Medical Specialty: Endocrinology
Sample Name: Diabetes Mellitus Followup

PROBLEM LIST:,1.  Type 1 diabetes mellitus, insulin pump.,2.  Hypertension.,3.  Hyperlipidemia.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus.  Her last visit was approximately 4 months ago.  Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks.  She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial.  She is not reporting polyuria, polydipsia or polyphagia.  She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well.  She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity.  She is keeping up with all her other appointments and has recently had a good eye examination.  She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144.,CURRENT MEDICATIONS:,1.  Zoloft 50 mg p.o. once daily.,2.  Lisinopril 40 mg once daily.,3.  Symlin 60 micrograms, not taking at this point.,4.  Folic acid 2 by mouth every day.,5.  NovoLog insulin via insulin pump about 90 units of insulin per day.,REVIEW OF SYSTEMS:,  She denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance.  She is not having painful urination or blood in the urine.  She is not reporting polyuria, polydipsia or polyphagia.,PHYSICAL EXAMINATION:,GENERAL:  Today showed a very pleasant, well-nourished woman, in no acute distress.  VITAL SIGNS:  Temperature not taken, pulse 98, respirations 20, blood pressure 148/89, and weight 91.19 kg.  THORAX:  Revealed lungs clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 auscultated.  ABDOMEN:  Nontender.  EXTREMITIES:  Showed no clubbing, cyanosis or edema.  SKIN:  Intact and do not appear atrophic.  Deep tendon reflexes were 2+/4 without a delayed relaxation phase.,LABORATORY DATA:,  Dated 10/05/08 showed a total cholesterol of 223, triglyceride 140, HDL 54, and LDL 144.  The hemoglobin A1c was 6.4 and the spot urine for microalbumin was 9.2 micrograms of protein, 1 mg of creatinine.  Sodium 136, potassium 4.5, chloride 102, CO2 30 mEq, BUN 11 mg/dL, creatinine 0.6 mg, estimated GFR greater than 60, blood sugar 118, calcium 9.4, and her LFTs were unremarkable.  TSH is 1.07 and free T4 is 0.81.,ASSESSMENT AND PLAN:,1.  This is a return visit to the endocrine clinic for the patient, a 39-year-old woman with history as noted above.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.  Basal rate is as follows, 12 a.m. 1.5, 02:30 a.m. 1.75, and 6 a.m. 1.5.  Her correction factor is 19.  Her carb/insulin ratio is 6.  Her active insulin time is 5 and her targets are at 12 a.m. 110 and 6 a.m. to midnight is 100.  We made adjustments to her pump and the plan will be to see her back in approximately 2 months.,2.  Hyperlipidemia.  The patient is not taking statin, therefore, we will prescribe Lipitor 20 mg one p.o. once daily.  Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now.,3.  We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well.
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DESCRIPTION: Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus.  Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.

endocrinology, endocrine clinic, insulin pump, diabetes mellitus, insulin, glycemic, fasting, polyuria, polydipsia, polyphagia, diabetes,

The situation involves a patient with type 1 diabetes mellitus who is experiencing difficulty with glycemic control due to a recent insulin pump malfunction. The stakes are significant because effective management of diabetes is crucial to prevent acute events and long-term complications, particularly as the patient is not reporting severe hypoglycemic events currently. The potential risk of poor glycemic control, which can lead to acute conditions such as diabetic ketoacidosis, or long-term complications, makes this situation moderately high-stakes. However, since the issue is being monitored and adjustments to her treatment plan are being made, and there is no immediate life-threatening condition reported, it does not reach the highest stakes level.


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

Medical Specialty: ENT - Otolaryngology
Sample Name: Vertigo Consult

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

ent - otolaryngology, electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo,

The situation involves a medical assessment and treatment plan for a patient experiencing vertigo. While the issue is a matter of health concern and may have significant implications for the patient's quality of life, it does not appear to be immediately life-threatening or urgent. The prescribed treatment and planned diagnostic procedures suggest ongoing management rather than emergency intervention. Overall, the stakes are moderate due to the patient's ongoing discomfort but not critical in the context of life-threatening conditions.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: ENT - Otolaryngology
Sample Name: Bilateral Myringotomies - 2

PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:,  Bilateral chronic otitis media,ANESTHESIA:,  General mask,NAME OF OPERATION:,  Bilateral Myringotomy with placement of PE tubes,PROCEDURE:,  The patient was taken to the operating room and placed in the supine position.  After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case.  First, the left and then the right tympanic membrane, was approached.  An anterior-inferior radial incision was made in the left tympanic membrane.  Suction revealed a substantial amount of mucopurulent drainage.  A Sheehy pressure equalization tube was placed in the myringotomy site.  Floxin drops were added.  The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage.  The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.
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DESCRIPTION: Bilateral Myringotomy with placement of PE tubes

ent - otolaryngology, placement of pe tubes, bilateral chronic otitis media, chronic otitis media, bilateral myringotomy, pe tubes, chronic otitis, otitis media, tympanic membrane, mucopurulent drainage, tympanic, membrane, mucopurulent, myringotomy, tubes,

The procedure described is a common ENT surgical procedure for treating bilateral chronic otitis media, involving the placement of pressure equalization tubes. While it involves general anesthesia and surgery, which inherently carries some risk, it is considered a routine and low-risk procedure in the context of surgeries. The stakes are relatively low as it is a standard treatment with generally safe outcomes, unless there are specific complications or unusual patient conditions not mentioned here.


