Medical Specialty: Nephrology
Sample Name: Discharge Summary - Nephrology

ADMITTING DIAGNOSES:,  Left renal cell carcinoma, left renal cyst.,DISCHARGE DIAGNOSIS:,  Left renal cell carcinoma, left renal cyst.,SECONDARY DIAGNOSES:,1.  Chronic obstructive pulmonary disease.,2.  Coronary artery disease.,PROCEDURES: , Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.,HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts.  He has undergone MRI of the abdomen on June 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma.  Of note, there are no other enhancing solid masses seen on this MRI.  After discussion of multiple management strategies with the patient including:,1.  Left partial nephrectomy.,2.  Left radical nephrectomy.,3.  Left renal cyst decortication.  The patient is likely to undergo the latter procedure.,HOSPITAL COURSE:  ,The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy.  Intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed.  The contents were aspirated and careful dissection of the cyst wall was performed.  Multiple specimens of the cyst wall were sent for pathology.  Approximately one liter of cystic fluid was drained during the procedure.  The renal bed was inspected for hemostasis, which appear to be adequate.  There were no complications with the procedure.  Single JP drain was left in place.  Additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra.  Furthermore, no gross lesions were encountered in the bladder.  The patient left OR with transfer to the PACU and subsequently to the hospital floor.,The patient's postoperative course was relatively uneventful.  His diet and activity were gradually advanced without complication.  On postoperative day #2, he was passing flatus and has had bowel movements.  His Jackson-Pratt drain was discontinued on postoperative day #3 that being the day of discharge.  His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly.  At the time of discharge, he was afebrile.  His vital signs indicated hemodynamic stability and he had no evidence of infection.  The patient was instructed to follow up with Dr. XYZ on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative.,DISPOSITION: , To home.,DISCHARGE CONDITION:,  Good.,MEDICATIONS:  ,Please see attached medication list.,INSTRUCTIONS: , The patient was instructed to contact Dr. XYZ's office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns.,FOLLOWUP: , The patient will follow up with Dr. XYZ for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment.
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DESCRIPTION: Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.

nephrology, decortication, cystoscopy, pain, nausea, vomiting, renal cyst decortication, renal cell carcinoma, robotic assisted, renal cyst, renal, robotic, laparoscopic, nephrectomy, cysts, cell, carcinoma, discharge,

The situation described involves a patient with a serious medical condition, specifically left renal cell carcinoma, who has undergone a surgical procedure. While the procedure and subsequent discharge appear to have gone smoothly without complications, any case involving cancer can inherently have high-stakes due to the potential for progression of the disease and the necessity for close monitoring post-surgery. The stakes are not at the critical level since the procedure was successful and the patient is stable upon discharge, but they are still significant due to the nature of the primary diagnosis and the potential implications for the patient's health.


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Medical Specialty: Nephrology
Sample Name: Discharge Summary - Hemodialysis

DISCHARGE DIAGNOSES:,1.  End-stage renal disease, on hemodialysis.,2.  History of T9 vertebral fracture.,3.  Diskitis.,4.  Thrombocytopenia.,5.  Congestive heart failure with ejection fraction of approximately 30%.,6.  Diabetes, type 2.,7.  Protein malnourishment.,8.  History of anemia.,HISTORY AND HOSPITAL COURSE: , The patient is a 77-year-old white male who presented to Hospital of Bossier on April 14, 2008.  The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization.  He also needed to continue with dialysis and he needed to improve his rehabilitation.  The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles.  He did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management.  The patient had remained afebrile.  He did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at Promise.  On the day of discharge, on May 9, 2008, the patient was in good spirits, was very clear and lucid.  He denied any complaints of pain.  He did have some trouble with sleep at night at times, but I think this was mainly tied into the fact that he sleeps a lot during the day.  The patient has increased his appetite some and has been eating some.  His vital signs remain stable.  His blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3.  PPD was negative.  An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise.,The patient and his family understood our plan and agreed with it.  He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him.  He did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge.,
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DESCRIPTION: The patient is being discharged for continued hemodialysis and rehab.

nephrology, end-stage renal disease, thrombocytopenia, anemia, hospitalization, hemodialysis and rehab, hemodialysis

The situation involves the discharge of a patient with multiple serious chronic conditions, including end-stage renal disease requiring hemodialysis, congestive heart failure, and diabetes. While the discharge itself is routine and the patient is in stable condition, the stakes are medium due to the complexity of the patient's medical needs, ongoing care requirements, and potential risks associated with his diagnoses. Ensuring a smooth transition to home care and continued treatment is vital, but it does not involve immediate life-threatening conditions or emergency decisions, which would increase the stakes significantly. The situation is manageable and doesn't involve immediate high-stakes elements, but it's still important to handle the transition carefully.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Nephrology
Sample Name: Excretory Urogram - IVP

There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,
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DESCRIPTION: Common Excretory Urogram - IVP template

Common Excretory Urogram - IVP template

nephrology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The report provided is a standard medical imaging finding indicating a normal intravenous pyelogram (IVP) result. A negative IVP suggests that there are no abnormalities or concerning findings in the urinary tract, kidneys, or bladder. The context is within routine medical diagnostics, with no critical issues identified that would suggest an urgent or high-risk situation. This indicates a low-stakes scenario as the findings are normal and not indicative of any immediate health concerns.


Medical Specialty: Nephrology
Sample Name: Cystoscopy, Ureteropyelogram, & Ureteral Barbotage

PREOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,4.  Extrarenal pelvis on the right.,5.  No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bilateral retrograde ureteropyelograms.,3.  Right ureteral barbotage for urine cytology.,4.  Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS:  ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability.  She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone.  She has some ureteral thickening in her distal right ureter.  She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile.  She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia.  She was placed in the lithotomy position, prepped and draped in the usual sterile fashion.  The 21-French cystoscope was inserted per urethra into the bladder.  The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities.  The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter.  This was gently advanced to the mid ureter.  Urine was collected for cytology.  Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen.  This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter.  An 0.038 guidewire was then passed up through the open-ended ureteral catheter.  The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis.  Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected.  The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level.  There were no intrapelvic or calyceal stones.  The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate.  The ureteroscope was then removed.  The cystoscope was reinserted.  Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system.  No evidence of extravasation or significant change in anatomy was visualized.  The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system.  The cystoscope was removed.  Foley catheter was inserted.  The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.
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DESCRIPTION: Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions.  Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.

nephrology, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine,

The situation involves a medical procedure performed on a patient with right hydronephrosis, right flank pain, and atypical/dysplastic urine cytology. While the procedure described includes diagnostic and therapeutic interventions such as cystoscopy, ureteropyelograms, and ureterorenoscopy, the findings from the procedure indicated no evidence of severe issues such as tumors or obstructions. The stakes are moderate due to potential renal implications and the patient's discomfort and disability. However, the condition does not appear life-threatening based on the information provided, and the procedure was performed under controlled surgical settings with minimal blood loss.


