Medical Specialty: Neurology
Sample Name: Neuropsychological Evaluation - 5

PROBLEMS AND ISSUES:,1.  Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2.  Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.  I obtained and documented a full history and physical examination.  I reviewed the new patient questionnaire, which she completed prior to her arrival today.  I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25.  She recalls that in 1996 when her husband died her headaches became more frequent.  They were pulsating.  She was given papaverine, which was successful in reducing the severity of her symptoms.  After six months of taking papaverine, she no longer had any headaches.  In 2004, her headaches returned.  She also noted that she had "zig-zag lines" in her vision.  Sometimes she would not see things in her peripheral visions.  She had photophobia and dizziness, which was mostly lightheadedness.  On one occasion she almost had a syncope.  Again she has started taking Russian medications, which did help her.  The dizziness and headaches have become more frequent and now occur on average once to twice per week.  They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:,  Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY:  ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms.  Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:,  On examination, the patient was pleasant.  She was able to speak English fairly well.  Her blood pressure was 130/84.  Heart rate was 80.  Respiratory rate was 16.  Her weight was 188 pounds.  Her pain score was 0/10.  Her general exam was completely unremarkable.  Her neurological examination showed subtle weakness in her left arm due to discomfort and pain.  She had reduced vibration sensation in her left ankle and to some degree in her right foot.  There was no ataxia.  She was able to walk normally.  Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable.  She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:,  The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s.  She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms.  Her diagnosis is consistent with vestibular migraine.  I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet.  I gave her instructions including a list of foods times, which worsen migraine.  I reviewed this information for more than half the clinic visit.  I would like to start her on amitriptyline at a dose of 10 mg at time.  She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms.  I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.
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DESCRIPTION: The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.

neurology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia,

The situation involves a medical consultation for a patient experiencing vestibular migraines and associated symptoms, which impact her quality of life. Although the symptoms are bothersome, they are not immediately life-threatening. The stakes in this context relate to ensuring effective management of the condition to prevent deterioration and improve the patient's quality of life. While important, this does not qualify as a high-stakes situation like a life-threatening emergency or a critical surgical procedure.


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

Medical Specialty: Neurology
Sample Name: Neurologic Consultation

REASON FOR CONSULTATION: , Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.,HISTORY OF PRESENT ILLNESS: , The patient is well known to me.  She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity.  She also has a history of factor V Leiden deficiency.  She was last seen at neurology clinic on 11/16/2007.  At that time, instructions were given to mom to maximize her Trileptal dose if seizures continue.  She did well on 2 mL twice a day without any sedation.  This past Friday, she had a 25-minute seizure reportedly.  This consisted of eye deviation, unresponsiveness, and posturing.  Diastat was used and which mom perceived was effective.  Her Trileptal dose was increased to 3 mL b.i.d. yesterday.,According to mom since her shunt revision on 12/18/2007, she has been sleepier than normal.  She appeared to be stable until this past Monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers.  According to mom, she had stopped vomiting since her hospitalization.  Reportedly, she was given a medication in the emergency room.  She still is lethargic, will not wake up spontaneously.  When she does awaken however, she is appropriate, and interacts with them.  She is able to eat well; however her overall p.o. intake has been diminished.  She has also been less feisty as her usual sounds.  She has been seizure free since her admission.,LABORATORY DATA: , Pertinent labs obtained here showed the following:  CRP is less than 0.3, CMP normal, and CBC within normal limits.  CSF cultures so far is negative.  Dr. Limon's note refers to a CSF, white blood cell count of 2, 1 RBC, glucose of 55, and protein of 64.  There are no imaging studies in the computer.  I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr. X, who indicated that there was no evidence of shunt malfunction or infection.,CURRENT MEDICATIONS: , Trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.,PHYSICAL EXAMINATION:,GENERAL:  The patient was asleep, but easily aroused.  There was a brief period of drowsiness, which she had some jerky limb movements, but not seizures.  She eventually started crying and became agitated.  She made attempts to sit by bending her neck forward.  Fully awake, she sucks her bottle eagerly.,HEENT:  She was obviously visually impaired.  Pupils were 3 mm, sluggishly reactive to light.,EXTREMITIES:  Bilateral lower extremity spasticity was noted.  There was increased flexor tone in the right upper extremity.  IV was noted on the left hand.,ASSESSMENT:  ,Seizure breakthrough due to intercurrent febrile illness.  Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.,I concur with Dr. X's recommendations.  I do not recommend any changes in Trileptal for now.  I will be available while she remains hospitalized.,
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DESCRIPTION: Neurologic consultation was requested to evaluate her seizure medication and lethargy.

neurology, lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal

This case involves monitoring and managing the seizure medication and lethargy of a patient with a complex neurological history, including epilepsy, cerebral palsy, and hydrocephalus. The stakes are high because any misjudgment in medication or failure to detect a serious complication like shunt malfunction could lead to significant negative outcomes for the patient, such as prolonged seizures, neurological deterioration, or other complications. The patient's condition and history demand careful medical evaluation to ensure appropriate treatment and prevent serious harm.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurology
Sample Name: Neuroblastoma - Consult

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

The situation described involves a very young child, only 11 months old, with a diagnosis of neuroblastoma, a serious form of cancer. The child is undergoing chemotherapy and facing side effects like immunosuppression and mucosal candidiasis. Although the disease has a favorable Shimada histology, indicating a better prognosis, managing the cancer at such a young age carries significant risks and requires careful monitoring. The situation is high-stakes due to the life-threatening nature of the disease, the complexity of treatment, and the vulnerability of the patient. The medical decisions and treatments will have direct implications on the child's immediate health and long-term development.


