Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thromboendarterectomy

OPERATIVE PROCEDURE,1.  Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:,  The patient was brought to the operating room, placed in supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The chest, abdomen and legs were prepped and draped in a sterile fashion.  The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution.  The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped.  A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The sternum was closed.  A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma.  The deep fascia was divided.  The facial vein was divided between clamps and tied with 2-0 silk.  The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves.  The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk.  Shunts were prepared.  A patch was prepared.  Heparin 50 mg was given IV.  Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery.  Distal internal was held with a forceps.  Internal carotid artery was opened with 11-blade.  Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond.  The shunt was placed and proximal and distal snares were tightened.  Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external.  All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line.  Suture line was completed and the neck was packed.,The pericardium was opened.  A pericardial cradle was created.  The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula.  A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet.  An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted.  The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg.  This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus.  The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture.  The vein was cut to length.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein.  The vein was cut to length.  The mammary was clipped distally, divided and spatulated for anastomosis.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture.  Warm blood potassium cardioplegia was given, and the cross-clamp was removed.  A partial-occlusion clamp was placed.  Two aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial- occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  Ventilation was commenced.  The patient was fully warmed.  The patient was weaned from cardiopulmonary bypass and de-cannulated in a 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, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.
---
DESCRIPTION: Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.

cardiovascular / pulmonary, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE

The procedure described involves a thromboendarterectomy and complex coronary artery bypass grafting, which are high-stakes due to the critical nature of the cardiovascular and pulmonary systems involved. These surgeries require immense precision and skill due to the risk of complications that could lead to severe outcomes, including death. The use of cardiopulmonary bypass and careful management of heart and blood flow during the surgery further underscores the high-stakes nature of the procedure.


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

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

PREOPERATIVE DIAGNOSES:,1.  Non-small-cell carcinoma of the left upper lobe.,2.  History of lymphoma in remission.,POSTOPERATIVE DIAGNOSES:,1.  Non-small-cell carcinoma of the left upper lobe.,2.  History of lymphoma in remission.,PROCEDURE: , Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection.  Intercostal nerve block for postoperative pain relief at five levels.,INDICATIONS FOR THE PROCEDURE: , This is an 84-year-old lady who was referred by Dr. A for treatment of her left upper lobe carcinoma.  The patient has a history of lymphoma and is in remission.  An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma.  A mass in the left upper lobe was biopsied with fine-needle aspiration and shown to be a primary non-small-cell carcinoma of the lung.  PET scan was, otherwise, negative for spread and resection was advised.  All the risk and benefits were fully explained to the patient and she elected to proceed as planned.  She was transferred to rehab for couple of weeks to buildup strength before the surgery.,PROCEDURE IN DETAIL:,  In the operating room under anesthesia, she was prepped and draped suitably.  Dr. B was the staff anesthesiologist.  Left muscle sparing mini thoracotomy was made.  The serratus and latissimus muscles were not cut but moved out to the way.  Access to the chest was obtained through the fifth intercostal space.  Two Tuffier retractors of right angles provided adequate exposure.,The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology.  The parietal pleural reflexion around the hilum was now circumcised, and lymph nodes were taken from station 8 and station 5.,The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30/2.5 staple gun or/and the smaller one were ligated with 2-0 silk.  The left superior pulmonary vein was transected using a TA30/2.5 staple gun, and the fissure was completed using firings of an endo-GIA 60/4.8 staple gun.  Finally, the left upper lobe bronchus was transected using a TA30/4.8 staple gun.  Please note, that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe.,The specimen was delivered and sent to pathology.  The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe.  Frozen section showed that the margin was negative.,The chest was irrigated with warm sterile water and when the left lower lobe inflated, there was no air leak.  A single 32-French chest tube was inserted, and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together.  A #2 Vicryl pericostal sutures were now applied.  The serratus and latissimus muscles retracted back in place.  A #19 French Blake drain placed in the subcutaneous tissues and 2-0 Vicryl used for the fat followed by 4-0 Monocryl for the skin.  The patient was transferred to the ICU in a stable condition.
---
DESCRIPTION: Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection.  Intercostal nerve block for postoperative pain relief at five levels.

cardiovascular / pulmonary, upper lobe, intercostal nerve block, non-small-cell carcinoma, axillary lymph node, endo-gia, latissimus, lobectomy, lymph node dissection, lymphoma, pulmonary vein, serratus, thoracotomy, muscle sparing mini thoracotomy, upper lobectomy, staple gun, intercostal,

The situation described involves a complex surgical procedure for the treatment of non-small-cell carcinoma in an elderly patient. Given the patient's age (84 years old), history of cancer (lymphoma in remission), and the extensive nature of the procedure (thoracotomy, lobectomy, and lymph node dissection), the stakes are high. Surgical procedures like these carry significant risks due to the patient's age and prior medical history. Furthermore, the complex nature of thoracic surgeries adds to the potential complications that can include respiratory issues, bleeding, and postoperative recovery challenges. Therefore, ensuring a successful surgical outcome is crucial for the patient's survival and quality of life.

