Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 34

Chief Complaint:, Chronic abdominal pain.,History of Present Illness:, 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated "with over the counter" antacids and obtained some relief so he did not seek medical attention at that time.,Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain.,The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems.,Past Medical History:, No significant past medical history.,Past Surgical History:, No prior surgeries.,Allergies:, No known drug allergies.,Medications:, Omeprazole 40 mg once a day. Denies herbal medications.,Family History:, Mother, father and siblings were alive and well.,Social History:, He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.,Physical Examination:, The patient was a thin male in no apparent distress. His oral temperature was 98.2 Fahrenheit, blood pressure was 114/67 mmHg, pulse rate of 91 beats per minute and regular, respiratory rate was 14 and his pulse oximetry on room air was 98%. Patient was 52 kg in weight and 173 cm height.,SKIN: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm.,HEENT: Head was normocephalic and atraumatic. Pupils were equal, round and reactive. Anicteric sclerae. Tympanic membranes had a normal appearance. Normal funduscopic examination. Oral mucosa was moist and pink. Oral/pharynx was clear.,NECK: No lymphadenopathy. No carotid bruits. Trachea midline. Thyroid non-palpable. No jugular venous distension.,CHEST: Lungs were clear bilaterally with good air movement.,HEART: Regular rate and rhythm. Normal S1 and S2 with no murmurs, gallops or rubs. PMI was non-displaced.,ABDOMEN: Abdomen was flat. Normal active bowel sounds. Liver span percussed sixteen centimeters, six centimeters below R costal margin with irregular border that was mildly tender to palpation. Slightly tender to palpation in epigastric area. There was no splenomegaly. No abdominal masses were appreciated. No CVA tenderness was noted.,RECTAL: No perirectal lesions were found. Normal sphincter tone and no rectal masses. Prostate size was normal without nodules. Guaiac positive.,GENITALIA: Testes descended bilaterally, no penile lesions or discharge.,EXTREMITIES: No clubbing, cyanosis, or edema. No peripheral lymphadenopathy was noted.,NEUROLOGIC: Alert and oriented times three. Cranial nerves II to XII appeared intact. No muscle weakness or sensory deficits. DTRs equal and normal.,Radiology/Studies: 2 view CXR: Mild elevation right diaphragm.,CT of abdomen and pelvis: Too numerous to count bilobar liver masses up to about 8 cm. Extensive mass in the pancreatic body and tail, peripancreatic region and invading the anterior aspect of the left kidney. Question of vague splenic masses. No definite abnormality of the moderately distended gallbladder, bile ducts, right kidney, poorly seen adrenals, bowel or bladder. Evaluation of the retroperitoneum limited by paucity of fat.,Patient underwent several diagnostic procedures and soon after he was transferred to Houston Veterans Administration Medical Center to be near family and to continue work-up and treatment. At the HVAMC these diagnostic procedures were reviewed.
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DESCRIPTION: A male patient presented for evaluation of chronic abdominal pain.

The situation involves a patient with complex symptoms including chronic abdominal pain, significant weight loss, and numerous liver and pancreatic masses, which are potentially indicative of a serious underlying condition such as cancer. The diagnostic imaging findings are concerning, suggesting extensive metastatic disease. This requires urgent medical evaluation and management, possibly including invasive diagnostic and therapeutic interventions, making it a high-stakes medical situation.


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Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 5

DATE OF ADMISSION:,  MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,REFERRING PHYSICIAN: , AB CD, M.D.,ATTENDING PHYSICIAN AT DISCHARGE:,  X Y, M.D.,ADMITTING DIAGNOSES:,1.  Ewing sarcoma.,2.  Anemia.,3.  Hypertension.,4.  Hyperkalemia.,PROCEDURES DURING HOSPITALIZATION:  ,Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.,HISTORY OF PRESENT ILLNESS: , Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.  She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY.  A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation.  MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction.  CT showed similar result.  The patient received her first cycle of chemotherapy on MM/DD/YYYY.  On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy.  She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.,HOSPITAL COURSE: ,1.  Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2.  She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.
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DESCRIPTION: A female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.

discharge summary, iron deficiency anemia, hypertension and obesity, iron deficiency, urine, anemia, hypertension, chemotherapy, discharge, ewing, sarcoma,

The situation described in the discharge summary concerns a patient with a serious medical condition, Ewing sarcoma, along with other health issues such as anemia and hypertension. The treatment process, including multiple cycles of chemotherapy and radiation, indicates significant medical management and monitoring requirements. The patient's journey through diagnosis and treatment involves potentially life-threatening complications, which suggests a high-stakes scenario, particularly from a medical and personal perspective. This discharge summary is intended for medical professionals, so the information must be accurate and clear to ensure continued high-quality patient care.

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Medical Specialty: Surgery
Sample Name: Triple Lumen Catheter Insertion - 1

PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED:  ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:,  The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site.  The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:,  The patient's legal guardian was talked to.  All questions were answered and consent was obtained.  The patient was sterilely prepped and draped.  Approximately 4 cc of 1% lidocaine was injected into the inguinal site.  A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated.  A guidewire was then placed through the needle.  The needle was then removed.  The skin was ________ at the base of the wire and a dilator was placed over the wire.  The triple lumen catheters were then flushed with bacteriostatic saline.  The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed.  Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports.  Each port was closed off and also kept off.  Straight needle suture was then used to suture the triple lumen catheter down to the skin.  Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site.  The surgical site was then sterilely cleaned.  The patient tolerated the full procedure well.  There were no complications.  The nurse was then contacted to allow for access of the triple lumen catheter.
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DESCRIPTION: Need for intravenous access.  Insertion of a right femoral triple lumen catheter.  he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.

surgery, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire

The procedure involves the insertion of a triple lumen catheter in a vulnerable patient, which is a crucial medical intervention. The patient depends on total parenteral nutrition due to inability to eat normally and has a high risk of complications due to the underlying health conditions, such as respiratory failure and malnutrition. The procedure, while routine, is essential for staying alive and can have serious consequences if not performed correctly, highlighting its critical importance. The stakes are high because failure or complications in catheter insertion can significantly impact the patient's health, considering their already precarious situation.