Medical Specialty: Consult - History and Phy.
Sample Name: Pseudotumor Cerebri

REASON FOR VISIT:  ,The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches.  She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS: , Dr. X has cared for her since 2002.  She has a Codman-Hakim shunt set at 90 mmH2O.  She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches.  We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself.  Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08.  She states that since that time her headaches have been bad.  They woke her up at night.  She has not been able to sleep.  She has not had a good sleep cycle since that time.  She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up.  She states that they feel a little bit better when lying down.  Medication shave not helped her.  She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief.  The pain is generalized, but also noted to be quite intense in the frontal region of her head.  She also reports ringing in the ears and states that she just does not feel well.  She reports no nausea at this time.  She also states that she has been experiencing intermittent blurry vision and dimming lights as well.  She tells me that she has an appointment with Dr. Y tomorrow.  She reports no other complaints at this time.,MAJOR FINDINGS:,  On examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty.  She is well developed, well nourished, and kempt.,Vital Signs:  Blood pressure 153/86, pulse 63, and respiratory rate 16.,Cranial Nerves:  Intact for extraocular movements.  Facial movement, hearing, head turning, tongue, and palate movements are all intact.  I did not know any papilledema on exam bilaterally.,I examined her shut site, which is clean, dry, and intact.  She did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir.  It looks like there is a little bit of dry blood there.,ASSESSMENT:,  The patient appears to have had worsening headaches since shunt adjustment back after an MRI.,PROBLEMS/DIAGNOSES:,1.  Pseudotumor cerebri without papilledema.,2.  Migraine headaches.,PROCEDURES:,  I programmed her shunt to 90 mmH2O.,PLAN:,  It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago.  I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x-ray.  However, the picture of the x-ray was not the most desirable picture.  Thus, I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x-ray to confirm the setting at 90.  In addition, she told me that she is scheduled to see Dr. Y tomorrow, so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment.  She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally.,Total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient.
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DESCRIPTION: The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches.

consult - history and phy., migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema

The situation involves a patient with pseudotumor cerebri, a condition related to increased intracranial pressure, experiencing new, acute headaches after a shunt adjustment. This could indicate shunt malfunction or improper adjustment, potentially leading to further complications if not addressed timely. Headaches, visual disturbances, and other symptoms raise concern. The dictated medical actions are critical but routine for managing the condition.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: HIV Followup

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old white male with a history of HIV disease.  His last CD4 count was 425, viral load was less than 50 in 08/07.  He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus.  He also has a history of hypertension and hypertriglyceridemia.  He had been having increased urination and thirst.  He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess.  The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide.  The patient reports that he has been taking the medication.  He is in general feeling better.  He says that his gluteal abscess is improving and he will be following up with Surgery today.,CURRENT MEDICATIONS:,1.  Gabapentin 600 mg at night.,2.  Metformin 1000 mg twice a day.,3.  Glipizide 5 mg a day.,4.  Flagyl 500 mg four times a day.,5.  Flexeril 10 mg twice a day.,6.  Paroxetine 20 mg a day.,7.  Atripla one at night.,8.  Clonazepam 1 mg twice a day.,9.  Blood pressure medicine, name unknown.,REVIEW OF SYSTEMS:,  He otherwise has a negative review of systems.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.)  HEENT:  Unremarkable except for some submandibular lymph nodes.  His fundi are benign.  NECK:  Supple.  LUNGS:  Clear to auscultation and percussion.  CARDIAC:  Reveals regular rate and rhythm without murmur, rub or gallop.  ABDOMEN:  Soft and nontender without organomegaly or mass.  EXTREMITIES:  Show no cyanosis, clubbing or edema.  GU:  Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions.,IMPRESSION:,1.  Human immunodeficiency virus disease with stable control on Atripla.,2.  Resolving left gluteal abscess, completing Flagyl.,3.  Diabetes mellitus, currently on oral therapy.,4.  Hypertension.,5.  Depression.,6.  Chronic musculoskeletal pain of unclear etiology.,PLAN: , The patient will continue his current medications.  He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter.  He has been encouraged to keep his appointment with his psychologist.
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DESCRIPTION: Human immunodeficiency virus disease with stable control on Atripla.  Resolving left gluteal abscess, completing Flagyl.  Diabetes mellitus, currently on oral therapy.  Hypertension, depression, and chronic musculoskeletal pain of unclear etiology.

soap / chart / progress notes, human immunodeficiency virus disease, diabetes mellitus, atripla, hiv, depression, musculoskeletal, diabetes, hypertension,

The patient's clinical situation involves multiple chronic conditions, including HIV, diabetes, and hypertension, which individually require ongoing management to prevent complications. The patient's HIV is stable, but the recent history of a gluteal abscess and hospitalization suggests complications can arise. Chronic diseases like diabetes and hypertension, if not well-managed, can lead to severe outcomes. Financial issues impacting treatment adherence add complexity and potential risk. However, the patient's conditions are currently stable with a plan for follow-up. Therefore, while the situation is manageable, it remains high-stakes due to the potential for rapid deterioration if any condition destabilizes.


Medical Specialty: Gastroenterology
Sample Name: Paracentesis

PREOPERATIVE DIAGNOSIS: , Abdominal mass.,POSTOPERATIVE DIAGNOSIS: , Abdominal mass.,PROCEDURE:,  Paracentesis.,DESCRIPTION OF PROCEDURE:  ,This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation.  At the present time, the patient is under radiation treatment.  Two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.  We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days.  The cytology of the fluid was negative and the culture was also negative.  Eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis.,The CAT scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size.  Therefore, I called the patient home and she came to the emergency department where the service was provided.  At that time, I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion.  Unfortunately, the catheter was open.  I did not have a drainage system at that time.  So, I withdrew directly with a syringe 700 mL of clear fluid.  The system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment.  She was given an appointment to see me in the office next Monday, which is three days from now.
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DESCRIPTION: Paracentesis.  A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.

gastroenterology, abdominal mass, clear fluid, cat scan, pigtail catheter, paracentesis,

This situation involves a medical procedure for a patient with a significant medical history, including stage II endometrial carcinoma and ongoing radiation treatment. Paracentesis is being performed due to a large abdominal mass and fluid accumulation, requiring careful monitoring and follow-up. While the patient's life is not immediately at risk, improper management could lead to complications, making it a moderately high-stakes scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization

EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  The right groin was prepped and draped in the usual sterile fashion.  After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein.  Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg.  The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg.  The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg.  The pulmonary arterial pressures were noted to be 31/14/21 mmHg.  Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter.  We were unable to cannulate the right coronary artery.  Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  Following this, the catheters were removed.  Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device.  The patient tolerated the procedure well.  There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  The left ventricle appears to be normal sized.  The aortic valve is heavily calcified.  The estimated ejection fraction is approximately 60%.  There was 4+ mitral regurgitation noted.  The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1.  Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.
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DESCRIPTION: Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.

cardiovascular / pulmonary, heart catheterization, cineangiography, selective coronary angiography, thermodilution technique, transducer, diffuse luminal irregularities, cardiac catheterization, luminal irregularities, aortic valve, coronary artery, artery, catheterization, regurgitation, angiography, thermodilution, coronary,

The situation involves a cardiac catheterization procedure, which is a moderately invasive diagnostic procedure generally used to examine how well the heart is working. It is used to diagnose and assess the severity of cardiovascular diseases. The patient in this situation has severe aortic stenosis and moderate-to-severe coronary artery disease, which are serious conditions that generally require swift medical attention to prevent further complications such as heart failure or myocardial infarction. The lack of complications during the procedure is a positive aspect, but the findings necessitate further consultations and potentially significant interventions, like valve replacement or repair. These factors contribute to it being a higher-stakes medical situation, though not at the utmost level, since the procedure was completed without immediate complications and there is a clear plan for further action.