Filled in based on scale_labels and scale_label_confidence


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

FINDINGS:,1.  The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.,2.  There was no significant change in heart rate or blood pressure on 80-degree tilt.,3.  No symptoms reported during the tilt study.,CONCLUSION: , Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.
---
DESCRIPTION: Tilt table test.  Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.

cardiovascular / pulmonary, blood pressure, tilt table test, vasovagal, vasodepressor, orthostasisNOTE

The situation involves the interpretation of a tilt table test in a cardiovascular and pulmonary specialty context. The findings indicate that the test results were negative for any evidence of vasovagal, orthostasis, or vasodepressor syndrome, and the patient did not experience any significant changes or symptoms. This suggests that the patient does not have these specific conditions, so there are no immediate risks or urgent issues to address. Thus, the stakes involved in this situation are relatively low since no immediate or critical concerns are present that require urgent intervention or decision-making.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracotomy & Bronchoscopy

PREOPERATIVE DIAGNOSIS:,  Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1.  Right thoracotomy, total decortication.,2.  Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDICATIONS FOR PROCEDURE:  ,The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion.  A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion.  On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.  Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,OPERATIVE PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department.  Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage.  Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation.  The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi.  At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear.  Bronchoscope was then removed.  Vital signs remained stable throughout this portion of the procedure.  The patient was re-intubated by Anesthesia with a double lumen endotracheal tube.  At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion.  At this point, the right chest was prepped and draped in the usual sterile fashion.  The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine.  The first port was placed through this incision intrathoracically.  A bronchoscope was placed for inspection of the intrathoracic cavity.  Pictures were taken.  There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax.  At this point, a second port site anteriorly was placed under direct visualization.  With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid.  Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped.  Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion.  Incision was made.  The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space.  The chest cavity was entered with the right lung deflated per Anesthesia at our request.  Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe.  With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand.  There was no evidence of gross leakage or bleeding at the conclusion of surgery.,Full lung re-expansion was noted upon re-inflation of the lung.  Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus.  The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction.  Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture.  Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure.  Steri-Strips were applied along with sterile occlusive dressings.  The patient was awakened from anesthesia without difficulty and extubated in the operating room.  The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung.  The patient was transported to the recovery with vital signs stable.  Stat portable chest x-ray is pending.  The patient will be admitted to the Intensive Care Unit for close monitoring overnight.
---
DESCRIPTION: Empyema.  Right thoracotomy, total decortication and intraoperative bronchoscopy.  A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion.  On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.

cardiovascular / pulmonary, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural,

The situation involves a surgical procedure on a patient with empyema, which required right thoracotomy, total decortication, and intraoperative bronchoscopy. The surgical intervention was necessary due to an entrapped right lower lobe and loculations identified in CT scans, which did not resolve completely with less invasive methods. Such procedures carry inherent risks, including potential complications from anesthesia, the risk of bleeding, and the need for intensive care monitoring post-surgery. The fact that the patient was admitted to the Intensive Care Unit postoperatively suggests that the procedure was complex, and the patient's condition needed close monitoring to ensure stability and recovery. The requirement for intensive monitoring, alongside the nature of the surgery, indicates a high-stakes scenario in the medical context.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracoabdominal Aneurysm

POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube.  Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle.  The left groin, abdominal and chest were prepped and draped in a sterile fashion.  A thoracoabdominal incision was made.  The 8th interspace was entered.  The costal margin was divided.  The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta.  The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm.  It was dissected free circumferentially.  The aortic bifurcation was dissected free, dissecting free both iliac arteries.  The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this.  The patient was heparinized.  Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet.  This was hooked to a venous inflow of left heart bypass machine.  A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow.  Bypass was instituted.  The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm.  The area was divided at this point.  A 26-mm graft was then sutured in place with running 3-0 Prolene suture.  The graft was brought into the diaphragm.  Clamps were then placed on the iliacs, and the pump was shut off.  The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation.  The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch.  The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference.  The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels.  The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture.  All clamps were removed, and flow was re-established.  An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal.  A partial-occlusion clamp was placed.  An area of graft was removed.  The end of the graft was cut to fit this and sutured in place with running Prolene suture.  The partial-occlusion clamp was removed.  Protamine was given.  Good hemostasis was noted.  The arterial cannula, of course, had been removed when that part of the aneurysm was removed.  The venous cannula was removed and oversewn with a 4-0 Prolene suture.  Good hemostasis was noted.  A 36 French posterior and a 32 French anterior chest tube were placed.  The ribs were closed with figure-of-eight #2 Vicryl.  The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch.  Patient tolerated the procedure well.
---
DESCRIPTION: A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.

cardiovascular / pulmonary, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE

The described situation involves a complex cardiovascular surgical procedure for the replacement of a type 4 thoracoabdominal aneurysm. This type of surgery is high-stakes due to the potential risks, such as severe bleeding, organ damage, or even death. The use of techniques like left heart bypass and cerebrospinal fluid drainage underscores the complexity and critical nature of the surgery. Additionally, the procedure involves major blood vessels and requires careful management to ensure patient safety. Given the potential consequences if the procedure were not successful or if complications arose, this is a high-stakes medical situation.