Medical Specialty: Orthopedic
Sample Name: MRI Foot - 1

EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:,  Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION:  ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,
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DESCRIPTION: Pain and swelling in the right foot, peroneal tendon tear.

orthopedic, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,

The situation involves a medical diagnosis from an MRI, revealing an avulsion of the peroneus longus tendon from the lateral aspect of the cuboid bone. While this is a significant orthopedic issue that may require intervention, it is not life-threatening and does not involve critical health risks. It is important for treatment planning and patient care but is not inherently a high-stakes emergency.


Medical Specialty: Surgery
Sample Name: Electronystagmogram

PROCEDURE:  ,This tracing was obtained utilizing silver chloride biopotential electrodes placed at the medial and lateral canthi at both eyes and on the superior and inferior orbital margins of the left eye along a vertical line drawn through the middle of the pupil in the neutral forward gaze.  Simultaneous recordings were made in both eyes in the horizontal direction and the left eye in the vertical directions.  Caloric irrigations were performed using a closed loop irrigation system at 30 degrees and 44 degrees C into either ear.,FINDINGS: , Gaze testing did not reveal any evidence of nystagmus.  Saccadic movements did not reveal any evidence of dysmetria or overshoot.  Sinusoidal tracking was performed well for the patient's age.  Optokinetic nystagmus testing was performed poorly due to the patient's difficulty in following the commands.  Therefore adequate OKNs were not achieved.  The Dix-Hallpike maneuver in the head handing left position resulted in moderate intensity left beating nystagmus, which was converted to a right beating nystagmus when she sat up again.  The patient complained of severe dizziness in this position.  There was no clear-cut decremental response with repetition.  In the head hanging left position, no significant nystagmus was identified.  Positional testing in the supine, head hanging, head right, head left, right lateral decubitus, and left lateral decubitus positions did not reveal any evidence of nystagmus.,Caloric stimulation revealed a calculated unilateral weakness of 7.0% on the right (normal <20%) and left beating directional preponderance of 6.0% (normal <20-30%).,IMPRESSION: , Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.  No other significant nystagmus was noted.  There was no evidence of clear-cut caloric stimulation abnormality.  This study would be most consistent with a right vestibular dysfunction.
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DESCRIPTION: Abnormal electronystagmogram demonstrating prominent nystagmus on position testing in the head hanging right position.

surgery, silver chloride biopotential electrodes, inferior orbital margins, lateral canthi, vestibular dysfunction, prominent nystagmus, head hanging, electronystagmogram, eyes, nystagmus,

The situation involves interpreting the results of an electronystagmogram (ENG) test, which is utilized to diagnose balance disorders related to the vestibular system. While it involves clinical data that could impact a patient's diagnosis and treatment, the test results themselves do not indicate an immediate life-threatening condition. The findings suggest a vestibular dysfunction, which is significant for understanding and managing the patient's symptoms but does not typically present an immediate high-risk scenario. Thus, while important for clinical decisions, the stakes are moderate rather than extremely high.


Medical Specialty: Urology
Sample Name: Hematuria - Consult

HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old male, who presents with gross hematuria that started this morning.  The patient is a difficult historian, does have a speech impediment, slow to answer questions, but daughter was able to answer lot of questions too.  He is complaining of no other pain.  He denies any abdominal pain.  Denies any bleeding anywhere else.  Denies any bruising.  He had an episode similar to this a year ago where it began the same with hematuria.  He was discharged after a workup in the hospital, in the emergency room, with Levaquin.  Three days later, he returned with a very large hematoma to his left neck and a coagulopathy with significant bleeding.  His H and H was down in the 6 level.  He received blood transfusions.  He was diagnosed with a malignancy, coagulopathy, and sounds like was in critical condition.  Family actually states that they were told that he was unlikely to live through that event, but he did.  Since then, he has had no bleeding.  The patient has had no fever.  No cough.  No chest pain or shortness of breath.  No bleeding gums.  No blurred vision.  No headache.  No recent falls or trauma.  He has had no nausea or vomiting.  No diarrhea.  No blood in the stool or melena.  No leg or calf pain.  No joint pain.  No rashes.  No swollen glands.  He has no numbness, weakness or tingling to his extremities.  No acute anxiety or depression.,PAST MEDICAL HISTORY: , Has prostate cancer.,MEDICATION: , He is receiving Lupron injection by Dr. Y. The only other medication that he takes is Tramadol.,SOCIAL HISTORY: , He does not smoke or drink.,PHYSICAL EXAMINATION:,Vital Signs:  Are all reviewed on triage.,General:  He is alert.  Answers slowly with a speech impediment, but answers appropriately.,HEENT:  Pupils equal, round, and reactive to light.  Normal extraocular muscles.  Nonicteric sclerae.  Conjunctivae are not pale.  His oropharynx is clear.  His mucous membranes are moist.,Heart:  Regular rate and rhythm, with no murmurs.,Lungs:  Clear.,Abdomen:  Soft, nontender, nondistended.  Normal bowel sounds.  No organomegaly or mass.,Extremities:  No calf tenderness, erythema or warmth.  He has no bruises noted.,Neurological:  Cranial nerves II through XII are intact.  He has 5/5 strength throughout.  ,GU:  Normal.,LABORATORY DATA:  ,The patient did on urinalysis have few red blood cells.  His urine was also grossly red, although no blood clots or gross blood was noted.  It was more of a red fluid.  He had a mild decrease in H and H at 12.1 and 34.6.  His white count was normal at 7.2.  His PT was elevated at 15.9.  PTT elevated at 36.4.  INR is 1.4.  His comprehensive metabolic profile is normal except for BUN of 19.,CONDITION: , The patient is stable at this time, although because of the history of the same happening and the patient beginning in the same fashion his history of coagulopathy, the patient is discussed with Dr. X and he is admitted for orders.  Also we will consult Dr. Y, see orders for further.
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DESCRIPTION: Patient presents with gross hematuria that started this morning.

urology, prostate cancer, bleeding, gross hematuria, speech impediment, hematuria, coagulopathy, blood,

This patient has a history of serious medical issues including prostate cancer and a previous episode of life-threatening coagulopathy. The present condition of gross hematuria, combined with the patient's history, particularly the significant bleeding and coagulopathy from the previous episode, makes this a potentially serious situation. Even though the patient is stable now, the potential for rapid deterioration and the history of a similar life-threatening event increases the stakes. Immediate medical evaluation and management are necessary to prevent another critical event.