Medical Specialty: Nephrology
Sample Name: AV Fistula - 3

TITLE OF PROCEDURE,Creation of AV fistula, left wrist in the anatomic snuffbox.,PREOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease, need for chronic access.,INDICATION OF THE PROCEDURE,This 74-year-old lady was referred by Dr. P for placement of an AV fistula.  She has been on dialysis since December 2006 by a PermCath placed in her right internal jugular vein.  She undergoes dialysis on Monday, Wednesday, and Friday at DaVita in Alameda and is under the care of Dr. P.  She underwent coronary bypass surgery in 2000 and her cardiologist is Dr. T.  She lives with her husband and she also has a son at home and she is a very active lady.  She is right handed.  The plan was to place an AV fistula at the left wrist.  The risks and benefits were fully explained to her.  She elected to proceed as planned.,PROCEDURE IN DETAIL,In the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically.  Lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist.  The cephalic vein was exposed.  The superficial branch of the radial artery was carefully protected and the radial artery was exposed.  There was moderate calcification of the radial artery.,The patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 Prolene suture.  There was an excellent Doppler signal in the cephalic vein all the way up the arm upon completion.,The wound was closed using absorbable suture and she was transferred to Recovery.  There were no complications.
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DESCRIPTION: Creation of AV fistula, left wrist in the anatomic snuffbox.

nephrology, av fistula, end-stage renal disease, permcath, chronic access, jugular vein, monitored anesthesia, monitored anesthesia care, prepped and draped, snuffbox, superficial branch, creation of av fistula, cephalic vein, radial artery, radial, artery, fistula

The situation involves a medical procedure for creating an arteriovenous (AV) fistula in a 74-year-old patient with end-stage renal disease. The creation of an AV fistula is necessary for the patient's dialysis treatment, which is critical to managing their condition. While the procedure is routine for nephrologists, it carries significant implications for the patient's long-term health and quality of life, making it high-stakes. The absence of complications in the report lends confidence to the procedure's success but does not diminish the stakes involved, given the patient's reliance on dialysis.


Medical Specialty: Nephrology
Sample Name: Shockwave Lithotripsy

PREOPERATIVE DIAGNOSIS:,  Right renal stone.,POSTOPERATIVE DIAGNOSIS:  ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:,  Minimal.  The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presented with right renal stone and right UPJ stone.  The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney.  The plan was for shockwave lithotripsy.  The patient had duplicated system on the right side.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed.  Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed.  The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the supine position.  Using Dornier lithotriptor total of 2500 shocks were applied.  Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up.  The shocks were started at 60 per minute and slowly increased up to 90 per minute.  The patient's heart rate and blood pressure were stable throughout the entire procedure.,After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion and cystoscopy was done.  Using graspers, the stent was grasped x2 and pulled out, both stents were removed.  The patient tolerated the procedure well.  The patient was brought to recovery in stable condition.  The plan was for the patient to follow up with us and plan for KUB in about two to three months.
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DESCRIPTION: Right shockwave lithotripsy, cystoscopy, and stent removal x2.

nephrology, renal stone, stent removal, upj stone, shockwave lithotripsy, cystoscopy, stent, renal, shocks, upj, shockwave, lithotripsy, stone

Shockwave lithotripsy is a common and generally low-risk procedure used to break down kidney stones non-invasively using shock waves. The procedure described appears to have gone smoothly with the patient remaining stable throughout. While any medical procedure carries some risk, the stakes here are relatively low because it is a routine procedure with low complication rates, and the patient's vital signs remained stable. Post-operative monitoring and follow-ups are usual protocol. The reference to risks and alternatives suggests that the patient was well-informed and consented to the procedure after considering other options. Overall, the situation doesn't involve immediate life-threatening conditions or major surgical interventions.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 54

HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.  The patient has a long history of psychological disorders.  As per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in ABC Medical Center.  The patient was evaluated in the emergency room.  The initial cardiac workup was negative.  The patient was admitted to telemetry unit for further evaluation.  In the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine.  The patient's EKG in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.,PAST MEDICAL HISTORY: , As mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, CHF, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer.  None of the details of these are available.,PAST SURGICAL HISTORY: , Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.,CURRENT MEDICATIONS AT HOME: , Included Dilantin 400 mg daily, Klonopin 2 mg 3 times a day, Elavil 300 mg at night, nitroglycerin sublingual p.r.n., Thorazine 300 mg 3 times a day, Neurontin 800 mg 4 times a day, and Phenergan 25 mg as tolerated.,OB HISTORY: , Her last menstrual period was 6/3/2009.  The patient is admitting to having a recent abortion done.  She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,She lives with her boyfriend.  The patient has history of tobacco abuse as well as multiple illicit drug abuse.,REVIEW OF SYSTEMS:  As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is alert, awake, and oriented.,VITAL SIGNS:  Her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.,HEENT:  Shows head is atraumatic.  Pupils are round and reactive to light.  Extraocular muscles are intact.  No oropharyngeal lesions noted.,NECK:  Supple, no JV distention, no carotid bruits, and no lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Reveals regular rate and rhythm.,ABDOMEN:  Soft, nontender, nondistended.  Bowel sounds are normally present.,LOWER EXTREMITIES:  Shows no edema.  Distal pulses are 2+.,NEUROLOGICAL:  Grossly nonfocal.,LABORATORY DATA: , The database that is available at this point of time, WBC count is normal, hemoglobin and hematocrit are normal.  Sodium, potassium, chloride, glucose, bicarbonate, BUN and creatinine, and liver function tests are normal.  The patient's 3 sets of cardiac enzymes including troponin-I, CPK-MB, and myoglobulin have been normal.  EKG is normal, sinus rhythm without any acute ST-T wave changes.  As mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana.  The patient also had a head CT done in the emergency room, which was fairly unremarkable.  The patient's beta-hCG level was marginally elevated at about 48.,ASSESSMENT AND EVALUATION:,1.  Chest pains, appear to be completely noncardiac.  The patient does seem to have a psychosomatic component to her chest pain.  There is no evidence of acute coronary syndrome or unstable angina at this point of time.,2.  Possible early pregnancy.  The patient's case was discussed with OB/GYN on-call over the phone.  Some of the medications have to be held secondary to potential danger.  The patient will follow up on an outpatient basis with her primary OB/GYN as well as PCP for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.,3.  Migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control.  Again, this is an outpatient diagnosis.  The patient will follow up with her PCP for control of migraine headache.,Overall prognosis is too soon to predict.,The plan is to discharge the patient home secondary to no evidence of acute coronary syndrome.
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DESCRIPTION: The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.   The patient has a long history of psychological disorders.

