Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Clostridium Difficile Colitis Followup

SUBJECTIVE:  ,The patient seen and examined feels better today.  Still having diarrhea, decreased appetite.  Good urine output 600 mL since 7 o'clock in the morning.  Afebrile.,PHYSICAL EXAMINATION,GENERAL:  Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS:  Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.,HEENT:  PERRLA, EOMI.,NECK:  Supple.,CARDIOVASCULAR:  Regular rate and rhythm.,RESPIRATORY:  Clear to auscultation bilaterally.,ABDOMEN:  Bowel sounds are positive, soft, and nontender. EXTREMITIES:  No edema.  Pulses present bilaterally.,LABORATORY DATA:  ,CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000.  BMP, BUN of 28.3 from 32.2, creatinine 1.8 from 1.89 from 2.7.  Calcium of 8.2.  Sodium 139, potassium 3.9, chloride 108, and CO2 of 22.  Liver function test is unremarkable.,Stool positive for Clostridium difficile.  Blood culture was 131.  O2 saturation result is pending.,ASSESSMENT AND PLAN:,1.  Most likely secondary to Clostridium difficile colitis and urinary tract infection improving.  The patient hemodynamically stable, leukocytosis improved and today he is afebrile.,2.  Acute renal failure secondary to dehydration, BUN and creatinine improving.,3.  Clostridium difficile colitis, Continue Flagyl, evaluation Dr. X in a.m.,4.  Urinary tract infection, continue Levaquin for last during culture.,5.  Leucocytosis, improving.,6.  Minimal elevated cardiac enzyme on admission.  Followup with Cardiology recommendations.,7.  Possible pneumonia, continue vancomycin and Levaquin.,8.  The patient may be transferred to telemetry.
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DESCRIPTION: Still having diarrhea, decreased appetite.

soap / chart / progress notes, decreased appetite, acute renal failure, urinary tract infection, leucocytosis, clostridium difficile colitis,

The follow-up notes indicate that the patient, previously diagnosed with Clostridium difficile colitis, is showing signs of improvement. While the patient's vital signs are stable and there is noted improvement in their laboratory data, some symptoms such as diarrhea and decreased appetite persist. There is an ongoing risk of dehydration due to diarrhea, and the patient has elevated cardiac enzymes and is being monitored for possible pneumonia. However, the patient is hemodynamically stable, and leukocytosis is improving. The patient is planned to be transferred to telemetry, indicating proactive monitoring rather than an immediate critical situation. Given that the patient is under medical care with a planned transfer for additional monitoring, the situation is moderately high-stakes, focusing on ensuring continued improvement and preventing complications.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Chronic Kidney Disease Followup

HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease.  His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him.  I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes.  On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control.  He has also brought a machine at home, and states his blood pressure readings have been better.  He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past.  He also needs followup for his elevated PSA in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,REVIEW OF SYSTEMS: , Really negative.  He continues to feel well.  He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,CURRENT MEDICATIONS:,1.  Vytorin 10/40 mg one a day.,2.  Rocaltrol 0.25 micrograms a day.,3.  Carvedilol 12.5 mg twice a day.,4.  Cozaar 50 mg twice a day.,5.  Lasix 40 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings.  GENERAL:  He is a thin African American gentleman in no distress.  LUNGS:  Clear.  CARDIOVASCULAR:  Regular rate and rhythm.  Normal S1 and S2.  I did not appreciate a murmur.  ABDOMEN:  Soft.  He has a very soft systolic murmur at the left lower sternal border.  No rubs or gallops.  EXTREMITIES:  No significant edema.,LABORATORY DATA: , Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9.  He is not on EPO yet.  His UA has been negative.,IMPRESSION:,1.  Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  His estimated GFR is 16 mL per minute.  He has no uremic symptoms.,2.  Hypertension, which is finally better controlled.,3.  Metabolic bone disease.,4.  Anemia.,RECOMMENDATION:,  He needs a number of things done in terms of followup and education.  I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes.  I also gave him websites that he can get on to find out more information.  I have not made any changes in his medications.  He is getting blood work done prior to his next visit with me.  I will check a PSA on him but he needs to get back into see urology, as his last PSA that I see was 37 and this was from 02/05.  He will see me back in about 4 to 6 weeks.
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DESCRIPTION: Chronic kidney disease, stage IV, secondary to polycystic kidney disease.  Hypertension, which is finally better controlled.  Metabolic bone disease and anemia.

soap / chart / progress notes, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney

The situation presented is a follow-up for a patient with stage IV chronic kidney disease (CKD), which is a severe condition that can lead to end-stage renal disease (ESRD). The patient has several complications, including hypertension, metabolic bone disease, and anemia, and is being educated about his condition and potential treatments like dialysis and transplantation. While his immediate condition is stable, the high stakes lie in the need for continued management, education about ESRD, and potential future interventions such as dialysis or transplantation. Non-compliance or deterioration could result in serious health outcomes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Chronic Medical Conditions - Followup

REASON FOR VISIT: , Followup evaluation and management of chronic medical conditions.,HISTORY OF PRESENT ILLNESS:,  The patient has been doing quite well since he was last seen.  He comes in today with his daughter.  He has had no symptoms of CAD or CHF.  He had followup with Dr. X and she thought he was doing quite well as well.  He has had no symptoms of hyperglycemia or hypoglycemia.  He has had no falls.  His right knee does pain him at times and he is using occasional doses of Tylenol for that.  He wonders whether he could use a knee brace to help him with that issue as well.  His spirits are good.  He has had no incontinence.  His memory is clear, as is his thinking.,MEDICATIONS:,1.  Bumex - 2 mg daily.,2.  Aspirin - 81 mg daily.,3.  Lisinopril - 40 mg daily.,4.  NPH insulin - 65 units in the morning and 25 units in the evening.,5.  Zocor - 80 mg daily.,6.  Toprol-XL - 200 mg daily.,7.  Protonix - 40 mg daily.,8.  Chondroitin/glucosamine - no longer using.,MAJOR FINDINGS:,  Weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and O2 saturation 94%.  He is afebrile.  JVP is normal without HJR.  CTAP.  RRR.  S1 and S2.  Aortic murmur unchanged.  Abdomen:  Soft, NT without HSM, normal BS.  Extremities:  No edema on today's examination.  Awake, alert, attentive, able to get up on to the examination table under his own power.  Able to get up out of a chair with normal get up and go.  Bilateral OA changes of the knee.,Creatinine 1.7, which was down from 2.3.  A1c 7.6 down from 8.5.  Total cholesterol 192, HDL 37, and triglycerides 487.,ASSESSMENTS:,1.  Congestive heart failure, stable on current regimen.  Continue.,2.  Diabetes type II, A1c improved with increased doses of NPH insulin.  Doing self-blood glucose monitoring with values in the morning between 100 and 130.  Continue current regimen.  Recheck A1c on return.,3.  Hyperlipidemia, at last visit, he had 3+ protein in his urine.  TSH was normal.  We will get a 24-hour urine to rule out nephrosis as the cause of his hypertriglyceridemia.  In the interim, both Dr. X and I have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia.  Specifically we were considering TriCor (fenofibrate).  Given his problems with high CPK values in the past for now, we have decided not to engage in that strategy.  We will leave open for the future.  Check fasting lipid panel today.,4.  Chronic renal insufficiency, improved with reduction in dose of Bumex over time.,5.  Arthritis, stable.  I told the patient he could use Extra Strength Tylenol up to 4 grams a day, but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day.  He states he will inch that up slowly.  With regard to a brace, he stated he used one in the past and that did not help very much.  I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease.  For now he will continue with his cane and walker.,6.  Health maintenance, flu vaccination today.,PLANS: , Followup in 3 months, by phone sooner as needed.
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DESCRIPTION: Followup evaluation and management of chronic medical conditions.  Congestive heart failure, stable on current regimen.  Diabetes type II, A1c improved with increased doses of NPH insulin.  Hyperlipidemia, chronic renal insufficiency, and arthritis.

