Medical Specialty: General Medicine
Sample Name: Ant Bait Exposure - ER Visit

CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.
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DESCRIPTION: Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.

general medicine, borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,

The scenario involves a 14-month-old child with possible exposure to ant bait containing Borax, but no symptoms or clear evidence of ingestion are present. After evaluation and consultation with Poison Control, the situation is deemed low risk and non-toxic due to the small quantity and lack of symptoms. The child is discharged with instructions to return if symptoms develop. While any potential ingestion by a child requires a precautionary approach, the details suggest low immediate risk to the child’s health.


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

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

DISCHARGE DIAGNOSIS:  ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1.  Chronic pain.,2.  Tobacco use.,3.  History of hepatitis C.,REASON FOR ADMISSION:,  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.  He has had prolonged hospitalizations because of this problem.  He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg.  Examination in the emergency room revealed significant concern for significant cellulitis.  Decision was made to admit him to the hospital.,HOSPITAL COURSE:,  The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking.  The patient had edema of his bilateral lower extremities.  The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C.  Hospital consult was obtained.  This included an ultrasound of his abdomen, which showed just mild cirrhosis.  His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well.  The patient eventually grew MRSA in a moderate amount.  He was treated with IV vancomycin.  Local wound care and elevation.  The patient had slow progress.  He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression.  The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days.  He was also given prescription for Percocet and OxyContin, picked up at my office.  He is instructed to do daily wound care and also wrap his leg with an Ace wrap.  Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.
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DESCRIPTION: Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.

discharge summary, chronic pain, methicillin-resistant staphylococcus aureus cellulitis, complex open wound, staphylococcus aureus, wound care, cellulitis, wound, hepatitis,

The situation involves a medical discharge summary for a patient with a serious condition: an open wound complicated by MRSA cellulitis, chronic pain, tobacco use, and a history of hepatitis C. While these conditions can be severe and require careful management, the patient has been treated and is being discharged in stable condition with specific instructions for care and follow-up. The stakes are moderate because non-compliance with discharge instructions or the progression of the underlying conditions could lead to serious health consequences, but the immediate context is one of transition to home care, which reduces the urgency. Therefore, the stakes are important but not critically high.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Urology
Sample Name: Bladder Cancer

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

urology, retrograde pyelogram, bladder biopsy, muscularis propria, bladder cancer, gross hematuria, bladder wall, ct scan, bladder, hematuria,

The patient has high-grade transitional cell carcinoma, a serious form of bladder cancer, which poses significant health risks and requires immediate and comprehensive medical intervention. The presence of a large tumor with potential bladder neck involvement increases the complexity and risks associated with treatment. Additionally, the patient's health is further complicated by a history of smoking, hypertension, diabetes, and other medical issues which can affect treatment outcomes. The planned TURBT procedure is critical for both treatment and diagnosis, making the situation high-stakes due to potential life-threatening implications if not managed correctly.


Medical Specialty: Consult - History and Phy.
Sample Name: Ant Bait Exposure - ER Visit

CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.
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DESCRIPTION: Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.

consult - history and phy., borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,

The situation involves a 14-month-old child with possible exposure to a small amount of ant bait containing Borax. The child shows no signs of ingestion or symptoms such as coughing, vomiting, or distress. Poison Control has indicated that the quantity involved is likely non-toxic. The child is discharged in stable condition with instructions to return if symptoms develop. While the situation involves a young child and a potential toxin, the absence of symptoms and the expert assessment suggesting low risk make it relatively low-stakes.