Medical Specialty: Neurology
Sample Name: Neurologic Consultation - 2

REASON FOR VISIT:  ,The patient is a 76-year-old man referred for neurological consultation by Dr. X.  The patient is companied to clinic today by his wife and daughter.  He provides a small portion of his history; however, his family provides virtually all of it.,HISTORY OF PRESENT ILLNESS: , He has trouble with walking and balance, with bladder control, and with thinking and memory.  When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder.  He is vaguely aware that he has trouble with his memory.,According to his family, he has had difficulty with his gait for at least three or four years.  At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself.  They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin.  As time progressed, he developed more and more difficulty.  He started to shuffle.  He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006.  At this point, he frequently if not always has trouble getting in or out of the seat.  He frequently tends to lean backwards or sideways when sitting.  He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking.  He has not fallen in the last month.  He did fall earlier, but there seemed to be fewer opportunities for him to fall.  His family has recently purchased a lightweight wheelchair to use if he is traveling long distances.  He has no stairs in his home, however, his family indicates that he would not be able to take stairs.  His handwriting has become smaller and shakier.,In regard to the bladder, he states, "I wet the bed."  In talking with his family, it seems as if he has no warning that he needs to empty his bladder.  He was diagnosed with a small bladder tumor in 2005.  This was treated by Dr. Y.  Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence.  The patient has worn a pad or undergarment for at least one to one and a half years.  His wife states that they go through two or three of them per day.  He has been placed on medications; however, they have not helped.,He has no headaches or sensation of head fullness.,In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates.  Now he seems less spontaneous and his family states he seems to have trouble expressing himself.  His wife took over his medications about two years ago.  She stopped his driving about three years ago.  She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more.  Apparently, he did not object.  At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home.  He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth.  He is a retired office machine repairman.  He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease.  He has been treated for the bladder.  He has not had lumbar puncture.,Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998.  The bladder tumor was discovered in 2005 and was treated noninvasively.  He has lost weight from about 200 pounds to 180 pounds over the last two or three years.  He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped.  He used to drink a significant amount of alcohol.  This was problematic enough that his wife was concerned.  She states he stopped when she retired and she was at home all day.,SOCIAL HISTORY:  ,He quit smoking in 1968.  His current weight is 183 pounds.  His tallest height is 5 feet 10 inches.,FAMILY HISTORY:  ,His grandfather had arthritis.  His father had Parkinson's disease.  His mother had heart disease and a sister has diabetes.,He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,REVIEW OF HYDROCEPHALUS RISK FACTORS: , None.,ALLERGIES: , None.,MEDICATIONS: , Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day.,PHYSICAL EXAM: , On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker.  He is well developed, well nourished, and kempt.,Vital Signs:  His weight is 180 pounds.,Head:  The head is normocephalic and atraumatic.  The head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,Spine:  The spine is straight and not tender.  I can easily palpate the spinous processes.  There is no scoliosis.,Skin:  No neurocutaneous stigmata.,Cardiovascular Examination:  No carotid or vertebral bruits.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 17/30.  He did not know the year, season, or day of the week nor did he know the building or specialty or the floor.  There was a tendency for perseveration during the evaluation.  He could not copy the diagram of intersecting pentagons.,Cranial Nerve Exam:  No evidence of papilledema.  The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,Motor Exam:  Normal bulk and strength, but the tone is marked by significant paratonia.  There is no atrophy, fasciculations, or drift.  There is tremulousness of the outstretched hands.,Sensory Exam:  Is difficult to interpret.  Either he does not understand the test or he is mostly guessing.,Cerebellar Exam:  Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests.  There is no dysarthria.,Reflexes:  Trace in the arms, 2+ at the knees, and 0 at the ankles.  It is not certain whether there is a Babinski sign or simply withdrawal.,Gait:  Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,REVIEW OF X-RAYS: , I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology.  It shows the ventricles are enlarged with a frontal horn span of 5.0 cm.  The 3rd ventricle contour is flat.  The span is enlarged at 12 mm.  The sylvian aqueduct is patent.  There is a pulsation artifact.  The corpus callosum is effaced.  There are extensive T2 signal abnormalities that are confluent in the corona radiata.  There are also scattered T2 abnormalities in the basal ganglia.  There is a suggestion of hippocampal atrophy.  There is also a suggestion of vermian atrophy.,ASSESSMENT: , The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus.  His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment.  His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,PROBLEMS/DIAGNOSES:,1.  Possible idiopathic normal pressure hydrocephalus (331.5).,2.  Probable cerebral small-vessel disease (290.40 & 438).,3.  Gait impairment (781.2).,4.  Urinary urgency and incontinence (788.33).,5.  Dementia.,6.  Hypertension.,7.  Hypercholesterolemia.
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DESCRIPTION: Patient has trouble with walking and balance, with bladder control, and with thinking and memory.

The situation involves a 76-year-old man showing significant neurological symptoms such as mobility issues, cognitive decline, and possible dementia, along with a history of bladder problems. These symptoms are indicative of serious conditions like idiopathic normal pressure hydrocephalus or cerebral small vessel disease that have severe implications for the patient's quality of life and require careful medical assessment and management. Moreover, late-stage neurological disorders often require long-term care planning, making this situation high-stakes.


Medical Specialty: Neurology
Sample Name: Neuro Consult - Leg Weakness

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.  He has difficulty recollecting the exact details and chronology of his problem.  To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg.  He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe.  Since that time, he has had difficulty pushing off when he walks.  He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness.  He has chronic mild back pain, but this has been persistent for many years and has not changed.  He has experienced cramps in both calves for the past year.  This dissipated about two months ago.  He does not think that his left leg is weak.  He does not have any bowel or bladder incontinence.  There is no radicular pain.  He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October.  He then saw you a couple of months later.  He has undergone an EMG and nerve conduction studies.  Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant.  He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia.  He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me.  He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it.  Once it was started, it increased to about 800 and then came down to about 500 when it was stopped.  He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s.  I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this.  More recently, he has been started taking Zetia.  He does not have any proximal weakness.  He denies any myalgias., ,PAST MEDICAL HISTORY:,  He has coronary artery disease and has received five stents.  He has hypertension and hypercholesterolemia.  He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  He believes that his glucose shot up to over 300 with this testing.  He does not take any medications for this and his blood glucoses are generally normal when he checks it.  He has had plastic surgery on his face from an orbital injury.  He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix.  , ,ALLERGIES:,  He has no known drug allergies., ,SOCIAL HISTORY:,  He lives with his wife.  He works at Shepherd Pratt doing network engineering.  He smokes a pack of cigarettes a day and is working on quitting.  He drinks four alcoholic beverages per night.  Prior to that, he drank significantly more.  He denies illicit drug use.  He was athletic growing up., ,FAMILY HISTORY:,  His mother died of complications from heart disease.  His father died of heart disease in his 40s.  He has two living brothers.  One of them he does not speak too much with and does not know about his medical history.  The other is apparently healthy.  He has one healthy child.  His maternal uncles apparently had polio.  When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg.  He is fairly certain that they had polio.  He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus.  He has difficulty sleeping.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:, ,Vital Signs:
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DESCRIPTION: The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.