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

PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE:  ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room.  After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line.  Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall.  Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid.  From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle.  At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine.  At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation.  We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,
---
DESCRIPTION: Thoracentesis, left.   Malignant pleural effusion, left, with dyspnea.

cardiovascular / pulmonary, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural,

The situation describes a thoracentesis procedure, which is a medical intervention to remove excess fluid from the pleural cavity. Although it is a routine procedure, it is not without risks as complications like pneumothorax can arise. The stakes are moderate due to the patient's condition (malignant pleural effusion), and while there were some procedural challenges and the patient experienced lightheadedness, the situation was managed effectively and the procedure was successful without major complications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Tesio Hemodialysis Catheter Insertion

OPERATION,1.  Insertion of a left subclavian Tesio hemodialysis catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered.  Next, the patient's chest and neck were prepped and draped in the standard surgical fashion.  Lidocaine 1% was used to infiltrate the skin in the region of the procedure.  Next a #18-gauge finder needle was used to locate the left subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle.  This process was repeated.  The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, the subcutaneous tunnel was created.  The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff.  A dilator and sheath were passed over the individual J wires.  The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn.  The process was repeated.  Both distal tips were noted to be in good position.  The Tesio hemodialysis catheters were flushed and aspirated without difficulty.  The catheters were secured at the cuff level with a 2-0 nylon.  The skin was closed with 4-0 Monocryl.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition.
---
DESCRIPTION: Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.

cardiovascular / pulmonary, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: 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.

The insertion of a Tesio hemodialysis catheter is a medical procedure intended for patients requiring dialysis treatment, which is common for those with kidney failure. The procedure involves accessing a major vein and using fluoroscopy for guidance, which requires precision and carries potential risks such as bleeding, infection, or damage to the blood vessels. The description indicates careful steps and a positive outcome, which is standard for such procedures. The stakes are significant because improper execution can lead to severe complications, but given the routine nature of such procedures with experienced professionals, the stakes are moderate overall. Although the situation is managed in a controlled environment with expertise, the necessity of the procedure for ongoing dialysis constitutes a high-stakes component for the patient's health.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Supraventricular Tachycardia - Consult

HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.
---
DESCRIPTION: The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.

cardiovascular / pulmonary, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,

The situation involves a 4-month-old patient with supraventricular tachycardia and significant cyanotic congenital heart disease. This is a critical condition requiring careful management, including medication and potential surgical intervention to ensure adequate pulmonary blood flow and manage heart function. Timely and accurate decisions are crucial to the patient's survival and long-term health, making it a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Subxiphoid Pericardial Window

PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.
---
DESCRIPTION: Emergent subxiphoid pericardial window, transesophageal echocardiogram.

cardiovascular / pulmonary, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic

The situation described is a surgical procedure involving an emergent subxiphoid pericardial window due to pericardial tamponade, a condition that can rapidly become life-threatening if not promptly treated. Additional factors such as the patient's history of endocarditis and aortic valve replacement, as well as the requirement for general anesthesia in an operating room, contribute to the high-stakes nature of the situation. The successful outcome and stable condition of the patient post-surgery are critical, but the initial scenario required urgent medical intervention, indicating a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Stress Test Graded Exercise Treadmill

INDICATIONS:,  Chest pain.,PROCEDURE DONE:,  Graded exercise treadmill stress test.,STRESS ECG RESULTS:,  The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol.  The heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate.  The blood pressure increased from 120/70 to 130/80.  The baseline resting electrocardiogram reveals a regular sinus rhythm.  The tracing is within normal limits.  Symptoms of chest pain occurred with exercise.  The pain persisted during the recovery process and was aggravated by deep inspiration.  Marked chest wall tenderness noted.  There were no ischemic ST segment changes seen during exercise or during the recovery process.,CONCLUSIONS,:,1.  Stress test is negative for ischemia.,2.  Chest wall tenderness occurred with exercise.,3.  Blood pressure response to exercise is normal.
---
DESCRIPTION: Chest pain,  Chest wall tenderness occurred with exercise.

cardiovascular / pulmonary, stress test, blood pressure, bruce protocol, chest pain, graded exercise, graded exercise treadmill, electrocardiogram, ischemia, sinus rhythm, treadmill, chest wall tenderness, chest wall, stress, chest,

The situation involves assessing a patient's heart condition through a stress test, which is generally used to identify potential cardiovascular issues. The stakes here are moderate because while the test indicates a negative result for ischemia (which is a good outcome), the patient experienced chest pain and chest wall tenderness during exercise. These symptoms can indicate other potential health issues that may need further investigation, albeit the blood pressure response and stress ECG results were normal. Immediate critical action is not required since no ischemic changes were observed, but follow-up would likely be recommended.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Subclavian Central Venous Catheter Insertion

PREOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries.  The patient went to OR today for an I&D of left lower extremity degloving injury.  Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was prepped and draped in the normal sterile fashion.  After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid.  Locator needle was used to correctly cannulate the right internal jugular vein.  Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach.  The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle.  A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch.  The right subclavian vein was then accessed.  A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin.  A dilator sheath was placed over the guidewire and subsequently removed.  The triple lumen catheter was then placed over the guidewire and advanced to 14 cm.  All ports aspirated and flushed.  Good blood return was noted and all ports were flushed well.  The triple lumen catheter was then secured at 14 cm using #0 silk suture.  A sterile dressing was then applied.  A stat portable chest x-ray was ordered to check line placement.  The patient tolerated the procedure well and there were no complications.
---
DESCRIPTION: Insertion of right subclavian central venous catheter.   Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.

cardiovascular / pulmonary, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion

The insertion of a central venous catheter is a significant medical procedure, especially given the context of the patient's situation. The patient is a 74-year-old woman with numerous injuries from a fall, and she has undergone other surgical procedures. This indicates a complex medical condition requiring careful management. Central venous catheter insertion is high-stakes as it involves significant risks such as infection, bleeding, or misplacement, and is critical for providing access for medications, fluids, or other required interventions. The fact that the procedure was performed after failed attempts at accessing the internal jugular vein further adds urgency and complexity. Overall, the procedure is essential for the patient's ongoing treatment and recovery.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Stenting