Medical Specialty: Nephrology
Sample Name: Cysto Stent Removal

PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:,  Cysto stent removal.,ANESTHESIA:,  Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose.  The patient was on vancomycin for the last 5 days.,BRIEF HISTORY:  ,The patient is a 53-year-old female who presented with Enterococcus urosepsis.  CT scan showed a lower pole stone with a stent in place.  The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology.  The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone.  There was some pus that came out.  The patient was cultured; actually it was negative at that time.  The patient subsequently was found to have lower extremity DVT and then was started on Coumadin.  The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE.  The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact.  The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers.  The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated.  Due to drug interaction, the patient was admitted for IV antibiotic treatment.  The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed.  Since the stone is not obstructing, there is no reason to replace the stent at this time.  We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated.  So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient.  Risks, benefits, and options were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  The patient understood all the risks and benefits of removing the stent and wanted to proceed.  The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was given some IV pain meds.  The patient had received vancomycin and Levaquin preop.  Cystoscopy was performed using graspers.  The stent was removed without difficulty.  Plan was for repeat cultures and continuation of the IV antibiotics.
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DESCRIPTION: Right lower pole renal stone and possibly infected stent.  Cysto stent removal.

nephrology, infected stent, cysto stent removal, cysto stent, renal stone, lower pole, infected, stone, stent, cysto,

The procedure described involves the removal of a possibly infected stent due to urinary tract infections and previous Enterococcus urosepsis in a patient with a history of complicated medical conditions, including a recent lower extremity DVT and ongoing treatment with Coumadin. While the procedure itself is relatively straightforward and the estimated blood loss is minimal, the stakes are higher due to the patient's complex medical situation, risk of infections, and inability to perform more definitive procedures until anticoagulation can be safely managed. The situation is compounded by the infection risk and previous sepsis, making careful management crucial. Therefore, while not life-threatening if managed correctly, there is a significant level of medical complexity and risk involved.


Medical Specialty: Nephrology
Sample Name: CT Abdomen & Pelvis - 9

CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:,  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS:  ,Postsurgical changes of a left lower quadrant ileostomy are again seen.  There is no evidence for an obstruction.  A partial colectomy and diverting ileostomy is seen within the right lower quadrant.  The previously seen 3.4 cm subcutaneous fluid collection has resolved.  Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  No obstruction is seen.  The appendix is not clearly visualized.  The urinary bladder is unremarkable.,IMPRESSION:,1.  Resolution of the previously seen subcutaneous fluid collection.,2.  Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  These findings may be due to a pelvic abscess.,3.  Right lower quadrant ileostomy has not significantly changed.,4.  Cholelithiasis.
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DESCRIPTION: Generalized abdominal pain with swelling at the site of the ileostomy.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.

nephrology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,

The CT scan results indicate a few noteworthy findings, such as cholelithiasis and a suspected pelvic abscess due to unchanged fluid collection. There is no acute obstruction or other immediately life-threatening findings. However, a potential pelvic abscess is a concern as it may require further medical intervention to prevent complications, such as infection spread or sepsis. The situation is moderate in stakes because while the findings are not immediately life-threatening, they do require clinical attention to prevent serious complications.


Medical Specialty: Nephrology
Sample Name: CT Abdomen & Pelvis - 2

EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast.  Total of 100 mL of Isovue was administered intravenously.  Oral contrast was also administered.,The lung bases are clear.  The liver is enlarged and decreased in attenuation.  There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney.  There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid.  There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum.  These findings are consistent with diverticulitis.  No pneumoperitoneum is identified.  There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis.  Please see report above.
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DESCRIPTION: CT scan of the abdomen and pelvis without and with intravenous contrast.

nephrology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,

The CT scan report indicates findings of diverticulitis, which can be a significant but typically manageable medical condition. While it requires medical attention, it is not an immediately life-threatening condition in the absence of complications such as severe infections or perforations. The report does not suggest any such acute complications, so the situation, while needing medical intervention and monitoring, is not extremely high-stakes.


Medical Specialty: Nephrology
Sample Name: Chronic Kidney Disease Followup

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

nephrology, metabolic bone disease, anemia, polycystic kidney disease, chronic kidney disease, blood pressure, transplant, metabolic, kidney

The situation involves a patient with stage IV chronic kidney disease, a serious and potentially life-threatening condition. This requires careful management to prevent progression to end-stage renal disease. The patient has been resistant to attending educational programs necessary for his treatment options, like dialysis and transplant education, which are critical for his future health and treatment planning. Ensuring proper education and preparation for potential kidney transplant or dialysis is very important. Additionally, he has related health issues such as hypertension, metabolic bone disease, and anemia, which need to be managed carefully. Therefore, the stakes are relatively high because any mismanagement could lead to deterioration of the patient's condition.


Medical Specialty: Nephrology
Sample Name: Chronic Kidney Disease - Followup

REASON FOR VISIT:,  Followup on chronic kidney disease.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old gentleman with stage III chronic kidney disease who on his last visit with me presented with classic anginal symptoms.  He was admitted to hospital and found to have an acute myocardial infarction.  He had a complex hospital course, which resulted in cardiac catheterization and two stents being placed.  His creatinine did pop above up to 3 but then came back to baseline.  His hospital stay was also complicated by urinary retention requiring a catheter and Flomax.  He returns today to re-establish care.  Of note, he was noted to have atrial fibrillation while hospitalized and had massive epistaxis.,ALLERGIES:,  None.,MEDICATIONS: , Starlix 120 mg b.i.d., Compazine b.i.d., aspirin 81 mg daily, Plavix 75 mg daily, glipizide 15 mg b.i.d., multivitamin daily, potassium 10 mEq daily, Cozaar 25 mg daily, Prilosec 20 mg daily, digoxin 0.125 mg every other day, vitamin C 250 mg daily, ferrous sulphate 325 mg b.i.d., metoprolol 6.25 mg daily, Lasix 80 mg b.i.d., Flomax 0.4 mg daily, Zocor 80 mg daily, and Tylenol p.r.n.,PAST MEDICAL HISTORY:,1.  Stage III CKD with baseline creatinine in the 2 range.,2.  Status post MI on May 30, 2006.,3.  Coronary artery disease status post stents of the circumflex.,4.  Congestive heart failure.,5.  Atrial fibrillation.,6.  COPD.,7.  Diabetes.,8.  Anemia.,9.  Massive epistaxis.,REVIEW OF SYSTEMS:,  Cardiovascular:  No chest pain.  He has occasional dyspnea on exertion.  No orthopnea.  No PND.  He has occasional edema of his right leg.  He has been dizzy and his dose of metoprolol has been gradually decreased.  GU:  No hematuria, foamy urine, pyuria, frequency, dysuria, weak stream or dribbling.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Pulse 70.  Blood pressure 114/58.  Weight 79.5 kg.  GENERAL:  He is in no apparent distress.  HEART:  Irregularly irregular.  No murmurs, rubs, or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Soft, nontender, and nondistended.  EXTREMITIES:  Trace edema on the right.,LABORATORY DATA: , Dated 07/05/06, hematocrit is 30.2, platelets 380, sodium 139, potassium 4.9, chloride 100, CO2 28, BUN 38, creatinine 2.2, glucose 226, calcium 9.7, and albumin 3.7.,IMPRESSION:,1.  Stage III chronic kidney disease with return to baseline GFR of 31 mL/min.  He is on an ARB.,2.  Coronary artery disease, status post stenting.,3.  Hypertension.  Blood pressures are on the low side at present.  I hesitate to increase his Cozaar although I would do this if tolerated in the future.,4.  Anemia of renal disease.  He is to start Aranesp.,5.  ? Atrial fibrillation.  We discussed anticoagulation issues involved with chronic Afib.  He may be popping in and out or this could just be a sinus arrhythmia.,PLAN:,1.  Check EKG.,2.  Start Aranesp 60 mcg every two weeks.,3.  Otherwise see him in four months.,4.  If EKG shows atrial fibrillation, I wanted to talk to Dr. XYZ about Coumadin.
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DESCRIPTION: Followup on chronic kidney disease.