Medical Specialty: Dermatology
Sample Name: Erythema Nodosum - Consult

REASON FOR VISIT:,  The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes.  She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands.  At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum.  Part of her workup included a colonoscopy.  The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway.  Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions.  She was seen in our clinic and by Dermatology on several occasions.  Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP.  In the following visits, no evident abnormality has been detected.  In the first visit, here some MTP discomfort detected.  It was thought that erythema nodosum may be present.  However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture.  When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised.  She had an equivocal rheumatoid fracture, but her CCP was negative.  She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative.  Her cardiolipin panel antibodies were negative as well.  We followed the IgM, IgG, and IgA being less than 10.  However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern.  It was thought that the onset of lupus may be the case.  It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum.  For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis.  It was done also in order to rule out sarcoid and the result was unremarkable.  Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed.  The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal.  A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen.  However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that.  Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.,In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne.  We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily.  While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain.  She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present.  Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes.  However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August.  I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently.  She also has evidence of acne, which does not seem to be present at the moment.  She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,Her workup during the initial appointment included an ACE level, which was normal.  She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110.  Her RVVT was normal, her rheumatoid factor was negative.  Her ANA was 1:40, speckled pattern.  The double-stranded DNA was negative.  Her RNP and Smith were negative as well.  RO and LA were negative and cardiolipin antibodies were negative as well.  A urinalysis at the moment was completely normal.  A CRP was 2.3 in the initial appointment, which was high.  A CCP was negative.  Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7.  This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles.  I am mentioning here that photosensitivity rash was mentioned in the past.  She tells me that she had it twice back in Europe after skiing where her whole face was swollen.  Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily.  Today we discussed about the effect of colchicine on a possible pregnancy.,MEDICATIONS: , Prednisone was stopped.  Vitamin D and calcium over the counter, we need to verify that.  Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,FINDINGS:,  On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress.  There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum.  Stasis dermatitis changes in both lower extremities present.  Mild livedo reticularis is present as well.,There is some periarticular ankle edema as well.  Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228.  Her microcytosis and hypochromia has resolved.  Her serum electrophoresis does not show a monoclonal abnormality.  Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation.  This points again towards some ileum pathology.  Her ANCA B and C were negative.  Her PF3 and MPO were unremarkable.  Her endomysial antibodies were negative.  Her sed rate at this time were 19.  The highest has been 30, but prior to her appointment here was even higher.  Her ANA continues to be positive with a titer of 1:40, speckled pattern.  Her double-stranded DNA is negative.  Her serum immunofixation confirmed the absence of monoclonal abnormality.  Her urine immunofixation was not performed.  Her IgG, IgA, and IgM levels are normal.  Her IgE levels are normal as well.  A urinalysis was not performed this time.  Her CRP is 0.4.  Her tissue transglutaminase antibodies are negative.  Her ASCA is normal and anti-OmpC was not tested.  Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific.  I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal.  Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency.  Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30.  Her TIBC was 345 pointing towards an iron deficiency anemia.  I am reminding you that her ACE levels in the past were normal and that she has a microcytosis.  Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive.  Her pelvic ultrasound showed normal uterus adnexa.  Her bladder was normal as well.  Subcentimeter inguinal nodes were found.  There was no large lytic or sclerotic lesion noted.  Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease.  Her capsule endoscopy was limited secondary to rapid transit.  There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum.  However, no significant inflammation or bleeding was seen and this could be small bowel crisis.  Neither evidence of bleeding or inflammation were seen as well.  Specifically, the terminal ileum appeared normal.  Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,ASSESSMENT:,  This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004.  She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers.  Since I took over her care, I have not seen a clear-cut erythema nodosum being present.  No evidence of synovitis was there.  Her serologies apart from an ANA of 1:40 were negative.  She has a livedo pattern, which has been worrisome.  The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency.  She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV.  We never received the x-ray of her hands which she had and she never had a DEXA scan.  Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well.  Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal.  We are going check a PPD to rule out tuberculosis.  We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern.  An anti-intrinsic factor will be added as well.  Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency.  In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash.  Regarding her heart murmur, we are going to proceed with an echocardiogram.  A PPD should be placed as well.  In her next appointment, we may fax a requisition for vitamin B replacement.,PROBLEMS/DIAGNOSES:,  1.  Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2.  Iron deficiencies, according to iron studies.,3.  Borderline B12 with increased methylmalonic acid and homocystine.,4.  On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.,5.  Typical ANCA, per records, were not verified here.  ANCA and ASCA were negative and the OmpC was not ordered.,6.  Acne.,7.  Recurrent arthralgia not present.  Rheumatoid factor, CCP negative, ANA 1:40 speckled.,8.  Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today.  Needs vaccination for influenza and pneumonia.,9.  Vitamin D deficiency.  She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10.  Recurrent ankle discomfort which necessitates ankle x-rays.,PLANS:,  We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies.  We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly.  We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome.  She should be taking vitamin D and calcium after the completion of vitamin D replacement.  She should be seen by her primary care physician, have the iron and B12 deficiency worked up.  She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist.  Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum.  We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies.  Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum.  An anti-intrinsic factor would be added, as I mentioned.  I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers.  She does not give a history of oral contraceptives or medications that could be related to erythema nodosum.  She does not have any evidence of lupus __________ mycosis.  Histoplasmosis coccidioidomycosis would be accompanied by other symptoms.  Hodgkin disease has probably been ruled out with a CAT scan.  However, we are going to add an LDH in future workup.  I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy.  The patient will return in 1 month.
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DESCRIPTION: The patient presents for a followup for history of erythema nodosum.

The case involves a complex diagnostic situation with a history of erythema nodosum and multiple comorbidities such as potential autoimmune disorders, nutritional deficiencies, and possible internal pathologies. Although the situation is medically complex and involves significant investigation, it is not currently life-threatening or imminently dangerous. The patient's condition is under control with ongoing management and follow-up care, reducing the immediate stakes. However, it should be closely monitored due to the complicating factors and potential for more serious underlying conditions such as inflammatory diseases.


Medical Specialty: Consult - History and Phy.
Sample Name: H&P - Cardio (Angina)

CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:
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DESCRIPTION: H&P for a female with Angina pectoris.

H&P for a female with Angina pectoris.

The patient, a 62-year-old female, is presenting with severe and sudden chest pain consistent with angina, combined with symptoms such as nausea and pain radiating to the arm and jaw. She has significant coronary risk factors, including a long history of smoking and untreated elevated cholesterol, and a family history of heart attacks. Additionally, her blood pressure is high, and there's evidence of limb edema. The presence of these symptoms and risk factors suggests a potential for myocardial infarction or other serious cardiovascular events, making it a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 8

PROCEDURES,1.  Left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculogram.,PREPROCEDURE DIAGNOSIS:,  Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,INDICATION:  ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:,  After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory.  He was prepped and draped in the usual sterile manner.  The right inguinal area was anesthetized with 2% Xylocaine.  A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique.  JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively.  Coronary angiographies were performed.  These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle.  Left ventriculography was performed.  The patient tolerated the procedure well.  At the end of the procedure, all catheters and sheaths were removed.  The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE:  ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL.  Ejection fraction was calculated to be 69%.  There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex.  The LAD is small in caliber.  In addition, there is a long bifurcating small-caliber diagonal branch noted.  LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch.  LCX and its branches are free of disease.,RCA:,  RCA is a dominant small-caliber vessel with long small-caliber PDA branch.  RCA and its branches are free of disease.,IMPRESSION,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain.
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DESCRIPTION: Left heart catheterization, coronary angiography, and left ventriculogram.  No angiographic evidence of coronary artery disease.  Normal left ventricular systolic function.  Normal left ventricular end diastolic pressure.