The situation involves a patient presenting with right leg weakness, a potential neurological issue, which could indicate an underlying serious neurologic condition such as neuropathy, myopathy, or a complication related to his history of statin use or cardiovascular issues. The inability to perform an MRI due to an ear implant limits diagnostic options, adding complexity to the case. The patient has multiple comorbidities, including coronary artery disease and diabetes, which could complicate the treatment and diagnosis process. While not immediately life-threatening, the combination of symptoms, comorbidities, and diagnostic challenges indicate a moderate level of stakes given the potential impacts on the patient's daily life and overall health. The situation requires careful management to prevent further complications.


Medical Specialty: Neurology
Sample Name: Neurologic Consultation - 3

HISTORY: , Neurologic consultation was requested to assess and assist with her seizure medication.  The patient is a 3-year 3 months old girl with refractory epilepsy.  She had been previously followed by XYZ, but has been under the care of the UCSF epilepsy program and recently by Dr. Y.  I reviewed her pertinent previous neurology evaluations at CHCC and also interviewed mom.,The patient had seizure breakthrough in August 2007, which requires inpatient admission, Thanksgiving and then after that time had seizures every other day, up-to-date early December.  She remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with Diastat.  She presented to our ER today with prolonged convulsive seizure despite receiving 20 mg of Diastat at home.  Mom documented 103 temperature at home.  In the ER, this was 101 to 102 degrees Fahrenheit.  I reviewed the ER notes.  At 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5.  UCSF fellow was contacted.  She was given additional fosphenytoin and had a total dose of 15 mg/kg administered.  Vital weight was 27.  Seizures apparently had stopped.  The valproic acid level obtained at 0835 hours was 79.  According to mom, her last dose was at 6 p.m. and she did not receive her morning dose.  Other labs slightly showed leukocytosis with white blood cell count 21,000 and normal CMP.,Previous workup here showed an EEG on 2005, which showed a left posterior focus.  MRI on June 2007 and January 2005 were within normal limits.  Mom describes the following seizure types:,1.  Eye blinking with unresponsiveness.,2.  Staring off to one side.,3.  Focal motor activity in one arm and recently generalized tonic seizure.,She also said that she was supposed to see Dr. Y this Friday, but had postponed it to some subsequent time when results of genetic testing would be available.  She was being to physicians' care as Dr. Z had previously being following her last UCSF.,She had failed most of the first and second line anti-epileptic drugs.  These include Keppra, Lamictal, Trileptal, phenytoin and phenobarbital.  These are elicited to allergies, but she has not had any true allergic reactions to these.  Actually, it has resulted in an allergic reaction resulting in rash and hypotension.,She also had been treated with Clobazam.  Her best control is with her current regimen of valproic acid and Tranxene.  Other attempts to taper Topamax, but this resulted increased seizures.  She also has oligohidrosis during this summertime.,CURRENT MEDICATIONS: , Include Diastat 20 mg; Topamax 25 mg b.i.d., which is 3.3 per kilo per day; Tranxene 15 mg b.i.d.; Depakote 125 mg t.i.d., which is 25 per kilo per day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 15 kg.,GENERAL:  The patient was awake, she appeared sedated and postictal.,NECK:  Supple.,NEUROLOGICAL:  She had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed.,She was able to follow commands such as when I request that she gave mom a kiss.  She acknowledged her doll.  Left fundus is sharp.  She resisted the rest of the exam.  There was no obvious lateralized findings.,ASSESSMENT:,  Status epilepticus resolved.  Triggered by a febrile illness, possibly viral.  Refractory remote symptomatic partial epilepsy.,IMPRESSION: , I discussed the maximizing Depakote to mom and she concurred.  I recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime.  For today, she did give an IV Depacon 250 mg and the above dosage can be continued IV until she is taking p.o.  Dr. X agreed with the changes and orders were written for this.  She can continue her current doses of Topamax and Tranxene.  This can be given by NG if needed.  Topamax can be potentially increased to 25 mg in the morning and 50 mg at night.  I will be available as needed during the rest of her hospitalization.  Mom will call contact Dr. Y an update him about the recent changes.
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DESCRIPTION: Neurologic consultation was requested to assess and assist with seizure medication.

neurology, eye blinking, status epilepticus, seizure medication, valproic acid, allergic reactions, neurologic consultation, seizure, neurologic, seizures,

This situation involves a young child with refractory epilepsy experiencing frequent and severe seizures. The situation requires careful medical assessment and adjustment of medication, which is critical to avoid potentially life-threatening seizure episodes and associated complications. The child's condition, combined with the need for fine-tuning her treatment regimen, carries significant health implications, hence making it a high-stakes scenario in a medical context.


Medical Specialty: Neurology
Sample Name: Neurologic Consultation - 1

SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed.  There are no changes, otherwise.,REVIEW OF SYSTEMS:,  Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented.  Extraocular movements are full.  The face is symmetric.  The uvula is midline.  Speech has normal prosody.  Today there is much less guarding of the left shoulder.  In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full.  The gait is narrow based and noncircumductive.  Rapid alternating movements are slightly off bilaterally.  The gait does not have significant slapping characteristics.  Sensory examination is largely unremarkable.  Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same.  We discussed the issue of adherence to Copaxone.  In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm.  His wife continues to inject him.  He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.
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DESCRIPTION: Neurologic consultation and follow-up.

Neurologic consultation and follow-up.

neurology, neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone,

This situation involves a neurologic consultation which typically requires a thorough examination and discussion of treatment plans. The stakes are moderate to high because ensuring proper medication adherence is crucial in managing the patient's condition effectively, and failure to do so could lead to deterioration in the patient's health. Nevertheless, it does not immediately suggest an emergency or life-threatening situation, as the patient is currently alert, oriented, and experiencing stable symptoms. The use of 'adherence to Copaxone,' a medication used to treat conditions like multiple sclerosis, underscores the importance of proper management to prevent potential relapse or progression of the disease.


Medical Specialty: Neurology
Sample Name: MRI L-Spine - Subarachnoid Seeding

CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of "drop" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.
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DESCRIPTION: MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.

neurology, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness,

The situation involves a clinical case with a history of glioblastoma multiforme (GBM) and evidence of subarachnoid seeding in a patient who has undergone extensive treatment. Subarachnoid seeding indicates metastasis, which is a serious complication. The patient is exhibiting progressive neurological symptoms leading to disability, and they have been moved to hospice care, suggesting a poor prognosis. Managing GBM with metastasis is considered high-stakes due to the complexities and potential life-threatening nature of the condition.


Medical Specialty: Neurology
Sample Name: MRI Cervical Spine - 2

EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.
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DESCRIPTION: MRI Cervical Spine without contrast.