The situation described involves a patient with a complex medical history, including psychological disorders, potential substance abuse, and a suspected non-cardiac chest pain episode triggered by emotional stress. While there are some medical concerns such as a positive toxicology screen and the possible complications of early pregnancy, the overall assessment by the healthcare team is that there is no immediate evidence of an acute coronary syndrome or other high-stakes conditions requiring urgent intervention. The patient is being discharged for outpatient follow-up, indicating that the immediate situation is manageable and not life-threatening.


Medical Specialty: Neurology
Sample Name: Arm Pain - Neuro Consult

HISTORY OF PRESENT ILLNESS:  ,The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain.  He states that a little less than a year ago he developed pain in his right arm.  It is intermittent, but has persisted since that time.  He describes that he experiences a dull pain in his upper outer arm.  It occurs on a daily basis.  He also experiences an achy sensation in his right hand radiating to the fingers.  There is no numbness or paresthesias in the hand or arm.,He has had a 30-year history of neck pain.  He sought medical attention for this problem in 2006, when he developed ear pain.  This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes.  He was then referred to Dr. X for treatment of neck pain.  He has been receiving epidural injections under the care of Dr. X since 2007.  When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain.  He also has taken several Medrol dose packs, which has caused his blood sugars to increase.  He is taking multiple other pain medications.  The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,PAST MEDICAL HISTORY: , He has had diabetes since 2003.  He also has asthma, hypertension, and hypercholesterolemia.,CURRENT MEDICATIONS: , He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral.  He also uses Lidoderm patches and multiple eye drops and creams.,ALLERGIES:,  He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.,FAMILY HISTORY:,  His father died from breast cancer.  He also had diabetes.  He has a strong family history of diabetes.  His mother is 89.  He has a sister with diabetes.  He is unaware of any family members with neurological disorders.,SOCIAL HISTORY:,  He lives alone.  He works full time in Human Resources for the State of Maryland.  He previously was an alcoholic, but quit in 1984.  He also quit smoking cigarettes in 1984, after 16 years of smoking.  He has a history of illicit drug use, but denies IV drug use.  He denies any HIV risk factors and states that his last HIV test was over two years ago.,REVIEW OF SYSTEMS: , He has intermittent chest discomfort.  He has chronic tinnitus.  He has urinary dribbling.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  HR 72. RR 16.,General Appearance:  Patient is well appearing, in no acute distress.,Cardiovascular:  There is a regular rhythm without murmurs, gallops, or rubs.  There are no carotid bruits.,Chest:  The lungs are clear to auscultation bilaterally.,Skin:  There are no rashes or lesions.,NEUROLOGICAL EXAMINATION:,Mental Status:  Speech is fluent without dysarthria or aphasia.  The patient is alert and oriented to name, place, and date.  Attention, concentration, registration, recall, and fund of knowledge are all intact.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Optic discs are normal.  Visual fields are full.  Extraocular movements are intact without nystagmus.  Facial sensation is normal.  There is no facial, jaw, palate, or tongue weakness.  Hearing is grossly intact.  Shoulder shrug is full.,Motor:  There is normal muscle bulk and tone.  There is no atrophy or fasciculations.  There is no action or percussion myotonia or paramyotonia.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,Sensory:  Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense.  Romberg is absent.,Coordination:  There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,Deep Tendon Reflexes:  Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles.  Plantar reflexes are flexor.  There are no finger flexors, Hoffman's sign, or jaw jerk.,Gait and Stance:  Casual gait is normal.  Heel, toe, and tandem walking are all normal.,RADIOLOGIC DATA:,  MRI of the cervical spine, 05/19/08:  I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.,IMPRESSION:  ,The patient is a 58-year-old gentleman with one-year history of right arm pain.  He also has a longstanding history of neck pain.  His neurological examination is normal.  He has an MRI that shows some degenerative changes.  I do believe that his symptoms are probably referable to his neck.  However, I do not think that they are severe enough for him to undergo surgery at this point in time.  Perhaps another course of physical therapy may be helpful for him.  I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal.  We could still try to treat him with neuropathic pain medications.,RECOMMENDATIONS:,1.  I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.,2.  I gave him a prescription for Neurontin.  I discussed the side effects of the medication with him.,3.  We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations.
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DESCRIPTION: Patient experiences a dull pain in his upper outer arm.  It occurs on a daily basis.  He also experiences an achy sensation in his right hand radiating to the fingers.  There is no numbness or paresthesias in the hand or arm.