The procedure involves heart catheterization and angiography, which are invasive techniques used to assess the coronary arteries and heart function. While the patient tolerated the procedure well and there was no evidence of coronary artery disease, the need for such a procedure indicates a serious underlying concern about the patient's cardiac health, made more complex by the patient's history of polysubstance abuse and other medical issues. Heart catheterization is typically performed to address potential life-threatening conditions like heart attacks or severe heart disease, thus making this a high-stakes situation, even if the result showed no coronary artery disease.


Medical Specialty: Hospice - Palliative Care
Sample Name: Lung Cancer & MI - Hospice Cosult

REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  Her daughter called 911 and her symptoms seemed to improve.  Then, she began vomiting.  When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI.  I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG.  She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer.  In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1.  Amiodarone 200 mg once a day.,2.  Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES:  ,CODEINE.  NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes.  She uses alcohol.  No use of illicit drugs.  She is divorced and lives with her daughter.  She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS:  ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  O2 saturation 100%.  On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  HEENT shows the cranium is normocephalic and atraumatic.  She has dry mucosal membrane.  She now has a right facial droop, which per her daughter is new.  Neck veins are not distended.  No carotid bruits visible.  Skin:  Warm, well perfused.  Lungs are clear to auscultation anteriorly.  No wheezes.  Cardiac exam:  S1, S2, regular rate.  No significant murmurs.  PMI is nondisplaced.  Abdomen:  Soft, nondistended.  Extremities:  Without edema, on limited exam.  Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above.  Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds.  Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1.  I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2.  Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3.  Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service.  I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient.
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DESCRIPTION: Patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.  The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.

The situation involves a patient with multiple severe medical conditions: metastatic non-small-cell lung cancer, recent hemorrhagic pericardial effusion, cerebrovascular accident, and a transient inferior myocardial infarction. The patient is on hospice care, indicating a focus on palliative rather than curative treatment, and the care involves significant decision-making regarding end-of-life management. These factors combined make the situation high-stakes concerning the patient's quality of life, comfort, and the difficult clinical and ethical decisions around treatment options.


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

Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central  Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, showed corrective saccades giving the impression of decompensated vestibular hypofunction.,IMPRESSION: , The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid.  ,PLAN:  ,Planned for  electronystagmography to document the degree of vestibular hypofunction.,
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DESCRIPTION: The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.

consult - history and phy., electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo,

The scenario involves a consult for a patient with recurrent vertigo, a condition that can significantly affect quality of life but isn't typically life-threatening as described. The consult includes diagnostic tests and ongoing management with medications and rehabilitation. While uncomfortable and potentially disruptive to daily activities, the situation described doesn't present an immediate life-threatening condition, but it is important for long-term management to prevent falls or further complications.