Medical Specialty: Pain Management
Sample Name: Tenosynovectomy & Cortisone Injection

PREOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,POSTOPERATIVE DIAGNOSES,1.  EMG-proven left carpal tunnel syndrome.,2.  Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level.,3.  Dupuytren's nodule in the palm.,PROCEDURE: , Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.,ANESTHESIA: , Local plus IV sedation (MAC).,ESTIMATED BLOOD LOSS:  ,Zero.,SPECIMENS:  ,None.,DRAINS: , None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery.  Routine prep and drape was employed.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure.  Hand was positioned palm up in the lead hand-holder.  A short curvilinear incision about the base of the thenar eminence was made.  Skin was sharply incised.  Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin.  Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm.  Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve.  Retinacular flap was retracted radially to expose the contents of the carpal canal.  Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing.  Locally adherent tenosynovium was present and this was carefully dissected free.  Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal.  Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium.  When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures.  A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the Dupuytren's nodule in the midpalm to relieve local discomfort.  Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.  Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n.  Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery.  She was asked to keep the dressings clean, dry and intact and follow up in my office.
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DESCRIPTION: Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.

pain management, carpal tunnel syndrome, pulley, dupuytren's, tenosynovitis, tenosynovectomy, carpal tunnel release, flexor tenosynovectomy, cortisone injection, dupuytren's nodule, injection, cortisone,

This medical procedure involves surgery to release carpal tunnel and address tenosynovitis and Dupuytren's nodule via cortisone injections. While surgery is a significant medical intervention, the use of local anesthesia and IV sedation indicates a controlled and typically low-risk environment. The estimated blood loss is zero, and no complications or complex post-operative care are mentioned. The patient is discharged on the same day with simple aftercare instructions, further indicating low urgency and risk. However, as with any surgical procedure, there is inherent risk involved, so it cannot be considered extremely low-stakes. Therefore, it can be considered a moderate-stakes situation.


Medical Specialty: Radiology
Sample Name: MRI T-L Spine - Schistosomiasis

CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with "pins & needles" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.
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DESCRIPTION: MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.

The situation involves a complex and serious medical condition where a patient has developed paraplegia secondary to an intradural spinal lesion caused by Schistosomiasis. This is compounded by neurological decline when the patient is in a remote region without immediate access to advanced medical care, leading to multiple interventions including airlifting to another country and surgical procedures. The high stakes arise from the risk of permanent neurological damage, potential complications from invasive procedures, and the challenges in managing a rare condition. Moreover, the condition's progression and treatment have significant implications for the patient's quality of life and future health. In the context of medical practice, this scenario requires urgent and decisive medical intervention, highlighting its high-stakes nature.


Medical Specialty: Neurosurgery
Sample Name: Phenol Neurolysis & Botulinum Toxin Injection - 3

PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.
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DESCRIPTION: Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.

neurosurgery, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin

The procedure described is a medical intervention involving neurolysis and botulinum toxin injections for treating spastic diplegic cerebral palsy. While complications are noted as none in this instance, the procedure involves significant injections and handling with anesthesia, and it aims to improve motor function for a patient with a challenging condition. Given the critical aspect of targeting specific nerves and muscles, any errors could lead to potential adverse effects or reduced therapeutic benefit. Therefore, it's relatively high stakes but non-life-threatening given the absence of immediate complications.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Appendectomy - 5

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.  She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table.  The abdomen was prepared and draped in usual sterile fashion.  After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made.  A Veress needle was inserted.  Abdomen was insufflated to 15 mmHg.  A 5-mm port and camera placed.  The abdomen was visually explored.  There were no obvious abnormalities.  A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two.  Blunt dissection was used to isolate the appendix.  Appendix was separated from surrounding structures.  A window was created between the appendix and the mesoappendix.  GIA stapler was tossed across it and fired.  Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler.  Appendix was placed in an Endobag and removed from the patient.  Right lower quadrant was copiously irrigated.  All irrigation fluids were removed.  Hemostasis was verified.  The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device.  All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures.  Steri-Strips and sterile dressings were applied.  Overall, the patient tolerated this well, was awakened and returned to recovery in good condition.
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DESCRIPTION: Laparoscopic appendectomy.  The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.

gastroenterology, gia stapler, laparoscopic appendectomy, appendectomy, endotracheal, mesoappendix, laparoscopic, appendicitis, appendix

The situation describes a routine laparoscopic appendectomy performed on a patient diagnosed with appendicitis. This is a common surgical procedure with a high success rate and a low risk of complications when conducted by professionals. While surgery inherently carries some level of risk, a laparoscopic appendectomy is considered minimally invasive and is usually low-stakes relative to other medical procedures. The document indicates the procedure was uncomplicated and the patient tolerated it well, further suggesting a low-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Attempted Suicide - Consult

IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.  Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital.  He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: , The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds.  He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS:  ,The patient is on a 72-your involuntary hold for danger to self and grave disability.  He has a history of bipolar disorder with mania and depression with anxiety and panic attacks.  Today, he went to involuntary court hearing and was released by the court.  He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:,  Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion.  He describes "allergy" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X.  Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication.  This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1.  Klonopin 1 mg t.i.d. p.r.n.,2.  Extended-release lithium 450 mg b.i.d.,3.  Depakote 1000 mg b.i.d.,4.  Seroquel 1000 mg per day.,SOCIAL HISTORY:  ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana.  The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:,  Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization.  There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD.  His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1.  Bipolar disorder.,2.  Major depression with anxiety and panic attacks.,3.  Polysubstance abuse, benzodiazepines, and others street meds.,4.  ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:,  History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay.  He has an appointment in four days with his outpatient psychiatrist, Dr. X.  He has four days' worth of medications and agrees to no self-harm or harm of others.  Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe.  His mother and stepfather have been informed of the patient's discharge and the followup plan.
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DESCRIPTION: The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.

