush catheter was advanced to the left distal external iliac artery.  The glidewire rather exchanged for an Amplatz stiff wire.  This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath.  This was advanced into the proximal superficial femoral artery and an angiogram performed.  I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,The patient was given 5000 units of heparin and this was allowed to circulate.  A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels.  A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,Final views after dilatation revealed a dissection.  A search for a 5-mm stent was performed, but none of this was available.  For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery.  Post dilatation was performed with a 4-mm angioplasty balloon.  Further views of the left lower extremity showed irregular change in the popliteal artery.  No significant stenosis could be identified in the left popliteal artery and noninvasive scan.  For this reason, I chose not to treat any further areas in the left leg.,I then performed closure of the right femoral artery with a 6-French Angio-Seal device.  Attention was turned to the left femoral artery and local anesthesia administered.  Access was obtained with the ultrasound and the femoral artery identified.  Guidewire was threaded followed by a 4-French sheath.  This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery.  The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath.  The destination was placed in the proximal superficial femoral artery and angiogram obtained.  Initial views had been obtained from the right femoral sheath before removal.,Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery.  For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon.  A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation.  No further significant abnormality was identified.  To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery.  A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis.  Reasonable use were obtained and possibly a 4-mm balloon could have been used.  However, due to her propensity for dissection I opted not to.  I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length.  This was placed into the left posterior tibial artery.  A 2-mm balloon was used to dilate the orifice of the posterior tibial artery.  I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel.  Final images showed improved run-off to the right calf.  The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.,FINDINGS: , Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma.  No evidence of renal artery stenosis is noted bilaterally.  There is a single left renal artery.  The infrarenal aorta, both common iliac and the external iliac arteries are normal.  On the right, a superficial femoral artery is widely patent and normal proximally.  At the distal third of the thigh there is diffuse disease with moderate stenosis noted.  Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted.  The perineal artery is functionally occluded at the midcalf.  The dorsal pedal artery filled by collateral at the high ankle level.,On the left, the proximal superficial femoral artery is patent.  Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery.  This was successfully treated with angioplasty and a stent placement.  The popliteal artery is diffusely diseased without focal stenosis.  The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,IMPRESSION,1.  Normal bilateral renal arteries with a small accessory right renal artery.,2.  Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3.  The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries.  Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4.  Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement.  Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.
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DESCRIPTION: Aortogram with bilateral, segmental lower extremity run off.  Left leg claudication.  The patient presents with lower extremity claudication.

cardiovascular / pulmonary, claudication, extremity run off, angio suite, superficial femoral artery, popliteal, superficial, femoral, aortogram, artery, balloon, glidewire, angioplasty, stenosis, renal,

The procedure described involves complex cardiovascular interventions including an aortogram, angioplasty, and stent placement due to significant artery stenosis and occlusions. Given the patient's age and the risks mentioned (e.g., bleeding, infection, arterial trauma), this procedure is high-stakes as it directly impacts the patient's cardiovascular health and overall well-being. This type of medical procedure involves considerable risk requiring significant medical expertise and carries potential for complications, which can be life-threatening.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortobifemoral Bypass - 1

PREOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,POSTOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:,  General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Note that previously the patient was found to have some baseline dementia, although slight.  The patient was seen and evaluated by the neurology team, who cleared the patient for surgery.  The patient was taken to the operating room and general endotracheal anesthesia was administered.  The abdomen was prepped and draped in the standard surgical fashion.  We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally.  Dissection was carried down to the level of the femoral vessels using Bovie electrocautery.  The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally.  Vessel loops were placed around the aforementioned arteries.  After doing so, we turned our attention to beginning our abdominal dissection.  We used a #10-blade scalpel to make a midline laparotomy incision.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The abdomen was opened and an Omni retractor was positioned.  The aorta was dissected out in the abdomen.  The left femoral vein was identified.  There was a nicely clampable portion of aorta visible.  We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis.  Full-dose heparin was given.  Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels.  A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors.  We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis.  We then created our tunnels over the iliac vessels.  We pulled the distal limbs over our ABF graft into the groin.  We then proceeded to perform our right anastomosis first.  We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries.  We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally.  We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries.  We then removed our clamp.  We opened the limb more proximally in the abdomen on the right side.  We then turned our attention to the left side and similarly placed our vascular clamps.  We used a #11-blade scalpel to make an arteriotomy in the vessel.  We then lengthened our arteriotomy both proximally and distally again onto the SFA.  We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we opened our clamps.  There was no noticeable leak from the newly constructed anastomosis.  We checked our proximal graft to aortic anastomosis, which was noted to be in good condition.  We then gave full-dose protamine.  We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion.  The abdomen was closed with #1 nylon in a running fashion.  The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion.  The instrument and sponge count was correct at end of case.  Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
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DESCRIPTION: Dementia and aortoiliac occlusive disease bilaterally.  Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.