Medical Specialty: Orthopedic
Sample Name: Low Back Pain - Consult

FAMILY HISTORY: , His parents are deceased.  He has two brothers ages 68 and 77 years old, who are healthy.  He has siblings, a brother and a sister who were twins who died at birth.  He has two sons 54 and 57 years old who are healthy.  He describes history of diabetes and heart attack in his family.,SOCIAL HISTORY:  ,He is married and has support at home.  He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.,ALLERGIES:,  Garamycin.,MEDICATIONS: , Insulin 20 to 25 units twice a day.  Lorazepam 0.05 mg, he has a history of using this medication, but most recently stopped taking it.  Glipizide 5 mg with each meal, Advair 250 as needed, aspirin q.h.s., cod liver oil b.i.d., Centrum AZ q.d.,PAST MEDICAL HISTORY:  ,The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years.  He also has a history of prostate cancer, which was treated by radiation.  He says his PSA is at 0.01.,PAST SURGICAL HISTORY:,  In 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer.,REVIEW OF SYSTEMS: , Musculoskeletal:  He is right-handed.  Respiratory:  For shortness of breath.  Urinary:  For frequent urination.  GI:  He denies any bowel or bladder dysfunction.  Genital:  He denies any loss of sensation or erectile problems.  HEENT:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Cardiac:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Psychiatric:  Negative and noncontributory.,PHYSICAL EXAMINATION: , He is 5 feet 10 inches tall.  Current weight is 204 pounds, weight one year ago was 212.  BP is 130/66.  Pulse is 78.  On physical exam, the patient is alert and oriented with normal mentation and appropriate speech, in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth, poor dentition.  Cranial nerves II, III, IV, and VI, vision intact, visual fields full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movements.  Cranial nerve VIII, hearing is intact.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.  Cardiac, regular rate, a holosystolic murmur is also noted which is about grade 1 to 2.  Chest and lungs are clear bilaterally.  Skin is warm and dry, normal turgor and texture.  No rashes or lesions are noted.  Peripheral vascular, no cyanosis, clubbing, or edema is noted.  General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy.  Station and gait are appropriate.  He ambulates well without any difficulties or assistance.  No antalgic or spastic gait is noted.  Examination of the low back reveals no paralumbar spasms.  He is nontender to palpation over his spinous process, SI joints, or paralumbar musculature.  Deep tendon reflexes are 2+ bilaterally at the knees and 1+ at the ankles.  No ankle clonus is elicited.  Babinski, toes are downgoing.  Sensation is intact.,He does have some decreased sensation to pinprick, dull versus sharp over the right lower extremity compared to that of the left.  Strength is 5/5 and equal bilateral lower extremities.  He is able to ambulate on his toes and his heels without any weakness noted.  He has negative straight leg raising bilaterally.,FINDINGS:,  The patient brings in lumbar spine MRI for 11/15/2007, which demonstrates degenerative disc disease throughout.  At L4-L5 and L5-S1 he has severe disc space narrowing.  At L3-L4, he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge, which caused moderate neuroforaminal narrowing.  At L4-L5, degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis.  At L5-S1, there is an annular disc bulge more to the right causing right-sided neuroforaminal stenosis, which is quite severe compared to that on the left.,ASSESSMENT: , Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.,PLAN: , We discussed treatment options with this patient including:,1.  Do nothing.,2.  Conservative therapies.,3.  Surgery.,The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed.  We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam.  I did phone the patient's primary care doctor, Dr. O.  Unfortunately Dr. O is out of the country, and I did speak with Dr. K, who is covering for Dr. O.  I informed Dr. K that the patient had a new-onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before, so I obtained an EKG.  A copy was provided to the patient and the patient was referred back to his primary care physician for workup.  He was also released from our care at this time to a p.r.n. basis, but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications, which he will receive from his primary doctor.,All questions and concerns were addressed.  If he should have any further questions, concerns, or complications, he will contact our office immediately.  Otherwise, we will see him p.r.n.  Warning signs and symptoms were gone over with him.  Case was reviewed and discussed with Dr. L.
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DESCRIPTION: New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.

orthopedic, back pain, ligamentum flavum hypertrophy, annular disc bulge, degenerative disc disease, spinal stenosis, cranial nerves, degenerative,

The situation detailed is a medical consultation for a patient with multiple chronic health issues, including degenerative disc disease, spinal stenosis, diabetes, and a history of prostate cancer. The stakes involve managing the patient's pain and addressing a newly discovered heart murmur, which could indicate underlying cardiovascular issues. While the patient's back pain is tolerable with minimal intervention, the new heart murmur suggests potential new risks that need to be investigated. However, the patient is already referred to their primary care physician for further evaluation. The situation is moderately high-stakes primarily due to the patient's complex medical history and the new onset of the cardiac murmur.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 4

NAME OF PROCEDURE,1.  Left heart catheterization with left ventriculography and selective coronary angiography.,2.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort.  The patient had elevated troponins which were suggestive of a myocardial infarction.  The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory.  The patient was brought to the catheterization laboratory in postabsorptive state.  The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region.  Using modified Seldinger technique, a 6-French arterial sheath was placed.  Then, the patient had already been on heparin.  Then, a Judkins left 4 catheter was intubated into the left main coronary artery.  Several projections were obtained and the catheter was removed.  A 3DRC catheter was intubated into the right coronary artery.  Several projections were obtained and the catheter was removed.  Then, a 3DRC guiding catheter was intubated into the right coronary artery.  Then, a universal wire was advanced across the lesion into the distal right coronary artery.  Integrilin was given.  Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds.  Then, a projection was obtained.  Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery.  The stent was deployed at 15 atmospheres for 25 seconds.  Post stent, the patient was given intracoronary nitroglycerin after one projection.  Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful.  Then, a pilot 150 wire was advanced across the lesion.  Then, attempt to place the 2.0 x 8 power saver across the lesion was performed.  However, it was felt that there was adequate flow and no further intervention needed to be performed.  Then, the stent delivery system was removed.  A pigtail catheter was placed into the left ventricle.  Hemodynamics followed by left ventriculography was performed.  Then, a pullback gradient was performed and the catheter was removed.  Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied.  The patient was transferred back to his room in good condition.,FINDINGS,1.  Hemodynamics:  The opening aortic pressure was 116/61 with a mean of 64.  The opening left ventricular pressure was 112 with end-diastolic pressure of 23.  LV pressure on pullback was 106 with end-diastolic pressure of 21.  Aortic pressure was 111/67 with a mean of 87.  The closing pressure was 110/67.,2.  Left ventriculography:  The left ventricle was of normal cavity, size, and wall thickness.  There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis.  The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%.  The mitral valve had no significant prolapse or regurgitation.  The aortic valve appeared to be trileaflet and moved normally.,3.  Coronary angiography:  The left main is a normal-caliber vessel.  This bifurcates into the left anterior descending and circumflex arteries.  The left main is free of any significant obstructive coronary artery disease.  The left anterior descending is a large vessel that extends to the apex.  It gives off approximately 10 septal perforators and 5 diagonal branches.  The first diagonal branch was large.  The left anterior descending had mild irregularities, but no high-grade disease.  The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches.  The two obtuse marginal branches are large.  There is a relatively small left atrial branch.  The left circumflex had a 50% stenosis after the first obtuse marginal branch.  The rest of the vessel is moderately irregular, but no high-grade disease.  The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches.  The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease.  However, distal between the second and third posterolateral branch, there is a 90% stenosis.  The rest of the vessels had mild irregularities, but no high-grade disease.  Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis.  Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch.  Then, a wire was advanced through this and there was improvement of flow.  There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1.  Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2.  Two-vessel coronary artery disease.,3.  Elevated left ventricular end-diastolic pressure.,4.  Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1.  Integrilin.,2.  Bed rest.,3.  Risk factor modification.,4.  Thallium scintigraphy in approximately six weeks.
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DESCRIPTION: Left heart catheterization with left ventriculography and selective coronary angiography.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.