The situation involves a patient with chronic right arm and neck pain, likely caused by degenerative changes in the cervical spine. While the patient experiences daily discomfort, the severity of the symptoms is not high enough to require surgical intervention at this time, as per the neurologist's assessment. Further diagnostic tests (EMG and nerve conduction studies) are scheduled to assess for nerve damage, but their results are anticipated not to suggest significant nerve damage. The recommendation includes treatment with pharmacological management and possibly physical therapy. Since the patient's condition does not currently involve serious or life-threatening complications or impair significant daily functions, the stakes are not extremely high.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation - 6

PROCEDURE: , Phacoemulsification with posterior chamber intraocular lens insertion.,INTRAOCULAR LENS: , Allergan Medical Optics model S140MB XXX diopter chamber lens.,PHACO TIME:,  Not known.,ANESTHESIA: , Retrobulbar block with local minimal anesthesia care.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:,  None.,DESCRIPTION OF PROCEDURE: , While the patient was in the holding area, the operative eye was dilated with four sets of drops.  The drops consisted of Cyclogyl 1%, Acular, and Neo-Synephrine 2.5 %.  Additionally, a peripheral IV was established by the anesthesia team.  Once the eye was dilated, the patient was wheeled to the operating suite.,Inside the operating suite, central monitoring lines were established.  Through the peripheral IV, the patient received intravenous sedation consisting of Propofol and once somnolent from this, retrobulbar block was administered consisting of 2 cc's of 2% Xylocaine  plain with 150 units of Wydase.  The block was administered in a retrobulbar fashion using an Atkinson needle and a good block was obtained.  Digital pressure was applied for approximately five minutes.,The patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery.  A Betadine prep was carried out of the face, lids, and eye.  During the draping process, care was taken to isolate the lashes.  A wire lid speculum was inserted to maintain patency of the lids.  With benefit of the operating microscope, a diamond blade was used to place a groove temporally.  A paracentesis wound was also placed temporally using the same blade.  Viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2.8 mm. diamond keratome was used to enter the anterior chamber through the previously placed groove.  The cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty.  The capsular remnant was withdrawn from the eye using long angled McPherson forceps.  Balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed.  The lens was noted to rotate freely within the capsular bag.  The phaco instrument was then inserted into the eye using the Kelman tip.  The lens nucleus was grooved and broken into two halves.  One of the halves was in turn broken into quarters.  Each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification.  Attention was then turned toward the remaining half of the nucleus and this, in turn, was removed as well, with the splitting maneuver.  Once the nucleus had been removed from the eye, the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections.  Once the cortical material had been completely removed, a diamond dusted cannula was inserted into the eye and the posterior capsule was polished.  Viscoelastic was again instilled into the capsular bag as well as the anterior chamber.  The wound was enlarged slightly using the diamond keratome.  The above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps.  Once inside the eye, the lens was unfolded into the capsular bag in a single maneuver.  It was noted to be centered nicely.  The viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine.,Next, Miostat was instilled into the operative eye and the wound was checked for water tightness.  It was found to be such.  After removing the drapes and speculum, TobraDex drops were instilled into the operative eye and a gauze patch and Fox protective shield were placed over the eye.,The patient tolerated the procedure extremely well and was taken to the recovery area in good condition.  The patient is scheduled to be seen in follow-up in the office tomorrow, but should any complications arise this evening, the patient is to contact me immediately.
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DESCRIPTION: Phacoemulsification with posterior chamber intraocular lens insertion.

ophthalmology, diopter, intraocular lens insertio, phacoemulsification, posterior chamber, diamond keratome, anterior chamber, capsular bag, intraocular lens, intraocular, allergan, eye, capsular, chamber, lens,

Phacoemulsification with lens implantation is a common ophthalmological procedure with a generally low risk of complications when performed by experienced surgeons. However, it still involves surgical manipulation, anesthesia, and potential for complications, thus some level of risk exists. Any surgery inherently involves stakes such as patient consent, potential complications, and recovery. Here, the procedure was completed successfully without complications, which decreases the stakes significantly. Additionally, there are measures in place for post-operative monitoring. While this is routine for ophthalmologists, it's important to recognize the high skill level required and the potential impact on the patient's vision if errors occur.


Medical Specialty: Consult - History and Phy.
Sample Name: Hand Pain - Consult

REASON FOR VISIT:  ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation.  He complained of ulnar-sided right hand pain and was seen in the emergency room.  Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room.  Today, he admits that his pain is much better.  Currently, since that time he has been in the splint with minimal pain.  He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY:  ,The patient is a nonsmoker and does not use illegal drugs.  Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand.  He has a normal cascade.  He has 70 degrees of MCP flexion and full IP flexion and extension.  He has 3 to 5 strength in his grip and intrinsics.  He has intact sensation to light touch in the radial, ulnar, and median nerve distribution.  Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand.  They show possible small fractures of the base of the fourth and third metacarpals.  Joint appears to be located.  A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals.  His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus.  I would like him to wear this for 2 weeks and then follow up with us.  At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist.  We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast.
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DESCRIPTION: New patient visit for right hand pain.  Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room.

consult - history and phy., hand pain, pain, hand, metacarpals

The current situation involves a new patient with right hand pain resulting from trauma after punching a wall. The condition involves small fractures and dislocations, which require a short-arm cast and follow-up but does not currently present with alarming symptoms like severe pain or nerve damage. While any fracture or dislocation can potentially lead to complications if not properly treated, the situation is typically managed with orthopedic follow-up and does not immediately threaten life or limb. Therefore, while important to address, it is not considered high-stakes in the medical field.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 35

Chief Complaint:, Confusion and hallucinations.,History of Present Illness:, The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment.,Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices "told him to do good things". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned.,The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved.,Past Medical History:, None. No history of hypertension or of cardiac, renal, lung, or liver disease.,Past Surgical History:, None,Past Psychological History: None,Social History:, The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was "very stressful". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind.,Family History:, The patient had a second-degree relative with a history of depression and "nervous breakdown".,Allergies:, There were no known drug allergies.,Medications:, Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines.,Physical Examination:, The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute.,HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.,NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly.,LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi.,HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB, no rubs or gallops, PMI nondisplaced, hyperdynamic precordium.,ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits.,EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses.,GENITOURINARY: Normal male phallus, no testicular masses.,RECTAL: Guaiac negative, no masses.,LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions.,SKIN: Acneiform eruption over back and trunk, no papules or vesicles.,NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative.,PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone.,Hospital Course:, The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed:,Twelve-lead EKG: sinus tachycardia.,CXR (PA/lat): normal cardiac silhouette and normal lung fields.,CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage.,Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative.,MRI with gadolinium: no discrete areas of abnormal signal intensity.,EEG: no focal or epileptiform activity.,The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed.
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DESCRIPTION: Patient with confusion and hallucinations.