MRI Cervical Spine without contrast.

neurology, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord

The MRI findings describe potential issues in the cervical spine, specifically disk/osteophyte impingement at C4-5 through C6-7. While they may contact and mildly indent the spinal cord, the report notes that there is no discrete cord signal abnormality or distinct compression identified. These findings can explain the patient's symptoms such as right arm pain and numbness but do not suggest an immediate or severe neurological crisis. However, spinal cord involvement and potential nerve impingement can become more serious if not addressed, potentially impacting the patient’s quality of life. Hence, the situation has some stakes involved, particularly in terms of ensuring proper management to prevent deterioration.


Medical Specialty: Neurology
Sample Name: MRI Brain - Wernicke aphasia

CC: ,Difficulty with speech.,HX:, This 72 y/o RHM awoke early on 8/14/95 to prepare to play golf. He felt fine. However, at 6:00AM, on 8/14/95, he began speaking abnormally. His wife described his speech as "word salad" and "complete gibberish." She immediately took him to a local hospital . Enroute, he was initially able to understand what was spoken to him. By the time he arrived at the hospital at 6:45AM, he was unable to follow commands. His speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. There were no other symptoms or signs. He had no prior history of cerebrovascular disease. Blood pressure 130/70 and Pulse 82 upon admission to the local hospital on 8/14/95.,Evaluation at the local hospital included: 1)HCT scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) Carotid Duplex scan showed ICA stenosis of 40%, bilaterally. He was placed on heparin and transferred to UIHC on 8/16/95.,In addition, he had noted memory and word finding difficulty for 2 months prior to presentation. He had undergone a gastrectomy 16 years prior for peptic ulcer disease. His local physician found him vitamin B12 deficient and he was placed on vitamin B12 and folate supplementation 2 months prior to presentation. He and his wife felt that this resulted in improvement of his language and cognitive skills.,MEDS:, Heparin IV, Vitamin B12 injection q. week, Lopressor, Folate, MVI.,PMH:, 1)Hypothyroidism (reportedly resolved), 2) Gastrectomy, 3)Vitamin B12 deficiency.,FHX: ,Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.,SHX:, Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use.,EXAM:, BP 110/70, HR 50, RR 14, Afebrile.,MS: A&O to person and place, but not time. Oral comprehension was poor beyond the simplest of conversational phrases. Speech was fluent, but consisted largely of "word salad." When asked how he was, he replied: "abadeedleedlebadle." Repetition was defective, especially with long phrases. On rare occasions, he uttered short comments appropriately. Speech was marred by semantic and phonemic paraphasias. He named colors and described most actions well, although he described a "faucet dripping" as a "faucet drop." He called "red" "reed." Reading comprehension was better than aural comprehension. He demonstrated excellent written calculations. Spoken calculations were accurate except when the calculations became more complex. For example, he said that ten percent of 100 was equal to "1,200.",CN: Pupils 2/3 decreasing to 1/1 on exposure to light. VFFTC. There were no field cuts or evidence of visual neglect. EOM were intact. Face moved symmetrically. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout with normal muscle tone and bulk. There was no evidence of drift.,SENSORY: unremarkable.,COORD: unremarkable.,Station: unremarkable. Gait: mild difficulty with TW.,Reflexes: 2/2 in BUE. 2/2+ patellae, 1/1 Achilles. Plantar responses were flexor on the left and equivocal on the right.,Gen Exam: unremarkable.,COURSE:, Lab data on admission: Glucose 97, BUN 20, Na 134, K 4.0, Cr 1.3, Chloride 98, CO2 24, PT 11, PTT 42, WBC 12.0 (normal differential), Hgb 11.4, Hct 36%, Plt=203k. UA normal. TSH 6.0, FT4 0.88, Vit B12 876, Folate 19.1. He was admitted and continued on heparin. MRI scan, 8/16/95, revealed increased signal on T2-weighted images in Wernicke's area in the left temporal region. Transthoracic echocardiogram on 8/17/95 was unremarkable. Transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. LAE 4.8cm, and spontaneous echo contrast in the left atrium were noted. There was no evidence of intracardiac shunt or clot. Carotid duplex scan on 8/16/95 revealed 0-15% BICA stenosis with anterograde vertebral artery flow, bilaterally. Neuropsychologic testing revealed a Wernicke's aphasia.,The impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left MCA. He was subsequently placed on warfarin. Thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95.,He has had no further stroke like episodes up until his last follow-up visit in 1997.
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DESCRIPTION: MRI Brain: Left Basal Ganglia, Posterior temporal lobe, and Left cerebellar (lacunar) infarctions with Wernickes Aphasia.

neurology, mri brain, difficulty with speech, left basal ganglia, posterior temporal lobe, wernicke's area, wernickes aphasia, cerebellar, infarctions, lacunar, word finding difficulty, carotid duplex scan, aphasia, wernicke's, mri, brain,

The situation involves a medical case where a patient has suffered a cardioembolic stroke leading to Wernicke's aphasia, a serious condition affecting speech and comprehension. The patient's symptoms included 'word salad' speech and difficulty following commands, which needed immediate medical attention. The stakes are high because prompt diagnosis and treatment are crucial to minimize potential long-term cognitive and language deficits associated with the stroke. Delays or mismanagement could significantly impact the patient's quality of life. Additionally, the condition required progressive treatment involving heparin, warfarin, and speech therapy. While the situation does not seem currently life-threatening given the improvement, it was a critical medical event requiring careful management.


Medical Specialty: Neurology
Sample Name: MRI Brain - Thrombus

CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of "startle response (myoclonic movement of the shoulders)" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia.
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DESCRIPTION: MRI Brain: Thrombus in torcula of venous sinuses.

neurology, mri brain, brain mri, thrombus, intraparenchymal hemorrhage, motor vehicle, prophylaxis, sinuses, torcula venous sinuses, venous, brain thrombus, bilateral decorticate, decorticate posturing, subdural hematomas, subdural, mri, brain, torcula

This case describes a severe traumatic brain injury in a 5-year-old boy following a high-speed motor vehicle-bicycle collision. The injury resulted in significant neurological damage, including intracranial hemorrhages, midline shift, and prolonged unconsciousness, necessitating multiple surgeries, including craniotomy and VP shunting. Over time, the child developed severe neurological sequelae, including extensor rigidity, spastic quadriplegia, and seizure disorders, indicating lasting and profound impairment. The ongoing medical follow-up and treatments, including managing seizures and monitoring for complications like hydrocephalus or thrombus presence in the venous sinuses, underscore the critical nature of the situation. The child's functional prognosis is poor, and the central role of medical intervention in mitigating further complications and providing supportive care contributes to the high-stakes nature of this case.


