Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Major Depressive Disorder - IME Consult

IDENTIFYING DATA:  ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  His confidence and self-esteem are significantly low.  He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  He has had suicidal ideation, but this is currently in remission.  Furthermore, he continues to have hopeless thoughts and crying spells.  Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee." This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him "bitch." Mr. T then retaliated, and went to hit the other employee.  Due to this event, Mr. T was fired.  It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to "deal with it.",There are no other apparent stressors in Mr. T's life at this time or in recent months.  Mr. T stated that work was his entire life and he based his entire identity on his work ethic.  It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:,  There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time.  Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:,  Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  He denied any suicide attempts, or profound suicidal or homicidal ideation.  Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:,  Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth.  Originally, he was raised by both parents, but they separated at an early age.  When he was about seven years old, he was raised by his mother and stepfather.  He did not sustain a relationship with his biological father from that time on.  He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old.  He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company.  He then became a homemaker while his wife worked for Chrysler for approximately two years.  Mr. T was married for eleven years, and divorced in 1993.  He has a son who is currently 20 years old.  After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam:  Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  At times he showed some involuntary movements that would be more akin to a resting tremor.  There was no psychomotor retardation, but there was some mild psychomotor excitement.  His speech was clear, concise, but pressured.  His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  There was no evidence of euphoria or diurnal mood variation.  His affective expression was restricted range, but there was no evidence of lability.  At times, his affective tone and facial expressions were inappropriate to the interview.  There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  There was no evidence of illusions, depersonalizations, or derealizations.  Mr. T presented with a sequential and goal directed stream of thought.  There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  There was evidence of concreteness for similarities and proverbs.  His intelligence was average.  His concentration was mildly impaired, and there was no evidence of distractibility.  He was oriented to time, place, person and situation.  There was no evidence of clouded consciousness or dissociation.  His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  There was a moderate preoccupation with his physical health pertaining to his headaches.  His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem.  His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  His credibility seemed good.  There was no evidence for potential self-injury, suicide, or violence.  The reliability and completeness of information was very good, and there were no barriers to communication.  The information gathered was based on the patient's self-report and objective testing and observation.  His attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy.  At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment.  Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year.  As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  Furthermore, it only appears logical that this would precipitate a major depressive episode.
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DESCRIPTION: Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.

ime-qme-work comp etc., muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric,

The situation involves a comprehensive assessment of Mr. T, who is experiencing a major depressive disorder following significant life events including job loss and previous harassment at work. Although Mr. T is showing symptoms consistent with depression, such as low motivation and energy, poor concentration, and previous suicidal ideation, his current suicidal ideation is reported to be in remission. His condition is affecting his ability to seek employment, but he has a good motivation for treatment. Given that mental health can be a critical issue, I would classify situations concerning major depressive disorders as moderately high-stakes due to the need for appropriate and timely interventions to prevent deterioration of mental health, possible relapse into suicidal ideation, and to aid recovery.


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

Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Back Injury IME

PAST MEDICAL CONDITION:,  None.,ALLERGIES:,  None.,CURRENT MEDICATION:,  Zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,CHIEF COMPLAINT: , Back injury with RLE radicular symptoms.,HISTORY OF PRESENT ILLNESS:,  The patient is a 52-year-old male who is here for independent medical evaluation.  The patient states that he works for ABC ABC as a temporary worker.  He worked for ABCD too.  The patient's main job was loading and unloading furniture and appliances for the home.  The patient was approximately there for about two and a half weeks.  Date of injury occurred back in October.  The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load.  Unfortunately at this particular event, the patient had sharp pain in his lower back.  Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee.  This became progressively worse.  He also states that some of his radiating pain went down to his left leg as well.  He noticed increase in buttock spasm and also noticed spasm in his buttocks.  He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe.  The patient states that after this treatment, his symptoms still persisted.  At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April.  After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids.  He was put on restricted duty.  The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement.,Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral.  The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief.  The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD.  The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping.  He has difficulty sleeping at nighttime because of increase in pain.  Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June.  The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side.  The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,PHYSICAL EXAMINATION:,  The patient was examined with the gown on.  Lumbar flexion was moderately decreased.  Extension was normal.  Side bending to the right was decreased.  Side bending to the left was within normal limits.  Rotation and extension to the right side was causing increasing pain.  Extension and side bending to the left was within normal limits without significant pain on the left side.  While seated, straight leg was negative on the LLE at 90° and also negative on the RLE at 90°.  There was no true root tension sign or radicular symptoms upon straight leg raising in the seated position.  In supine position, straight leg was negative in the LLE and also negative on the RLE.  Sensory exam shows there was a decrease in sensation to the S1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits.  Deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the Achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side.  Medial hamstring reflex was 2+/4 on both hamstrings as well.  On prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side.  Increase in pain at deep palpatory examination in midline of the L5 and S1 level.,MEDICAL RECORD REVIEW:,  I had the opportunity to review Dr. XYZ's medical records.  Also reviewed Dr. ABC procedural note, which was the epidural steroid injection block that was performed in December.  Also, reviewed Dr. X's medical record notes and an EMG and nerve study that was performed by Dr. ABCD, which was essentially normal.  The MRI of the lumbar spine that was performed back in April, which showed no evidence of herniated disc.,DIAGNOSIS: , Residual from low back injury with right lumbar radicular symptomatology.,EVALUATION/RECOMMENDATION:,  The patient has an impairment based on AMA Guides Fifth Edition and it is permanent.  The patient appears to have re-aggravation of the low back injury back in October related to his work at ABC when he was working unloading and loading an 18-wheel truck.  Essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left.  The patient also has increase in back pain with lumbar flexion and rotational movement to the right side.  With these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function.  Therefore, the patient is assigned 8% impairment of the whole person.  We are able to assign this utilizing the Fifth Edition on spine section on the AMA guide.  Using page 384, table 15-3, the patient does fall under DRE Lumbar Category II under criteria for rating impairment due to lumbar spine injury.  In this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy.  The patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% WPI.  In the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back.  His one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain.  The patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management.  The patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,
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DESCRIPTION: Back injury with RLE radicular symptoms.  The patient is a 52-year-old male who is here for independent medical evaluation.