soap / chart / progress notes, congestive heart failure, diabetes, hyperlipidemia, chronic renal insufficiency, arthritis, chronic medical conditions, heart,

The patient's chronic conditions, including congestive heart failure, diabetes type II, and chronic renal insufficiency, are currently stable and being managed effectively. No immediate symptoms or acute issues are reported, and regular follow-ups are scheduled. Despite the chronic nature of the conditions, there is no indication of immediate risk or need for urgent intervention, making the situation relatively low-stakes in terms of immediate medical action.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: CAD - 6-Month Followup

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

The situation is a follow-up visit for a patient with coronary artery disease (CAD) and other complexities such as dyspnea, knee pain, chronic anxiety, and abdominal issues. His chest pains don't seem alarming, but there are concerns about his weight and shortness of breath. The management plan involves medication adjustments and specialist referrals, indicating moderate stakes because critical symptoms like chest pain and shortness of breath require careful monitoring to prevent severe exacerbations that could lead to emergencies.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Atrial Fibrillation - SOAP

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

soap / chart / progress notes, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic,

The medical situation described involves a patient with a history of atrial fibrillation, Wolff-Parkinson-White Syndrome, recent aortic valve replacement, and hyperlipidemia. These are serious medical conditions, especially the arrhythmias and post-surgical status, which require careful monitoring and management. The presence of Wolff-Parkinson-White syndrome and the recent postoperative state following aortic valve replacement put the patient at risk for significant cardiac events. The treatment plan includes converting from IV to oral amiodarone, an antiarrhythmic medication, and monitoring electrolyte levels, which suggests ongoing monitoring and potential risks if complications arise.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Aplastic Anemia Followup

CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone on 03/30/10.  She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury.  Her cyclosporine level was 555.  It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital.  She was transfused 2 units of packed red blood cells while in the hospital.  Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:,  Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  GERD.,3.  Osteoarthritis.,4.  Status post tonsillectomy.,5.  Status post hysterectomy.,6.  Status post bilateral cataract surgery.,7.  Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY:  ,She has no tobacco use.  She has rare alcohol use.  She has three children and is a widow.  Her husband died after they were married only eight years.  She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: Aplastic anemia.  After several bone marrow biopsies, she was diagnosed with aplastic anemia.  She started cyclosporine and prednisone.

The situation described is the follow-up of a patient with aplastic anemia, a serious and potentially life-threatening condition where the bone marrow fails to produce enough blood cells. The patient had a recent hospitalization due to acute kidney injury likely caused by cyclosporine, which is a critical part of her treatment. This situation involves the management of a complex medical condition with potential for serious complications, requiring careful monitoring and adjustment of treatment. Given the patient's age and the severity of aplastic anemia, as well as the recent acute kidney injury related to treatment, this situation is high-stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Allergic Rhinitis

SUBJECTIVE:,  This 23-year-old white female presents with complaint of allergies.  She used to have allergies when she lived in Seattle but she thinks they are worse here.  In the past, she has tried Claritin, and Zyrtec.  Both worked for short time but then seemed to lose effectiveness.  She has used Allegra also.  She used that last summer and she began using it again two weeks ago.  It does not appear to be working very well.  She has used over-the-counter sprays but no prescription nasal sprays.  She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals:  Weight was 130 pounds and blood pressure 124/78.,HEENT:  Her throat was mildly erythematous without exudate.  Nasal mucosa was erythematous and swollen.  Only clear drainage was seen.  TMs were clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,ASSESSMENT:,  Allergic rhinitis.,PLAN:,1.  She will try Zyrtec instead of Allegra again.  Another option will be to use loratadine.  She does not think she has prescription coverage so that might be cheaper.,2.  Samples of Nasonex two sprays in each nostril given for three weeks.  A prescription was written as well.
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DESCRIPTION: A 23-year-old white female presents with complaint of allergies.

soap / chart / progress notes, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic,

The situation presented is a routine medical evaluation for a patient with allergic rhinitis. The patient has not shown severe symptoms or complications such as anaphylaxis or severe asthma attacks, and her treatment involves non-emergency measures such as trying different medications and nasal sprays. While the patient's condition affects quality of life, it does not pose an immediate threat to her health or life. Therefore, the situation is low-stakes in the context of potential medical emergencies.


Medical Specialty: Sleep Medicine
Sample Name: Video EEG - 1

DATE OF EXAMINATION: , Start:  12/29/2008 at 1859 hours.  End:  12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:,  12 hours, 29 minutes.,PATIENT HISTORY:,  This is a 46-year-old female with a history of events concerning for seizures.  The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,VIDEO EEG DIAGNOSES,1.  Awake:  Normal.,2.  Sleep:  Activation of a single left temporal spike seen maximally at T3.,3.  Clinical events:  None.,DESCRIPTION:  ,Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed.  During the waking state, there is a 9-Hz dominant posterior rhythm.  The background of the record consists primarily of alpha frequency activity.  At times, during the waking portion of the record, there appears to be excessive faster frequency activity.  No activation procedures were performed.,Approximately four hours of intermittent sleep was obtained.  A single left temporal, T3, spike is seen in sleep.  Vertex waves and sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep.  The patient had no clinical events during the recording period.  Clinical correlation is required.
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DESCRIPTION: The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.

sleep medicine, non-epileptic events, temporal spike, eeg monitoring, video eeg, epilepsy, frequency, eeg, epileptic,

The situation involves diagnosing and understanding the nature of episodes in a patient with a history of epilepsy and non-epileptic events, which is significant but not immediately life-threatening. Video EEG monitoring aids in distinguishing between epileptic and non-epileptic events, impacting treatment plans and management of the condition. While important for accurate diagnosis and effective treatment, if the patient is stable with no clinical events during the recording, the immediacy and critical nature are lower compared to active seizure situations.