Medical Specialty: Neurology
Sample Name: MRI Brain - Pilocytic Astrocytoma

CC:, Headache.,HX: ,The patient is an 8y/o RHM with a 2 year history of early morning headaches (3:00-6:00AM) intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was "normal" then, but no brain imaging was performed. His headaches progressively worsened, especially in the past two months prior to this presentation. For 2 weeks prior to his 1/25/93 evaluation at UIHC, he would awake screaming. His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,Vermox was prescribed and arrangements were made for a neurologic evaluation. On the evening of 1/24/93 the patient awoke screaming and began to vomit. This was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. He was taken to a local ER and a brain CT revealed an intracranial mass. He was given Decadron and Phenytoin and transferred to UIHC for further evaluation.,MEDS:, noted above.,PMH: ,1)Born at 37.5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother. Pregnancy complicated by vaginal bleeding at 7 months. Met developmental milestones without difficulty. 2) Frequent otitis media, now resolved. 3) Immunizations were "up to date.",FHX:, non-contributory.,SHX:, lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.,EXAM:, BP121/57mmHg HR103 RR16 36.9C,MS: Sleepy, but cooperative.,CN: EOM full and smooth. Advanced papilledema, OU. VFFTC. Pupils 4/4 decreasing to 2/2. Right lower facial weakness. Tongue midline upon protrusion. Corneal reflexes intact bilaterally.,Motor: 5/5 strength. Slightly increased muscle on right side.,Sensory. No deficit to PP/VIB noted.,Coord: normal FNF, HKS and RAM, bilaterally.,Station: Mild truncal ataxia. Tends to fall backward.,Reflexes: BUE 2+/2+, Patellar 3/3, Ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,Gen exam: unremarkable.,COURSE:, The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs. Brain MRI, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images. There were areas of cystic formation at its periphery. The mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. There was no sign of uncal herniation. He underwent bilateral VP shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. He then received 5040cGy of radiation therapy in 28 fractions completed on 3/25/93. A 3/20/95 neuropsychological evaluation revealed low average intellect on the WISC-III. There were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. He remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. Neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. MRI revealed tumor progression and he was subsequently placed on Carboplatin/VP-16 (CG 9933 protocol chemotherapy, regimen A). He was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.
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DESCRIPTION: MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.

neurology, mri brain, pilocytic astrocytoma, caudate, thalamus, headache, astrocytoma, hemiplegia, pilocytic, mri,

The case involves a young child with a serious medical condition, specifically a brain tumor (pilocytic astrocytoma) in critical regions of the brain, such as the thalamus and caudate. This has already led to severe symptoms and required extensive interventions including surgery, radiation, and chemotherapy. The situation affects the child's neurological functions and cognitive abilities, impacting his quality of life significantly. The stakes are high due to the potential for further neurological decline, risk of complications from treatments, and the overall impact on the child's development and future. Given the complexity and sensitivity of managing a brain tumor in a child, this situation is very high-stakes.


Medical Specialty: Neurology
Sample Name: MRI Brain - Pontine Stroke

CC:, Left sided weakness.,HX:, 74 y/o RHF awoke from a nap at 11:00 AM on 11/22/92 and felt weak on her left side. She required support on that side to ambulate. In addition, she felt spoke as though she "was drunk." Nevertheless, she was able to comprehend what was being spoken around her. Her difficulty with speech completely resolved by 12:00 noon. She was brought to UIHC ETC at 8:30AM on 11/23/92 for evaluation.,MEDS:, none. ,ALLERGIES:,  ASA/ PCN both cause rash.,PMH:, 1)?HTN. 2)COPD. 3)h/o hepatitis (unknown type). 4)Macular degeneration.,SHX:, Widowed; lives alone. Denied ETOH/Tobacco/illicit drug use.,FHX:, unremarkable.,EXAM: , BP191/89 HR68 RR16 37.2C,MS: A & O to person, place and time. Speech fluent; without dysarthria. Intact naming, comprehension, and repetition.,CN: Central scotoma, OS (old). Mild upper lid ptosis, OD (old per picture). Lower left facial weakness.,Motor: Mild Left hemiparesis (4+ to 5- strength throughout affected side). No mention of muscle tone in chart.,Sensory: unremarkable.,Coord: impaired FNF and HKS movement secondary to weakness.,Station: Left pronator drift. No Romberg sign seen.,Gait: Left hemiparetic gait with decreased LUE swing.,Reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. Plantars: Left babinski sign; and flexor on right.,General Exam: 2/6 SEM at left sternal border.,COURSE:, GS, CBC, PT, PTT, CK, ESR were within normal limits. ABC 7.4/46/63 on room air. EKG showed a sinus rhythm with right bundle branch block. MRI brain, 11/23/95, revealed a right pontine pyramidal tract infarction. She was treated with Ticlopidine 250mg bid. On 11/26/92, her left hemiparesis worsened. A HCT, 11/27/92, was unremarkable. The patient was treated with IV Heparin. This was discontinued the following day when her strength returned to that noted on 11/23/95. On 11/27/92, she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies. Carotid duplex showed 0-15% bilateral ICA stenosis and antegrade vertebral artery flow bilaterally. Transthoracic echocardiogram revealed aortic insufficiency only. Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. There was calcification and possible thrombus seen in the descending aorta. Cardiology did not feel the later was an indication for anticoagulation. She was discharged home on Isordil 20 tid, Metoprolol 25mg q12hours, and Ticlid 250mg bid.
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DESCRIPTION: Right pontine pyramidal tract infarct.

Right pontine pyramidal tract infarct.

neurology, mri brain, pontine stroke, difficulty with speech, hemiparesis, pontine pyramidal tract infarct, weakness, mri, brain, pyramidal, echocardiogram, pontine, infarct,

The scenario involves a patient who experienced a stroke, specifically a right pontine pyramidal tract infarct. Strokes are critical medical emergencies that require prompt diagnosis and treatment to prevent long-term disabilities or death. Although the patient's initial symptoms partially resolved and there was no major blockage found, her condition did worsen at a point, and she was treated with medications such as Ticlopidine and Heparin. The situation also involved cardiac concerns, further increasing the urgency. Overall, a stroke and potential complications such as worsening hemiparesis and angina are high stakes due to the severe consequences they can have if not managed appropriately.