ime-qme-work comp etc., rle, radicular symptoms, independent medical evaluation, injury, lle, deep tendon reflex, emg, mri, lumbar radicular symptomatology,

This situation is related to a medical evaluation for a back injury sustained during work. Although it involves ongoing pain and impairment ratings, the issue primarily affects the patient's daily life and work capabilities rather than posing an immediate threat to health or life. The stakes are significant for the patient's quality of life and ability to work but are not critical in a medical emergency sense. Additionally, this is an IME (Independent Medical Evaluation) which often relates to legal and compensation claims, adding complexity rather than health risk immediacy.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Hospice - Palliative Care
Sample Name: Hospice Visit - CA of Cervix

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum, lung, which was diagnosed approximately two years ago.  There is a nodule in her lung, which was treated by excision in February of 2007 on the right side.  She had spread to her kidney.  She had right-sided nephrectomy and left-sided nephrostomy.  She also had invasion of the bladder.  Currently, all of her urine comes out through the renal nephrostomy.  She complains of burning vaginal pain, as well as chronic discharge, which has improved slightly recently.  She is not able to engage in intercourse because of the pain and bleeding.  She also has pain with bowel movements, as well as painful urgency.  The pain is at least 3-4/10 and is partially relieved with methadone rescues and interferes with her ability to sleep at night as she feels exhausted and tired.  She has some nausea and diminished appetite.  No hallucinations.  She is anxious frequently and this is helped with clonazepam, which she has taken chronically for her anxiety disorder and recently started Zyprexa.  She has occasional shortness of breath, which used to be helped with oxygen in the hospital.,PAST MEDICAL HISTORY:,  Peptic ulcer disease, hypertension.,REVIEW OF SYSTEMS:,  She has constipation with hard bowel movements.,MEDICATIONS:,  Norvasc 10 mg daily, isosorbide 60 mg every 24 hours, olanzapine at 2.5-5 mg in bedtime, clonazepam 1 mg every eight hours, Sorbitol 30 cc twice a day, Senna-S two tabs daily, methadone 60 mg every eight hours, and 30 mg every four hours p.r.n. pain.,ALLERGIES:,  She has no known allergies.,SOCIAL HISTORY: , The patient lives with her common law husband and her daughter.  Code Status: DNR.  Religion.  Catholic.  She has a past history of heroin use and was enrolled in MMTP program for 12 hours.  She reports feeling discouraged from her symptoms and pain.,PHYSICAL EXAMINATION: , Blood pressure 120/80, pulse 80, and respirations 14.  General Appearance:  Mildly obese woman.  PERRLA, 3 mm.  Oral mucosa moist without lesions.  Lungs:  Clear.  Heart:  RRR without murmurs.  Abdomen:  Somewhat distended, but soft and nontender.  There is firmness found in the low abdomen bilaterally.  There is erythema in the intertriginous area and vulva, as well as some serous discharge from the vagina.  Neurological Exam:  Cranial nerves II through XII are grossly intact.  There is normal tone.  Power is 5-/5.  DTRs nonreactive.  Sensation intact to fine touch.  Mental Status:  The patient is alert, fully oriented, normal speech, and thought process.  Normal affect.,ASSESSMENT AND PLAN: , ,1.  Carcinoma of the cervix metastatic to the retroperitoneum, bladder, and lung with irritable obstruction and gradual decline in the performance status.  Given this, her prognosis is likely to be limited to six months and she will benefit from home hospice care.,2.  Pain, which is a combination of somatic nociceptive pain due to the retroperitoneal invasion, as well as a neuropathic component from pelvic and nerve involvement by the surgery as well as radiation therapy and disease itself.  We are going to increase methadone to 70 mg every eight hours and continue 30 mg for breakthrough.  We will add pregabalin 50 mg three times a day and titrate the dose up as needed.,3.  Nausea and poor appetite.  We will start Megace 200 mg daily.,4.  Shortness of breath.  We will provide oxygen p.r.n.,5.  Candidal infection.  We will start clotrimazole 1% cream b.i.d.,6.  Constipation.  We will advance the bowel regimen to Sorbitol 30 cc three times a day and Senna-S three tabs twice a day.,7.  Psychosocial.  The patient is getting discouraged.  We will provide supportive counseling.,Length of the encounter was 80 minutes; more than half spent on exchange of information.,Thank you for the opportunity to participate in the care for this patient.
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DESCRIPTION: Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.

hospice - palliative care, hospice, carcinoma of the cervix, code status, length of the encounter, mmtp program, normal affect, shortness of breath, bladder, decline, exchange of information, hospice care, irritable obstruction, lung, nephrectomy, nephrostomy, performance status, poor appetite, prognosis is likely to be limited to, retroperitoneum, carcinoma, metastatic, cervix, lungs,

The situation involves the palliative care of a patient with advanced cancer with a prognosis of less than six months. Decisions regarding the management of her pain, psychological support, and treatment of physical symptoms like nausea and infections are critical. The psychological aspect is also paramount, given her discouraged state and history of substance use. Moreover, adjusting medications such as methadone and managing side effects are key to her quality of life. Her DNR status further emphasizes the terminal nature of her condition, making these consultations high-stakes because they significantly impact her remaining quality of life and health management.