Followup on chronic kidney disease.

The patient has multiple chronic and acute medical conditions, including chronic kidney disease, a recent myocardial infarction, and other significant cardiovascular issues like atrial fibrillation and coronary artery disease. The presence of these complex, interrelated health issues raises the stakes due to the potential for rapid deterioration or complications. Furthermore, the management of these conditions involves careful monitoring and medication adjustments, indicating significant potential consequences for the patient's health if not properly addressed.


Medical Specialty: Nephrology
Sample Name: Chronic Kidney Disease - Consult

HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments.  He was last seen in this clinic on 05/29/2007 by Dr. X.  This is the first time that I have met the patient.  The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication.  He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year.  He had a baseline creatinine during that time of between 3.2 to 3.3.  When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen.  Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic.  He is currently on three-drug antiretroviral therapy.  His last CD4 count in 03/2008 was 350.  He has had no HIV complications since he was last seen in our clinic.  The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year.  The patient has an AV fistula that was placed in late 2006.  The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9.  These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation.  The only complaint that the patient has at this time is some difficulty sleeping.  He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping.  He says that he has trouble getting to sleep.  The Ambien will allow him to sleep for about two hours, and then he is awake again.  He is tired during the day, but is not taking any daytime naps.  He has no history of excessive snoring or apneic periods.  He has no history of falling asleep at work or while driving.  He has never had a formal sleep study.  He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS:  ,He denies any change in his appetite.  He has actually gained some weight in recent months.  He denies any nausea, vomiting, or abdominal discomfort.  He denies any pruritus.  He denies any lower extremity edema.  All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1.  Stage IV chronic kidney disease with most recent GFR of 22.,2.  HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3.  Hyperlipidemia.,4.  Hypertension.,5.  Secondary hyperparathyroidism.,6.  Status post right upper extremity AV fistula in the fall of 2006.,7.  History of a right brachial plexus palsy.,8.  Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:,  HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1.  Kaletra daily.,2.  Epivir one daily.,3.  Ziagen two daily.,4.  Lasix 20 mg b.i.d.,5.  Valsartan 20 mg b.i.d.,6.  Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD.  He is employed at the sales counter of a local butcher shop.  He continues to smoke one pack of cigarettes daily, as he has for the past 28 years.  He denies any alcohol or illicit substances.,FAMILY HISTORY:,  His mother is deceased.  He said that she had some type of paralysis before she died.  His father is deceased at age 64 of a head and neck cancer.  He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy.  He has a 41-year-old brother who has hypertension.  He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 191 pounds.  His temperature is 97.1.  Pulse is 94.  Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT:  His oropharynx is clear without thrush or ulceration.,NECK:  Supple without lymphadenopathy or thyromegaly.,HEART:  Regular with normal S1 and S2.  There are no murmurs, rubs, or gallops.  He has no JVD.,LUNGS:  Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN:  Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL:  He has difficulty with abduction of his right shoulder.,ACCESS:  He has a right forearm AV fistula with an audible bruit and a palpable thrill.  There is no sign of stenosis.  The vascular access looks like it is ready to use.,EXTREMITIES:  No peripheral edema.,SKIN:  No bruises, petechiae, or rash.,LABS:  ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18.  BUN is 49, creatinine 4.3.  GFR is 19.  Albumin 3.2.  Protein 7.  AST 17, ALT 16, alkaline phosphatase 106.  Total bilirubin 0.4.  Calcium 9.1., phosphorus 4.7, PTH of 448.  The corrected calcium was 9.7.  WBC is 8.9, hemoglobin 13.4, platelet 226.  Total cholesterol 234, triglycerides 140, LDL 159, HDL 47.  His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION:  ,This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.,RECOMMENDATIONS:,1.  Renal.  His serum creatinine is progressively worsening.  His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3.  This represents a GFR of 19.  This is stage IV chronic kidney disease.  He does have vascular access and this appears to be ready to use.  He is having some difficulty sleeping and it is possible that this represents some early signs of uremia.  Otherwise, he has no signs or symptoms of uremia at this time.  I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes.  He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes.  I have encouraged him to continue to exercise his right forearm.  I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant.  Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2.  Hypertension.  I have added labetolol 100 mg b.i.d. to his antihypertensive regimen.  He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased.  Goal blood pressure would be less than 130/80.,3.  Hyperkalemia.  I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily.  I will have him return in one week to recheck his potassium.  If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4.  Bone metabolism.  His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals.  His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5.  Acid base.  His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6.  Anemia.  His hemoglobin is at goal for this stage of chronic kidney disease.  His iron stores are adequate.
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DESCRIPTION: This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.

This situation involves a patient with stage IV chronic kidney disease, potentially approaching the need for dialysis, combined with a lack of compliance with previous medical appointments and complex co-morbidities including HIV. Managing such a patient is high-stakes because it involves monitoring and adapting treatment to prevent further deterioration of kidney function, potential life-threatening symptoms like hyperkalemia, and coordinating care across multiple specialties. The progression towards dialysis or the potential need for a transplant adds to the urgency and seriousness. This makes the stakes quite high, as the patient's health decisions will significantly impact his quality of life and longevity.