NAME OF PROCEDURE:,  Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:,  Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:,  Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.,ANTICOAGULATION:  ,The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.,COMPLICATIONS: , None.,INFORMED CONSENT: , I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,HEMODYNAMIC DATA: , The aortic pressure was in the physiologic range.,ANGIOGRAPHIC DATA: , Left coronary artery:  The left main coronary artery showed insignificant disease.  The left anterior descending showed fairly extensive calcification.  There was 90% stenosis in the proximal to midportion of the vessel.  Insignificant disease in the circumflex.,SUCCESSFUL STENTING: , A wire crossed the lesion.  We first predilated with a balloon, then advanced, deployed and post dilated the stent.  Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30.  He is saturating at 96% on 4 L nonrebreather.,GENERAL:  The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3.  The patient cannot speak and communicates through writing.,HEENT:  Very small moles on face.  However, pupils equal, round and regular and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is moist.,NECK:  Supple.  Tracheostomy site is clean without blood or discharge.,HEART:  Regular rate and rhythm.  No gallop, murmur or rub.,CHEST:  Respirations congested.  Mild crackles in the left lower quadrant and left lower base.,ABDOMEN:  Soft, nontender and nondistended.  Positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  Cranial nerves II-XII grossly intact.  No focal deficit.,GENITALIA:  The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,CONCLUSIONS,1. Successful stenting of the left anterior descending.  Initially, there was 90% stenosis.  After stenting with a drug-eluting stent, there was 0% residual.,2. Insignificant disease in the other coronaries.,PLAN:,  The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins.  I have discussed this with him, and I have answered his questions.
---
DESCRIPTION: Successful stenting of the left anterior descending.  Angina pectoris, tight lesion in left anterior descending.

The situation involves a cardiovascular procedure, specifically the stenting of the left anterior descending artery, which was initially 90% stenosed. Such procedures are critical in preventing heart attacks and alleviating symptoms of angina. While the procedure was successful and free of complications, the initial condition was severe, indicating a high-stakes nature due to the potential consequences of not addressing the stenosis. Furthermore, given the patient's advanced age and other medical complexities, there is always a significant risk involved, such as the need for emergency procedures or the risk of restenosis.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: SOAP - Shortness of Breath

SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.  I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 78 and blood pressure 130/60.,LUNGS:  Clear.,HEART:  A soft systolic murmur in the aortic area.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.,IMPRESSION:,1.  Status shortness of breath responding well to medical management.,2.  Atrial fibrillation, chronic, on anticoagulation.,3.  Aortic stenosis.,RECOMMENDATIONS:,1.  Continue medications as above.,2.  The patient would like to follow with her cardiologist regarding aortic stenosis.  She may need a surgical intervention in this regard, which I explained to her.  The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.
---
DESCRIPTION: The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.

cardiovascular / pulmonary, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,

The patient's condition involves multiple cardiac issues: chronic atrial fibrillation and severe aortic stenosis, both of which can be life-threatening if not properly managed. The presence of shortness of breath and severe aortic stenosis indicates the potential need for surgical intervention. However, the patient is currently stable, responding well to medical management, and is under the care of a cardiologist with plans for follow-up. This reduces the immediate risk, but the severity of the potential outcomes if untreated keeps it high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Q-Fever Endocarditis

HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis.  He is also taking digoxin, aspirin, warfarin, and furosemide.  Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well.  This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute.  He tolerated this procedure well.  He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE:  Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT:  Remarkable for the badly degenerated left lower molar.  Funduscopic exam is unremarkable.,NECK:  Supple without adenopathy.,CHEST:  Clear including the sternal wound.,CARDIOVASCULAR:  A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN:  Soft.  He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU:  Deferred.,EXTREMITIES:  Examination of extremities reveals no embolic phenomenon.,SKIN:  Free of lesions.,NEUROLOGIC:  Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5.  Hydroxychloroquine level obtained at that time was undetectable.  Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL.  Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers.  Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN:  ,1.  Continue doxycycline and hydroxychloroquine.  I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications.  She assures me that he is compliant with his medications.  We will however repeat his hydroxychloroquine and doxycycline levels.,2.  Repeat Q-fever serology.,3.  Comprehensive metabolic panel and CBC.,4.  Return to clinic in 4 weeks.,5.  Clotting times are being followed by Dr. X.
---
DESCRIPTION: A 16-year-old male with Q-fever endocarditis.

cardiovascular / pulmonary, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever,

The patient is a 16-year-old male with Q-Fever endocarditis, a potentially serious infection of the heart's inner lining caused by the Q fever bacterium. He has recently undergone a significant surgical procedure for valve replacement and pseudoaneurysm resection. The case involves complex medication management with multiple medications including antibiotics, managing loose stools, and potential implications from surgery. The need for precise and continuous monitoring of medication blood levels, recurrence of serology tests, and the careful monitoring of clotting times indicates a high-stakes situation because of the risk of complications like heart failure, uncontrolled infection, or bleeding risks. Furthermore, the patient's age and complexity of his medical regimen add to the critical nature of ongoing management and follow-up.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Valve Stenosis