Medical Specialty: Hematology - Oncology
Sample Name: Thyroid Mass Consult

REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.
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DESCRIPTION: Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.

The situation involves a 16-year-old patient with papillary thyroid carcinoma that has metastasized to the lungs, indicating an advanced stage of cancer. Immediate surgical intervention and complex treatment decisions are necessary, including a total thyroidectomy and potential adjunct treatment with radioactive iodine. The potential complications of surgery, such as hypoparathyroidism and damage to vocal cord nerve functions, make the situation more critical. Given the need for urgent action and the potential life-altering consequences, this is a high-stakes medical situation.


Medical Specialty: Hematology - Oncology
Sample Name: Thrombocytosis Followup

CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: Essential thrombocytosis.  He underwent a bone marrow biopsy, which showed essential thrombocytosis.  His CBC has been very stable.

The situation involves a follow-up on a patient diagnosed with essential thrombocytosis, a chronic condition characterized by an elevated platelet count. While this condition requires management and monitoring to prevent complications such as thrombosis, the clinical notes indicate that the patient is well-controlled on medication with stable blood counts and no acute symptoms. The patient's vital signs and overall condition are stable, as indicated by a good performance status and no alarming symptoms. Hence, while the situation requires ongoing attention and management to prevent future complications, it is not immediately life-threatening or critical, placing it in the moderate-stakes category.


Medical Specialty: Hematology - Oncology
Sample Name: Tongue Lesion Biopsy

PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED:  ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region.  This was completely excised.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine in position under general anesthesia.  First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated.  The lesion in the tongue could be seen.  Then, it was injected with 1% lidocaine and 1:100,00 epinephrine.  After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total.  Suction cautery was used for hemostasis.  Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.
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DESCRIPTION: Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.  Right lateral base of tongue lesion, probable cancer.

hematology - oncology, excisional biopsy, tongue lesion, mouth, biopsy,

The document describes a medical procedure being performed on a lesion that is suspected to be cancerous. Cancer is a serious medical condition, and deciding on treatment steps based on biopsy results involves significant considerations. However, this specific excisional biopsy procedure appears to have been uncomplicated and successfully performed. The immediate clinical procedure itself had minimal blood loss, no complications, and a stable patient condition. Therefore, while any procedure involving a suspect cancerous lesion is inherently high-stakes due to the potential implications of findings, the stakes are not maximized due to the straightforward nature of the procedure and the stable outcome.


Medical Specialty: Hematology - Oncology
Sample Name: Prostate Brachytherapy

PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.
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DESCRIPTION: Prostate Brachytherapy - Prostate I-125 Implantation

hematology - oncology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Prostate brachytherapy is a medical procedure involving the implantation of radioactive seeds for cancer treatment, which involves coordination among medical professionals and real-time adjustments. While it's a common treatment, its success is critical for the cancer patient's health and safety. Complications, such as radiation overdosage to surrounding organs, though rare, can have severe consequences. Therefore, this scenario involves a moderately high-stakes situation due to the potential risks and the importance of accurate procedure to patient outcomes.


Medical Specialty: Hematology - Oncology
Sample Name: Sepsis - Consult

REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.
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DESCRIPTION: Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

The situation involves a medical case with multiple serious components: advanced age, sepsis, potential urinary tract obstruction, and numerous comorbidities including heart disease and dementia. Sepsis is an acute and potentially life-threatening condition requiring immediate medical attention. The presence of bilateral hydronephrosis and hydroureter suggests serious concerns about kidney function. This high complexity and risk profile make it a high-stakes medical situation.