Medical Specialty: Sleep Medicine
Sample Name: Snoring

CHRONIC SNORING,Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome.  Both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardiovascular system.  Symptoms like daytime somnolence, fatigue, hyperactivity, behavior difficulty (i.e., ADHD) and decreased school performance have been reported with these conditions.  In addition, the most severe cases may be associated with right ventricular hypertrophy, pulmonary and/or systemic hypertension and even cor pulmonale.,In this patient, the risks for a sleep-disordered breathing include obesity and the tonsillar hypertrophy.  It is therefore indicated and medically necessary to perform a polysomnogram for further evaluation.  A two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed.
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DESCRIPTION: Chronic snoring in children

Chronic snoring in children

sleep medicine, snoring, chronic snoring, behavior difficulty, fatigue, hyperactivity, obstructive sleep apnea, oxygen, oxygen desaturation, polysomnogram, poor sleep quality, right ventricular hypertrophy, school performance, sleep fragmentation, somnolence, systemic hypertension, upper airway, upper airway resistant syndrome, snoring chronic, hypertrophy, sleepNOTE,: 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 involves a child with chronic snoring, which could be indicative of more serious conditions like obstructive sleep apnea. These conditions can have significant health impacts, including cardiovascular issues and developmental concerns such as behavioral difficulties and decreased school performance. The recommendation to perform a polysomnogram and to maintain a sleep diary suggests a careful approach to diagnosing and managing the condition. While the immediate risk to life might not be high, the potential long-term health implications and the need for accurate diagnosis make it a higher than average stakes situation.


Medical Specialty: Sleep Medicine
Sample Name: Overnight Polysomnogram

The patient underwent an overnight polysomnogram on 09/22/06 and the details of the polysomnographic study are reported separately.  The highlights of the study include the following:,A.  Obstructive apneas and hypopneas were identified with an overall apnea-hypopnea index of 15.2 events per hour in the supine position.  All events occurred in the supine position and were more prominent during stage REM sleep.  Minimum oxygen saturation was 88%.,B.  Periodic limb movements in sleep were identified with an overall index of 32 events per hour of sleep.,C.  The patient's sleep efficiency was reduced to 89.2%.  There was significant sleep fragmentation due to the obstructive apneas and hypopneas as well as due to the periodic limb movements in sleep disorder.  The patient did not achieve any stage III/IV sleep and stage REM sleep was diminished at 12.7%.  There was a corresponding increase in stage I sleep and stage II sleep at 10.8% and 65.7% respectively.,DIAGNOSTIC IMPRESSION:,1.  Obstructive sleep apnea syndrome, supine position dependent, moderate (780.53-0).,2.  Periodic limb movement in sleep disorder, moderate (780.53-4).,CASE DISCUSSION: , Thank you once again for allowing us to participate in the care of the patient here at the Sleep Clinic.,The patient exhibits obstructive sleep apnea, a condition associated with increased risk of myocardial infarction, stroke and sudden death.  Furthermore, patients with this condition are susceptible to excessive daytime sleepiness while driving and there is a higher incidence of automobile accident.  The patient should be warned with regards to these possibilities.,Patients with this condition can be successfully treated with nasal CPAP (continuous positive airway pressure), so that the patient should return to the sleep laboratory for repeat overnight polysomnogram with CPAP titration.  The sleep laboratory if necessary can introduce the patient to the proper use of the CPAP equipment and to determine a necessary pressure to prevent apneas.,It is reported that the patient undergo careful ENT/maxillofacial evaluation by a physician familiar with sleep disorders.  Anatomical abnormalities in the upper airway often cause or predispose to this condition.  Surgical intervention may be helpful or necessary if such conditions exist.  Alternatively, ________ may be of benefit in some patients depending upon the anatomical abnormalities.,Obstructive sleep apnea is worsened by obesity.  The patient should be encouraged to lose weight.  Patients usually lose weight more effectively when involved in a behavioral weight loss program.  It is sometimes difficult for patients to lose weight until the OSA is adequately treated because excessive daytime sleepiness results in decreased physical activity in the daytime.,Patient may have worsening obstructive sleep apnea by nasal airway obstruction and nasal congestion.  If present, these conditions should be treated.  In addition, any home allergens such as pets, down bedding or other factors should be removed from the sleep environment.,The patient should be informed that obstructive sleep apnea may be worsened by the use of alcohol or sedative medications particularly taken in the evening.  Therefore, the evening use of sedative medications and alcohol are to be avoided.,The patient also exhibits periodic limb movements in sleep disorder.  This may require treatment.  However, it will be appropriate to obtain the repeat overnight polysomnogram with CPAP titration to see if the PLMS continues to be troublesome.  If so, treatment recommendations will be made.
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DESCRIPTION: The patient underwent an overnight polysomnogram.

sleep medicine, periodic limb movement, cpap, limb movements in sleep, obstructive sleep apnea, overnight polysomnogram, sleep, overnight, polysomnogram, obstructive, apneas,

The situation described involves a moderate level of medical urgency due to the conditions diagnosed: obstructive sleep apnea syndrome and periodic limb movement disorder. Obstructive sleep apnea, if untreated, can lead to serious health risks including myocardial infarction, stroke, and increased risk of automobile accidents due to excessive daytime sleepiness. These potential outcomes raise the stakes to a moderately high level. However, since these conditions are manageable and treatable with interventions like CPAP therapy and lifestyle modifications, the immediate threat is not extremely high. Therefore, this scenario is not acute but demands attention to prevent serious consequences.


Medical Specialty: Sleep Medicine
Sample Name: Pulmonary Consultation - 1

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

The situation involves a 61-year-old male with symptoms suggestive of obstructive sleep apnea, a condition associated with significant cardiovascular and health risks if left untreated. Ensuring a correct diagnosis through a sleep study is important for proper management and preventing potential complications such as heart disease and daytime accidents due to sleepiness. Although the issue is medical and requires attention, it does not represent an immediate emergency, but it involves moderate stakes given the potential impact on long-term health and quality of life.


Medical Specialty: Sleep Medicine
Sample Name: Obesity Hypoventilation Syndrome

HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep.  She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep.",MEDICATIONS: , Current medications are as previously noted.  Changes include reduction in prednisone from 9 to 6 mg by mouth every morning.  She continues to take Ativan 1 mg every six hours as needed.  She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs:  Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest.  Chest is clear.  Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used.  She used it for greater than 4 hours per night on 67% of night surveyed.  Her estimated apnea/hypopnea index was 3 per hour.  Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy.  She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%).  Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour.  Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%.  During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1.  Obesity hypoventilation syndrome.  The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity.  In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2.  Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute.  The breathing pattern is that of cluster or Biot's breathing throughout sleep.  The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3.  Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4.  Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep.  These will include, (1).  Decrease in evening doses of MS Contin, (2).  Modest weight loss of approximately 10 to 20 pounds, and (3).  Instituting Automated Servo Ventilation via nasal mask.  With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements.  I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed.  I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time.  She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation.  Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing.
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DESCRIPTION: Obesity hypoventilation syndrome.  A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.

sleep medicine, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity,

The medical situation involves a 61-year-old patient with multiple complex and interrelated medical issues, including severe central sleep apnea, obesity hypoventilation syndrome, polyarteritis nodosa, and significant opiate use for pain management. These conditions collectively contribute to significant health challenges, such as poor oxygenation, increased risk of cardiovascular complications, and potential for respiratory failure. The adjustments in medication, especially opiate dosages, and the introduction of Automated Servo Ventilation require careful monitoring and management due to potential risks. Given these complexities and potential health consequences, the stakes are moderately high as improper management may lead to serious health deterioration.