surgery, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography

The procedure described is a cardiac catheterization involving angioplasty and stent placement in a patient with suspected myocardial infarction. Cardiovascular procedures generally involve significant risk due to the potential for complications such as stroke, heart attack, or bleeding. Additionally, successfully restoring blood flow in a patient with significant coronary artery disease directly impacts patient survival and long-term health outcomes. This is high-stakes due to both the inherent risks and the critical nature of the procedure to the patient's immediate and future health.


Medical Specialty: Consult - History and Phy.
Sample Name: Hypersensitivity to Coumadin

PROBLEM:,  Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty.  At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity.  However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels.  Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise.  Her prothrombin time is now 83.3 seconds with an INR of 6.52.  Hematology/Oncology consult was requested for recommendation regarding further evaluation and management.,SOCIAL HISTORY: , The patient is originally from Maine.  She has lived in Arizona for 4 years.  She has had 2 children; however, only one is living.  She had one child died from complications of ulcerative colitis.  She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.,CHILDHOOD HISTORY: , Negative for rheumatic fever.  The patient has usual childhood illnesses.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , The patient's mother died from gastric cancer.  She had a brother who died from mesothelioma.  He did have a positive asbestos exposure working in the shipyards.  The patient's father died from motor vehicle accident.  She had a sister who succumbed to pneumonia as a complication to Alzheimer disease.,HABITS: , No use of ethanol, tobacco, illicit, or recreational substances.,ADULT MEDICAL PROBLEMS: , The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X.  In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.,SURGERIES: , The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.,MEDICATIONS: , The patient's medications on admission include:,1.  Fosamax.,2.  TriCor.,3.  Gabapentin.,4.  Hydrochlorothiazide.,5.  Labetalol.,6.  Benicar.,7.  Crestor.,8.  Detrol.,REVIEW OF SYSTEMS: , Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time.  She is arousable, but not particularly conversant.,OBSERVATIONS:,GENERAL:  The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female.,HEENT:  Pupils were equal, round, and reactive to light and accommodation.  Extraocular muscles are grossly intact.  Oropharynx benign.,NECK:  Supple.  Full range of motion without bruits or thyromegaly.,LUNGS:  Clear to auscultation and percussion.,BACK:  Without spine or CVA tenderness.,HEART:  Regular rate and rhythm without murmurs, rubs, thrills, or heaves.,ABDOMEN:  Soft and nontender.  Positive bowel sounds without mass or visceromegaly.,LYMPHATIC:  No appreciable adenopathy.,EXTREMITIES:  The patient has some postoperative fullness involving her left knee.  She has a dressing over the left knee.,SKIN:  Without lesions.,NEURO:  Unable to assess in light of post morphine obtunded state.,ASSESSMENT: , Hypersensitivity to Coumadin.,PLAN: , Gave the patient vitamin K at this time.  Literature suggested oral vitamin K is actually more efficacious than parenteral.  However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion.  Repeat prothrombin time and INR in a.m.  Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively.
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DESCRIPTION: Probable Coumadin hypersensitivity.

Probable Coumadin hypersensitivity.

The situation involves a significant medical issue with an elderly patient experiencing a severe hypersensitivity reaction to Coumadin, leading to dangerously high INR levels, which pose a serious risk of bleeding. Given her age, existing medical conditions, and the context of having undergone surgery, the stakes are high as this situation could result in critical complications without prompt and appropriate medical intervention. Managing the patient's condition requires careful balancing of anticoagulation to prevent thromboembolic events while avoiding hemorrhage.