Medical Specialty: Nephrology
Sample Name: AV Fistula - 5

PREOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell.  He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy.  This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula.  All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given.  This was done under monitored anesthesia care.  He was prepped and draped in the usual sterile fashion.  He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery.  Incision was deepened down through the subcutaneous fascia.  The vein was identified, dissected for a good length, and then the artery was identified and dissected.  Heparin 5000 units was given.  The artery clamped proximally and distally, opened up in the middle.  It was found to have Monckeberg's arteriosclerosis of a moderate intensity.  The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down.  Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.
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DESCRIPTION: Left forearm arteriovenous fistula between cephalic vein and radial artery.

nephrology, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic

The situation involves a surgical procedure, specifically the creation of an arteriovenous fistula for dialysis access in a patient with end-stage renal disease and ischemic cardiomyopathy. These medical conditions are serious and life-threatening, requiring surgical intervention to manage the patient's chronic kidney disease. The procedure itself, although common for patients needing dialysis, carries inherent risks such as bleeding, infection, or failure of the fistula. Additionally, the patient's existing comorbidities, such as severe heart disease indicated by a low ejection fraction, increase the stakes. The success of the procedure is crucial for the patient's ongoing dialysis and overall treatment plan.


Medical Specialty: Nephrology
Sample Name: Basilic Vein Transposition

PREOPERATIVE DIAGNOSIS:,  End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,FINDINGS:,  Excellent flow through fistula following the procedure.,STATEMENT OF MEDICAL NECESSITY:  ,The patient is a 68-year-old black female who recently underwent a brachiobasilic AV fistula, but without transposition.  She has good flow, excellent physical exam, and now is ready for superficialization of the basilic vein.  After discussing the risks and benefits of the procedure with the patient preoperatively, the patient voiced understanding and signed informed consent.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room, placed supine on the operating table.  After adequate general endotracheal anesthesia was obtained, the right arm was circumferentially prepped and draped in a standard sterile fashion.  A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife.  The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues.  This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion.  Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection.  The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein.  There was noted to be excellent flow through the vein.  A pocket was then created just lateral to the incision in the subcutaneous tissue.  The vein was then placed into this pocket securing with multiple interrupted 3-0 Vicryl sutures.  The bed of dissection of the basilic vein was then treated with fibrin sealant.  The subcutaneous tissue was then reapproximated with 3-0 Vicryl sutures in interrupted fashion.  The skin was closed using 4-0 Monocryl suture for a subcuticular stitch.  Dermabond was applied to the incision.  Again, there was noted to be good palpable thrill throughout the superficialized vein.  The patient was then awakened, and taken to the recovery room in stable condition.
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DESCRIPTION: Right basilic vein transposition.  End-stage renal disease with need for a long-term hemodialysis access.  Excellent flow through fistula following the procedure.

nephrology, end-stage renal disease, hemodialysis, av fistula, brachiobasilic, basilic vein transposition, hemodialysis access, vein, basilic,

The situation involves a surgical procedure to create a long-term hemodialysis access for a patient with end-stage renal disease (ESRD). Hemodialysis is crucial for ESRD patients and their survival depends on effective access for dialysis. The procedure, basilic vein transposition, although standard, is critically important as it directly impacts the patient's ability to receive life-sustaining treatment. However, given the routine nature and minimal complications reported, the procedure is not at the highest end of the risk spectrum but is still vital.