Medical Specialty: Sleep Medicine
Sample Name: Electroencephalogram - 3

IMPRESSION:,  Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.  Clinical correlation is suggested.
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DESCRIPTION: Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.

sleep medicine, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: 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 involves the interpretation of an electroencephalogram (EEG) which shows abnormalities. EEG results can indicate various neurological conditions such as seizures, brain injuries, or sleep disorders. This requires a medical professional to perform a clinical correlation to determine the significance and potential treatment options, affecting the patient's health outcomes. However, without immediate life-threatening implications specified, the scenario is moderate in stakes but not at the highest level.


Medical Specialty: Sleep Medicine
Sample Name: Electroencephalogram - 2

REPORT:  ,This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.  The patient was reported to be cooperative and was awake throughout the recording.,CLINICAL NOTE:  ,This is a 51-year-old male, who is being evaluated for dizziness.  Spontaneous activity is fairly well organized, characterized by low-to-medium voltage waves of about 8 to 9 Hz seen mainly from the posterior head region.  Intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region.,Eye opening caused a bilateral symmetrical block on the first run.  In addition to the above description, movement of muscle and other artifacts are seen.,On subsequent run, no additional findings were seen.,During subsequent run, again no additional findings were seen.,Hyperventilation was omitted.,Photic stimulation was performed, but no clear-cut photic driving was seen.,EKG was monitored during this recording and it showed normal sinus rhythm when monitored.,IMPRESSION:  ,This record is essentially within normal limits.  Clinical correlation is recommended.
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DESCRIPTION: Electroencephalogram (EEG).  This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system.

sleep medicine, referential electrodes, scalp, hyperventilation, photic stimulation, electroencephalogram

The EEG report indicates that the findings are essentially within normal limits and recommends clinical correlation. Given that the patient was evaluated for dizziness, but the EEG did not reveal any abnormal findings, the immediate implications of the report are not critical. While there is always some concern when evaluating symptoms like dizziness, the report itself does not suggest an urgent or life-threatening condition. Therefore, this situation does not seem to involve high-stakes decision-making at this moment.


Medical Specialty: Sleep Medicine
Sample Name: Electroencephalography

HISTORY:, This is a digital EEG performed on a 75-year-old male with seizures.,BACKGROUND ACTIVITY:, The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson's. Part of the EEG is obscured by the muscle contraction artifact. There are also left temporal sharps occurring infrequently during the tracing. At one point of time, there was some slowing occurring in the right frontal head region.,ACTIVATION PROCEDURES:, Photic stimulation was performed and did not show any significant abnormality.,SLEEP PATTERNS:, No sleep architecture was observed during this tracing.,IMPRESSION:, This awake/alert/drowsy EEG is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. The slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. The tremor probably represents a Parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended.
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DESCRIPTION: Electroencephalographic findings and interpretation

sleep medicine, electroencephalography, eeg, hz rhythm, parkinson's tremor, photic stimulation, frontal head region, temporal head region, muscle contractions, seizures, parkinson's, temporal,

The scenario involves an EEG interpretation for a 75-year-old male with seizures, which suggests assessing his neurological status for any serious conditions such as Parkinson's tremor, seizures, or structural abnormalities like stroke or subdural hematoma. Accurate interpretation of this EEG can directly impact the patient's treatment plan and outcomes, making it a clinically significant and potentially high-stakes situation.


Medical Specialty: Sleep Medicine
Sample Name: Electroencephalogram - 1

REPORT:,  The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally.  Little activity in the beta range is noted.  Waves of 4-7 cycle/second of low amplitude were occasionally noted.  Abundant movements and technical artifacts are noted throughout this tracing.  Hyperventilation was not performed.  Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:,  The electroencephalogram is essentially normal.
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DESCRIPTION: Electroencephalogram (EEG).  Photic stimulation reveals no important changes.  Essentially normal.

sleep medicine, beta range, hyperventilation, photic stimulation, electroencephalogramNOTE,: 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 involves reviewing the results of an electroencephalogram (EEG) test which is a common procedure in sleep medicine. The report indicates that the EEG is essentially normal, which suggests that there are no significant abnormalities or immediate health concerns. Typically, a normal EEG result is not considered high-stakes, as it suggests that the brain's electrical activity is functioning within normal parameters. There is no immediate threat to the patient's health or need for urgent intervention based on this report.


Medical Specialty: Sleep Medicine
Sample Name: CPAP Titration Study

PROCEDURE: , The test was performed in an observed hospital laboratory due to the evidence of obstructive sleep apnea.  The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.,CPAP TITRATION STUDY:,  Total sleep time 425 minutes, sleep onset 7.8 minutes, and sleep efficiency 95%.  Stage I 6%, stage II 53%, stage III 20%, and REM stage 15%, and awake 5%.  Number of awakenings 6.  Total arousals 36 with index 5.4, mild leg jerk movement with index 10.1.  There was one apnea and 17 hypopneas with apnea/hypopnea index 2.7.  The pressures required to prevent apnea/hypopnea varied between 5 and 11 cm H2O.  The optimal pressure was 11 cm H2O, which prevented all of the apneas/hypopneas.  The patient spent all his sleeping time in supine position.  Average oxygen saturation 94% with lowest oxygen saturation 89%.  Only less than 0.2 minutes was spent with oxygen saturation less than 90%.,SUMMARY: , Weight loss, PFTs if not done and CPAP with nasal mask at 11 cm H2O.
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DESCRIPTION: The patient was monitored for EEG, EOG, jaw and leg EMG, thoracoabdominal impedance, oral/nasal thermistors, EKG, and oximetry.

sleep medicine, obstructive sleep apnea, cpap titration study, cpap titration, oral/nasal thermistors, thermistors ekg, oxygen saturation, eeg, eog, emg, thoracoabdominal, thermistors, ekg, oximetry, apnea, cpap, oral/nasalNOTE

The situation involves a CPAP titration study for obstructive sleep apnea, which is a common yet potentially serious medical condition. However, the study summary indicates that the patient has a mild case with effective management through CPAP at a pressure of 11 cm H2O, which prevents apnea/hypopnea. While sleep apnea can have serious consequences if not treated, this particular case seems well-handled and stable. Therefore, the stakes are moderate, considering the effective management and monitoring in place.