HISTORY: , The patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm Gore-Tex shunt between the ascending aorta and pulmonary artery with a snare.  This was complicated by shunt thrombosis __________ utilizing a 10-mm balloon.  Resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy.  On 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon.  He has been followed conservatively since that time.  A recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmHg.  Right coronary artery to pulmonary artery fistula was also appreciated.  The patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,PROCEDURE:,  The patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted.  The right femoral vein advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was then exchanged over wire for a 5-French marker pigtail catheter, which was directed into the main pulmonary artery.,Using a 5-French sheath, a 5-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  This catheter was then exchanged for a Judkins right coronary catheter for selective cannulation of the right coronary artery.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with no evidence of intracardiac shunt.  Left-sided heart was fully saturated.  Phasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Right ventricular systolic pressure was mildly elevated at 45% systemic level.  There was a 25 mmHg peak systolic gradient across the outflow tract to the main branch pulmonary arteries.  Phasic branch pulmonary artery pressures were normal.  Right-to-left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency.  The right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation.  There is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus.  The pulmonary valve appeared to be thin and moved well.  The median branch pulmonary arteries were of good size with normal distal arborization.  Angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,INITIAL DIAGNOSES:,1.  Membranous pulmonary atresia.,2.  Atrial septal defect.,3.  Right coronary artery to pulmonary artery fistula.,SURGERIES (INTERVENTIONS):  ,1.  Pulmonary valvotomy surgical.,2.  Aortopulmonary artery central shunt.,3.  Balloon pulmonary valvuloplasty.,CURRENT DIAGNOSES:  ,1.  Pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2.  Mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3.  Small right coronary artery to main pulmonary fistula.,4.  Static encephalopathy.,5.  Cerebral palsy.,MANAGEMENT: , The case to be discussed with combined Cardiology/Cardiothoracic Surgery case conference.  Given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated.  Conservative outpatient management is to be recommended.  Further patient care will be directed by Dr. X.
---
DESCRIPTION: Pulmonary valve stenosis, supple pulmonic narrowing, and static encephalopathy

cardiovascular / pulmonary, membranous pulmonary atresia, atrial septal defect, pulmonary artery fistula, pulmonary valvotomy, central shunt, pulmonary valvuloplasty, static encephalopathy, cerebral palsy, hypoplastic pulmonary annulus, pulmonary valve stenosis, outflow tract obstruction, ventricular systolic pressure, branch pulmonary arteries, systolic pressure, pulmonary arteries, pulmonary valve, branch pulmonary, coronary artery, catheterization, artery, pulmonary, pressures, coronary,

This case involves a complex medical situation with a history of congenital heart defects and interventions, including surgeries and catheterizations. The patient has a combination of cardiovascular issues, including pulmonary valve stenosis and outflow tract obstruction, and significant neurological consequences from past hypoxic events. Though the immediate management is conservative, the conditions being monitored are severe and potential for future intervention might arise. The stakes are high due to the complexity and potential for life-altering complications, but immediate life-threatening action is not needed at this time as per the current management plan.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Function Test - 4

SPIROMETRY:,  Spirometry reveals the FVC to be adequate.,FEV1 is also adequate 93% predicted.  FEV1/FVC ratio is 114% predicted which is normal and FEF25 75% is 126% predicted.,After the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,MVV is also normal.,LUNG VOLUMES: , Reveal a TLC to be 80% predicted.  FRC is mildly decreased and RV is also mildly decreased.  RV/TLC ratio is also normal 97% predicted.,DIFFUSION CAPACITY:,  After correction for alveolar ventilation, is 112% predicted which is normal.,OXYGEN SATURATION ON ROOM AIR:,  98%.,FINAL INTERPRETATION: , Pulmonary function test shows mild restrictive pulmonary disease.  There is no significant obstructive disease present.  There is no improvement after the use of bronchodilator and diffusion capacity is normal.  Oxygen saturation on room air is also adequate.  Clinical correlation will be necessary in this case.,
---
DESCRIPTION: Sample of Pulmonary Function Test

Sample of Pulmonary Function Test

cardiovascular / pulmonary, fev1, fev1/fvc, fvc, fef25, frc, lung volumes, saturation on room air, pulmonary function test, diffusion capacity, oxygen saturation, pulmonary function, function test, spirometry, fev, bronchodilator, diffusion, capacity, oxygen, saturation, pulmonary,

The pulmonary function test results indicate a mild restrictive pulmonary disease with no significant obstructive issues. The patient's oxygen saturation on room air is adequate. The situation suggests a need for clinical correlation, but it does not imply an immediate life-threatening condition. This evaluation is standard for diagnosing and managing respiratory issues, which generally bear moderate stakes in healthcare but are not acutely critical unless accompanied by severe symptoms.