Medical Specialty: Hematology - Oncology
Sample Name: Polycythemia Vera Followup

DIAGNOSIS:,  Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis.  Diagnosis was made some time in 2005/2006.  Initially, he underwent phlebotomy.  He subsequently transferred his care here.  In the past, he has been on hydroxyurea and interferon but did not tolerate both of them.  He is JAK-2 positive.  He does not have any siblings for a match-related transplant.  He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period.  He did well with the combination.  Subsequently, he developed intolerance to lenalidomide.  He complained of severe fatigue and diarrhea.  This was subsequently stopped.,The patient reports some injury to his left leg last week.  His left leg apparently was swollen.  He took steroids for about 3 days and stopped.  Left leg swelling has disappeared.  The patient denies any other complaints at this point in time.  He admits to smoking marijuana.  He says this gives him a great appetite and he has actually gained some weight.  Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute.  GENERAL:  He is in no acute distress.  HEENT:  There is no pallor, icterus or cervical adenopathy that is noted.  Oral cavity is normal to exam.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  ABDOMEN:  Soft and nontender with no hepatomegaly.  Spleen is palpable 4 fingerbreadths below the left costal margin.  There is no guarding, tenderness, rebound or rigidity noted.  Bowel sounds are present.  EXTREMITIES:  Reveal no edema.  Palpation of the left tibia revealed some mild tenderness.  However, I do not palpate any bony abnormalities.  There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1.  JAK-2 positive myeloproliferative disorder.  The patient has failed pretty much all available options.  He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.  I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial.  Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2.  I am concerned about the risk of thrombosis with his elevated white count.  He is on aspirin prophylaxis.  The patient has been told to call me with any complaints.,3.  Left shin pain.  I have ordered x-rays of the left tibia and knee today.  The patient will return to the clinic in 3 weeks.  He is to call me in the interim for any problems.
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DESCRIPTION: Followup for polycythemia vera with secondary myelofibrosis.  JAK-2 positive myeloproliferative disorder.   He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.

hematology - oncology, jak-2 positive myeloproliferative disorder, secondary myelofibrosis, mud transplant, ecog scale, myeloproliferative disorder, radioactive phosphorus, jak positive, polycythemia vera, thrombosis, myelofibrosis,

The situation involves a follow-up consultation for a patient with a serious condition: polycythemia vera with secondary myelofibrosis, which is a chronic blood cancer. The patient has tried multiple treatments unsuccessfully and there are concerns about thrombosis due to elevated white blood cell counts. The medical professional is considering entry into a clinical trial. While the patient's current condition appears stable and they're not in acute distress, the potential risks and decisions regarding treatment options can significantly impact the patient's long-term health and quality of life, making this a mid to high-stakes situation.


Medical Specialty: Hematology - Oncology
Sample Name: Neuroblastoma - Consult

REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.
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DESCRIPTION: The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.

The case involves an 11-month-old with neuroblastoma currently undergoing chemotherapy. Neuroblastoma, particularly in infants, is a serious and potentially life-threatening condition that requires careful and continuous medical management. The disease itself, along with the side effects of chemotherapy, can have significant impacts on the child's health. The management and treatment of this condition require careful monitoring to ensure the best possible outcomes. Additionally, the situation involves aspects such as immunosuppression and resolving neutropenia, which are critical components of the patient's care. Given the age of the patient and the severity of the condition, this is a high-stakes medical situation.


Medical Specialty: Hematology - Oncology
Sample Name: Non-Hodgkin lymphoma Followup

CHIEF COMPLAINT:,  Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma.  His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy.  In 1990, his CT scan showed retroperitoneal lymphadenopathy.  Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP.  In 1999, he was treated with m-BACOD.  He also received radiation to his pelvis.  On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma.  His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well.  He has a good energy level, his ECOG performance status is 0.  He denies any fever, chills or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2.  He had bilateral ureteral obstruction and is status post a stent placement.  The obstruction was secondary to his pelvic radiation.,3.  History of congestive heart failure.,4.  History of schwannoma resection.  It was resected from T12 to L1 in 1991.,5.  He has chronic obstruction of his inferior vena cava.,6.  Recurrent lower extremity cellulitis.,SOCIAL HISTORY:  ,He has no tobacco use.  No alcohol use.  He is married.  He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago.  There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: Follicular non-Hodgkin's lymphoma.  Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  Received six cycles of CHOP chemotherapy.

The patient has a long history of follicular non-Hodgkin's lymphoma, a type of cancer, which has recurred over the years requiring multiple treatments including chemotherapy and radiation. This case is significant due to the chronic nature of the disease, the extensive treatment history, and the potential complications associated with both the lymphoma and its treatments. While currently stable and without acute symptoms, the management of this type of cancer remains important, as recurrence or complications could arise, potentially impacting the patient's prognosis and quality of life.


Medical Specialty: Hematology - Oncology
Sample Name: Mullerian Adenosarcoma

PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.
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DESCRIPTION: Discharge summary of a patient presenting with a large mass aborted through the cervix.

hematology - oncology, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma

The situation described involves a patient diagnosed with Mullerian adenosarcoma, a rare cancer, who underwent significant surgery (total abdominal hysterectomy and bilateral salpingo-oophorectomy). This aspect of oncology treatment typically involves close monitoring and has potential complications, as indicated by the postoperative fever and ileus, although the patient was discharged in stable condition. The follow-up care plan, including restrictions and the need for monitoring signs of complications, suggests that although the immediate situation is not critical, it is still high-stakes given the nature of the disease, treatment, and potential for complications.


Medical Specialty: Hematology - Oncology
Sample Name: Mesothelioma - Port-A-Cath Insertion

PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:,  None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma.  He was brought to the operating room now for Port-A-Cath placement for chemotherapy.  After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position.  After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted.  Needle was removed.  Small incision was made large enough to harbor the port.  Dilator and introducers were then placed over the guidewire.  Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers.  Introducers were peeled away without difficulty.  He measured with fluoroscopy and cut to the appropriate length.  The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium.  It was then connected to the hub of the port.  Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall.  Wounds were then closed.  Needle count, sponge count, and instrument counts were all correct.
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DESCRIPTION: Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy.

hematology - oncology, biopsy-proven mesothelioma, placement of port-a-cath, port a cath, subclavian vein, fluoroscopy, mesothelioma,

This situation involves a medical procedure for a patient with mesothelioma, a type of cancer, requiring the placement of a Port-A-Cath for chemotherapy. While the procedure itself is routine for medical professionals, it is performed on an elderly patient (74 years old) with a serious condition. The stakes are elevated, given the patient's age and underlying mesothelioma, but the actual procedure has a very low complication rate and is done using fluoroscopy, improving accuracy and safety. However, due to the context of cancer treatment and the necessity of the procedure to facilitate chemotherapy, it remains a relatively high-stakes situation.