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

Medical Specialty: Rheumatology
Sample Name: Rheumatoid Arthritis

RHEUMATOID ARTHRITIS, (or RA) is a chronic, systemic condition with primary involvement of the joints.  Joint inflammation is present due to an abnormal immune response in which the body attacks its own tissue.  Specifically, the tissues lining the joint are involved as well as cartilage and muscle and sometimes the eyes and blood vessels.  The cause of rheumatoid arthritis is obscure but it is associated with a family history, genetic and autoimmune problems, people ages 20-60, female gender 3:1 or a Native American background.,SIGNS AND SYMPTOMS:,*  Joint pain, swelling, redness, warmth.  Commonly involved joints are the small joints of the hands and feet and the ankles, wrists, knees, shoulders and elbows.,*  Multiple swollen joints (more than 3) with simultaneous involvement of same joints on opposite side of the body.,*  Morning stiffness that lasts longer than 30 minutes.,*  Difficulty making a fist; poor grip strength.,*  Night pain.,*  Feeling "sick" - low fever, loss of appetite, tiredness, generalized aching and stiffness, weakness.,*  Rheumatoid nodules under the skin, usually along the surface of tendons or over bony prominences.,*  Disease may lead to deformed joints, decreased vision, anemia, muscle weakness, peripheral nerve problems, pericarditis, enlarged spleen, increased frequency of infections.,*  Blood tests will reveal a positive rheumatoid factor (RF) to be present the majority of the time.,TREATMENT:,*  To diagnose RA, blood studies are done to detect a substance known as rheumatoid factor and x-rays may show typical findings.,*  Night splints for involved joints.  Avoid putting a pillow under the knees as this will contribute to joint contracture.,*  Heat helps relieve the pain; hot water soaks, whirlpool baths, heat lamps, heating pads, etc. applied to affected joints 15-20 minutes 3 times per day is helpful.,*  Sleep on a firm mattress and sleep at least 10-12 hours per night.  Get rest during the day; take naps.,*  Get bed rest during an active flare-up until symptoms subside.,*  Avoid humid weather if possible.,*  NSAIDs (non-steroidal anti-inflammatory drugs).,*  DMARDs (disease-modifying anti-rheumatic drugs) - gold compounds, D-penicillamine, sulfasalazine, methotrexate, antimalarials.,*  Immunosuppressive drugs.,*  Acetaminophen (Tylenol) for pain relief only when necessary.,*  Oral corticosteroids short term; corticosteroid injection into joint can temporarily relieve pain and inflammation.,*  Exercise as recommended by your physician.  Exercise helps keep the joints limber and increases strength.  Swimming and water activities are a good way to workout.  Put all your joints through their full ranges of motion every day to prevent contractures. *  Physical therapy may be recommended.,*  Surgical intervention.,*  Lose excess weight as being overweight will only stress the joints further.,*  Eat a normal, well-balanced diet.
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DESCRIPTION: A sample note on Rheumatoid Arthritis

A sample note on Rheumatoid Arthritis

rheumatology, ra, rheumatoid arthritis, joint inflammation, swollen joints, arthritis, joints, inflammation, corticosteroids, rheumatoid,

Rheumatoid arthritis (RA) is a chronic condition that can significantly impact a person's quality of life due to its systemic involvement and potential to cause joint deformity, pain, weakness, and other complications. Managing RA involves a multi-faceted approach including medication, physical therapy, and lifestyle changes. However, while RA management is crucial for maintaining life quality, the typical progression does not threaten immediate life or safety, which reduces the stakes in terms of acute complications. Nonetheless, challenges related to long-term management, treatment adherence, and potential for disability make it somewhat high-stakes, particularly affecting life quality and long-term health.


Medical Specialty: Rheumatology
Sample Name: Rheumatoid Arthritis - Consult

HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She was followed by another rheumatologist.  She says she has been off and on, on prednisone and Arava.  The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone.  She says she had been on prednisone for the last 6 to 9 months.  She is on 5 mg a day.  She recently had a left BKA and there was a question of infection, so it had to be debrided.  I was consulted to see if her prednisone is to be continued.  The patient denies any joint pains at the present time.  She says when this started she had significant joint pains and was unable to walk.  She had pain in the hands and feet.  Currently, she has no pain in any of her joints.,REVIEW OF SYSTEMS: , Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,PAST MEDICAL HISTORY: , Significant for hypertension, peripheral vascular disease, and left BKA.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Denies tobacco, alcohol or illicit drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS:  BP 130/70, heart rate 80, and respiratory rate 14.,HEENT:  EOMI.  PERRLA.,NECK:  Supple.  No JVD.  No lymphadenopathy.,CHEST:  Clear to auscultation.,HEART:  S1 and S2.  No S3, no murmurs.,ABDOMEN:  Soft and nontender.  No organomegaly.,EXTREMITIES:  No edema.,NEUROLOGIC:  Deferred.,ARTICULAR:  She has swelling of bilateral wrists, but no significant tenderness.,LABORATORY DATA:,  Labs in chart was reviewed.,ASSESSMENT AND PLAN:,  A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone.  She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that.  As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow.  If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone.  I would defer that to Dr. X.  If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone.  I discussed this at length with the patient and she is in full agreement with the plan.  I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there.
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DESCRIPTION: A 71-year-old female who I am seeing for the first time.  She has a history of rheumatoid arthritis for the last 6 years.  She is not on DMARD, but as she recently had a surgery followed by a probable infection.

rheumatology, prednisone, joint pains, rheumatoid arthritis, arthritis, dmard, rheumatologist, rheumatoid, pains,

The situation involves a 71-year-old female with rheumatoid arthritis, a chronic condition, who has recently undergone surgery with a probable infection. The primary decision here is whether to continue prednisone, a corticosteroid, amid her complex medical history. The potential discontinuation of prednisone is significant due to its implications for disease management and potential for flare-ups, considering past reliance on it and its side effects. While the decision is clinically consequential, it's not acutely life-threatening, so it's not extremely high-stakes.


Medical Specialty: Rheumatology
Sample Name: Discoid Lupus

HISTORY:  ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit.  She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus.  A has been doing well with just Plaquenil alone and mother said that during the summer, the rash gets brighter, but now that it is getting darker and she is at school, the rash is starting to become lighter again.  She has been using her cream, which is hydrocortisone at night and applying it with no problems.  She denies any hair losses, denies any decrease in appetite, actually, she has been gaining some weight.  She denies any ulcerations in her mouth, eye problems, or any lumps in her body.  She denies any fevers or any problems with the urine.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Today temperature is 100.1, weight is 73.5 kg, blood pressure is 121/61, height is 158, and pulse is 84.,GENERAL:  She is alert, active, and oriented in no distress.,HEENT:  She had a head full of hair with no bald spots.  She has a macular rash on her cheeks bilaterally with hyperpigmented circles.  No scales, no excoriations, and no palpable erythema.  Oral mucosa is clear with no ulcerations.,NECK:  Soft with no masses.  She does have acanthosis nigricans on the base of the neck.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft and nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation, swelling, or tenderness in any of her joints.,SKIN:  Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size, but most of them are about 1 cm in diameter, which are hyperpigmented.  No erythema, no purpura, no petechiae, and no raised borders.  They look more like cigarette points.  She has this in her upper extremities especially in the forearms and also on her lower extremities, on the legs, but just very few lesions and very light.  She has some periungual erythema, as well as some palmar erythema, but this is minimal.,LABORATORY DATA:,  Laboratories today done, we have a CBC with a white blood cell count of 7.9, hemoglobin is 14.3, platelet count is 321,000, sed rate is only 11, and CMP shows no abnormalities.  Pending is antinuclear antibody complement level.,ASSESSMENT: , She is 12-year-old with discoid lupus on the control with optimal regimen.  We are going to switch her to Protopic at night, especially in the face.  Continue on Plaquenil, get some laboratories and wait for the results.  Diet evaluation today because of the gaining weight and acanthosis nigricans, and will see her back in about 3 months for follow-up.  Future plans will be depending on whether or not she evolves into a full-blown lupus.  I discussed the plan with her mother and they had no further questions.
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DESCRIPTION: A 12-year-old with discoid lupus on the control with optimal regimen.