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

HISTORY:  ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  No confirmed prior history of heart attack, myocardial infarction, heart failure.  History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies.  She never had treated hypertension.  She said the blood pressure came down.  She is obviously very hypertensive this evening.  She has some mid scapular chest discomfort.  She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:,  Does not smoke, lipids unknown.  Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:,  Negative for coronary disease.  Dad died of lung cancer.,DRUG SENSITIVITIES:,  Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:,  Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision.  Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  No reflux, abdominal distress.  No other types of indigestion, GI bleed.  GU:  Negative.  She is unaware of any kidney disease.  Did not have arthritis or gout.  No back pain or surgical joint treatment.  Did not have claudication, carotid disease, TIA.  All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS:  Presenting blood pressure was 170/120 and her pulse at that time was 137.  Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  Saturation of 86%.  Currently, blood pressure 120/70, heart rate is down to 100.,EYES:  No icterus or arcus.,DENTAL:  Good repair.,NECK:  Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS:  Fine and coarse rales, lower two thirds of chest.,HEART:  Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  There is loud third heart sound.  No murmur.,ABDOMEN:  Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL:  No acute joints.,EXTREMITIES:  Good pulses.  No edema.,NEUROLOGICALLY:  No focal weakness.,MENTAL STATUS:  Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:,  All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1.  Acute pulmonary edema.,2.  Physical findings of dilated left ventricle.,3.  Left bundle-branch block.,4.  Breast cancer in 1992.,PLAN:  ,Admit.  Aggressive heart failure management.  Get echo.  Start ACE and Coreg.  Diuresis of course underway.
---
DESCRIPTION: This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.   No confirmed prior history of heart attack, myocardial infarction, heart failure.

The situation involves a 61-year-old patient presenting with acute symptoms that indicate a severe cardiovascular condition, specifically pulmonary edema. This condition can be potentially life-threatening and requires urgent medical intervention. The plan involves aggressive heart failure management, indicating the seriousness of the condition. Additionally, the presence of physical findings such as dilated left ventricle and left bundle-branch block further increases the medical complexity and risk. Given the acute nature and the potential for complications, this case can be considered high-stakes in the context of medical urgency and patient safety.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Function Test - 3

SPIROMETRY: , Spirometry reveals the FVC to be adequate.,FEV1 is also normal at 98% predicted and FVC is 90.5% predicted.  FEF25-75% is also within normal limits at 110% predicted.  FEV1/FVC ratio is within normal limits at 108% predicted.,After the use of bronchodilator, there is some improvement with 10%.  MVV is within normal limits.,LUNG VOLUMES:,  Shows total lung capacity to be normal.  RV as well as RV/TLC ratio they are within normal limits.,DIFFUSION CAPACITY:,  Shows that after correction for alveolar ventilation, is also normal.,Oxygen Saturation on Room Air:  98%.,FINAL INTERPRETATION:,  Pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease.  There is some improvement after the use bronchodilator.  Diffusion capacity is within normal limits.  Oxygen saturation on room air is also normal.  Clinical correlation will be necessary in this case.
---
DESCRIPTION: Sample of Pulmonary Function Test

Sample of Pulmonary Function Test

cardiovascular / pulmonary, fvc, fev1, fev1/fvc ratio, fef, lung volumes, saturation on room air, pulmonary function test, pulmonary function, oxygen saturation, spirometry, bronchodilator, lung, diffusion, oxygen, saturation, pulmonary, capacity,

The scenario presented involves the interpretation of a pulmonary function test, which is routine in assessing lung function. The results indicate normal pulmonary function with some improvement after bronchodilator use and normal oxygen saturation, reducing immediate concern. While clinical correlation is recommended, the findings do not suggest an acute or critical medical issue. This makes the situation relatively low-stakes in nature, as there is no indication of disease or urgent need for intervention.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Function Test

OBSERVATIONS: , The forced vital capacity is 2.84 L and forced expiratory volume in 1 second is 1.93 L. The ratio between the two is 68%.  Small improvement is noted in the airflows after bronchodilator therapy.  Lung volumes are increased with a residual volume of 196% of predicted and total lung capacity of 142% of predicted.  Single-breath diffusing capacity is slightly reduced.,IMPRESSION: , Mild-to-moderate obstructive ventilatory impairment.  Some improvement in the airflows after bronchodilator therapy.
---
DESCRIPTION: Pulmonary function test.  Mild-to-moderate obstructive ventilatory impairment.  Some improvement in the airflows after bronchodilator therapy.

cardiovascular / pulmonary, lung volume, forced expiratory volume, forced vital capacity, airflows, total lung capacity, bronchodilator therapy, bronchodilatorNOTE,: 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.,

The scenario involves interpreting results from a pulmonary function test which indicates mild-to-moderate obstructive ventilatory impairment. While it is medically relevant and requires appropriate follow-up, the condition described is not immediately life-threatening or critically urgent, implying moderate stakes rather than high stakes. The condition is manageable with bronchodilator therapy showing some effectiveness.


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

CHIEF COMPLAINT:,  Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  He denies any gasping, choking, or coughing episodes while asleep at night.  His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  He has two to three episodes of nocturia per night.  He denies any morning symptoms.  He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:,  Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:,  TURP.,MEDICATIONS:,  Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:,  None.,FAMILY HISTORY:,  Hypertension.,SOCIAL HISTORY:,  Significant for about a 20-pack-year tobacco use, quit in 1991.  No ethanol use or illicit drug use.  He is married.  He has one dog at home.  He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:,  His weight has been steady over the years.  Neck collar size is 17½".  He denies any chest pain, cough, or shortness of breath.  Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:,  A pleasant, obese, African-American male in no apparent respiratory distress.  T:  98.  P:  90.  RR:  20.  BP:  156/90.  O2 saturation:  97% on room air.  Ht:  5' 5".  Wt:  198 lb.  HEENT:  A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD.  CARDIAC:  Regular rate and rhythm without any adventitious sounds.  CHEST:  Clear lungs bilaterally. ABDOMEN:  An obese abdomen with active bowel sounds.  EXTREMITIES:  No cyanosis, clubbing, or edema.  NEUROLOGIC:  Non-focal.,IMPRESSION:,1.  Probable obstructive sleep apnea syndrome.,2.  Hypertension.,3.  Obesity.,4.  History of tobacco use.,PLAN:,1.  We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  Encouraged weight loss.,3.  Check TSH.,4.  Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  Asked to return to the clinic one week after sleep the study is done.
---
DESCRIPTION: Obstructive sleep apnea syndrome.  Loud snoring.  Schedule an overnight sleep study.