The situation involves a 27-year-old patient with acute confusion and hallucinations, significant changes in mental status, and potential cardiovascular symptoms, including high blood pressure and a systolic murmur. This suggests a potentially serious underlying condition that may require urgent diagnosis and treatment. Furthermore, the psychiatric symptoms like hallucinations and paranoia significantly impact the patient’s safety and ability to function. These factors together indicate a situation with potentially severe health consequences, making it high-stakes.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - Open

PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE:  ,Open carpal tunnel release.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the skin was repaired with 4-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Carpal tunnel syndrome.  Open carpal tunnel release.  A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.

orthopedic, carpal ligament, carpal tunnel release, carpal tunnel syndrome, transverse carpal ligament, transverse, ligament, hemostat, tunnel, incision

The procedure described is an open carpal tunnel release, which is a common surgical treatment for carpal tunnel syndrome. This is a routine procedure with a low risk of complications, and the report confirms that no complications occurred. The stakes in terms of risk and potential harm are relatively low compared to more complex surgeries that could affect vital organs or have life-threatening consequences.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 3

CHIEF COMPLAINT:, Blood-borne pathogen exposure., ,HISTORY OF PRESENT ILLNESS: ,The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam., ,REVIEW OF SYSTEMS: ,The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat. There was no chest pain or troubled breathing. He did have abdominal symptoms as described above but no abdominal pain. There were no urinary symptoms. No darkening of the skin or eyes. He had no yellowing or darkening of the urine. He had no rash to the skin. There was no local infection at the side of the fingerstick. All other systems were negative., ,PAST MEDICAL HISTORY: ,Significant for degenerative disc disease in the back., ,MEDICATIONS: ,Nexium., ,ALLERGIES:, IV contrast., ,CURRENT WORK STATUS:, He continues on full duty work., ,PHYSICAL EXAMINATION:, The patient was awake and alert. He was seated upright. He did not appear ill or toxic, and was well hydrated. His temperature was 97.2 degrees, pulse was 84, respirations 14 and unlabored, and blood pressure 102/70. HEENT exam, the sclerae were clear. Ocular movements were full and intact. His oropharynx was clear. There was no pharyngeal erythema. No tonsillar enlargement. His neck was supple and nontender. He had no masses. There was no adenopathy in his cervical or axillary chain. Breath sounds were clear and equal without wheeze or rales. Heart tones were regular without murmur or gallop. His abdomen was soft, flat, and nontender. There was no enlargement of the liver or spleen. His extremities were without rash or edema. He had normal gait and balance without ataxia., ,ASSESSMENT: ,The patient presents for evaluation after a contaminated needlestick to the index finger. The source patient was tested and found to be negative for HIV. However, he did test positive for hepatitis C. He was described as a carrier without active disease. The patient has been followed with periodic evaluation including blood testing. He has completed a 3 shot series for hepatitis B and had titers drawn that showed protected antibodies. He also was up-to-date on his immunization including tetanus. The patient has been well during this time except for the onset of a intestinal illness being investigated with some squeakiness and vomiting. He had no other symptoms that were suggestive of acute hepatitis. His abdominal exam was normal. He had no generalized lymphadenopathy and no fever. Blood tests were drawn on 02/07/2005. The results of which were reviewed with the patient. His liver function test was normal at 18. His hepatitis C and HIV, both of which were negative. He had no local signs of infection, and otherwise has been doing well except for his acute intestinal illness as described above., ,IMPRESSION:, Blood-borne pathogen exposure secondary to contaminated needlestick., ,PLAN: ,The patient is now six months out from his injury. He had negative lab studies. There were no physical findings that were suggestive of disease transmission. He was counseled on ways to prevent exposure in the future including use of protective gear including gloves, which he states that he always does. He was counseled that ways to prevent transmission or exposure to intimate contacts., ,WORK STATUS:, He was released to regular work., ,CONDITION: ,He was reassured that no signs of disease transmission had occurred as result of his injury. He therefore was found to be medically stationary without signs of impairment of today's date.
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DESCRIPTION: Examination due to blood-borne pathogen exposure.

The situation involves a healthcare worker who experienced a needlestick injury and potential exposure to a blood-borne pathogen, specifically hepatitis C. The situation is considered moderately high-stakes due to the potential health implications and anxiety surrounding disease transmission, even though the tests showed no active disease and the individual was cleared to return to normal work duties. The psychological impact of such an incident and the potential for future health implications increases the stakes, but the absence of current active disease and the support from the healthcare system mitigate the immediate high-stakes nature. The issue is primarily concerning for the individual involved and involves occupational health protocols, but it is not life-threatening given the current findings.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Repeat C-section

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 weeks.,2.  History of previous cesarean section x2.  The patient desires a repeat section.,3.  Chronic hypertension.,4.  Undesired future fertility.  The patient desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 weeks.,2.  History of previous cesarean section x2.  The patient desires a repeat section.,3.  Chronic hypertension.,4.  Undesired future fertility.  The patient desires permanent sterilization.,PROCEDURE PERFORMED:  ,Repeat cesarean section and bilateral tubal ligation.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  800 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Male infant in cephalic presentation with anteflexed head, Apgars were 2 at 1 minute and 9 at 5 minutes, 9 at 10 minutes, and weight 7 pounds 8 ounces.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 31-year-old gravida 5, para 4 female, who presented to repeat cesarean section at term.  The patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section, additionally she desires permanent fertilization.  The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and the possible need for further surgery and informed consent was obtained.,PROCEDURE NOTE: , The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using the Bovie.  The rectus muscles were dissected in the midline.,The peritoneum was identified and entered using Metzenbaum scissors; this incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction.,Clear fluid was noted.  The infant was subsequently delivered using a Kelly vacuum due to anteflexed head and difficulty in delivering the infant's head without the Kelly.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  The placenta was delivered spontaneously intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  Attention was turned to the right fallopian tube, which was grasped with Babcock clamp using a modified Pomeroy method, a 2 cm of segment of tube ligated x2, transected and specimen was sent to pathology.  Attention was then turned to the left fallopian tube, which was grasped with Babcock clamp again using a modified Pomeroy method, a 2 cm segment of tube was ligated x2 and transected.  Hemostasis was visualized bilaterally.  The uterus was returned to the abdomen, both fallopian tubes were visualized and were noted to be hemostatic.  The uterine incision was reexamined and it was noted to be hemostatic.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl suture, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
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DESCRIPTION: Repeat cesarean section and bilateral tubal ligation.