rheumatology, lupus, systemic lupus, acanthosis nigricans, discoid lupus, extremities, rash, erythema, discoid,

The situation involves a 12-year-old female with discoid lupus being monitored for potential progression to systemic lupus erythematosus, which can be a serious condition. The patient's condition is currently stable, and there is a plan in place for ongoing monitoring and treatment adjustments. The immediate risk seems low as the patient is controlled on an optimal regimen, but the possibility of progression requires cautious monitoring. Therefore, the situation has moderate stakes given the age of the patient and the potential for systemic lupus development.


Medical Specialty: Rheumatology
Sample Name: Oligoarticular Arthritis - 2

HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria.  A was worked up for collagen vascular diseases and is here to find out the results.  Also was recommended to take 7.5 mg of Mobic every day for her joint pains.  She states that she continues with some joint pain and feeling tired all the time.  Mother states that also her seizure has continued without any control so far.  She is having some studies in the next few days.  She is mostly stiff on her legs, neck, and also on her hands.  The rest of the review of systems is in the chart.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Temperature today is 99.2 degrees Fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.,HEENT:  She has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations.  Pupils are reactive to accommodation.  Funduscopic examination is within normal limits.,NECK:  No neck masses.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,SKIN:  No rashes today.,MUSCULOSKELETAL:  Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.,LABORATORY DATA: , Laboratories were not done recently, but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease, but shows some evidence of decreased calcium and vitamin D levels.,ASSESSMENT: , This is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D.  She also has chronic proteinuria and seizure disorder.  My recommendation is to start her on vitamin D and calcium supplements, and also increase the Mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking.  We are going to refer her to physical therapy and see her back in 2 months for followup.  The plan was discussed with A and her parents and they have no further questions.
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DESCRIPTION: A lady with symptoms consistent with possible oligoarticular arthritis of her knees.

rheumatology, arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular,

The situation involves a young lady with multiple health issues, including seizure disorder, possible oligoarticular arthritis, chronic proteinuria, and vitamin D deficiency. However, the immediate plan is non-emergent management, such as adjusting medication, starting supplements, and referring to physical therapy, with a follow-up in two months. This suggests that while the medical condition is complex, it is not immediately life-threatening or requiring urgent intervention. Thus, I would classify this situation as moderate stakes given the chronic nature of the ailments and the current non-urgent treatment approach.


Medical Specialty: Radiology
Sample Name: X-RAY - Neck Soft Tissues

EXAM: , Two views of the soft tissues of the neck.,HISTORY:,  Patient has swelling of the left side of his neck.,TECHNIQUE:,  Frontal and lateral views of the soft tissues of the neck were evaluated. There were no soft tissues of the neck radiographs for comparison. However, there was an ultrasound of the neck performed on the same day.,FINDINGS: , Frontal and lateral views of the soft tissues of the neck were evaluated and reveal there is an asymmetry seen to the left-sided soft tissues of the patient's neck which appear somewhat enlarged when compared to patient's right side. However the trachea appears to be normal caliber and contour.  Lateral views show a patent airway. The adenoids and tonsils appear normal caliber without evidence of hypertrophy. Airway appears patent. Osseous structures appear grossly normal.,IMPRESSION:,1. Patent airway. No evidence of any soft tissue swelling involving the patient's adenoids/tonsils, epiglottis or aryepiglottic folds. No evidence of any prevertebral soft tissue swelling.,2. Slight asymmetry seen to the soft tissues of the left side of the patient's neck which appears somewhat larger when compared to the right side.
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DESCRIPTION: X-RAY of the soft tissues of the neck.

X-RAY of the soft tissues of the neck.

radiology, swelling, soft tissues, ultrasound, tonsils, adenoids, osseous structures, epiglottis, aryepiglottic folds, frontal and lateral, normal caliber, frontal, asymmetry,

The described X-ray findings report a slight asymmetry in the soft tissues on the left side of the neck. While there is some enlargement, the critical aspects such as the trachea, airway, adenoids, and tonsils are noted as normal. This indicates a non-life-threatening situation. Furthermore, no swelling is observed in the prevertebral soft tissues. The presence of asymmetry could indicate an underlying condition that may require further investigation, but based on the report, there is nothing immediately alarming. Thus, while some follow-up might be necessary, this situation does not currently seem urgent or critical.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 5

GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,
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DESCRIPTION: This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.

The given ultrasound report of a 24-year-old pregnant patient indicates mild oligohydramnios, which is a condition of having less amniotic fluid than normal, but other factors such as fetal cardiac activity, anatomy, and biophysical profile appear to be normal. While mild oligohydramnios can require monitoring and potential intervention, it is not necessarily immediately high-stakes if managed correctly. Overall, the situation does not indicate an immediate threat but does require attention to ensure the health of both the mother and the fetus.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 7

GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM.  Fetal Lie: Longitudinal.  Fetal Presentation: Cephalic.  Placenta: Anterior Grade I.  Uterus: Normal.  Cervix: Closed.  Adnexa: Not seen.  Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:
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DESCRIPTION: A 27-year-old female with a size and date discrepancy.