Medical Specialty: Hematology - Oncology
Sample Name: Mesothelioma - Thoracotomy & Lobectomy

PREOPERATIVE DIAGNOSIS:,  Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1.  Right thoracotomy.,2.  Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:,  Stable, extubated, to PACU.,PROCEDURE IN DETAIL:,  Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm.  He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma.  Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm.  He was explained the risks, benefits, and alternatives to this procedure.  He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed.  He was put in a supine position where SCDs and Foley catheter were placed.  He was put under general endotracheal anesthesia with a double-lumen endotracheal tube.  He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered.  Upon entering the chest, the chest wall retractor was inserted and the cavity inspected.  It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm.  He also had some marked lymphadenopathy.  With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection.  Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly.  We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe.  The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties.  Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment.  This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk.  This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe.  This was also ligated in continuity and actually doubly ligated.  Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein.  The superior pulmonary vein was visualized as well.  The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie.  Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures.  The bronchial anatomy was defined.  Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe.  A TA-30 4.8 stapler was then closed.  The lung insufflated.  The right middle lobe and right upper lobe were noted to inflate well.  The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm.  There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin.  Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved.  It seemed that it would be a mucoid shallow portion.  The Bovie was set to high cautery.  The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver.  It did leave quite a shallow defect in the liver.  Hemostasis was achieved with Bovie cautery and gentle pressure.  The specimen was then taken off the table and sent to Pathology for permanent.  The area was inspected for hemostasis.  A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension.  A single 32 straight chest tube was also placed.  The lung was seen to expand.  We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe.  Hemostasis was observed at the end of the case.  The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump.  The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs.  The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin.  The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.
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DESCRIPTION: Right nodular malignant mesothelioma.

Right nodular malignant mesothelioma.

hematology - oncology, double lumen endotracheal, en bloc resection, malignant mesothelioma, lung mass, endotracheal tube, chest tube, bovie cautery, en bloc, diaphragm, lobectomy, mesothelioma, thoracotomy,

The situation described involves a complex surgical procedure for a patient with a serious diagnosis of malignant mesothelioma, invading multiple critical areas like the diaphragm and liver. The outcome of such a surgery could have significant implications on the patient's health, and the potential for complications is high. While the patient was stable post-surgery, the intricate nature of the operation and potential risks associated with it indicate that this is a high-stakes situation.


Medical Specialty: Hematology - Oncology
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 metastatic non-small-cell lung cancer who is on hospice care and has experienced an inferior ST-elevation myocardial infarction (MI). The patient has a history of recent complex medical events, including strokes and pericardial effusion. The care plan involves delicate considerations around the administration of blood thinners due to the risk of recurring hemorrhagic pericardial effusion and the patient's hospice status. The decision-making process involves multiple specialists and the understanding of family members. Given the patient's advanced cancer, recent myocardial infarction, and enrollment in hospice, the scenario is high-stakes as it involves critical decisions impacting the patient's quality of life and potential life expectancy.


Medical Specialty: Hematology - Oncology
Sample Name: Mantle Cell Lymphoma

PRINCIPAL DIAGNOSES:,1.  A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3.  Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4.  Diabetes.,5.  Bipolar disorder.,6.  Chronic muscle aches.,7.  Chronic lower extremity edema.,8.  ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup.  I am seeing him once every 4 to 8 weeks.  He is off of all immunosuppression.  He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints.  He has had hematochezia.  I referred him to gastroenterology.  They did an upper and lower endoscopy.  No evidence of ulcers or any abnormality was found.  Some polyps were removed.  They were benign.  He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1.  Paxil 40 mg once daily.,2.  Cozaar.,3.  Xanax 1 mg four times a day.,4.  Prozac 20 mg a day.,5.  Lasix 40 mg a day.,6.  Potassium 10 mEq a day.,7.  Mirapex two tablets every night.,8.  Allegra 60 mg twice a day.,9.  Avandamet 4/1000 mg daily.,10.  Nexium 20 mg a day.,11.  NovoLog 25/50.,REVIEW OF SYSTEMS:,  Fatigue, occasional rectal bleeding, and obesity.  Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18.  HEENT:  Oral cavity, no mucositis.  NECK:  No nodes.  AXILLA:  No nodes.  LUNGS:  Clear.  CARDIAC:  Regular rate and rhythm without murmurs.  ABDOMEN:  No palpable masses.  Morbid obesity.  EXTREMITIES:  Mild lower extremity edema.  SKIN:  Mild dryness.  CNS:  Grossly intact.,LABORATORY DATA:,  White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9.  Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1.  The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant.  He is without evidence of disease at the present time.  Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2.  He is slightly anemic, may be iron deficient.  He has had recurrent rectal bleeding.  I told him to take multivitamin with iron and see how that helps the anemia.,3.  Regarding the hematochezia, he had an endoscopy.  I reviewed the results from the previous endoscopy.  It appears that he has polyps, but there is no evidence of graft versus host disease.,4.  Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5.  He is followed for his diabetes by his internist.,6.  If he should have any fever or anything suggestive of infection, I advised him to call me.  I will see him back in about 2 months from now.
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DESCRIPTION: A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.