Medical Specialty: Neurology
Sample Name: MRI Brain - Leukoencephalopathy

CC: ,Progressive left visual field loss.,HX:, This 46y/o RHF with polymyositis since 1988, presented with complaint of visual field loss since 12/94. The visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia. She began experiencing stiffness, numbness, tingling and incoordination of her left hand, 6 weeks prior to this admission,. These symptoms were initially attributed to carpal tunnel syndrome. MRI scan of the brain (done locally) on 6/23/95 revealed increased periventricular white matter signal on T2 images, particularly in the left temporo-occipital and right parietal lobes. There was ring enhancement of a lesion in the left occipital lobe on T1 gadolinium contrast enhanced images. There was gyral enhancement near the right Sylvian fissure. Cerebral angiogram on 7/19/95 (done locally) was unremarkable. Lumbar puncture on 7/19/95 was unremarkable. She complained of frequent holocranial throbbing headaches for the past 6 months; the HA's are associated with photophobia, phonophobia and nausea, but no vomiting. She has also been experiencing chills and night sweats for the past 2-3 weeks. She denies weight loss, but acknowledged decreased appetite and increased generalized fatigue for the past 3-4 months.,She was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness. She has been on immunosuppressive drugs since 1988, including Prednisone, Prednisone and methotrexate, Cyclosporin, Imuran, Cytoxan, and Plaquenil. At present she in ambulatory with use of walker. Her last CK=3,125 and ESR=16, on 6/28/95.,MEDS:, Prednisone 20mg qd, Cytoxan 75mg qd, Zantac 150mg bid, Vasotec 10mg bid, Premarin 0.625 qd, Provera 2.5mg qd, CaCO3 500mg bid, Vit D 50,000units qweek, Vit E qd, MVI 1 tab qd.,PMH:, 1)polymyositis diagnosed in 1988 by muscle biopsy. 2)hypertension. 3)lichen planus. 4)Lower extremity deep venous thrombosis one year ago--placed on Coumadin and this resulted in postmenopausal bleeding.,FHX:, Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years.,SHX:, Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.,EXAM:, BP160/74 HR95 RR12 35.8C Wt. 86.4kg Ht. 5'6",MS: A&O to person, place and time. Speech was normal. Mood euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. No RAPD noted. Optic Disk were flat. EOM testing unremarkable. Confrontational visual field testing revealed a left homonymous hemianopsia. The rest of the CN exam was unremarkable.,MOTOR: Upper extremities: 5/5 proximally, 5/4 @ elbow/wrist/hand. Lower extremities: 4/4 proximally and 5/5 @ and below knees.,SENSORY: unremarkable.,COORD: Dyssynergia of LUE FNF movement. Slowed finger tapping on left. HNS movements were normal, bilaterally.,Station: LUE drift and fix on arm roll. No Romberg sign elicited.,Gait: Waddling gait, but could TT and stand on both heels. She had difficulty with tandem walking, but did not fall to any particular side.,Reflexes: 2/2 brachioradialis and biceps. 2/2+ triceps, 1+/1+ patellae, 1/1 Achilles. Plantar responses were flexor on the right and withdrawal response on the left.,GEN EXAM: No rashes. II/VI systolic ejection murmur at the left sternal border.,COURSE:, Electrolytes, PT/PTT, Urinalysis and CXR were normal. ESR=38 (normal<20), CRP1.4 (normal<0.4). CK 2,917, LDH 356, AST 67. MRI Brain, 8/8/95, revealed slight improvement of the abnormal white matter changes seen on previous outside MRI. In addition new sphenoid sinus disease suggestive of sinusitis was seen. She underwent stereotactic biopsy of the right parietal region on 8/10/95 which on H&E and LFB stained sections revealed multiple discrete areas of demyelination, containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic, ground-glass nuclei, enlarged astrocytes, and sparse perivascular lymphocytic infiltrates. In situ hybridization performed on block A2 (at the university of Pittsburgh) is positive for JC virus. The ultrastructural studies demonstrated no viral particles.,She was tapered off all immunosuppressive medications and her polymyositis remained clinically stable. She had a seizure in 12/95 and was placed on Dilantin. Her neurologic deficits worsened slightly, but reached a plateau by 10/96, as indicated by a 4/14/97 Neurology clinic visit note.,1/22/96, MRI Brain demonstrated widespread hyperintense signal on T2 and Proton Density weighted images throughout the deep white matter in both hemispheres, worse on the right side. There was interval progression of previously noted abnormalities and extension into the right frontal and left parieto-occipital regions. There was progression of abnormal signal in the Basal Ganglia, worse on the right, and new involvement of the brainstem.
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DESCRIPTION: MRI Brain - Progressive Multifocal Leukoencephalopathy (PML) occurring in an immunosuppressed patient with polymyositis.

neurology, mri brain, pml, progressive multifocal leukoencephalopathy, polymyositis, visual field loss, leukoencephalopathy, lower extremity, field loss, white matter, visual field, signal, brain, mri,

The situation described involves a patient with a complex medical history, including immunosuppression and a suspected serious neurological condition, Progressive Multifocal Leukoencephalopathy (PML). PML is a rare and often fatal demyelinating disease of the central nervous system caused by the JC virus, particularly affecting immunocompromised individuals. The patient's symptoms, MRI findings, and medical management indicate a high-stakes scenario due to the potential for severe neurological impairment, life-threatening complications, and the need for highly specialized medical intervention. The management of PML requires careful consideration of immunosuppressive therapy versus the risk of disease progression, making it a significant and challenging issue for neurologists.