This situation involves a young male with a history of mental health disorders (bipolar disorder, anxiety, ADHD), polysubstance abuse, and a recent attempt to jump from a moving vehicle, indicating potentially suicidal behavior. The patient is on a 72-hour involuntary hold for danger to self and grave disability but was released from the hold despite serious concerns. His GAF score of 40 suggests significant impairment in functioning. Although he was discharged with a follow-up plan and medication, his history of noncompliance and substance abuse, along with his recent behaviors, make it a high-stakes situation. If not handled correctly, there are risks of further mental health crises or attempts at self-harm.


Medical Specialty: Surgery
Sample Name: EGD With Photos & Biopsies.

1.  Odynophagia.,2.  Dysphagia.,3.  Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Hiatal hernia.,PROCEDURE PERFORMED:  EGD with photos and biopsies.,GROSS FINDINGS:  This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia.  She has a previous history of hiatal hernia.  She was on Prevacid currently.  At this time, an EGD was performed to rule out stricture.  At the time of EGD, there was noted some antral gastritis and hiatal hernia.  There are no strictures, tumors, masses, or varices present.,OPERATIVE PROCEDURE:  The patient was taken to the Endoscopy Suite in the lateral decubitus position.  She was given sedation by the Department Of Anesthesia.  Once adequate sedation was reached, the Olympus gastroscope was inserted into oropharynx.  With air insufflation entered through the proximal esophagus to the GE junction.  The esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices.  There was a hiatal hernia present.  The scope was passed through the hiatal hernia into the body of the stomach.  In the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions.  Multiple biopsies were obtained.  The scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits.  The scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and GE junction.  As stated, multiple biopsies were obtained.,The scope was then slowly withdrawn.  The patient tolerated the procedure well and sent to recovery room in satisfactory condition.
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DESCRIPTION: EGD with photos and biopsies.  This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia.  She has a previous history of hiatal hernia.  She was on Prevacid currently.

surgery, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia,

This medical procedure description involves an Esophagogastroduodenoscopy (EGD) to evaluate a 75-year-old patient presenting with odynophagia, dysphagia, and a history of hiatal hernia. While the procedure is not inherently life-threatening, it is essential for diagnosing potential serious conditions like strictures or tumors. Since the findings include antral gastritis and hiatal hernia but no strictures or masses, the immediate situation is not high-stakes. However, given the patient's age and symptoms, this situation requires careful attention but does not present immediate high-stakes consequences.


Medical Specialty: Orthopedic
Sample Name: Antibiotic-Impregnated Beads Placement

PREOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,POSTOPERATIVE DIAGNOSIS:,  Open calcaneus fracture on the right.,PROCEDURES:,  ,1.  Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2.  Placement of antibiotic-impregnated beads.,ANESTHESIA:,  General.,BLOOD LOSS:,  Minimal.,COMPLICATIONS:,  None.,FINDINGS:,  Healing skin with no gross purulence identified, some fibrinous material around the beads.,SUMMARY:,  After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion.  The tourniquet was inflated and the previous wound was opened.  Dr. X came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound.  The wound margins were healthy with the exception of very central triangular incision area.  The edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,The skin edges were approximated under minimal tension.  The soft dressing was placed.  An Ace was placed.  She was awakened from the anesthesia and taken to recovery room in a stable condition.  Final needle, instrument, and sponge counts were correct.
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DESCRIPTION: Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads.  Open calcaneus fracture on the right.

orthopedic, open calcaneus fracture, irrigation and debridement, antibiotic impregnated beads, irrigation, subcutaneous, placement, debridement, calcaneus, fracture, wound, beads, antibiotic

The procedure described involves the management of an open calcaneus fracture, which is a serious injury due to the potential for infection and long-term complications if not properly treated. The use of antibiotic-impregnated beads indicates concern for preventing infection, a serious risk in open fractures. While the blood loss was minimal and there were no complications during the procedure, the operation itself is significant given the potential impact on patient mobility and health if not successful. The stakes are moderate to high due to the nature of the injury and the focus on preventing infection.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Wound Check - Status Post APR

HISTORY OF PRESENT ILLNESS:,  Ms. Connor is a 50-year-old female who returns to clinic for a wound check.  The patient underwent an APR secondary to refractory ulcerative colitis.  Subsequently, she developed a wound infection, which has since healed.  On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound.  She describes no drainage or erythema from her bottom.  She is having good ostomy output.  She does not describe any fevers, chills, nausea, or vomiting.  The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy.  She has been taking Percocet for this pain and it does work.  She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain.  She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds.  This is a pleasant female in no acute distress.  The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar.  There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant.  There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.  She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter.  I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less.  I have counseled her on refraining from soft drinks and fruit drinks.  I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy.  She also had questions about her occasional abdominal pain.  I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain.  I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain.  The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery.  This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping.  I told her that I felt that this would continue to improve as it has done over the past two months since her surgery.  I told her to continue doing hand exercises as she has been doing and this seems to be working for her.  Overall, I think she has healed from her surgery and is doing very well.  Again, her quality of life is significantly improved.  She is happy with her performance.  We will see her back in six months just for a general routine checkup and see how she is doing at that time.
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DESCRIPTION: This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.