cardiovascular / pulmonary, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels,

The situation involves a major vascular surgical procedure, the aortobifemoral bypass, which is high-stakes due to its complexity, the potential for significant blood loss, and the vital nature of the arteries involved. Moreover, the patient having dementia adds another layer of complexity, increasing the stakes due to the possible impact on the patient's overall health and recovery process. The surgery requires careful postoperative monitoring, as it can have life-altering consequences if complications arise. Additionally, this procedure involves clearing the patient through neurologic evaluation, indicating its seriousness. However, the procedure described was completed successfully with the patient in good condition postoperatively, which slightly mitigates the immediate high-stakes concern.


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

Medical Specialty: Cardiovascular / Pulmonary
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.

This case involves a 74-year-old woman with complex medical conditions, including atrial fibrillation, severe pulmonary hypertension, and a recent fall. The stakes are high because the decision on anticoagulation therapy, particularly the use of Coumadin, must balance the benefits of reducing stroke risk against the increased risk of bleeding due to falls. The patient's chronic conditions such as end-stage renal disease, mini-strokes, and seizure disorder also complicate management, making her clinical care more precarious. The situation requires careful coordination among healthcare providers, adding to its complexity and significance.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Arterial Imaging

INDICATIONS:,  Peripheral vascular disease with claudication.,RIGHT:,  ,1.  Normal arterial imaging of right lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic.,4.  Ankle brachial index is 0.96.,LEFT:,1.  Normal arterial imaging of left lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4.  Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.
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DESCRIPTION: Arterial imaging of bilateral lower extremities.

cardiovascular / pulmonary, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial,

The situation involves a standard diagnostic procedure, arterial imaging, which is used to assess vascular health. The results are mostly normal except for a slight variation in the left posterior tibial artery. However, such findings are not uncommon and may often not require immediate intervention. The findings suggest good overall vascular health, with ABI values within normal limits. This does not imply an immediate life-threatening situation. While important for long-term health planning, the situation isn't urgent or critical at present.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angiogram & StarClose Closure

EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1.  Left main is a large-caliber vessel.  It is angiographically free of disease,,2.  LAD is a large-caliber vessel.  It gives rise to two diagonals and septal perforator.  It erupts around the apex.  LAD shows an area of 60% to 70% stenosis probably in its mid portion.  The lesion is a type A finishing before the takeoff of diagonal 1.  The rest of the vessel is angiographically free of disease.,3.  Diagonal 1 and diagonal 2 are angiographically free of disease.,4.  Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM.  It is angiographically free of disease.,5.  OM-1 is angiographically free of disease.,6.  RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL.  RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7.  LVEDP is measured 40 mmHg.,8.  No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1.  60% to 70% mid left anterior descending stenosis.,2.  Mild 30% to 40% stenosis of the proximal right coronary artery.,3.  Status post StarClose closure of the right common femoral artery.,PLAN:  ,Plan will be to perform elective PCI of the mid LAD.
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DESCRIPTION: Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.

cardiovascular / pulmonary, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral,

The case involves a cardiovascular procedure to investigate and manage lesions in the coronary arteries, specifically a 60% to 70% stenosis in the left anterior descending (LAD) artery and a milder 30% to 40% stenosis in the right coronary artery (RCA). The plan includes performing elective percutaneous coronary intervention (PCI) on the mid LAD, which addresses significant but not immediately life-threatening stenosis. While the procedures are serious and require careful consideration, they are not emergent or critical in nature, as they are performed electively based on existing findings. However, cardiac procedures inherently involve some risk, such as potential complications from invasive procedures or contrast use, which slightly elevates the stakes.