Medical Specialty: Surgery
Sample Name: Appendectomy - 2

PREOPERATIVE DIAGNOSES,1.  Acute appendicitis.,2.  29-week pregnancy.,POSTOPERATIVE DIAGNOSES,1.  Acute appendicitis.,2.  29-week pregnancy.,OPERATION: , Appendectomy.,DESCRIPTION OF THE PROCEDURE:  ,After obtaining the informed consent including all risks and benefits of the procedure, the patient was urgently taken to the operating room where a spinal anesthetic was given and the patient's abdomen was prepped and draped in a usual fashion.  Preoperative antibiotics were given.  A time-out process was followed.  Local anesthetics were infiltrated in the area of the proposed incision.  A modified McBurney incision was performed.  A very abnormal appendix was immediately found.  There was a milky fluid around the area and this was cultured both for aerobic and anaerobic cultures.  The distal end of the appendix had transformed itself into an abscess.  The proximal portion was normal.  The appendix was very friable and a no-touch technique was used.  It was carefully dissected off the cecum, and then it was ligated and excised after the mesoappendix had been taken care of.  Then the stump was buried with a pursestring of 2-0 Vicryl.  The operative area was abundantly irrigated with warm saline and then closed in layers.  The layer was further irrigated.  A subcuticular suture of Monocryl was performed in the skin followed by the application of Dermabond.,Further local anesthetic was infiltrated at the end of the procedure in the operative area and the patient tolerated the procedure well, and with an estimated blood loss that was not consequential, was transferred from recovery to ICU in a satisfactory condition.
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DESCRIPTION: Acute appendicitis and 29-week pregnancy.  Appendectomy.

surgery, mcburney incision, appendectomy, appendicitis, appendix,

The situation described involves a pregnant patient undergoing an appendectomy, a surgical procedure performed to remove an inflamed appendix. This is a high-stakes situation because it combines common surgical risks with the added complexity and risk factors associated with a 29-week pregnancy. Any abdominal surgery during pregnancy carries additional risks to both the mother and the fetus, including potential premature labor and challenges related to anesthesia. The stakes are further heightened by the fact that the appendix was found to be abscessed, indicating a potentially more complicated procedure.


Medical Specialty: General Medicine
Sample Name: Consult - CHF & Lymphedema

HISTORY OF PRESENT ILLNESS:,  The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.  He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung.  This consultation was made for better control of his blood sugars.  On questioning, the patient says that he does not have diabetes.  He says that he has never been told about diabetes except during his last admission at Jefferson Hospital.  Apparently, he was started on glipizide at that time.  His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem.  He is not sure.  He is not following any specific diet.  He says "my doctor wants me to lose 30-40 pounds in weight" and he would not mind going on a diet.  He has a long history of numbness of his toes.  He denies any visual problems.,PAST MEDICAL HISTORY: , As above that includes CA of the lung, COPD, bilateral cataracts.  He has had chronic back pain.  There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,SOCIAL HISTORY: , The patient has been a smoker since the age of 10.  So, he was smoking 2-3 packs per day.  Since being started on Chantix, he says he has cut it down to half a pack per day.  He does not abuse alcohol.,MEDICATIONS: ,1.  Glipizide 5 mg p.o. daily.,2.  Theophylline.,3.  Z-Pak.,4.  Chantix.,5.  Januvia 100 mg daily.,6.  K-Lor.,7.  OxyContin.,8.  Flomax.,9.  Lasix.,10.  Advair.,11.  Avapro.,12.  Albuterol sulfate.,13.  Vitamin B tablet.,14.  OxyContin and oxycodone for pain.,FAMILY HISTORY: , Positive for diabetes mellitus in the maternal grandmother.,REVIEW OF SYSTEMS: , As above.  He says he has had numbness of toes for a long time.  He denies any visual problems.  His legs have been swelling up from time to time for a long time.  He also has history of COPD and gets short of breath with minimal activity.  He is also not able to walk due to his weight.  He has had ulcers on his legs, which he gets discharge from.  He has chronic back pain and takes OxyContin.  He denies any constipation, diarrhea, abdominal pain, nausea or vomiting.  There is no chest pain.  He does get short of breath on walking.,PHYSICAL EXAMINATION:,The patient is a well-built, obese, white male in no acute distress.,Vital signs:  Pulse rate of 89 per minute and regular.  Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18.,HEENT:  Head is normocephalic and atraumatic.  Eyes, PERRLA.  EOMs intact.  Fundi were not examined.,Neck:  Supple.  JVP is low.  Trachea central.  Thyroid small in size.  No carotid bruits.,Heart:  Shows normal sinus rhythm with S1 and S2.,Lungs:  Show bilateral wheezes with decreased breath sounds at the bases.,Abdomen:  Soft and obese.  No masses.  Bowel sounds are present.,Extremities:  Show bilateral edema with changes of chronic venostasis.  He does have some open weeping sores.  Pulses could not be palpated due to leg swelling.,IMPRESSION/PLAN:,1.  Diabetes mellitus, type 2, new onset.  At this time, the patient is on Januvia as well as glipizide.  His blood sugar right after eating his supper was 101.  So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet.  We will continue to follow his blood sugars closely and make adjustments as needed.,2.  Neuropathy, peripheral, query etiology.  We will check TSH and B12 levels.,3.  Lymphedema.,4.  Recurrent cellulitis.,5.  Obesity, morbid.,6.  Tobacco abuse.  He was encouraged to cut his cigarettes down to 5 cigarettes a day.  He says he feels like smoking after meals.  So, we will let him have it after meals first thing in the morning and last thing at night.,7.  Chronic venostasis.,8.  Lymphedema.  We would check his lipid profile also.,9.  Hypertension.,10.  Backbone pain, status post back surgery.,11.  Status post hernia repair.,12.  Status post penile implant and removal.,13.  Umbilical hernia repair.
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DESCRIPTION: The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema.