Medical Specialty: Nephrology
Sample Name: Acute Kidney Failure

REASON FOR VISIT: , Acute kidney failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old Korean gentleman with a history of coronary artery disease, hypertension, diabetes and stage III CKD with a creatinine of 1.8 in May 2006 corresponding with the GFR of 40-41 mL/min.  The patient had blood work done at Dr. XYZ's office on June 01, 2006, which revealed an elevation in his creatinine up to 2.3.  He was asked to come in to see a nephrologist for further evaluation.  I am therefore asked by Dr. XYZ to see this patient in consultation for evaluation of acute on chronic kidney failure.  The patient states that he was actually taking up to 12 to 13 pills of Chinese herbs and dietary supplements for the past year.  He only stopped about two or three weeks ago.  He also states that TriCor was added about one or two months ago but he is not sure of the date.  He has not had an ultrasound but has been diagnosed with prostatic hypertrophy by his primary care doctor and placed on Flomax.  He states that his urinary dribbling and weak stream had not improved since doing this.  For the past couple of weeks, he has had dizziness in the morning.  This is then associated with low glucose.  However the patient's blood glucose this morning was 123 and he still was dizzy.  This was worse on standing.  He states that he has been checking his blood pressure regularly at home because he has felt so bad and that he has gotten under 100/60 on several occasions.  His pulses remained in the 60s.,ALLERGIES: , None.,MEDICATIONS: , Imdur 20 mg two to three times daily, nitroglycerin p.r.n., insulin 70/30 40/45 units daily, Zetia 10 mg daily, ? Triglide 50 mg daily, Prevacid 30 mg daily, Plavix 75 mg daily, potassium 10 mEq daily, Lasix 60 mg daily, folate 1 mg b.i.d., Niaspan 500 mg daily, atenolol 50 mg daily, enalapril 10 mg b.i.d., glyburide 10 mg b.i.d., Xanax 0.25 mg b.i.d., aspirin 325 mg daily, Tylenol p.r.n., Zantac 150 mg b.i.d., Crestor 5 mg daily, TriCor 145 mg daily, Digitek 0.125 mg daily, Celexa 20 mg daily, and Flomax 0.4 mg daily.,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post CABG x 5 in December 2001.,2.  Three stents last placed approximately 2002.,3.  Heart failure, ejection fraction of 30%.,4.  Hypertension since 1985.,5.  Diabetes since 1985 with history of laser surgery.,6.  Moderate mitral regurgitation.,7.  GI bleed.,8.  Hyperlipidemia.,9.  BPH.,10.  Back surgery.,11.  Sleep apnea.,SOCIAL HISTORY: , He is a former tailor from Korea.  He is divorced.  He has one daughter who has brain injury status post severe seizure as a child.  He is the primary caregiver.  No drug abuse.  He quit tobacco and alcohol 15 years ago.,FAMILY HISTORY: , Parents both died in Korea.  Has one sister with hypertension and the other sister lives in Detroit and is healthy.,REVIEW OF SYSTEMS: , He has lost about 10 pounds over the past month.  He has been fatigue and weak with no appetite.  He has occasional chest pain and dyspnea on exertion on fast walking.  His lower extremity edema has improved with higher doses of furosemide.  He does complain of some early satiety.  He complains of urinary frequency, nocturia, weak stream and dribbling.  He has never passed the stone.  He gets dizzy when his blood sugars are in the 40s to 60s but now this is continuing with him running, glucose is in the 120s.  He has some right back pain today and complains of farsightedness.  The remainder of review of systems is done and negative per the patient.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Pulse 78.  Blood pressure 116/60.  Height 5'7" per the patient.  Weight 78.6 kg.  Supine pulse 60 with blood pressure 128/55.  Standing pulse 60 with blood pressure of 132/50.  GENERAL:  He is in no apparent distress, but he is dizzy on standing for prolonged period.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements are intact.  Sclerae not icteric.  HEENT:  He wears upper and lower dentures.  Lips acyanotic.  Hearing is grossly intact.  Oropharynx is otherwise clear.  NECK:  Supple.  No JVD.  No bruits.  No masses.  HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Active bowel sounds.  Soft, nontender, and nondistended.  No suprapubic tenderness.  EXTREMITIES:  No clubbing, cyanosis or edema.  MUSCULOSKELETAL:  5/5 strength bilaterally.  No synovitis, arthritis or gait disturbance.  SKIN:  Old scars in his low back as well as his left lower extremity.  No active rashes, purpura or petechiae.  Midline sternotomy scar is well healed.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Reflexes are poor to 1+ bilaterally.  10 g monofilament sensation is intact except for the big toes bilaterally.  No asterixis.  Finger-to-nose testing is intact.  PSYCHIATRIC:  Fully alert and oriented.,LABORATORY DATA:,  December 2004, creatinine was 1.5.  Per report May 2006, creatinine was 1.8 with a BUN of 28.  Labs dated 06/01/06, hematocrit was 32.3, white blood cell count 7.2, platelets 263,000, sodium 139, potassium 4.9, chloride 100, CO2 25, BUN 46, creatinine 2.3, glucose 162, albumin 4.7, LFTs are normal.  CK was elevated at 653.  A1c is 7.6%.  LDL cholesterol is 68, HDL is 35.  Urinalysis reveals microalbumin to creatinine ratio 59.8.  UA was otherwise negative with a pH of 5.  Today his urinalysis showed specific gravity 1.020, negative glucose, bilirubin, ketones and blood, 30 mg/dL of protein, pH of 5, negative nitrates, leukocyte esterase.  Microscopic exam was bland.,IMPRESSION:,1.  Acute on chronic kidney failure.  He has underlying stage III CKD with the GFR approximately 41 mL/min.  He has episodic hypotension at home and low diastolic pressure here.  His weight is down 2 to 3 Kg from June and he may be prerenal.  He also has a history of prostatic hypertrophy and obstruction must be investigated.  I am also concerned about his use of Chinese herbs which can cause chronic interstitial nephritis.  There is no evidence of pyuria today although this can present with a fairly bland sediment.  An additional concern is that TriCor can cause an artifactual increase in the creatinine due to changes in metabolism.  I think this would be a diagnosis of exclusion.,2.  Orthostatic hypotension.  He is maintaining systolic but his diastolic pressures are gotten in to a point where he may not be perfusing his brain well.,3.  Elevated creatine kinase consistent with myositis.  It could be a result of Crestor alone or combination of TriCor and Crestor.  I do not think this is enough to cause rhabdomyolysis, however.,RECOMMENDATIONS:,1.  The patient was cautioned about using NSAIDs and told to avoid any further Chinese herbs.,2.  Recheck labs including CBC with differential, SPEP, uric acid and renal panel.,3.  Decrease atenolol to 25 mg daily.,4.  Decrease enalapril to 10 mg daily.,5.  Decrease Lasix to 20 mg daily.,6.  Stop Crestor.,7.  Check renal ultrasound.,8.  See him back in two weeks for review of the studies.
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DESCRIPTION: Patient with a history of coronary artery disease, hypertension, diabetes, and stage III CKD.

The situation describes a patient with multiple significant health issues, including acute kidney failure, coronary artery disease, diabetes, and hypertension. The consultation concerns new and potentially severe health developments, such as increased creatinine levels indicating worsening kidney function, orthostatic hypotension, and elevated creatine kinase levels suggesting possible myositis. The patient is also taking multiple medications, some of which may interact negatively with his conditions or contribute to his symptoms. Additionally, the patient's dizziness, weight loss, and recent use of herbal supplements heighten the concern for potential drug interactions and nephrotoxicity. This complex medical case requires careful management to prevent further deterioration and ensure appropriate treatment, making it a high-stakes situation.


Medical Specialty: Nephrology
Sample Name: AV Fistula - 1

PREOPERATIVE DIAGNOSIS,End-stage renal disease.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease.,PROCEDURE,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,ANESTHESIA,General.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room where after induction of general anesthetic, the patient's arm was prepped and draped in a sterile fashion.  The IV catheter was inserted into the vein on the lower surface of the left forearm.  Venogram was performed, which demonstrated adequate appearance of the cephalic vein above the elbow.,Through a transverse incision, the cephalic vein and brachial artery were both exposed at the antecubital fossa.  The cephalic vein was divided, and the proximal end was anastomosed to the artery in an end-to-side fashion with a running 6-0 Prolene suture.,The clamps were removed establishing flow through the fistula.  Hemostasis was obtained.  The wound was closed in layers with PDS sutures.  Sterile dressing was applied.  The patient was taken to recovery room in stable condition.
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DESCRIPTION: Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.

nephrology, end-stage renal disease, prolene suture, venogram, antecubital fossa, arteriovenous, arteriovenous fistula, brachiocephalic arteriovenous fistula, cephalic vein, fistula, prepped and draped, brachiocephalic, cephalic, vein

The procedure described involves the creation of an arteriovenous fistula, which is critical for patients requiring hemodialysis due to end-stage renal disease. An AV fistula is a lifeline for such patients as it is necessary for effective dialysis treatment. The successful completion of the procedure is crucial for the patient's ongoing treatment and quality of life, indicating a high-stakes situation. However, the procedure itself is routinely performed by experienced nephrologists and vascular surgeons, and the documentation indicates the procedure was completed without complications, which suggests established protocols and a controlled environment.