The ultrasound results show normal findings in various aspects of the fetal condition, such as cardiac activity, fetal lie and presentation, and normal amniotic fluid. The biometry measurements align well with the gestational age indicated. However, a size and date discrepancy could indicate potential complications, such as growth restriction or discrepancies with dating. While this could lead to a need for further monitoring, the immediate findings do not indicate an urgent threat to the mother or baby. However, as this pertains to a prenatal evaluation and any discrepancies are generally taken seriously, I assess this as moderately high-stakes.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 8

REASON FOR EXAM: , Pregnant female with nausea, vomiting, and diarrhea.,FINDINGS: , The uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign.  A yolk sac is visualized.  What appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.,Please note however that no fetal heart tones are seen.  However, fetal heart tones would be expected at this age.,The right ovary measures 3.1 x 1.6 x 2.3 cm.  The left ovary measures 3.3 x 1.9 x 3.5 cm.  No free fluid is detected.,IMPRESSION: , Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09.  A live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time.  A close interval followup in correlation with beta-hCG is necessary as findings may represent an inevitable abortion.
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DESCRIPTION: Pregnant female with nausea, vomiting, and diarrhea.  OB ultrasound less than 14 weeks, transvaginal.

radiology, intrauterine pregnancy, estimated date of delivery, nausea, vomiting, fetal heart tones, ovary measures, fetal heart, ultrasound, ob, ovary, pregnancy, sac, fetal, intrauterine

The situation involves a pregnant female at 6 weeks where a fetal heartbeat is not detected, and there is a suggestion of an inevitable abortion if certain conditions are met. This is a high-stakes diagnostic situation for the patient, as it involves the potential loss of a pregnancy. Decisions and follow-up actions based on these findings impact the patient's immediate and future reproductive health, emotional well-being, and requires timely and sensitive medical intervention.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 4

GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:
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DESCRIPTION: Twin pregnancy with threatened preterm labor.

The situation involves a twin pregnancy with biometry showing discrepancies in fetal development and is flagged as 'threatened preterm labor.' This condition is high-stakes as it requires careful monitoring and potential interventions to prevent premature birth, which could pose significant health risks to both the mother and the babies.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 2

FINDINGS:,By dates the patient is 8 weeks, 2 days.,There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler.,There is no fluid within the endometrial cavity.,There is a 2.8 x 1.2cm right adnexal cyst.,IMPRESSION:,Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks, 2 days.,A preliminary report was called by the ultrasound technologist to the referring physician.
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DESCRIPTION: A 34-year old female with no fetal heart motion noted on office scan.

radiology, fetal heart motion, gestational sac, endometrial cavity, fetal pole, fetal heart, heart motion, gestational, fetal

The report indicates a finding of fetal demise, which is a serious situation for the patient. The difference between gestational age by dates and by measurement, as well as the absence of fetal heart motion, are concerning findings that can have significant emotional and medical implications. This situation requires careful communication and follow-up with the patient and possibly further medical intervention.


Medical Specialty: Radiology
Sample Name: Ultrasound - Pelvis

EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm.  It appears to be completely replaced by multiple ill-defined fibroids.  The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids.  The right ovary measures 3.9 x 1.9 x 2.3 cm.  The left ovary is not seen.  No complex cystic adnexal masses are identified.,IMPRESSION:  ,Essential replacement of the uterus by fibroids.  It is difficult to measure given their heterogenous and diffuse nature.  MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.
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DESCRIPTION: Ultrasound of pelvis - menorrhagia.

Ultrasound of pelvis - menorrhagia.

radiology, pelvis, mri, menorrhagia, ultrasound, adnexa, echo complex, endometrial, fibroids, ovary, uterine fibroid, uterus, ultrasound of pelvis

The situation involves the medical finding of an enlarged uterus replaced by fibroids and suggests an MRI for further evaluation. While it is an important medical finding that could affect the patient's treatment plan and quality of life, it is not immediately life-threatening. However, it does require further assessment to determine appropriate management, which makes it moderately high-stakes from a medical perspective.


Medical Specialty: Radiology
Sample Name: Ultrasound - Lower Extremity

EXAM: , Bilateral lower extremity ultrasound for deep venous thrombus.,REASON FOR EXAM: , Lower extremity edema bilaterally.,TECHNIQUE: , Colored, grayscale, and Doppler imaging is all employed.,FINDINGS: , This examination is limited.  There is prominent edema bilaterally and there is large body habitus.  These two limit assessment especially of the right lower extremity.,As visualized, there is no gross evidence of DVT.  The right leg grayscale images are limited.  No obvious clot identified on the color flow or Doppler images.  The left leg is better visualized than the right, but again is limited.  No definite clot is seen.,IMPRESSION: , Limited study secondary to body habitus and edema.  No obvious DVT as visualized.
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DESCRIPTION: Bilateral lower extremity ultrasound for deep venous thrombus.

radiology, edema, grayscale images, deep venous thrombus, lower extremity, grayscale, doppler, ultrasound, extremity,

The situation in the report relates to a medical examination using ultrasound to check for deep venous thrombus (DVT) in the lower extremities. DVT can be a serious condition because it may lead to complications such as a pulmonary embolism if a clot travels to the lungs. However, the report indicates limitations in the examination due to body habitus and edema but notes no obvious DVT. Although the absence of clear evidence of DVT is positive, the limitations mean that a thorough assessment wasn't possible. Therefore, the stakes are relatively high since a potential DVT was not definitively ruled out.


Medical Specialty: Radiology
Sample Name: Ultrasound - Kidney

EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:,  Ureteral stricture.,AP ABDOMEN ,FINDINGS:,  Comparison is made to study from Month DD, YYYY.  There is a left lower quadrant ostomy.  There are no dilated bowel loops suggesting obstruction.  There is a double-J right ureteral stent, which appears in place.  There are several pelvic calcifications, which are likely vascular.  No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent.  No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:,  The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  There is a right renal/ureteral stent identified.  There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis.  No stone or solid masses seen.  The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1.  Left-sided hydronephrosis.,2.  No visible renal or ureteral calculi.,3.  Right ureteral stent.
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DESCRIPTION: AP abdomen and ultrasound of kidney.

AP abdomen and ultrasound of kidney.

radiology, ureteral stricture, ap abdomen, bowel loops, calcified, calculi, double-j, echogenicity, hydronephrosis, kidney, left lower quadrant, obstruction, ostomy, perinephric, renal, solid mass, stent, ultrasound, ureteral stent, ureteral stones, ureters, ureteral,

The situation involves the interpretation of radiological findings related to the kidney, specifically identifying hydronephrosis and the placement of a ureteral stent. While it is crucial for diagnosing and managing patient health, the findings indicate no immediate or significant emergency issues such as obstructions or calculi that could require urgent intervention. Therefore, while the situation demands medical attention, it is not as high-stakes as other life-threatening conditions.


Medical Specialty: Radiology
Sample Name: Transesophageal Echocardiogram - 4

PROCEDURE NOTE:,  The patient was brought to the transesophageal echo laboratory after informed consent was obtained.  The patient was seen by Anesthesia for MAC anesthesia.  The patient's posterior pharynx was anesthetized with local Cetacaine spray.  The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,FINDINGS: ,1.  Left ventricle is normal in size and function; ejection fraction approximately 60%.,2.  Right ventricle is normal in size and function.,3.  Left atrium and right atrium are normal in size.,4.  Mitral valve, aortic valve, tricuspid valve, and pulmonic valve with no evidence of vegetation.  Aortic valve is only minimally thickened.,5.  Mild mitral regurgitation and mild tricuspid regurgitation.,6.  No left ventricular thrombus.,7.  No pericardial effusion.,8.  There is evidence of patent foramen ovale by contrast study.,The patient tolerated the procedure well and is sent to recovery in stable condition.  He should be n.p.o. x4 hours, then liquid, then increase as tolerated.  Once his infection is cleared, he should follow up with us with regard to followup of patent foramen ovale.
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DESCRIPTION: Transesophageal echocardiogram.   The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.

radiology, ventricle, atrium, mitral valve, aortic valve, tricuspid valve, pulmonic valve, regurgitation, transesophageal probe, transesophageal echocardiogram, posterior pharynx, transesophageal, valve

The procedure note describes a successful transesophageal echocardiogram with no immediate complications and a stable patient outcome. While a patent foramen ovale (PFO) was detected, which may require future monitoring or treatment, the current situation is relatively stable. The patient is in recovery and instructions for follow-up and dietary progression have been given. The stakes are moderate primarily because any cardiac procedure can have potential risks, and the need for future consideration of the PFO is noted.