Medical Specialty: Neurology
Sample Name: MRI Brain - Cryptococcus

CC: ,Headache.,HX: ,This 37y/o LHM was seen one month prior to this presentation for HA, nausea and vomiting. Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. These symptoms had been recurrent since onset.,At presentation he complained of mild blurred vision (OU), difficulty concentrating and HA which worsened upon sitting up. The headaches were especially noticeable in the early morning. He described them as non-throbbing headaches. They begin in the bifrontal region and radiate posteriorly. They occurred up to 6 times/day. The HA improved with lying down or dropping the head down between the knees towards the floor. The headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. He denied any scotomata or positive visual phenomena. He denies any weakness, numbness, tingling, dysarthria or diplopia. His weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. His appetite has been especially poor in the past month.,MEDS:,Sulfasalazine qid. Tylenol 650mg q4hours.,PMH:, 1)Ulcerative Colitis dx 1989. 2)HTN 3) occasional HAs since the early 1980s which are different in character and much less severe than his current HAs. They were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking.,FHX:, MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.,SHX:, Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.,EXAM: ,BP159/92 HR 48 (sitting): BP126/70 HR48 (supine). RR14 36.2C,MS: A&O to person, place and time. Speech clear. Appears uncomfortable but acts appropriately and cooperatively. No difficulty with short and long term memory.,CN: Grad 2-3 papilledema OS; Grade 1 papilledema (@2 o'clock) OD. Pupils 4/4 decreasing to 2/2 on exposure to light. Bilateral horizontal sustained nystagmus on right and leftward gaze. Bilateral vertical sustained nystagmus on up and downward gaze. Face symmetric with full movement and PP sensation. Tongue midline with full ROM. Gag and SCM were intact bilaterally.,Motor: Full strength throughout with normal muscle bulk and tone.,Sensory: Unremarkable.,Coord: Mild dysynergia on FNF movements in BUE. HNS and RAM were unremarkable.,Station: Unsteady with and without eyes open on Romberg test. No drift in any particular direction.,Gait: Wide based, ataxic and to some degree magnetic and apraxic.,Gen Exam: Unremarkable.,COURSE:, Urinalysis revealed 1-2RBC, 2-3WBC and bacteria were noted. Repeat Urinalysis was negative the next day. PT, PTT, CXR and GS were normal. CBC revealed 10.4WBC with 7.1Granulocytes. HCT, 10/18/95, revealed hydrocephalus. MRI, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. There was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of Magendie. These changes were felt suggestive of bacterial or granulomatous meningitis. The patient underwent ventriculostomy on 10/19/94. CSF taken on 10/19/94 via V-P shunt insertion revealed: 22 WBC (21 lymphocytes, 1 monocyte), 380 RBC, Glucose 58, Protein 29, GS negative, Cultures (bacterial, fungal, AFB) negative, Cryptococcal Antigen and India Ink were negative. Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg/dl. Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions. VDRL and HIV testing was unremarkable. 10/27/94 and 10/31/94 CSF cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. The patient was treated with amphotericin and showed some improvement. However, scarring had probably occurred by then and the V-P shunt was left in place.
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DESCRIPTION: MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual.

neurology, ventriculomegaly, foramen of magendie, mri brain, blurred vision, headache, brain, ventricles, cryptococcus, foramen, csf,

The situation is quite high-stakes due to several factors: the patient is experiencing significant neurological symptoms that have resulted in a diagnosis of cryptococcal meningitis, a serious condition. This condition is usually seen in immunocompromised patients, but in this case, the individual is non-immunocompromised and HIV negative, making the situation rare and potentially more complex to manage. The presence of complications such as ventriculomegaly and the necessity for a V-P shunt suggests an urgent need for medical intervention and long-term management. The need for precise treatment to prevent further neurological damage or complications is critical.


Medical Specialty: Neurology
Sample Name: Limbic Encephalitis

CC:, Rapidly progressive amnesia.,HX: ,This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally. There was no mass affect. The areas mildly enhanced with gadolinium.,PMH:, 1) CAD; MI x 2 (1978 and 1979). 2) PVD; s/p aortic endarterectomy (3/1991). 3)HTN. 4)Bilateral inguinal hernia repair.,FHX/SHX:, Mother died of a stroke at age 58. Father had CAD and HTN. The patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. He had been a feed salesman all of his adult life.,ROS:, Unremarkable. No history of cancer.,EXAM:, BP 136/75 HR 73 RR12 T36.6,MS: Alert but disoriented to person, place, time. He could not remember his birthdate, and continually asked the interviewer what year it was. He could not remember when he married, retired, or his grandchildren's names. He scored 18/30 on the Follutein's MMSE with severe deficits in orientation and memory. He had moderate difficulty naming. He repeated normally and had no constructional apraxia. Judgement remained good.,CN: unremarkable.,Motor: Full strength throughout with normal muscle tone and bulk.,Sensory: Intact to LT/PP/PROP,Coordination: unremarkable.,Station: No pronator drift, truncal ataxia or Romberg sign.,Gait: unremarkable.,Reflexes: 3+ throughout with downgoing plantar responses bilaterally.,Gen Exam: unremarkable.,STUDIES:, MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor. EEG was normal awake and asleep. Antineuronal antibody screening was unremarkable. CSF studies were unremarkable and included varicella zoster, herpes zoster, HIV and HTLV testing, and cytology. The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes, but no organism or etiology was concluded. TFT, B12, VDRL, ESR, CRP, ANA, SPEP and Folate studies were unremarkable. Neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,IMPRESSION:, Limbic encephalitis secondary to cancer of unknown origin.,He was last seen 7/26/96. MMSE 20/30 and category fluency 20 . Disinhibited affect. Mild right grasp reflex. The clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .
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DESCRIPTION: Patient with a 1-year history of progressive anterograde amnesia

neurology, mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory,

The situation is a high-stakes medical case due to the serious and ongoing neurological symptoms the patient is experiencing, which significantly impact quality of life and cognitive function. Limbic encephalitis involves inflammation in critical regions of the brain responsible for memory, which can be life-threatening or lead to severe long-term impairment. While the clinical course is described as non-progressive, the underlying cause (likely paraneoplastic) indicates serious potential concerns related to cancer. Diagnosis and treatment are critical, necessitating prompt and careful evaluation by neurology and possibly oncology specialists.


Medical Specialty: Neurology
Sample Name: Lumbar Discogram

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.
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DESCRIPTION: Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.

neurology, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,

The lumbar discogram procedure involves injecting contrast dye into the intervertebral discs to diagnose sources of back pain. While it is an invasive procedure requiring careful preparation and execution, and carries some risks (e.g., infection, pain exacerbation, or nerve damage), it is considered routine in a controlled medical environment with experienced professionals. It's not life-threatening and doesn't involve immediate life-or-death decisions. Therefore, the situation is moderately risky but not extremely high-stakes in the context of medical procedures.


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

Medical Specialty: Neurology
Sample Name: Laminectomy & Foraminotomy Followup

REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was "restless leg syndrome" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.
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DESCRIPTION: Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.

neurology, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine,

The follow-up visit for a patient after a significant spinal surgery like an L4-L5 laminectomy, foraminotomies, and posterior spinal fusion with instrumentation does have important implications for the patient's recovery and quality of life. However, this specific situation appears to be lower-stakes than initially anticipated, as the patient is showing improvement, and there is no current indication for further surgery. The main concerns seem to be managing ongoing symptoms and ensuring no postoperative complications, which are crucial for the patient's quality of life and recovery, but the situation does not currently involve life-threatening conditions or immediate severe risks.