This situation involves a detailed assessment and ongoing management of a patient with a history of mantle cell lymphoma, multiple comorbidities, and previous significant medical interventions such as stem cell transplants. While the patient is currently without evidence of active lymphoma, they are experiencing potential complications like mild chronic graft versus host disease (GVHD), ongoing anemia, and intermittent rectal bleeding. Given the nature of the disease and the medical history, this case involves high-stakes decisions with potentially serious consequences if mismanaged. The complexity is increased by the patient's other health conditions, including diabetes and bipolar disorder, which require careful coordination of care. However, since there is no immediate life-threatening situation or active lymphoma, the stakes are not at the very highest level.


Medical Specialty: Hematology - Oncology
Sample Name: Intraperitoneal Mesothelioma

REASON FOR ADMISSION:,  Intraperitoneal chemotherapy.,HISTORY: , A very pleasant 63-year-old hypertensive, nondiabetic, African-American female with a history of peritoneal mesothelioma.  The patient has received prior intravenous chemotherapy.  Due to some increasing renal insufficiency and difficulties with hydration, it was elected to change her to intraperitoneal therapy.  She had her first course with intraperitoneal cisplatin, which was very difficultly tolerated by her.  Therefore, on the last hospitalization for IP chemo, she was switched to Taxol.  The patient since her last visit has done relatively well.  She had no acute problems and has basically only chronic difficulties.  She has had some decrease in her appetite, although her weight has been stable.  She has had no fever, chills, or sweats.  Activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease.  She had a recent CT scan of the chest and abdomen.  The report showed the following findings.  In the chest, there was a small hiatal hernia and a calcification in the region of the mitral valve.  There was one mildly enlarged mediastinal lymph node.  Several areas of ground-glass opacity were noted in the lower lungs, which were subtle and nonspecific.  No pulmonary masses were noted.  In the abdomen, there were no abnormalities of the liver, pancreas, spleen, and left adrenal gland.  On the right adrenal gland, a 17 x 13 mm right adrenal adenoma was noted.  There were some bilateral renal masses present, which were not optimally evaluated due to noncontrast study.  A hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst.  It was unchanged from February and measured 9 mm.  There was again minimal left pelvic/iliac _______ with right and left peritoneal catheters noted and were unremarkable.  Mesenteric nodes were seen, which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them.  There was a conglomerate omental mass, which had decreased in volume when compared to previous study, now measuring 8.4 x 1.6 cm.  In the pelvis, there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter.  No suspicious osseous lesions were noted.,CURRENT MEDICATIONS: , Norco 10 per 325 one to two p.o. q.4h. p.r.n. pain, atenolol 50 mg p.o. b.i.d., Levoxyl 75 mcg p.o. daily, Phenergan 25 mg p.o. q.4-6h. p.r.n. nausea, lorazepam 0.5 mg every 8 hours as needed for anxiety, Ventolin HFA 2 puffs q.6h. p.r.n., Plavix 75 mg p.o. daily, Norvasc 10 mg p.o. daily, Cymbalta 60 mg p.o. daily, and Restoril 30 mg at bedtime as needed for sleep.,ALLERGIES: , THE PATIENT STATES THAT ON OCCASION LORAZEPAM DOSE PRODUCE HALLUCINATIONS, AND SHE HAD DIFFICULTY TOLERATING ATIVAN.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient's height is 165 cm, weight is 77 kg.  BSA is 1.8 sq m.  The vital signs reveal blood pressure to be 158/75, heart rate 61 per minute with a regular sinus rhythm, temperature of 96.6 degrees, respiratory rate 18 with an SpO2 of 100% on room air.,GENERAL:  She is normally developed; well nourished; very cooperative; oriented to person, place, and time; and in no distress at this time.  She is anicteric.,HEENT:  EOM is full.  Pupils are equal, round, reactive to light and accommodation.  Disc margins are unremarkable as are the ocular fields.  Mouth and pharynx within normal limits.  The TMs are glistening bilaterally.  External auditory canals are unremarkable.,NECK:  Supple, nontender without adenopathy.  Trachea is midline.  There are no bruits nor is there jugular venous distention.,CHEST:  Clear to percussion and auscultation bilaterally.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,BREASTS:  Unremarkable.,ABDOMEN:  Slightly protuberant.  Bowel tones are present and normal.  She has no palpable mass, and there is no hepatosplenomegaly.,EXTREMITIES:  Within normal limits.,NEUROLOGICAL:  Nonfocal.,DIAGNOSTIC IMPRESSION,1.  Intraperitoneal mesothelioma, partial remission, as noted by CT scan of the abdomen.,2.  Presumed left lower pole kidney hemorrhagic cyst.,3.  History of hypertension.,4.  Type 1 bipolar disease.,PLAN: , The patient will have appropriate laboratory studies done.  A left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney.  Interventional radiology will access for ports in the abdomen.  She will receive chemotherapy intraperitoneally.  The plan will be to use intraperitoneal Taxol.
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DESCRIPTION: A female with a history of peritoneal mesothelioma who has received prior intravenous chemotherapy.

hematology - oncology, chemo, taxol, intraperitoneal mesothelioma, peritoneal mesothelioma, intravenous chemotherapy, adrenal gland, hemorrhagic cyst, peritoneal, intraperitoneal, hemorrhagic, mesothelioma, chemotherapy,

The situation involves a patient with intraperitoneal mesothelioma undergoing chemotherapy. Mesothelioma is an aggressive cancer, and the patient has a complex medical history, including renal insufficiency and bipolar disorder. Chemotherapy can have significant side effects, and managing these while monitoring renal health and psychological needs presents high stakes for patient well-being and treatment effectiveness. Thus, this is a high-stakes situation for both the patient's health and the medical team managing her care.