The patient has a complex medical history with multiple chronic conditions, including CHF, lymphedema, obesity, diabetes, COPD, and a history of smoking, which require careful management to prevent acute exacerbations. His health issues, like heart failure and new-onset diabetes, can potentially lead to life-threatening situations if not properly managed. The consultation aims to better control his blood sugars and address various other conditions. While the patient is currently stable, his numerous serious overlapping health issues and the need for careful ongoing management suggest a reasonably high-stakes scenario.


Medical Specialty: Neurology
Sample Name: Lumbar Puncture - 1

PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.
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DESCRIPTION: Lumbar puncture with moderate sedation.

Lumbar puncture with moderate sedation.

neurology, moderate sedation, lumbar puncture, needle, lumbar,

The case involves a lumbar puncture on a 2-year-old child to rule out meningitis, amidst complex clinical symptoms and signs of a possible underlying condition. Lumbar punctures are invasive procedures with potential risks, particularly involving young children due to their fragility and the necessity of adequate sedation and monitoring. The stakes involve ensuring patient safety during the procedure, accurately diagnosing the patient's condition, and preventing any complications. Given the detailed consideration of the procedure and the potential implications on the child's health, this situation can be considered high-stakes in a medical context.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Depression - 1

CC: , "Five years ago, I stopped drinking and since that time, I have had severe depression.  I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again.  I started lithium three weeks ago.",HPI:  ,The patient is a 45-year-old married white female without children currently working as a billing analyst for Northwest Natural.  The patient has had one psychiatric hospitalization for seven days in April of 1999.  The patient now presents with recurrent depressive symptoms for approximately four months.  The patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite.  The patient states her sleep is normal and her ability to concentrate is normal.  The patient states that last night she had an argument with her husband in which he threaten to divorce her.  The patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth.  She felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done.  The patient reports that she has had increased tension with her husband as of recent.  She notes that approximately a week ago she struck her husband several times.  She states that he has never hit her but instead pushed her back after she was hitting him.  She reports no history of abuse in the past.  The patient identifies recent stressors as having ongoing conflict at work with her administrator with them "cracking down on me." The patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child.  She states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant.  The patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment.  She states that she feels "abandoned." The patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband.  The patient states she saw her therapist most recently last Friday.  She sees the therapy weekly and indicates the therapy helps, although she is unable to specify how.  When asked for specifics of what she has learned from the therapy, the patient was unable to reply.  It appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation.  The patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization.  The patient, at that point, stated that she would be safe through Monday despite having made a gesture last night.  At present, the patient's mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after I have given her my assessment, she appears calmed and not depressed.  When asked if she is suicidal at present, she states no.  The patient does not want to go into the hospital.  The patient also indicates at the end of the session she felt hopeful.  The patient reports her current sleep is about eight hours per night.  She states that longest she has been able to stay awake in the past has been 24 hours.  She states that during periods where she feels up she sleeps perhaps six hours per night.  The patient reports no spending sprees and no reports no sexual indiscretions.  The patient states that her sexuality does increase when she is feeling better but not enormously so.  The patient denies any history of delusions or hallucinations.  The patient denies any psychosis.  The patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest.  She states that more predominately she has depression.  The patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so.  The patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment.  The patient indicates some satisfaction when she is called on her behavior "I need to answer for my actions." The patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized.  Most typically, the patient will drink at least a bottle of wine per day.  The patient has attended AA but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility.  The patient states she is not working through any of the steps at present.,PPH: , The patient denies any sexual abuse as a child.  She states that she was disciplined primarily by her father with spankings.  She states that on occasion her mother would use a belt to spank her or with her hand or with a spoon.  The patient has been seeing Dr. A for the past five years.  Prior to that she was admitted to a hospital for her suicide attempt.  The patient also has one short treatment experienced with the Day Treatment Program here in Portland.  The patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with.  The patient, also as a child, had a history of cutting behaviors.  The patient was admitted to the hospital after lacerating her arm.,MEDICAL HISTORY:  ,The patient has hypothyroidism and last had her TSH drawn a week ago but does not know the results.  Janet Green is her primary physician.  The patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically.,CURRENT MEDICATIONS: , The patient currently is taking Synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. The patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test.,ALLERGIES: , No known drug allergies.,SUBSTANCE HISTORY: , The patient has been sober for five years.  She drank one bottle of wine per day as per HPI.  History of drinking for approximately 25 years.  The patient does not currently have a sponsor.  The patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago.,SOCIAL HISTORY: , The patient's mother is age 66, father is age 70, and she has a brother age 44.  Her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage.  He made a suicide attempt at age 17.  The patient's father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem.  He also has arthritis.  The patient's mother is arthritic.  She states that her mother stopped working at middle age after being laid off and appears somewhat reclusive.,EDUCATIONAL HISTORY: , The patient was educated through high school and has two years of Night College.  The patient states that she grew up and was raised in Portland but notes her childhood was primarily lonely.  She states she was unliked and unpopular child because she was "shy" and "not smart enough." The patient denies having secrets.  The patient reports that this is her second marriage, which has lasted two years.  Her first marriage lasted I believe it was five years.  The patient also had a relationship in recovery for four years, which ended after they went "different directions.",MSE:,  The patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals.  The patient is suspicious and somewhat confrontative early in the session.  She asked me regarding my cancellation policy, why I require seven days and not 24 hours.  The patient also is irritated with paper required of her.  Psychomotor is increased slightly.  The patient makes strong eye contact.  Speech is normal rate, rhythm, and volume.  Mood is "irritated." Affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated.  Thought is directed.  Content is nondelusional.  There are no auditory and no visual hallucinations.  The patient has no homicidal ideation.  The patient does endorse suicidal ideations.  Regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none.  The patient states that she will not try to hurt herself currently and that she poses no risk at present.  The patient notes that she does not want to go to the hospital at present.  The patient is alert and oriented x 3.  Recall is three for three at five minutes.  Proverbs are concrete.  She has fair impulse control, poor judgment, and poor insight.,FORMULATION:  ,The patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning.  The patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression.  The patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states.  The patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant.  She notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets.  The patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy.  The patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter.  Symptoms are consistent with a longstanding dysthymia and reoccurring depression.  In addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder.  This latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist's absence and departure.  This is exacerbated by instability in the patient's marital life.,DIAGNOSIS:,Axis I:  Dysthymia.  Major depression, moderate severity, recurrent, with partial remission.,Axis II:  Borderline personality disorder.,Axis III:  Hypothyroidism and cervical disc herniation and sinus surgery.,Axis IV:  Medical access.  Marital discord.,Axis V:  A GAF of 30.,PLAN:  ,The patient is unlikely to have bipolar disorder.  We will recommend the patient's thyroid be rechecked to ensure she is currently euthymic.  We would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient's reaction to her therapist's departure.  We would also recommend dialectical behavioral therapy while the therapist is on leave.  We would recommend continued treatment with SSRIs for dysthymia and depression.  We would suggest prescribing long acting antidepressant such as Prozac, given the patient's ambivalence regarding medications.  Prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg.  We might also supplement the Prozac with a (anti-sleep medication).,Time spent with the patient was 1.5 hours.
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DESCRIPTION: Psychiatric Consultation of patient with recurring depression.