soap / chart / progress notes, perineal wound, wound infection, wound, wound check, ulcerative colitis, apr, ileostomyNOTE

The situation involves a post-operative follow-up for a patient who underwent an abdominoperineal resection (APR) due to refractory ulcerative colitis. While this involves assessing her recovery and offers an opportunity to address any post-surgical complications and adjust pain management, it is a routine checkup rather than an immediate life-threatening situation. The patient is in no acute distress, her wound has healed, and she is adjusting well to her ileostomy, indicating stable postoperative progress. The discussion of pain management and dietary adjustments is part of routine postoperative care. Therefore, while important for the patient's comfort and ongoing recovery, the situation is not high-stakes in terms of immediate risk to life or severe medical intervention.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Elevated PSA - Chart Note

REASON FOR VISIT:  ,Elevated PSA with nocturia and occasional daytime frequency.,HISTORY: , A 68-year-old male with a history of frequency and some outlet obstructive issues along with irritative issues.  The patient has had history of an elevated PSA and PSA in 2004 was 5.5.  In 2003, he had undergone a biopsy by Dr. X, which was negative for adenocarcinoma of the prostate.  The patient has had PSAs as high as noted above.  His PSAs have been as low as 1.6, but those were on Proscar.  He otherwise appears to be doing reasonably well, off the Proscar, otherwise does have some irritative symptoms.  This has been ongoing for greater than five years.  No other associated symptoms or modifying factors.  Severity is moderate.  PSA relatively stable over time.,IMPRESSION: , Stable PSA over time, although he does have some irritative symptoms.  After our discussion, it does appear that if he is not drinking close to going to bed, he notes that his nocturia has significantly decreased.  At this juncture what I would like to do is to start with behavior modification.  There were no other associated symptoms or modifying factors.,PLAN: , The patient will discontinue all caffeinated and carbonated beverages and any fluids three hours prior to going to bed.  He already knows that this does decrease his nocturia.  He will do this without medications to see how well he does and hopefully he may need no other additional medications other than may be changing his alpha-blocker to something of more efficacious.
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DESCRIPTION: Elevated PSA with nocturia and occasional daytime frequency.

soap / chart / progress notes, daytime frequency, psa, irritative symptoms, elevated psa, frequency, nocturia

The situation involves a medical evaluation of a 68-year-old male with an elevated PSA and urinary symptoms such as nocturia. The stakes are moderate as it involves monitoring possible prostate health issues, including the risk of prostate cancer, given his age and history. However, the current situation is stable and not indicating immediate life-threatening conditions as previous biopsies were negative, and management is centered around behavior modification without medication. The visit is important for ongoing health monitoring but not critical or emergency-level high-stakes.


Medical Specialty: Orthopedic
Sample Name: Diskectomy

PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 10 mL.,BLOOD REPLACED:, None.,CRYSTALLOID GIVEN:, 800 mL.,DRAIN (S):, None.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room in supine position. General endotracheal anesthesia was administered. He was turned into the prone position on the operating table and positioned in the modified knee-chest position with Andrews frame being used. Care was taken to protect pressure points. The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made, excising scar from previous surgery. Dissection was carried down through the subcutaneous tissue with electrocautery technique. The lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. Cross-table lateral was also made to confirm position. The scar was then loosened from the inferior portion of 4, superior of L5 lamina, and a portion of the lamina was removed. I did identify normal dura. The scar was then lysed from the medial wall. Dura and nerve root were identified and protected with nerve root retractor. The bulging disk fragment was still contained under the longitudinal ligament. A rent was made with the Penfield and a moderately large fragment was removed. The disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. When no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a Murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. Check was made for CSF leakage, and no evidence of significant epidural bleeding was present. The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.,After a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room.
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DESCRIPTION: Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.

orthopedic, herniation, andrews frame, csf leakage, depo-medrol, l4-5, proxi-strips, diskectomy, endotracheal anesthesia, lumbosacral fascia, modified knee-chest position, radiculopathy, supine position, nerve root, duraprep,

The document describes a redo L4-5 diskectomy, a surgical procedure addressing a recurrent herniated disk with radiculopathy, meaning there is an issue impacting nerve roots. While surgeries inherently carry risk, this one appears to have been completed without complications and with minimal blood loss, indicating it went smoothly. The stakes, as such, can be considered moderate due to inherent surgical risks and the potential impact on the patient's quality of life if not successful, but not extremely high given the procedure's routine nature and absence of complications.


Medical Specialty: Rheumatology
Sample Name: Consult - Weankness & Polymyositis

REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you.
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DESCRIPTION: Consultation - an 87-year-old white female with weakness and a history of polymyositis.

This case involves an 87-year-old patient with a complex medical history, including polymyositis, spine disease, and recent diagnoses of pneumonia and shingles. Additionally, there is a sudden worsening of her lower extremity weakness, raising concerns about a recurrence of her inflammatory myopathy or the development of a new condition like inclusion body myositis or spine-related issues. The potential deterioration of her condition due to these factors and her age implies significant medical risks, though not life-threatening at the immediate moment. The situation involves diagnostic uncertainty that could affect her quality of life and mobility significantly.