obstetrics / gynecology, bilateral tubal ligation, permanent sterilization, undesired future fertility, repeat cesarean section, intrauterine pregnancy, mayo scissors, kocher clamps, metzenbaum scissors, fallopian tube, babcock clamp, pomeroy method, rectus muscles, cesarean section, intrauterine, cesarean,

The situation involves a medical procedure, specifically a repeat cesarean section combined with bilateral tubal ligation. While there are inherent risks to any surgical procedure, including potential complications for the mother and newborn, the report indicates the procedure was executed without complications and the patient was stable afterward. The Apgar scores improved rapidly for the infant, and the procedure went as planned with informed consent obtained. Chronic hypertension is noted, adding some risk, but it seems to have been managed appropriately. Therefore, the situation is not extremely high-stakes as it was managed well and had a good outcome.


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

Medical Specialty: Ophthalmology
Sample Name: Bilateral Upper Lid Blepharoplasty

PREOPERATIVE DIAGNOSIS:,  Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction.  The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient.  All questions have been thoroughly answered, and the patient understands the surgery indicated.  She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation.  The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously.  The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen.  The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction.  The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection.  Hemostasis was obtained with a bipolar cautery.  A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right.  The defect in the orbital septum was identified, and herniated orbital fat was exposed.  The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit.  A similar procedure was performed exposing herniated portion of the nasal pocket.  Great care was taken to obtain perfect hemostasis with this maneuver.  A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion.  Careful hemostasis had been obtained on the upper lid areas.  The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact.  There was no diplopia, no ptosis, no ectropion.  Wounds were reexamined for hemostasis, and no hematomas were noted.  Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition.
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DESCRIPTION: Bilateral upper lid blepharoplasty to correct bilateral upper eyelid dermatochalasis.

ophthalmology, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis

The described procedure, bilateral upper lid blepharoplasty, is a common cosmetic surgery aimed at correcting dermatochalasis, which is excess sagging skin on the eyelids. While it involves surgical intervention and requires careful execution to prevent complications, it is generally considered a low-risk, elective procedure. The narrative indicates that the surgery was planned thoroughly with informed consent, performed without any immediate complications, and the patient was discharged in satisfactory condition. Although there are inherent risks with any surgery, this particular case, in the context of medical procedures, does not involve high stakes such as life-threatening conditions or severe complications.


Medical Specialty: Orthopedic
Sample Name: Spinal Manipulation

PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,ANESTHESIA: , Conscious Sedation.,INFORMED CONSENT: , After adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia (MUA).  The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,INDICATION:,  This patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,COMMENTS: , This patient understands the essence of the diagnosis and the reasons for the MUA- The associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient.  Alternatives to the procedure, including the course of the condition without MUA, were discussed.  The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome.  The patient has given both verbal and written informed consent for the listed procedure.,PROCEDURE IN DETAIL: , The patient was draped in the appropriate gowning and accompanied to the operative area.  Following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure.  When the patient and I were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome I desired.,THORACIC SPINE: , With the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine.  The first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure.  With the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand.  The elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure.  The procedure was completed at the level of TI-TI2.  Cavitation was achieved.,LUMBAR SPINE/SACRO-ILIAC JOINTS:,  With the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal.  Linear force was used to increase the hip flexion gradually during this maneuver.  Simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature.  Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver.  The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time).  This was repeated with the opposite lower extremity.  Following this, a Patrick-Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,With the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc.  The lower extremity was then tractioned, and straight caudal and internal rotation was accomplished.  Using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees.  This procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally.  These procedures were then repeated on the opposite lower extremity.,By approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance
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DESCRIPTION: Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.

orthopedic, fibromyositis, myalgia, segmental dysfunction, sacro-iliitis, spinal manipulation under anesthesia, lumbar segmental dysfunction, informed consent, iliac joints, spinal manipulation, sacro iliitis, lower extremity, spinal, mua, cephalad, dysfunction, segmental, lumbar,

The procedure described is a spinal manipulation under anesthesia, which inherently carries certain risks due to the use of anesthesia and the nature of spinal manipulation. Potential complications, such as anesthesia complications, fractures, and vascular accidents, increase the stakes. However, the patient has failed conservative treatments and has consented to this procedure after being informed of the risks and alternatives. While it is a significant medical procedure, it is not life-threatening if performed correctly, assuming all safety measures are in place. Therefore, the stakes are moderate to high due to the potential for serious complications, but it is not an emergency, life-or-death situation.


Medical Specialty: Surgery
Sample Name: Atrioventricular Septal Defect

HISTORY:  ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.  As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries.  He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital.  This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve.  A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve.  The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung.  The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case.  The patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was exchanged over wire.  A 5-French marker pigtail catheter was directed into the main pulmonary artery.  A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle.  Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents.  The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm.  The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter.  The left femoral venous sheath was exchanged over wire for a 7-French sheath.  Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist.  The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram.  The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:  ,Oxygen consumption was assumed to be in normal.  Mixed venous saturation that was not normal with no evidence of intracardiac shunt.  Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg.  Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery.  There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery.  Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg.  Left ventricular systolic pressure was systemic.  No outflow constriction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification.  The proximal narrowing of the distal main pulmonary artery was appreciated.  Neointimal ingrowth within the proximal stents were appreciated.  There is good distal growth of the pulmonary arteries.  Arborization appeared normal.  Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch.  Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation.  Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%.  The main pulmonary pressures remained similar.  There was 10 mmHg systolic gradient into the branch of pulmonary arteries.  There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg.  Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve.  A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens.  There was no evidence of intimal disruption.,DIAGNOSES: ,1.  Atrioventricular septal defect.,2.  Tetralogy of Fallot with the pulmonary atresia.,3.  Bilateral superior vena cava.  The left cava draining to the coronary sinus.,4.  The right aortic arch.,5.  Discontinuous pulmonary arteries.,6.  Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Repair of tetralogy of Fallot with external conduit.,3.  The atrioventricular septal defect repair.,4.  Unifocalization of branch pulmonary arteries.,5.  Bilateral balloon pulmonary angioplasty and stent implantation.,6.  Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES:  ,1.  Mild-to-moderate proximal branch pulmonary stenosis.,2.  Well-functioning Contegra valve and current intervention.  A balloon dilation of the right pulmonary artery.,3.  Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued.  Further cardiologic care be directed by Dr. X.
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DESCRIPTION: The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.