Medical Specialty: Letters
Sample Name: Rolandic Epilepsy

City, State,Dear Dr. Y:,I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z.  His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy.  To review, his birth was unremarkable.  He is a second child born to a G3, P1 to 2 female.  He has had normal development, and is a bright child in 7th grade.  He began having seizures, however, at 9 years of age.  It is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep.  He also had smaller spells with more focal convulsion and facial twitching.  His EEGs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere).  Most recent EEG in May 2006 shows the same abnormalities.,ABC initially was placed on Tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to Trileptal.  He has done very well taking 300 mg twice a day without any further seizures.  His last event was the day of his last EEG when he was sleep deprived and was off medication.  That was a convulsion lasting 5 minutes.  He has done well otherwise.  Parents deny that he has any problems with concentration.  He has not had any behavior issues.  He is an active child and participates in sports and some motocross activities.  He has one older sibling and he lives with his parents.  Father manages Turkey farm with foster farms.  Mother is an 8th grade teacher.,Family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known.  There is no other relevant family history.,Review of systems is positive for right heel swelling and tenderness to palpation.  This is perhaps due to sports injury.  He has not sprained his ankle and does not have any specific acute injury around the time that this was noted.  He does also have some discomfort in the knees and ankles in the general sense with activities.  He has no rashes or any numbness, weakness or loss of skills.  He has no respiratory or cardiovascular complaints.  He has no nausea, vomiting, diarrhea or abdominal complaints.,Past medical history is otherwise unremarkable.,Other workup includes CT scan and MRI scan of the brain, which are both normal.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male in no acute distress.  VITAL SIGNS:  His weight today is 80.6 pounds.  Height is 58-1/4 inches.  Blood pressure 113/66.  Head circumference 36.3 cm.  HEENT:  Atraumatic, normocephalic.  Oropharynx shows no lesions.  NECK:  Supple without adenopathy.  CHEST:  Clear auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.  ABDOMEN:  Benign without organomegaly.  EXTREMITIES:  No clubbing, cyanosis or edema.  NEUROLOGIC:  The patient is alert and oriented.  His cognitive skills appear normal for his age.  His speech is fluent and goal-directed.  He follows instructions well.  His cranial nerves reveal his pupils equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Disks are sharp bilaterally.  Face moves symmetrically with normal sensation.  Palate elevates midline.  Tongue protrudes midline.  Hearing is intact bilaterally.  Motor exam reveals normal strength and tone.  Sensation intact to light touch and vibration.  His gait is nonataxic with normal heel-toe and tandem.  Finger-to-nose, finger-nose-finger, rapid altering movements are normal.  Deep tendon reflexes are 2+ and symmetric.,IMPRESSION:  ,This is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic.  Most recent electroencephalogram still shows abnormalities, but it has not been done since May 2006.  The plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal.  At that time, he will be tapered off of medication.  I anticipate at some point in the near future, within about a year or so, he will actually be taken off medication.  For now, I will continue on Trileptal 300 mg twice a day, which is a low starting dose for him.  There is no indication that his dose needs to be increased.  Family understands the plan.  We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months.  Parents will contact us after the electroencephalogram is done so they can get the results.,Thank you very much for allowing me to access ABC for further management.
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DESCRIPTION: Diagnosis of benign rolandic epilepsy.

Diagnosis of benign rolandic epilepsy.

letters, tonic-clonic seizures, benign rolandic epilepsy, rolandic epilepsy, epilepsy, seizures, electroencephalogram,

The situation involves a medical follow-up and management plan for a child diagnosed with benign rolandic epilepsy. While it involves monitoring a neurological condition that affects a child's health, it is described as 'benign', indicating it is generally not life-threatening and can be outgrown by adolescence. The child is currently well-controlled on medication with no recent seizures, and regular follow-up is planned. While important, in the context of medical conditions, this is considered lower stakes since the condition is stable and the outlook is positive.


Medical Specialty: Letters
Sample Name: Wilson's Disease - Letter

Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future.  He is a pleasant gentleman with a history of Wilson's disease.  It has been treated with penicillamine.  He was diagnosed with this at age 14.  He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort.  He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate.  He was admitted there and observed.  He converted to normal sinus rhythm spontaneously and so he required no further interventions.  He was started on Lopressor, which he has tolerated well.  An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement.  Normal ejection fraction.  No other significant valvular abnormality.  He reported to physicians there that he had cirrhosis related to his Wilson's disease.  Therefore hepatologist was consulted.  There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day.,In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt.  His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine.,I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control.  He is in normal sinus rhythm as of my evaluation of him on 06/12/2008.  He is tolerating his metoprolol and aspirin without any difficulty.  I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes.,I appreciate your input regarding this friendly gentleman.  His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day.,If you have any questions regarding his care, please feel free to call me to discuss his case.  Otherwise, I will look forward to hearing back from you regarding his evaluation.  Thank you as always for your care of our patient.
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DESCRIPTION: A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.

letters, atrial enlargement, wilson's disease, penicillamine,

The letter describes a patient's medical history with Wilson's disease, atrial fibrillation, and potential cirrhosis. Treatment decisions such as anticoagulation therapy are being discussed, particularly concerning Coumadin use due to liver concerns. While the individual patient care could have high implications, the note itself is routine medical correspondence to coordinate care. The stakes are moderate due to possible health risks if incorrect treatment decisions are made, but these are common scenarios in medical practice.


Medical Specialty: Letters
Sample Name: Optometry - Letter

RE:  Sample Patient,Dear Dr. Sample:,Sample Patient was seen at the Vision Rehabilitation Institute on Month DD, YYYY.  She is an 87-year-old woman with a history of macular degeneration, who admits to having PDT therapy within the last year.  She would like to get started with some vision therapy so that she may be able to perform her everyday household chores, as well as reading small print.  At this time, she uses a small handheld magnifier, which is providing her with only limited help.,A complete refractive work-up was performed today, in which we found a mild change in her distance correction, which allowed her the ability to see 20/70 in the right eye and 20/200 in the left eye.  With a pair of +4 reading glasses, she was able to read 0.5M print quite nicely.  I have loaned her a pair of +4 reading glasses at this time and we have started her with fine-detailed reading.  She will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her.  I think that she is an excellent candidate for low vision help.  I am sure that we can be of great help to her in the near future.,Thank you for allowing us to share in the care of your patient.,With best regards,,Sample Doctor, O.D.
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DESCRIPTION: Woman with a history of macular degeneration.  PDT therapy.  Some vision therapy.  Complete refractive work-up.

letters, optometry, letter, optometry letter, pdt therapy, distance correction, macular degeneration, reading glasses, vision therapy, complete refractive, macular, degeneration,

The situation involves the management of a patient's visual impairment due to macular degeneration. While the patient requires ongoing care and adjustments to assistive devices, like reading glasses, to improve her quality of life, this specific situation described in the letter appears to be routine follow-up care. It is not an immediate or life-threatening situation. The letter suggests that the patient is responding well to the interventions and that further assistance is planned. Therefore, this situation is not high-stakes compared to emergencies but requires sensitive handling to enhance the patient's daily living.