The situation described in the psychiatric consultation indicates a patient with complex psychiatric needs, including major depression, suicidal ideation, and borderline personality disorder, further complicated by personal stressors and a history of alcohol abuse. The patient has a recent history of self-harm and possesses a suicide plan, both of which significantly elevate the risk of harm and potential for crisis. The patient's resistance to hospitalization despite these risk factors highlights the critical nature of her mental state. Additionally, the presence of marital discord and unresolved emotions regarding her therapist's upcoming leave can exacerbate her condition. Given these factors, the stakes are quite high, as there's an immediate risk to the patient's safety and well-being that needs urgent and effective intervention.


Medical Specialty: Orthopedic
Sample Name: Kyphoplasty

PRE-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:,  Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1.  KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2.  Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:,  Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating.  She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics.  She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2.  In addition to the fractures, she presents with kyphotic posture.  Films on 1/04 demonstrated L1 and L2 osteoporotic fractures.  Films on 2/04 demonstrated increased loss of height at L1.  Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1.  The L2 fracture is documented on radiographic studies as being chronic and a year or more old.  The T12 fracture has the most significant kyphotic deformity.  Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:,  The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed.  The patient was positioned prone on the Jackson table.  The back was prepped and draped.  The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker.  In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate.  An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side.  Positioning was confirmed on the AP and lateral plane.  Following satisfactory placement of the needle, the stylet was removed.  A guide pin was inserted through the 11g to a point 3mm from the anterior cortex.  AP and lateral images were taken to verify position and trajectory.  Alongside of the guide pin a 1-cm paramedian incision was made.  The needle was then removed leaving the guide pin in place.  The osteointroducer was placed over the guide pin and advanced through the pedicle.  Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall.  Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel.  The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex.  After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex.  The radiopaque marker bands on the bone tamp were identified using AP and lateral images.  The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body.  Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi.  Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position.  The inflation was monitored with AP and lateral imaging.  The final balloon volume was 3.5 cc on the right side and 3 cc on the left.  There was no breach of the lateral wall or anterior cortex of the vertebral body.  Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved.  Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement.  The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side.  Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12.  An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved.  Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures.  The patient was kept in the prone position for approximately 10 minutes post cement injection.  She was then turned supine, monitored briefly and returned to the floor.  She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications.  Estimated blood loss was minimal.
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DESCRIPTION: KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy.

orthopedic, osteoporosis, pathologic fractures, kyphosis, bone cement, balloon kyphoplasty, kyphon balloon kyphoplasty, bone biopsy, kyphon, insertion of kyphon, ap and lateral, vertebral body, kyphon balloon, anterior cortex, vertebral, body, fractures, insertion, bone, kyphoplasty, guide, balloon, pedicles, cortex, positioned, therapy

This medical scenario describes a KYPHON Balloon Kyphoplasty procedure for a 75-year-old patient with severe osteoporosis-related vertebral fractures. The condition is debilitating and poses significant health risks due to pain and potential further fractures. While the procedure was described as successful without complications, it inherently involves risks associated with surgery, anesthesia, and potential complications that could arise in elderly patients with multiple comorbidities like COPD, diabetes, and hypertension. The stakes are high as successful intervention can significantly improve quality of life, while any complications could severely impact the patient's health. Given the patient's age and health conditions, this makes the situation relatively high-stakes in the context of orthopedic surgery.