This situation involves a medical consultation for a suspected case of obstructive sleep apnea (OSA), which can be a serious condition with potential implications for cardiovascular health and overall safety. Yet, the patient is not in immediate distress and the plan involves scheduling a sleep study, encouraging lifestyle changes, and caution against unsafe activities while sleepy. While OSA can have significant long-term health implications, this particular scenario does not present an immediate life-threatening emergency. The stakes are moderate due to the chronic nature of the condition and its potential to impact the patient's quality of life and health if untreated.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Port-A-Cath Insertion

PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Minimal.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  The left subclavian vein was cannulated with a wire.  Fluoroscopic confirmation of the wire in appropriate position was performed.  Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.  Once the catheter was advanced through the sheath, the sheath was peeled away.  Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed.  No hemorrhage was identified.  The port was in appropriate position with fluoroscopic confirmation.  The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch.  Dressed with Steri-Strips and 4 x 4's.  Port was checked.  Had good blood return, flushed readily with heparinized saline.
---
DESCRIPTION: Port-A-Cath insertion template.  Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.

cardiovascular / pulmonary, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire,

The situation involves the insertion of a port-a-cath, which is a common, but still significant medical procedure primarily used for prolonged intravenous access. While the procedure is routine and the note indicates no complications, minimal blood loss, and successful catheter placement, the nature of the procedure still pertains to a sensitive area related to cardiovascular and pulmonary health. Mistakes or complications could have serious consequences for the patient, such as infection, incorrect placement, or damage to nearby structures. However, the successful completion of the procedure as noted reduces the immediate stakes. Thus, the stakes are moderate considering the potential risks if something were to go wrong, despite everything having gone well.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pneumoconiosis

HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.
---
DESCRIPTION: Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.

The situation involves a 91-year-old male with a complicated medical history, including pneumoconiosis, cardiac issues, and a dependency on ventilatory support. The patient has also experienced cardiac arrest and requires mechanical ventilation with unsuccessful weaning, indicating a critical and potentially volatile health condition. The presence of multiple comorbidities, including COPD, coronary artery disease, and ongoing respiratory depression, further elevates the stakes. Given the age and complexity of the medical issues involved, this situation represents a high-stakes scenario where any change in health status could have significant consequences.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pigtail Catheter Insertion

PREOPERATIVE DIAGNOSIS:  ,Left hemothorax, rule out empyema.,POSTOPERATIVE DIAGNOSIS: , Left hemothorax rule out empyema.,PROCEDURE: , Insertion of a 12-French pigtail catheter in the left pleural space.,PROCEDURE DETAIL:  ,After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion.  Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space.  It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR.  Samples were sent for culture and sensitivity, aerobic and anaerobic.,The patient and I decided to admit him for a period of observation at least overnight.,He tolerated the procedure well and the postprocedure chest x-ray showed no complications.
---
DESCRIPTION: Left hemothorax, rule out empyema.  Insertion of a 12-French pigtail catheter in the left pleural space.

cardiovascular / pulmonary, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax,

The procedure involves the insertion of a pigtail catheter to address a left hemothorax and potentially rule out empyema. While the procedure is conducted in a minor OR and the patient tolerated it well, the fact that it involves the drainage of fluid from the pleural space indicates some level of risk. The post-operative observation suggests a need for vigilance in case of complications, such as infection or further bleeding. However, the successful complication-free outcome as noted reduces the urgency. Given these factors, it is a moderately high-stakes situation due to potential health implications if complications arise.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pleurodesis

PREOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,PROCEDURE:,1.  Conscious sedation.,2.  Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion.  Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day.  Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:,  None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:,  After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation.  Vital signs were taken.  These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV.  After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax.  She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped.  The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive.  The patient tolerated the procedure well.  She did complain of up to a 7/10 pain, but quickly this was brought under control.  The chest tube was unclamped.  Now, the patient will be left to rest and she will get a chest x-ray in the morning.
---
DESCRIPTION: Chest tube talc pleurodesis of the right chest.

cardiovascular / pulmonary, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube

The procedure described is a medical intervention, specifically a pleurodesis, performed to manage a recurrent pleural effusion in a patient with cirrhosis. While it involves potential risks such as pain and the need for careful management to avoid complications like pneumothorax, the situation reflects a routine yet serious medical procedure rather than an emergency or life-threatening situation. However, the fact that the patient has significant underlying health problems (cirrhosis and recurrent effusion) adds some level of risk. The procedure is performed with conscious sedation, and the patient's vitals remained stable throughout. Therefore, while it is not a high-stakes emergency, it is still an important medical procedure with moderate stakes due to the patient's condition.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pericardial Effusion