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

Medical Specialty: Hematology - Oncology
Sample Name: Glioma - Consult

REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  She did well for the next 10 years or so, and developed Parkinson disease, possibly related to radiation therapy.  She has been followed by neurology, Dr. Z, to treat seizure activity.  She has a vagal stimulator in place to help control her seizure activity.,Over the last few months, she has had increasing weakness on the right side.  She has been living in a nursing home.  She has not been able to walk, and she has not been able to write for the past three to four years.,MRI scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  There was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,Surgery was performed during this admission to remove some of the posterior part of the tumor.  She tolerated the procedure well.  She has noticed no worsening or improvement in her weakness.  Pathology shows a low- to intermediate-grade glioma.  The second opinion by Dr. A is still pending.,The patient is feeling well today.  She is not having headache, and reports no new neurologic symptoms.  She has not had leg swelling, cough, shortness of breath, or chest pain.,CURRENT MEDICATIONS:  ,1.  Ambien p.r.n.  ,2.  Vicodin p.r.n.  ,3.  Actonel every Sunday.  ,4.  Colace.  ,5.  Felbatol 1200 mg b.i.d.  ,6.  Heparin injections for prophylaxis.  ,7.  Maalox p.r.n.  ,8.  Mirapex 0.5 mg t.i.d.  ,9.  Protonix 40 mg daily.  ,10.  Tylenol p.r.n.  ,11.  Zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  ,12.  She has Zofran p.r.n., albuterol inhaler q.i.d., and Aggrenox, which she is to start.,The rest of the history is mostly from the chart.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,PAST MEDICAL HISTORY:  ,1.  Parkinson's, likely secondary to radiation therapy.,2.  History of prior stroke.,3.  Seizure disorder secondary to her brain tumor.,4.  History of urinary incontinence.,5.  She has had hip fractures x2, which have required surgical pinning.,6.  Appendectomy.,7.  Cholecystectomy.,SOCIAL HISTORY:,  Shows that she does not smoke cigarettes or drink alcohol.  She lives in a nursing home.,FAMILY HISTORY:,  Shows a family history of breast cancer.,PHYSICAL EXAMINATION:,  ,GENERAL:  Today, she is sitting up in the chair, alert, and appropriate.  She tends to lean towards the right.  The right arm and hand are noticeably weaker than the left.  She is quite thin.,VITAL SIGNS:  Temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,HEENT:  There is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  The oropharynx shows no thrush or mucositis.,LUNGS:  Clear bilaterally to auscultation.,CARDIAC:  Exam shows regular rate.,ABDOMEN:  Soft.,EXTREMITIES:  No peripheral edema or evidence of deep venous thrombosis (DVT) is noted on the lower extremities.,IMPRESSION AND PLAN:,  Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.,We reviewed the phase II trials that have used Temodar in the setting of grade 2 gliomas.  Although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  We discussed using Temodar after she heals from her surgery.  Toxicities would include fatigue, nausea, and myelosuppression primarily.
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DESCRIPTION: Progressive low-grade glioma, now more than 20 years since initially diagnosed.  She is status post craniotomy for debulking and has done well with the surgery.

The patient has a long history of a low-grade glioma, and the recent consultation involves considerations for further treatment after a recent surgery. While her current condition appears stable, the situation involves ongoing management and potentially starting a new treatment (Temodar), which carries risks of side effects. The stakes are higher because it involves cancer management in an elderly patient with a complex medical history and multiple comorbidities such as Parkinson's and a seizure disorder. However, the immediate situation is not life-threatening.


Medical Specialty: Hematology - Oncology
Sample Name: Hyperfractionation

HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours).  The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors.  The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.
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DESCRIPTION: Hyperfractionation.  This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.

hematology - oncology, irradiated, oxygenated, tumors, malignancy, radiobiologic, hyperfractionation, hyperfractionated, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation described involves hyperfractionated radiotherapy, which is used to treat malignancies, particularly aggressive or hard-to-treat tumors. The procedure uses multiple fractions of radiation to potentially increase the effectiveness of treatment, but also increases the risk of severe acute side effects. Since the patient's treatment and well-being directly depend on the precise administration and monitoring of this therapy, any errors or oversight could negatively affect the treatment outcome or exacerbate side effects.