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

Medical Specialty: Surgery
Sample Name: EGD & PEG Tube Placement

PREOPERATIVE DIAGNOSES:,1.  protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1.  Protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,3.  Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHESIA: , IV sedation with 1% lidocaine for local.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS:  ,None.,BRIEF HISTORY: , This is a 44-year-old African-American female who is well known to this service.  She has been hospitalized multiple times for intractable nausea and vomiting and dehydration.  She states that her decreased p.o. intake has been progressively worsening.  She was admitted to the service of Dr. Lang and was evaluated by Dr. Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube.,PROCEDURE: , After risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room.  She was placed in the supine position.  The area was prepped and draped in the sterile fashion.  After adequate IV sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed.  The esophagus, stomach, and duodenum were visualized without difficulty.  There was no gross evidence of any malignancy.  There was some enterogastritis which was noted upon exam.  The appropriate location was noted on the anterior wall of the stomach.  This area was localized externally with 1% lidocaine.  Large gauge needle was used to enter the lumen of the stomach under visualization.  A guide wire was then passed again under visualization and the needle was subsequently removed.  A scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well.  A dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty.  The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break-away sheath and visualized within the lumen of the stomach.  The balloon was then insufflated and the break-away sheath was then pulled away.  Proper placement of the tube was ensured through visualization with a scope.  The tube was then sutured into place using nylon suture.  Appropriate sterile dressing was applied.,DISPOSITION:  ,The patient was transferred to the recovery in a stable condition.  She was subsequently returned to her room on the General Medical Floor.  Previous orders will be resumed.  We will instruct the Nursing that the PEG tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings.
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DESCRIPTION: EGD with PEG tube placement using Russell technique.  Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.

surgery, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis

The procedure described involves the placement of a PEG tube for a patient with protein-calorie malnutrition and intractable nausea and vomiting. These symptoms are quite serious and impinge significantly on the patient's ability to intake nutrition, which is critical for their health and well-being. However, the procedure itself, while involving surgery, is commonly performed and typically has a relatively low complication rate. The lack of recorded complications and the patient's stable condition post-operatively add to the understanding that while important, the situation isn't extremely high-stakes as any immediate life-threatening aspects were not reported.


Medical Specialty: Consult - History and Phy.
Sample Name: URI & Eustachian Congestion

HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  She has had a dry cough and a fever as high as 100, but this has not been since the first day.  She denies any vomiting or diarrhea.  She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:,  The patient does note some pressure in her sinuses.  She denies any skin rash.,SOCIAL HISTORY:,  Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  Room air oximetry is 100%.,GENERAL:  Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT:  Head is normocephalic, atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  Both TMs are easily visualized and are clear with good light reflex and no erythema.  Sinuses do show some mild tenderness to percussion.,NECK:  No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,SKIN:  No rash.,ASSESSMENT:,  Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:,  I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort.  I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses.  If she is unimproved in five days, follow up with her PCP for re-exam.
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DESCRIPTION: Viral upper respiratory infection (URI) with sinus and eustachian congestion.  Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.

consult - history and phy., upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar

The situation involves a common viral upper respiratory infection in a teenage patient, accompanied by sinus and eustachian congestion. The symptoms are typical and not severe, with the patient appearing only mildly ill. The plan includes the use of over-the-counter medication with a low likelihood of complications. While any medical condition has some level of importance, this situation is very typical and manageable, and does not currently involve any high-risk factors or severe symptoms.


Medical Specialty: Pain Management
Sample Name: Knee Injection - 1

PROCEDURE: , Right knee joint steroid injection.,PREOPERATIVE DIAGNOSIS:,  Osteoarthritis of the right knee.,POSTOPERATIVE DIAGNOSIS:,  Osteoarthritis of the right knee.,PROCEDURE:  ,The patient was apprised of the risks and the benefits of the procedure and consented.  The patient's right knee was sterilely prepped with Betadine.  A 4 mg of dexamethasone was drawn up into a 5 mL syringe with a 3 mL of 1% lidocaine.  The patient was injected with a 1.5-inch 25-gauze needle at the medial aspect of his right flexed knee.  There were no complications.  The patient tolerated the procedure well.  There was minimal bleeding.  The patient was instructed to ice his knee upon leaving clinic and refrain from overuse over the next 3 days.  The patient was instructed to go to the emergency room with any usual pain, swelling, or redness occurred in the injected area.  The patient was given a followup appointment to evaluate response to the injection to his increased range of motion and reduction of pain.
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DESCRIPTION: Osteoarthritis of the right knee.  Right knee joint steroid injection.

pain management, injection, knee joint, steroid injection, osteoarthritis, knee

The procedure described is a knee injection for osteoarthritis, a common and generally low-risk procedure. The patient was informed of the potential risks and benefits, experienced no complications, and was given routine aftercare instructions. While any medical procedure carries some risk, this one is well-established with a low likelihood of severe complications, making it low-stakes in the context of medical interventions.


Medical Specialty: Orthopedic
Sample Name: Ingrown Toenail Removal

PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE:  ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion.  The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail.  The matrix was excised down to the bone and then the skin flap was placed over it.  Hemostasis had been achieved with a cautery.  A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well.  Estimated blood loss was negligible.  The patient was sent back to Same Day Surgery for recovery.
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DESCRIPTION: Painful ingrown toenail, left big toe.  Removal of an ingrown part of the left big toenail with excision of the nail matrix.

orthopedic, toenail, nail matrix, ingrown toenail, painful, ingrown,

The situation involves the removal of a painful ingrown toenail. While it requires surgical intervention and proper care to prevent infection and ensure healing, it's a common and relatively minor procedure typically performed in a minor surgical setting. Complications are rare, and the patient was well-tolerated without any significant issues. Despite the use of sedation and some level of surgical precision, this does not equate to a high-stakes scenario compared to more critical or complex surgical procedures.