REASON FOR CONSULTATION:,  Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.  A CT of the chest was done, which shows pericardial effusion.  This consultation is for the same.  The patient denies any lightheadedness or dizziness.  No presyncope or syncope.  Activity is fairly stable.,CORONARY RISK FACTORS: , History of borderline hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is within normal limits.  No history of established coronary artery disease.  Family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY:  ,Hysterectomy and bladder surgery.,MEDICATIONS AT HOME:  ,Aspirin and thyroid supplementation.,ALLERGIES:,  None.,PERSONAL HISTORY:,  She is a nonsmoker.  She does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,1.  Hypothyroidism.,2.  Borderline hypertension.,3.  Arthritis.,4.  Presentation at this time with chest pain and shortness of breath.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, blurring of vision, or glaucoma.,CARDIOVASCULAR:  Chest pain.  No congestive heart failure.  No arrhythmia.,RESPIRATORY:  No history of pneumonia in the past, valley fever.,GASTROINTESTINAL:  Epigastric discomfort.  No hematemesis or melena.,UROLOGICAL:  Frequency.  No urgency.  No hematuria.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.  No significant carotid bruit.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA:  ,White count of 20 and H&H 13 and 39.  BUN and creatinine within normal limits.  Cardiac enzyme profile negative.,RADIOGRAPHIC STUDIES: , CT of the chest preliminary report, pericardial effusion.  Echocardiogram shows pericardial effusion, which appears to be chronic.  There is no evidence of hemodynamic compromise.,IMPRESSION:,1.  The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder.  She has elevated white count, possible infection.,2.  Pericardial effusion without any hemodynamic compromise, could be chronic.
---
DESCRIPTION: The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  Low-grade fever was noted last few weeks.  The patient also has chest pain described as dull aching type in precordial region.  No relation to exertion or activity.  No aggravating or relieving factors.

The situation involves an elderly patient with pericardial effusion identified by CT and echocardiogram. Although no hemodynamic compromise is present, pericardial effusion can potentially lead to cardiac tamponade, which is life-threatening. The patient's symptoms, including shortness of breath and chest pain, along with a high white count indicating possible infection, add complexity. Given the patient's age and symptoms, this situation holds significant risk even though it is currently stable.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Patent Ductus Arteriosus Ligation

TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.
---
DESCRIPTION: Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.

cardiovascular / pulmonary, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation

The procedure described is a patent ductus arteriosus ligation on a premature infant weighing only 600 grams, which is extremely delicate due to the patient's severe prematurity and low weight. Such surgeries on very low birth weight infants are inherently high-risk, as they involve tiny and fragile anatomical structures. Additionally, there's the challenge of managing anesthesia in such small bodies. Missteps can lead to serious life-threatening complications. However, no complications were noted during the procedure, and vital structures were preserved, indicating the surgery was successfully managed. Despite this, the inherent risks make it a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Nuclear Cardiac Stress Report

NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes.  At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol.  During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion.  No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time.  A fixed defect is seen in the high anterolateral segment.  A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum.  There is no evidence for active ischemia in either distribution.  Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity.  When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall.  A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS:  ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above.  There is no indication for active ischemia at this time.
---
DESCRIPTION: Nuclear cardiac stress report.  Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.

cardiovascular / pulmonary, angina pectoris, ischemic cardiomyopathy, myocardial perfusion, adenosine provocation, cardiolite perfusion, nuclear cardiac stress report, coronary artery disease, active ischemia, ischemic, angina,

This situation involves interpreting a nuclear cardiac stress report for a patient with recurrent angina pectoris and documented ischemic heart disease. The report indicates that the patient has multivessel coronary artery disease and likely had previous infarcts, though no active ischemia was found at the time of the study. While the test results do not show immediate ischemia, the underlying conditions such as ischemic cardiomyopathy and multivessel disease are serious and require careful ongoing management. The stakes are moderate to high because the patient's cardiovascular health is at risk, but there are no immediate life-threatening findings in this study.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pacemaker (Single Chamber) - 1

REFERRAL INDICATION,1.  Tachybrady syndrome.,2.  Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a single-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME:  ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Benadryl 50 mg.,3.  Versed 3 mg.,4.  Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation.  She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.  Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  Percutaneous access of the left axillary vein was then performed.  A wire was then advanced in the left axillary vein using fluoroscopy.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein.  The dilator and wire were removed.  An active pacing lead was then advanced down in the right atrium.  The peel-away sheath was removed.  Lead was passed across the tricuspid valve and positioned in an apical septal location.  This was an active fixed lead and the screw was deployed.  Adequate pacing and sensing function were established.  The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was washed with antibiotic-impregnated saline.  A pulse generator was obtained and connected securely to the lead.  The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2.  Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:,  Right ventricular lead impedance 630 ohms.  R wave measures 17.5 mV.  Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1.  Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2.  Chest x-ray to rule out pneumothorax and verify lead position.,3.  Completion of course of antibiotics.,4.  Device interrogation in the morning.,5.  Home dismissal instructions provided in a written format.,6.  Wound check in 7 to 10 days.,7.  Enrollment in Device Clinic.
---
DESCRIPTION: Implantation of a single-chamber pacemaker.  Fluoroscopic guidance for implantation of single-chamber pacemaker.

The given situation involves a medical procedure for implanting a single-chamber pacemaker, which is a critical intervention for managing tachybrady syndrome and chronic atrial fibrillation in the patient. This procedure involves inherent risks, such as bleeding, infection, cardiac perforation, and even death, as noted in the documentation of patient consent. The potential consequences of procedure success or failure directly impact the patient's health and well-being, making it a significant decision. Therefore, the stakes are high, as it involves complex medical procedures and patient outcomes.