Medical Specialty: Neurology
Sample Name: Hepatic Encephalopathy

REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  He said that he was doing fine prior to that and denied having any complaints.  He was sitting watching TV and he felt sleepy.  So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  His head hit the toilet seat.  Then, he started having bleeding and had pain in the area with headache.  He did not lose consciousness as far as he can tell.  He went and woke up his sister.  This happened somewhere between 10:30 and 11 p.m.  His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology.  On his lab work, his ammonia was found to be markedly elevated at 106.  So, he is being admitted for management of this.  He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia.  He said he has been taking his medicines, but he could not recall those.  He denied having any symptoms prior to this fall.  He said earlier today he also fell.  He also said that this was an accidental fall caused by problem with his walker.  He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1.  Liver cirrhosis caused by alcohol.  This is per the patient.,2.  He thinks he is diabetic.,3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1.  He has a surgery on his stomach as a child.  He does not know the type.,2.  Surgery for a leg fracture.,3.  Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister.  He is separated from his wife who lives in Coolidge.  He smokes one or two cigarettes a day.  Denies drug abuse.  He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:,  Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL:  Denies fever or chills.  He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days.  He does not know the details.,ENT:  No visual changes.  No runny nose.  No sore throat.,CARDIOVASCULAR:  No syncope, chest pain, or palpitations.,RESPIRATORY:  No cough or hemoptysis.  No dyspnea.,GI:  No abdominal pain.  No nausea or vomiting.  No GI bleed.  History of alcoholic liver disease.,GU:  No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL:  Denies any acute joint pain or swelling.,SKIN:  No new skin rashes or itching.,CNS:  Had a seizure many years ago with no recurrences.  Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE:  He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL:  The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT:  His skull has a scar on the left side from previous surgery.  On the back of his head, there is a laceration, which has two staples on.  It is still oozing minimally.  It is tender.  No other traumatic injury is noted.  Eyes, pupils react to light.  Sclerae anicteric.  Nostrils are normal.  Oral cavity is clear with no thrush or exudate.,NECK:  Supple.  Trachea midline.  No JVD.  No thyromegaly.,LYMPHATICS:  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.  Regular rate and rhythm.,ABDOMEN:  Soft, distended, nontender.  No organomegaly or masses.,LOWER EXTREMITIES:  +1 edema bilaterally.  Pulses strong bilaterally.  No skin ulcerations noted.  No erythema.,SKIN:  Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK:  No tenderness by exam.,RECTAL:  No masses.  No abscess.  No rectal fissures.  Guaiac was performed by me and it was negative.,NEUROLOGIC:  He is alert and oriented x2.  He is slow to some extent in his response.  No asterixis.  Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  Increased tone noted in upper and lower extremities on the right compared to the left.  Deep tendon reflexes are +3 on the right and +2 on the left.  Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  The upper extremity is +4/5.  Lower extremity is 3/5.  The left side has a normal strength.  Sensation appears to be intact.  Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC:  Flat affect.  Mood appeared to be appropriate.  No active hallucinations or psychotic symptoms.,LABORATORY DATA:
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DESCRIPTION: A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.

The patient's condition involves hepatic encephalopathy, a serious complication of liver cirrhosis, and he has had a recent fall with head trauma. While the CT ruled out acute intracranial pathology, his elevated ammonia levels indicate a risk for increased confusion and potential for further neurological compromise, which are high-stakes in managing hepatic encephalopathy. The patient's history of alcohol use and lack of clarity about his medical regimen add complexity and urgency to his current health situation.


Medical Specialty: Neurology
Sample Name: Intractable Epilepsy

CHIEF COMPLAINT:,  Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms.  Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis.  He has had severe global developmental delay, and is nonverbal.  He can follow objects with his eyes, but has no ability to interact with his environment to any great degree.  He has noted if any purposeful use of the hands.  He has abnormal movements constantly, which are more choreiform and dystonic.  He has spastic quadriparesis, which is variable at times.  The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms.  I began seeing him at 20 months of age.  At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms.  The patient had benefit from this medication, and was doing well at that time with regard to that seizure type.  He initially was on phenobarbital, which failed to give him benefit.  He continued on phenobarbital; however, for a long period time thereafter.  The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly.  Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2.  Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense.  It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day.  These events manifest as tonic spells with eye deviation and posturing.  Mother reports flexion of the upper extremities, extension with lower extremities.  During that time, he is not able to cry or say any sounds.  These events last from seconds to minutes, and occur at least multiple times per week.  There are times where he has none for a few days and other times where he has multiple days in a row with events.  He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout.  He may vomit after these episodes, then seems to calm down.  It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:,  The patient's medications include Lamictal for a total of 200 mg twice a day.  It is a 150 mg tablet and 25 mg tablets.  He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day.  He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias.  No respiratory or cardiovascular complaints.  He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a slender male who is microcephalic.  He has EEG electrodes in place and is on the video EEG at that time.,HEENT:  His oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Benign with G-tube in place.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL:  The patient is alert and has bilateral esotropia.  He is able to fix and follow objects briefly.  He is unable to reach for objects.  He exhibits constant choreiform movements when excited.  These are more prominent in the upper extremities and lower extremities.  He has some dystonic posture with flexion of the wrist and fingers bilaterally.  He also has plantar flexion at the ankles bilaterally.  His cranial nerves reveal that his pupils are equal, round, and reactive to light.  Extraocular movements are intact other than bilateral esotropia.  His face moves symmetrically.  Palate elevates in midline.  Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above.  He has clonus at the ankles bilaterally, and some valgus contracture of the ankles.  His sensation is intact to light touch bilaterally.  Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy.  He has microcephaly as well as dystonic cerebral palsy.  He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort.  He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types.  He will remain hospitalized for probably at least 48 hours to 72 hours.  He could be discharged sooner if multiple events are captured.  His medications, we will continue his current dose of Zonegran and Lamictal for now.  Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.
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DESCRIPTION: Intractable epilepsy, here for video EEG.

neurology, brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg,

This is a high-stakes medical situation involving a child with intractable epilepsy and other serious neurological and developmental issues. The patient has a history of complex seizures and congenital brain malformations, requiring precise and possibly urgent medical interventions to manage his condition and improve his quality of life. The ongoing video EEG monitoring is crucial for capturing seizure events to better understand and manage the seizures. The stakes are high due to the potential impact on the child's health, development, and well-being if not properly managed.