Medical Specialty: Urology
Sample Name: Inguinal Exploration

PREOPERATIVE DIAGNOSES:,  Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair, cerebral palsy, asthma, seizure disorder, developmental delay, and gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSES: , Left inguinal hernia, bilateral hydroceles, and right torsed appendix testis.,PROCEDURE: , Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.,FLUIDS RECEIVED:  ,700 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,10 mL.,SPECIMENS:,  Tissue sent to pathology is calcified right appendix testis.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:  ,Sponge and needle counts were correct x2.,ANESTHESIA: , General inhalational anesthetic and 0.25% Marcaine ilioinguinal nerve block, 30 mL given per surgeon.,INDICATIONS FOR OPERATION:  ,The patient is a 14-1/2-year-old boy with multiple medical problems, primarily due to cerebral palsy, asthma, seizures, gastroesophageal reflux disease, and developmental delay.  He had a hernia repair done on the right in the past, but developed a new hernia on the right and a smaller on the left.  The plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then placed in the supine position.  IV antibiotics were given.  He was then sterilely prepped and draped.  A right inguinal incision was made in the previous incisional site with a 15-blade knife, extended down through the subcutaneous tissue and Scarpa fascia with electrocautery.  Electrocautery was used for hemostasis.,The external oblique fascia was then visualized and incised.  There was a moderate amount of scar tissue noted, but we were able to incise that and go down into the right inguinal canal.  Upon dissection there, we did not find any hernias; however, he did have a fairly sizable hydrocele.  We went down towards the external ring and found that this was indeed tight without any hernias.,We then closed up the external oblique fascia and made an incision after doing a shave on the right and left scrotum into the upper scrotal sac with a curvilinear incision with a 15-blade knife.  We then extended down to the subcutaneous tissue.  Electrocautery was used for hemostasis.  The hydrocele sac was visualized and then drained after incising into it with a curved Metzenbaum scissors.  The testis was then delivered and found to have a moderate amount of scar tissue with a calcified appendix testis, which was then excised and sent to pathology.  We then checked the upper aspect of the tunica vaginalis pouch and found that there was indeed no other connection, was up above, so we then wrapped the sac around the back of the testis, and closed it with a 4-0 chromic suture in a Lord maneuver.  We then closed the upper aspect of the subdartos pouch with a pursestring suture of 4-0 chromic and placed the testis into the scrotum in the proper orientation.  We then used an ilioinguinal nerve block and wound instillation on both incisional areas with 0.25% Marcaine without epinephrine; 15 mL was given.,We performed a similar procedure on the left, incising it at the scrotal area first, rather than below, and found this tunica vaginalis, and dissected it in a similar fashion and cauterized the appendix testis, which was not torsed.  This was a smaller hydrocele, but because of the __________ shunt, we went up above and found that there was a very small connection, which was then dissected off the cord structures gently, twisted upon itself, suture ligated with a 2-0 Vicryl suture.,The ilioinguinal nerve block and other wound instillations again with 15 mL total of 0.25% Marcaine were then done by the surgeon as well.  The external oblique fascia was closed on both sides with a running suture of 2-0 Vicryl.  4-0 chromic was then used to close the Scarpa fascia.  The skin was closed with a 4-0 Rapide subcuticular closure.  The scrotal incisions were closed with a subcutaneous and dartos closure using 4-0 chromic.  IV Toradol was given at the end of the procedure.  Dermabond tissue adhesive was placed on all 4 incisions.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.
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DESCRIPTION: Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.

urology, inguinal exploration, inguinal hernia repair, hydrocele repair, appendix testis, ilioinguinal nerve block, external oblique fascia, tunica vaginalis, ilioinguinal nerve, inguinal hernia, hernia repair, hernia, torsed, inguinal, hydrocele, appendix, testis,

The situation involves a detailed description of a surgical procedure in a pediatric patient with multiple complex medical issues, including cerebral palsy, asthma, and seizure disorders. Surgery always comes with inherent risks, particularly in a patient with such a medical history, which can complicate anesthesia and recovery. The stakes are raised due to the patient's age and the need for careful management of their pre-existing conditions during and post-operation. The procedure itself appears to have proceeded without complications, but the need to manage and foresee potential complications related to the patient's history contributes to the overall stakes.


Medical Specialty: Neurology
Sample Name: Neurologic Consultation - 5

HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him.  This was not preceded by lightheadedness.  He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  He started using a walker from that time, prior to that he was able to walk approximately two miles per day.  He again had a fall in August of 2008 after his legs gave way.  Again, there was no lightheadedness associated with this.  He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  He did not, however, return to the pre-July baseline.  In October of 2008, after another fall, he was found to have pneumonia again and shingles.  He is currently in a Chronic Rehabilitation Unit.  He cannot use a walker and uses a wheelchair for everything.  He states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  He is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse.  He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs.  He does not report any cramps, problems with swallowing or problems with breathing.  He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  He has had some problems with blood pressure drops, and does feel presyncopal when he stands.  He also reports that he has no feeling in his feet, and that his feet feel like sponges.  This has been present for about nine months.  He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1.  Pneumonia.  He has had recurrent episodes of pneumonia, which started at approximately age 20.  These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  He is usually treated with antibiotics and then discharged.  There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2.  He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  The patient does not have any history of diabetes and does not report any other medical problems.  He has lost approximately 18 pounds in the past month.,3.  He had an appendectomy in the 1940s.,4.  He had an ankle resection in 1975.,SOCIAL HISTORY:  ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  He has not smoked for the past 27 years.  He hardly ever uses alcohol.  He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:,  He has no medication or food allergies.,REVIEW OF SYSTEMS:,  Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair.  His pain score was 0.,APPEARANCE:  No acute distress.  He is pleasant and well-groomed.,HEENT:  Atraumatic, normocephalic.  No carotid bruits appreciated.,LUNGS:  There were few coarse crackles in both lung bases.,CARDIOVASCULAR:  Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  The pulse was regular and of normal volume.,ABDOMEN:  Soft with no masses and normal bowel sounds.  There were no carotid bruits.,EXTREMITIES:  No contractures appreciated.,NEUROLOGICAL EXAM:,MSE:  His orientation, language, calculations, 100-7 tests were all normal.  There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES:  Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  His palatal movement was normal and gag reflex was normal.,MOTOR:  Strength was decreased in all muscle groups as follows:  Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  There was atrophy in both hands and general atrophy of the lower limb muscles.  The feet were both cold and showed dystrophic features.  Fasciculations were present mainly in the hands.  There was evidence of dysmetria and past pointing in the left hand.,REFLEXES:  Reflexes were 0 in all sites in the arms and legs.  The jaw reflex was 2+.  Vibration was severely decreased at the elbow and wrist and was absent in the fingers.  Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  Joint position sense was absent in the toes and severely decreased in the fingers.  Pin perception was absent in the feet and was decreased to the upper thighs.  Pin was decreased or absent in the fingers and decreased above the elbows.  The same distribution of sensory loss was found with monofilament testing.,COORDINATION:  Coordination was barely normal in the right hand.  Rapid alternating movements were decreased in the left hand greater than the right hand.  The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports.  There were extensive patient reports, all of which were reviewed.  A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  The posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  There was no significant stenosis, but there was minor extracranial stenosis noted.  An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  There was also no significant sinusitis or mastoiditis.  This was an essentially normal brain MRI.  A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal.  An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  The glucose was 86.  TSH performed in January 2009 was 1.57, which is within the normal range.  Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT.  The ECG was non-diagnostic.  There was normal regional wall motion of the left ventricle.  The left ventricular ejection fraction was 68%, which is within the normal range for males.  A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5.  At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4.  An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION:  ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008.  As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  There was no involvement of the tongue on EMG.  The laboratory testing as indicated below failed to show a specific cause for the neuropathy.  We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic.  This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease.  In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  The patient did not receive any of these.  It may also be seen as part of a paraneoplastic syndrome.  Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation.  The verbal reports of these possibly did not show any evidence of a cancer.  We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  This showed evidence of severe axonal loss.  There was no evidence of a vasculitis.  The vessels did show some mild intimal changes that would be consistent with atherosclerosis.  There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  Again, there was no evidence of inflammation or vasculitis.  Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  Specifically, there is no history of HIV exposure.  We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  I have discussed these issues at length with the patient and with his son.  We also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2.  However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1.  Nerve conduction and EMG will be performed today.  The results were indicated above.,2.  The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12.  These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  The B12 was greater than 2000.  The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative.  The B12 level was greater than 2000.  Liver function tests were normal.  The glucose was 90.  ESR was 10.  Hemoglobin A1c was 5.5.,3.  A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4.  CT of chest, abdomen and pelvis.,5.  Whole body gallium scan for evidence of an underlying neoplasm.,6.  The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7.  We have not made any changes to his medication.  He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8.  Followup will be as determined by the family.
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DESCRIPTION: Approximately one and a half years ago, patient fell down while walking in the living room from the bedroom.  At that time, he reports both legs gave away on him and he fell.  He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.