Medical Specialty: Hematology - Oncology
Sample Name: Hematology Consult - 1

HISTORY OF PRESENT ILLNESS:,  The patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis.  We corrected her hematocrit last year with intravenous (IV) iron.  Ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis.  Her course has been very complicated since then with needing multiple surgeries for removal of hematoma.  This is partly because she was on anticoagulation for a right arm deep venous thrombosis (DVT) she had early this year, complicated by septic phlebitis.,Chart was reviewed, and I will not reiterate her complex history.,I am asked to see the patient again because of concerns for coagulopathy.,She had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,She is on total parenteral nutrition (TPN) as well.,LABORATORY DATA:,  Labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000.  MCV is 89.  Her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000.  Her hematocrit has been essentially stable for the past month or so.  White blood count has improved.,PT has been markedly elevated and today is 44.9 with an INR of 5.0.  This is despite stopping Coumadin on 05/31/2007, and with administration of vitamin K via the TPN, as well as additional doses IV.  The PT is slightly improved over the last few days, being high at 65.0 with an INR of 7.3 yesterday.,PTT has not been checked since 05/18/2007 and was normal then at 28.,LFTs have been elevated.  ALT is 100, AST 57, GGT 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, LDH normal, and pre-albumin low at 16.  Creatinine is at 1.5, with an estimated creatinine clearance low at 41.7.  Other electrolytes are fairly normal.,B12 was assessed on 05/19/2007 and was normal at 941.  Folic acid was normal.  Iron saturation has not been checked since March, and was normal then.  Ferritin has not been checked in a couple of months.,CURRENT MEDICATIONS: , Erythropoietin 45,000 units every week, started 05/16/2007.  She is on heparin flushes, loperamide, niacin, pantoprazole, Diovan, Afrin nasal spray, caspofungin, daptomycin, Ertapenem, fentanyl or morphine p.r.n. pain, and Compazine or Zofran p.r.n. nausea.,PHYSICAL EXAMINATION: ,GENERAL:  She is alert, and frustrated with her prolonged hospital stay.  She notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,VITAL SIGNS:  Today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95.  She is not requiring oxygen.,SKIN:  No significant ecchymoses are noted.,ABDOMEN:  Ileostomy is in place, with greenish black liquid output.  Midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,EXTREMITIES:  She has no peripheral edema.,CARDIAC:  Regular rate.,LYMPHATICS:  No adenopathy is noted.,LUNGS:  Clear bilaterally.,IMPRESSION AND PLAN:,  Markedly elevated PT/INR despite stopping Coumadin and administering vitamin K.  I will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated LFTs, decreased albumin, and decreased pre-albumin.,It is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated PTT and not PT.  I will check a PTT and check mixing studies if that is prolonged.  It is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting.  I agree with continuing off of anticoagulation for now.,She has markedly elevated platelet count.  I suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,Anemia has been stable, and is multifactorial.  Given her decreased creatinine clearance, I agree with erythropoietin support.  She was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again.  She has had part of her small bowel removed, so there may be a component of poor absorption as well.  If she is iron deficient, this may contribute also to her elevated platelet counts.  I will check a ferritin.  This may be difficult to interpret because of inflammation.  If it is decreased, plan will be to add iron supplementation intravenously.  If it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,She needs continued treatment as you are for her infections.,I will discuss the case with Dr. X as well since there is a question as to whether she might need additional surgery.  She is not a surgical candidate now with her elevated PT/INR.
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DESCRIPTION: Markedly elevated PT INR despite stopping Coumadin and administering vitamin K. Patient with a history of iron-deficiency anemia due to chronic blood loss from colitis.

The situation involves a complex and serious medical case. The patient has multiple complications including coagulopathy, which is indicated by the markedly elevated PT/INR despite discontinuing anticoagulation and administering vitamin K. This could suggest a potential bleeding risk or continued anticoagulopathy, which is critical to resolve. The patient also has elevated platelet counts likely reactive to infection and is on multiple antibiotics for vancomycin-resistant enterococcus. Additionally, the patient has a history of complications from surgeries, and there may be a need for future surgical interventions which are currently not feasible due to her coagulopathy. All these factors combined contribute to a high-stakes scenario because any misstep in managing her condition could lead to significant health deterioration.


Medical Specialty: Hematology - Oncology
Sample Name: HDR Brachytherapy

HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified.  Simulation films were obtained, documenting its positioning.  The 3-dimensional treatment planning process was accomplished utilizing the CT derived data.  A treatment plan was selected utilizing sequential dwell positions within a single catheter.  The patient was taken to the treatment area.  The patient was appropriately positioned and the position of the intracavitary device was checked.  Catheter length measurements were taken.  Appropriate measurements of the probe dimensions and assembly were also performed.  The applicator was attached to the HDR after-loader device.  The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication.  The brachytherapy source was appropriately removed back to the brachytherapy safe within the device.  Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty.  The patient was in no apparent distress and was discharged home.
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DESCRIPTION: HDR Brachytherapy

HDR Brachytherapy

hematology - oncology, geiger-muller, treatment planning, hdr brachytherapy, intracavitary, applicator, brachytherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Considering the procedure described involves HDR (High Dose Rate) brachytherapy, a type of cancer treatment, there are significant considerations regarding patient safety, precision in treatment delivery, and potential complications. Radiation treatment is highly sensitive and requires careful planning and execution to avoid harm to the patient and ensure effective treatment. Moreover, the procedure involves invasive steps and significant radiation exposure, both of which contribute to its high-stakes nature. However, according to the sample, the procedure was completed without complications, which reduces the overall immediate stakes.