Medical Specialty: Radiology
Sample Name: Transesophageal Echocardiogram - 5

CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed.  Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained.  There were no complications.  The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1.  Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp.  The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2.  Mitral valve is calcified and thick.  No vegetation seen.  There is mild-to-moderate MR present.  There is mild AI present also.,3.  Tricuspid valve and pulmonary valve are structurally normal.,4.  There is a mild TR present.,5.  There is no clot seen in the left atrial appendage.  The velocity in the left atrial appendage was 0.6 m/sec.,6.  Intraatrial septum was intact.  There is no clot or mass seen.,7.  Normal LV and RV systolic function.,8.  There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1.  There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis.  Calculated aortic valve area was 0.6 sq. cm.,2.  Normal LV systolic function.,
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DESCRIPTION: Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.

radiology, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal

The transesophageal echocardiogram procedure in this context is conducted to rule out endocarditis in a patient with MRSA bacteremia and aortic stenosis. Both conditions are critical given their potential complications and mortality risks. MRSA bacteremia can lead to severe infections, and the presence of suspected endocarditis is particularly serious due to risks of further systemic complications. Additionally, the aortic stenosis, a significant finding, suggests an already compromised cardiac function, which increases the overall stakes of this medical evaluation.


Medical Specialty: Radiology
Sample Name: Testicular Ultrasound

TESTICULAR ULTRASOUND,REASON FOR EXAM:  ,Left testicular swelling for one day.,FINDINGS:  ,The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm.  The right epididymis measures up to 9 mm.  There is a hydrocele on the right side.  Normal flow is seen within the testicle and epididymis on the right.,The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm.  The left testicle shows normal blood flow.  The left epididymis measures up to 9 mm and shows a markedly increased vascular flow.  There is mild scrotal wall thickening.  A hydrocele is seen on the left side.,IMPRESSION:,1.  Hypervascularity of the left epididymis compatible with left epididymitis.,2.  Bilateral hydroceles.
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DESCRIPTION: Left testicular swelling for one day.  Testicular Ultrasound.  Hypervascularity of the left epididymis compatible with left epididymitis.  Bilateral hydroceles.

radiology, hypervascularity, bilateral hydroceles, epididymis, epididymitis, testicular ultrasound, ultrasound, flow, hydroceles, testicle, testicular,

The situation involves the interpretation of a testicular ultrasound finding. The identified condition, epididymitis, can be painful and potentially serious if not treated, but is typically not life-threatening. Bilateral hydroceles are generally benign. Immediate medical attention is important to manage symptoms and prevent complications, but the stakes are not extremely high compared to other medical emergencies like a testicular torsion, which would require urgent intervention to prevent permanent damage.


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Medical Specialty: Radiology
Sample Name: Stress Test Graded Exercise Treadmill

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

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

The situation involves a medical stress test, which is a significant procedure used to assess heart health, especially as the patient experienced chest pain during the test. Although the test was negative for ischemia, any procedure involving cardiac assessment carries a level of importance due to the potential for serious underlying conditions. However, given that the results were negative for ischemia and no immediate life-threatening abnormalities were detected, this situation does not appear to be acutely high-stakes, particularly in the absence of ischemic changes. The primary concern now appears to be related to chest wall tenderness rather than a cardiac event.


Medical Specialty: Radiology
Sample Name: Stress Test Dobutamine Myoview

INDICATIONS:  ,Chest pain, hypertension, type II diabetes mellitus.,PROCEDURE DONE:,  Dobutamine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes.  Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion.  The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality.  The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate.  The blood pressure increased from 130/80 to 160/70.  A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion.  No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview.  Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview.  The lung heart ratio is 0.36.  Myocardial perfusion images were normal both at rest and with stress.  Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.,CONCLUSIONS:,1.  Stress test is negative for dobutamine-induced myocardial ischemia.,2.  Normal left ventricular size, regional wall motion, and ejection fraction.
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DESCRIPTION: Chest pain, hypertension.  Stress test negative for dobutamine-induced myocardial ischemia.  Normal left ventricular size, regional wall motion, and ejection fraction.

radiology, chest pain, dobutamine myoview, dobutamine myoview stress test, spect imaging, stress test, dobutamine infusion, ejection fraction, hypertension, myocardial ischemia, myocardial perfusion, ventricular size, wall motion, dobutamine, stress, myocardial, myoview, ischemia, ventricular, perfusion,

This situation involves a medical stress test using dobutamine to evaluate myocardial perfusion and heart function in a patient with chest pain, hypertension, and type II diabetes. The results indicate no evidence of myocardial ischemia, suggesting the test was negative for significant cardiac issues. While the test is important for diagnosing potential heart conditions, the fact that the results are negative for ischemia reduces the immediate urgency or risk. However, given the patient's conditions, regular follow-up and monitoring are important. Thus, while the stakes are moderate due to the potential for serious cardiac issues, they are not extremely high due to the negative test result.


Medical Specialty: Radiology
Sample Name: Slipped Capital Femoral Epiphysis (SCFE)

EXAM: , Two views of the pelvis.,HISTORY:,  This is a patient post-surgery, 2-1/2 months.  The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY.  Lateral view of the right hip was evaluated.,FINDINGS:,  Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY.  Current films reveal stable appearing post-surgical changes.  Again demonstrated is a single intramedullary screw across the left femoral neck and head.  There are 2 intramedullary screws through the greater trochanter of the right femur.  There is a lucency along the previous screw track extending into the right femoral head and neck.  There has been interval removal of cutaneous staples and/or surgical clips.  These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1.  Stable-appearing right hip joint status-post pinning.,2.  Interval removal of skin staples as described above.
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DESCRIPTION: Frontal and lateral views of the hip and pelvis.

radiology, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip

The scenario involves a post-surgical evaluation of a patient with a history of slipped capital femoral epiphysis (SCFE). The findings suggest stable post-surgical changes, with further monitoring necessary due to the presence of lucency along the screw track and prior deformity. While the stability is a positive sign, the potential complications from the surgical history and current state could lead to serious health issues if not monitored adequately. However, as the current findings are relatively stable and routine follow-up appears to be part of the care plan, the medical stakes, while significant, do not seem extraordinarily high at this moment.