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

Medical Specialty: Letters
Sample Name: Ophthalmology - Letter - 2

XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  Mr. ABC is being referred for evaluation of glaucoma.  The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally.  The patient's visual fields are full to confrontation.  Extraocular muscles are intact.  There is no relative afferent pupillary defect and applanation pressures are 15 mmHg bilaterally.  On slit lamp examination, the patient has a normal anterior segment with 1+ nuclear sclerosis.  On dilated examination, the patient has a cup-to-disc ratio in the right eye of 0.4.  Macula, vessels, and periphery were within normal limits.  On the left eye, the patient has a cup-to-disc ratio of 0.3 and macula vessels and periphery are also within normal limits.  On gonioscopy, the patient shows deep anterior chamber angle OU and is open to the ciliary body band 360 degrees.,In conclusion, my initial impression is that Mr. ABC does not have glaucoma.  He has fairly symmetric and small cup-to-disc ratios OU.  His intraocular pressures were within normal limits in our office today.  I discussed at length with him the alternatives of observation versus continued work-up and testing.  He seemed to understand very well and went with my recommendation to continue observation for now.  We will take fundus photos of his optic nerves for future comparison, but I think given the lack of any strong findings suspicious for glaucoma, we will defer further testing at this time.,Should you have any specific questions or any other information that you think that I may not have included in this evaluation, please feel free to contact me.  I have recommended him to follow up with you for continued examination, continued check-ups, and should you find any other abnormal findings, I would be happy to address those again.,Again, thank you for your referral of Mr. ABC.,Sincerely,,
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DESCRIPTION: Patient being referred for evaluation of glaucoma.

letters, cup to disc ratio, referred for evaluation, cup to disc, disc ratio, macula vessels, ophthalmology, pressures, eye, macula, vessels, visual, cup, disc, glaucoma, examination, intact,

This letter describes a routine ophthalmology evaluation for glaucoma where no immediate diagnosis has been made. The patient has been advised for observation without immediate further testing, indicating the situation is not urgent or life-threatening. The stakes are moderate as the monitoring of potential glaucoma is important for long-term eye health, but currently there are no signs requiring urgent or high-stakes intervention.


Medical Specialty: Letters
Sample Name: Cardiovascular - Letter

Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation.  This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND.  He is known to have a mother with coronary heart disease.  He has never been a smoker.  He has never had a syncopal episode, MI, or CVA.  He had his gallbladder removed.  No bleeding tendencies.  No history of DVT or pulmonary embolism.  The patient is retired, rarely consumes alcohol and consumes coffee moderately.  He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  His heart rate was 98 beats per minute and regular.  His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position.  He is in no distress.  Venous pressure is normal.  Carotid pulsations are normal without bruits.  The lungs are clear.  Cardiac exam was normal.  The abdomen was obese and organomegaly was not palpated.  There were no pulsatile masses or bruits.  The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  There was no peripheral edema.  ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  Renal function was normal.  His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL.  His sodium was a little bit increased.  His A1c hemoglobin was increased.  He had a spirometry, which was reported as normal.  ,He had a resting electrocardiogram on December 20, 2002, which was also normal.  He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  There were no symptoms or ischemia by EKG.  There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.  ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  He also should start aggressively losing weight.  I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis.  ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix.  The patient is allergic to aspirin.  I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should.  This, however, I will leave entirely up to you to decide.  If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D.
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DESCRIPTION: Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity.  Risk factors for coronary heart disease.

letters, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy, heart, atherosclerosis, diabetes, coronary, aspirin

The situation involves a 67-year-old patient with several significant risk factors for coronary heart disease, including obesity, hypertension, family history, borderline diabetes, and a possible metabolic syndrome. While the patient is currently asymptomatic in terms of coronary heart disease, the health risks are non-trivial and necessitate ongoing medical management and monitoring to prevent potential serious health events. However, there is no immediate life-threatening condition presented in the documentation, as the letter discusses preventive measures and risk management rather than urgent, acute medical emergencies.


Medical Specialty: Letters
Sample Name: Abnormal Cholesterol Result - Letter

ABNORMAL CHOLESTEROL RESULT LETTER,Recently you had a cholesterol test done.  The cholesterol levels were abnormal.  These are usually associated with increased risk for stroke and heart attack.  I am writing this letter to you to let you know that your levels are high enough that I think intervention is the next best step.  I would like you to make an appointment, if you are interested in treatment for this.  There are several treatment options available at this time.  Diet is one of the options, although there is limited reduction in total cholesterol and LDL cholesterol with dieting.  Most of the time under strict diet patients can achieve a 15% reduction in cholesterol.  If your cholesterol levels are moderate to severely elevated, usually diet is not the first line of therapy.  If you are diabetic or have hypertension these two also increase your risk with the combination of hypercholesterolemia.  Most of the time cholesterol that is elevated is from your genetic background and is independent of diet.  New research shows that treatment of high cholesterol can decrease your risk of developing Alzheimer’s disease.,Again, I am recommending at least we discuss medical treatment for hypercholesterolemia.  Please consider calling for a followup appointment concerning your cholesterol levels.  If you should have any further questions, please do not hesitate to contact me.  I am enclosing a copy of your lab results for your review.
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DESCRIPTION: Letter to the patient to let him know about his abnormal cholesterol test results.

letters, letter, ldl, abnormal, cholesterol, cholesterol level, cholesterol test, heart attack, hypercholesterolemia, increased risk, lab results, stroke, total cholesterol, abnormal cholesterol result, abnormal cholesterol, cholesterol levels, levels, treatment, dietNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The letter informs the patient about abnormal cholesterol levels, which are associated with significant health risks like stroke and heart attack. This situation is high-stakes as it directly relates to the patient's health and the potential for severe complications if untreated. The letter also emphasizes the importance of discussing potential treatments. The impact on the patient's life and health outcomes makes this a high-stakes situation.


Medical Specialty: Lab Medicine - Pathology
Sample Name: Immunohistochemical Study

CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma.  During her preop evaluation it was noted that she had a lesion on her chest x-ray.  CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:,  Tumor cells show no reactivity with cytokeratin AE1/AE3.  No significant reactivity with CAM5.2 and no reactivity with cytokeratin-20 are seen.  Tumor cells show partial reactivity with cytokeratin-7.  PAS with diastase demonstrates no convincing intracytoplasmic mucin.  No neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains.  Tumor cells show cytoplasmic and nuclear reactivity with S100 antibody.  No significant reactivity is demonstrated with melanoma marker HMB-45 or Melan-A.  Tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (TTF-1).  The immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,FINAL DIAGNOSIS:,Histologic Tumor Type:  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,Tumor Size:  2.7 x 2.0 x 1.4 cm.,Visceral Pleura Involvement:  The tumor closely approaches the pleural surface but does not invade the pleura.,Vascular Invasion:  Present.,Margins:  Bronchial resection margins and vascular margins are free of tumor.,Lymph Nodes:  Metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,Pathologic Stage:  pT1N1MX.
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DESCRIPTION: Specimen - Lung, left lower lobe resection.  Sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.  The tumor closely approaches the pleural surface but does not invade the pleura.

lab medicine - pathology, cytokeratin-20, hmb-45, melanoma, spindle cell carcinoma, tumor cells, carcinoma, immunohistochemical, lung, cytokeratin, sarcomatoid, spindle, pleural, cell, tumor,

The case involves the diagnosis of a malignant tumor in the lung, specifically a sarcomatoid carcinoma, which is a high-grade and aggressive type of cancer. It can significantly impact patient prognosis and treatment plans. The presence of vascular invasion and metastasis in a lymph node further elevates the stakes, as these factors suggest a more advanced disease and potential for spread. Accurate diagnosis and staging are crucial for determining the appropriate treatment strategy, which may include surgery, chemotherapy, or radiation therapy, making this situation high-stakes in the medical context.