This situation involves a patient with a complex medical history experiencing progressive and significant neurological symptoms. The patient's current condition includes severe neuropathy, motor and sensory deficits, repeated falls, and substantial weight loss, which are signs of possible serious underlying conditions such as paraneoplastic syndrome or other severe neurological disorders. The stakes are high because the patient's quality of life is significantly affected, and the progression of symptoms without a clear diagnosis or treatment plan could lead to further deterioration or complications. The medical team is engaged in extensive diagnostic efforts and surveillance for potentially life-threatening conditions.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Substance abuse

REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use.  The patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago.  The patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over.  The patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago.  The patient says he was depressed and agitated.  He says he used cocaine by snorting and nitrous oxide but denies other drug usage.  He says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital.  The patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure.  The patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations.  The patient is A&O x3.,PAST PSYCHIATRIC HISTORY:,  Substance abuse as per HPI.  The patient went to a well sober for 15 months.,PAST MEDICAL HISTORY:,  Seizures.,PAST SURGICAL HISTORY:,  Shoulder injury.,SOCIAL HISTORY:,  The patient lives alone in an apartment uses prior to sobriety 15 months ago.  He was a binge drinker, although unable to provide detail about frequency of binges.  The patient does not work since brother became ill 3 months ago when he quit his job to care for him.,FAMILY HISTORY:,  None reported.,MEDICATIONS OUTPATIENT:,  Seroquel 100 mg p.o. daily for insomnia.,MEDICATIONS INPATIENT:,1.  Gabapentin 300 mg q.8h.,2.  Seroquel 100 mg p.o. q.h.s.,3.  Seroquel 25 mg p.o. q.8h. p.r.n.,4.  Phenergan 12.5 mg IV q.4h. p.r.n.,5.  Acetaminophen 650 mg q.4h. p.r.n.,6.  Esomeprazole 40 mg p.o. daily. ,MENTAL STATUS EXAMINATION: , The patient is a 42-year-old male who appears stated age, dressed in a hospital gown.  The patient shows psychomotor agitation and is somewhat irritable.  The patient makes fair eye contact and is cooperative.  He had answers my questions with "I do not know."  Mood "depressed" and "agitated."  Affect is irritable.  Thought process logical and goal directed with thought content.  He denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations.  Insight and judgment are both fair.  The patient seems to understand why he is in the hospital and patient says he will return to Alcoholics Anonymous and will try to stay sober in all substances following discharge.  The patient is A&O x3.,ASSESSMENT:,AXIS I:  Substance withdrawal, substance abuse, and substance dependence.,AXIS II:  Deferred.,AXIS III:  History of seizures.,AXIS IV:  Lives alone and unemployed.,AXIS V:  55.,IMPRESSION:,  The patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety.  The patient is experiencing mild symptoms of cocaine withdrawal.,RECOMMENDATIONS:,1.  Gabapentin 300 mg q.8h. for agitation and history of seizures.,2.  Reassess this afternoon for reduction in agitation and withdrawal seizures.,Thank you for the consult.  Please call with further questions.
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DESCRIPTION: Psychiatric consultation for substance abuse.

The situation involves a patient experiencing substance abuse and withdrawal symptoms, with a history of seizures potentially exacerbated by drug use. The patient is undergoing psychiatric evaluation in an ER setting. The risk of further seizures, the potential for future substance abuse relapses, and the complications of managing both withdrawal and psychiatric symptoms contribute to the scenario being moderately high-stakes. While the patient is currently stable and cooperative, the potential consequences of unmanaged withdrawal or relapse elevate the importance of this consultation.