The patient is a young child with Down syndrome and a history of complex congenital heart disease, including atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia. The medical history involves multiple previous surgeries and interventions, indicating a very complex and precarious cardiovascular condition. The procedures and management plan described carry significant risk given the patient's age, condition, and the severity of their cardiac issues. The case is discussed in a multidisciplinary conference indicating high stakes and complexity. Any decision made in such a context could greatly impact the patient's quality of life and survival, making it a high-stakes situation.


Medical Specialty: Neurology
Sample Name: Organic Brain Syndrome

REASON FOR CONSULT:,  Organic brain syndrome in the setting of multiple myeloma.,SOURCE OF HISTORY:  ,The patient himself is not able to give a good history.  History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.  Not a very clear history at this time and the patient himself is not able to give any history despite no family member was present in the room.  Neurology consult was called to evaluate any organic brain syndrome in the setting of multiple myeloma.  The patient since the morning has improved, but still not completely back to the baseline.  Even I evaluated the patient previously, hence not very sure about his baseline.,PAST MEDICAL HISTORY:,  History of IgG subtype multiple myeloma.,SURGICAL HISTORY:,  Nothing significant.,PSYCHIATRIC HISTORY:  ,Nothing significant.,SOCIAL HISTORY:  ,No history of any smoking, alcohol or drug abuse.,ALLERGIES: , CODEINE AND FLAGYL.,IMMUNIZATION HISTORY: , Nothing significant.,FAMILY HISTORY: , Unobtainable.,REVIEW OF SYSTEMS:  ,The patient was considered to ask question for systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy/immunology, endocrinology, toxicology, oncology, and found to be positive for the symptoms mentioned in the history of the presenting illness.  The patient himself is not able to give any history only source is the chart.  For details, please review the chart.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 97/54, heart rate of 97, respiratory rate of 19, and temperature 98.5.  The patient on supplemental oxygen was FiO2 on 2 L 96%.  Limited physical examination.,HEENT:  Head, normocephalic and atraumatic.  Throat clear.  No discharge from the ear and the nose.  No discoloration of conjunctivae and the sclerae.,NECK:  Supple.  No signs of any meningismus.  Though a limited examination, the patient does appear to have arthritic changes, questioning contracture deformities, as not able to follow the commands to show full range of motion.  No bruit auscultated over the neck and the orbits.,LUNGS:  Clear to auscultation.,HEART:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.  No rash.  No leptomeningeal or neurocutaneous disorder.,NEUROLOGIC:  Examination is limited.  Mental state examination, the patient is awake, alert, and oriented to himself, not able follow commands, and give a proper history, and still appeared to be confuse and disoriented.  Cranial nerve examination limited, but apparently nonfocal.  Motor examination is very limited except for the grips, which were strong enough.  I was not able to obtain much.  Deep tendon reflexes were not reliable.  Toes equivocal and downgoing.  Sensory examination is not reliable, though intact for painful stimuli with limited examination.  Coordination could not be tested.  Gait could not be tested.,IMPRESSION:,  History of multiple myeloma and altered mental status in multiple myeloma setting.  Rule out brain metastasis including lepto-meningismus, possible transient ischemic attack related to hyperviscosity syndrome or provoked seizure related to ischemia, and delirium related to any electrolyte imbalance or underlying infarction.,PLAN AND RECOMMENDATIONS: , The patient is to continue with current level of management.  I will review the chart before ordering any further testing that may include a CT scan of the brain, if has not been ordered, EEG, urine test, and the latest CBC with diff. to rule out any urinary tract infection or indication of any other seen of infection.  No other intervention at this time.  The patient may be started on aspirin, if it is okay with Dr. X.
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DESCRIPTION: Organic brain syndrome in the setting of multiple myeloma.  The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.

The situation involves a patient with multiple myeloma experiencing neurological symptoms such as disorientation and confusion, which could potentially indicate serious conditions like brain metastasis, transient ischemic attack, or electrolyte imbalance. This is a high-stakes medical situation as it requires immediate attention and correct diagnosis to manage potential complications effectively. The patient's inability to provide a coherent history adds to the complexity, necessitating urgent and careful evaluation by the healthcare team to avoid severe outcomes.


Medical Specialty: Orthopedic
Sample Name: MRI C-spine

CC:, Left hemibody numbness.,HX:, This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.,MEDS:, none.,PMH:, 1)Bronchitis twice in past year (last 2 months ago).,FHX:, Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.,SHX:, Denies Tobacco/ETOH/illicit drug use.,EXAM:, BP112/76 HR52 RR16 36.8C,MS: unremarkable.,CN: unremarkable.,Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.,Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.,Coord: positive rebound in RUE.,Station/Gait: unremarkable.,Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.,Rectal exam not done.,Gen exam reportedly "normal.",COURSE:, GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.,The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.
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DESCRIPTION: MRI C-spine: C4-5 Transverse Myelitis.

MRI C-spine: C4-5 Transverse Myelitis.

orthopedic, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf,

The situation involves a patient with left hemibody numbness and subsequent neurological symptoms, along with MRI findings indicating transverse myelitis at the C4-6 levels. Transverse myelitis is a serious inflammatory neurological condition that can lead to significant complications, including persistent motor and sensory deficits, and warrants careful monitoring and follow-up. The gradual improvement and resolution of symptoms within a month might reduce immediate urgency, but the condition itself holds high stakes due to potential for recurrence or long-term neurological impact. The patient's failure to return for a scheduled follow-up MRI suggests a lapse in essential medical care, which increases stakes given the need to monitor the disease progression and adjust treatment as necessary.