Medical Specialty: Lab Medicine - Pathology
Sample Name: Pathology - Ovarian Cyst

GROSS DESCRIPTION: ,  Specimen labeled "right ovarian cyst" is received fresh for frozen section.  It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid.  Both surfaces of the wall are pink-tan, smooth and grossly unremarkable.  No firm or thick areas or papillary structures are noted on the cyst wall externally or internally.  After removal the fluid, the cyst weight 68 grams.  The fluid is transparent and slightly mucoid.  A frozen section is submitted.,DIAGNOSIS: , Benign cystic ovary.,
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DESCRIPTION: Specimen labeled "right ovarian cyst" is received fresh for frozen section.

lab medicine - pathology, right ovarian cyst, specimen, ovarian cyst, frozen section, ovarian, frozen, sectionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation involves the analysis of a benign ovarian cyst through pathology. While pathology results can be crucial for a patient's treatment plan, in this specific case, the cyst has been diagnosed as benign, indicating no immediate life-threatening condition. However, the accuracy of such diagnosis still holds importance for ongoing patient care. Therefore, while not life-threatening, it is moderately important to ensure accurate results for proper medical care.


Medical Specialty: Lab Medicine - Pathology
Sample Name: Lung Biopsy Pathology Report

CLINICAL HISTORY:,  A 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.  The lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter.  The patient was referred for surgical treatment.,SPECIMEN:,A.  Lung, wedge biopsy right lower lobe,B.  Lung, resection right upper lobe,C.  Lymph node, biopsy level 2 and 4,D.  Lymph node, biopsy level 7 subcarinal,FINAL DIAGNOSIS:,A.  Wedge biopsy of right lower lobe showing:  Adenocarcinoma, Grade 2, Measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.,B.  Right upper lobe lung resection showing:  Adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin.  Two (2) hilar lymph nodes with no metastatic tumor.,C.  Lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.,D.  Lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor.,COMMENT:  ,The morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe.  This suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces.  Furthermore, immunoperoxidase stain for Ck-7, CK-20 and TTF are performed on both the right lower and right upper lobe nodule.  The immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe.,
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DESCRIPTION: Lung, wedge biopsy right lower lobe and resection right upper lobe.  Lymph node, biopsy level 2 and 4 and biopsy level 7 subcarinal.  PET scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by CT scan.

lab medicine - pathology, pet scan, wedge biopsy, morphology, lung wedge biopsy, lymph node biopsy, lymph node, lower lobe, tumor, biopsy, lobe, lung, mass, lymph, node

The pathology report indicates the presence of adenocarcinoma in both the patient's right upper and lower lung lobes, with evidence suggesting the lower lobe tumor is secondary to the upper lobe tumor. The report also mentions the absence of metastatic tumor in the lymph nodes. The high-stakes nature comes from the diagnosis of cancer, which is a serious medical condition requiring prompt and effective treatment. The involvement of multiple lobes and the need for surgical intervention further emphasize the gravity of the situation. Cancer diagnoses typically require urgent attention, coordinated care, and have significant implications for patient treatment and prognosis.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Qualified Medical Evaluation Report

HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman.  He is complaining chiefly of persistent lower back pain.  He states the pain is of a rather constant nature.  He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back.  He states he has difficulty with prolonged standing or sitting.  He can only stand for about 5-10 minutes, then he has to sit down.  He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain.  He has difficulty with bending and stooping maneuvers.  He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot.  He gets numbness along the lateral aspect of the foot itself.  He also describes chronic pain complaints with associated tension in the back of his neck.  He states the pain is of a constant nature in his neck.  He states he gets pain that radiates into the right shoulder girdle area and the right forearm.  He describes some numbness along the lateral aspect of the right forearm.  He states he has trouble trying to use his arm at or above shoulder height.  He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity.  He describes pain at the anterior aspect of his shoulder, in particular.  He denies any headache complaints.  He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person.  He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck.  He lost his footing and fell.  He reached out to grab the hand railing.  He fell backwards on his back and his right shoulder.  He had immediate onset of shoulder pain, neck pain, and low back pain.  He had pain into his right leg.  He initially came under the care of Dr. H, an occupational physician in Modesto.  Initially, he did not obtain any MRIs or x-rays.  He did undergo some physical therapy and received some medications.  Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful.  The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990.  He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat.  He continues with rather persistent pain in his right shoulder.  He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff.  The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories.  He felt that the patient might require a cortisone injection or possibly a surgical intervention.  The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck.  There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels.  The patient was also seen by Dr. P, a neurologist for a Neurology consult.  It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities.  The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994.  He returned back to regular duty.  Dr. N declared him permanent and stationary on 04/04/1995.  The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer.  At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician.  Dr. N took him off work again.  He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon.  He had a new MRI of his lumbar spine performed.  The MRI was performed on 05/20/1997.  It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis.  The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam.  Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation.  Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive.  The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left.  Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities.  The patient did see Dr. R for a neurosurgical consult.  Dr. R evaluated both his neck and lower back pain complaints on several occasions.  Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks.  The patient underwent these injections with Dr. K.  The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections.  It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine.  Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness.  The patient also was noted to have a C4-5 with rather severe degenerative disc disease.  He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6.  Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease.  He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1.  He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain.  He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms.  He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him.  He is currently taking no medications to manage his pain complaints.  He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury.  He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician.  The patient states he has not been back to work since.  He has since applied for social security disability and now is receiving social security disability benefits.  The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful.  Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,
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DESCRIPTION: Qualified medical evaluation report of a patient with back pain.

The situation involves a detailed medical evaluation report for a patient experiencing significant and ongoing complications from workplace injuries. The report includes medical history, a variety of treatments, and potential surgical interventions. While it is critical for the patient's healthcare decisions, from a high-stakes perspective, it mainly involves medical and administrative assessments rather than immediate life-threatening situations. This assumes the context is more about disability and insurance evaluations, rather than acute emergency care.