Medical Specialty: Neurology
Sample Name: Huntington's Disease

CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed "fidgety movements" of his hand and feet.,He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect.,MEDS:, Fluoxetine.,PMH: ,1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy.,FHX:, Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice.,He and his wife have 2 adopted children.,SHX: ,unemployed. 2 years of college education. Married 22 years.,ROS: ,No history of Dopaminergic or Antipsychotic medication use.,EXAM:, Vital signs normal.,MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control.,CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable.,Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,There was no motor impersistence on tongue protrusion or hand grip.,COURSE:, He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only.,His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile.,6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally.
---
DESCRIPTION: Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.

The situation involves a patient with Huntington's Disease, a serious and progressive neurodegenerative disorder with significant impacts on motor skills, cognitive function, and mental health. The condition is known to lead to severe disability over time and has genetic implications, which poses a high-stakes situation for both the patient's quality of life and family members due to the hereditary nature of the disease. The description indicates that the patient's symptoms are progressive and worsening, confirming the high-stakes nature due to potential loss of independence and impact on daily living.


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

Medical Specialty: Neurology
Sample Name: Huntington's Disease - Consult

CHIEF COMPLAINT: , "A lot has been thrown at me.",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.
---
DESCRIPTION: This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.

This situation involves a 69-year-old woman with Huntington's disease who has made multiple recent suicide attempts. Her condition and actions pose immediate risks to her life, evidenced by her overdoses and a recent incident involving a firearm. Her history, coupled with the complexity of Huntington's disease and associated depression, creates a high-stakes situation. Immediate psychiatric intervention is required to ensure her safety and to address her mental health challenges.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurology
Sample Name: Headache - Office Visit

She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.
---
DESCRIPTION: The patient with continued problems with her headaches.

neurology, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran

The situation involves a patient with multiple chronic health conditions including severe neuropathies, uncontrolled diabetes (A1c of 10), a past history of stroke (CVA), and diabetic retinopathy. The stakes are heightened due to the potential risk of complications from uncontrolled diabetes and the necessity for coordinated management across multiple specialists. The ongoing headache issue adds complexity, requiring careful management to avoid worsening the patient's overall health status. Hence, the situation involves significant healthcare management challenges that can have serious implications if not addressed properly, indicating moderate to high stakes.


Medical Specialty: Neurology
Sample Name: Glioma - 2

CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with "bone cancer." AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992.
---
DESCRIPTION: Headache.  Right frontal lobe glioma.

Headache.  Right frontal lobe glioma.

neurology, frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma,

The patient has been diagnosed with a brain tumor (initially suspected to be glioblastoma, later diagnosed as xanthomatous astrocytoma). This situation inherently involves serious health concerns due to the potential for disease progression, risk from surgeries and treatments, and the impact on the patient's quality of life. The surgical interventions, radiation therapy, and chemotherapy being considered are all significant medical procedures with potential risks and side effects, making it a high-stakes medical scenario. The potential for tumor progression and life-threatening complications, along with the complexity of treatment, elevate the stakes.


Medical Specialty: Neurology
Sample Name: Glioma - 1

CC:, Dysarthria,HX: ,This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of "tumor or reactive lymphocytosis." One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR, Mammogram, PPD, ANA, TFT, and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images.,MEDS: ,none.,PMH:, 1)G3P3, 2)last menses one year ago.,FHX:, Mother suffered stroke in her 70's. DM and Htn in family.,SHX:, Married, Secretary, No h/o tobacco/ETOH/illicit drug use.,ROS:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,EXAM:, BP139/74, HR 90, RR20, 36.8C,MS: Drowsy to somnolent, occasionally "giddy." Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart).,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout. Normal muscle tone and bulk.,Sensory: No deficit to LT/PP/VIB/PROP.,Coord: difficulty with RAM in BUE, and ataxia on FNF and HKS in all extremities.,Station: Romberg sign present.,Gait: unsteady, wide-based, with notable difficulty on TW, TT and HW.,Reflexes: 2/2 BUE, 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45), Albumin 68 (normal 14-20), IgG10mg/dl (normal <6.2), IgG index -O.1mg/24hr (normal),,No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil), RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE, SPEP, Urine histoplasmin were negative.,Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted.,Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA, LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable.,She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma.,She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal , HSV, CMV and AFB cultures were negative. HSV, and VZV antigen was negative.,Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility.
---
DESCRIPTION: Dysarthria.  Probable brainstem glioma.

Dysarthria.  Probable brainstem glioma.

The situation involves a probable diagnosis of a brainstem glioma in a 52-year-old patient, who has exhibited a progressively worsening neurological condition. This has led to significant functional impairment, such as loss of ability to walk, somnolence, and the necessity for nasogastric tube feeding. The clinical deterioration and the potential life-threatening nature of the condition elevate the stakes significantly. Furthermore, the patient has been made Do Not Resuscitate (DNR) upon family request, indicating a serious consideration of end-of-life care. Such cases are often critical due to the impact on the patient's quality of life, prognosis, and the emotional and ethical implications for the patient's family and healthcare providers.


Medical Specialty: Neurology
Sample Name: Guillain-Barre Syndrome

CHIEF COMPLAINT: , Followup of hospital discharge for Guillain-Barre syndrome.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis.  She was admitted to the hospital.  The MRI showed only an old right basal ganglion infarct.  She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP.  The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms.  Her vital capacities were normal during the hospitalization.  Her chest x-ray was negative for any acute process.  She was discharged to rehab from July 12, 2006 to July 20, 2006.  She made some progress in which she notes that her walking is definitely better.  However, she notes that she still has some problems with eye movement and her vision.  This is possibly her main problem.  She also reports tightness and pain in her mid back.,REVIEW OF SYSTEMS:,  Documented in the clinic note.  The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Diabetes mellitus.,3.  Stroke involving the right basal ganglion.,4.  Guillain-Barre syndrome diagnosed in June of 2006.,5.  Bilateral knee replacements.,6.  Total abdominal hysterectomy and cholecystectomy.,FAMILY HISTORY:,  Multiple family members have diabetes mellitus.,SOCIAL HISTORY:,  The patient is retired on disability due to her knee replacements.  She does not smoke, drink or use any illicit drugs.,MEDICATIONS:,  Percocet 5/325 mg 4-6 hours p.r.n., Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d., Norvasc 10 mg q.d., glipizide ,10 mg q.d., fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d., and Zocor 1 mg q.d.,ALLERGIES: , No known drug allergies.,PHYSICAL EXAMINATION: , Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds.  Pain scale 5/10.  Please see the written note for details.  General exam is benign other than mild obesity.  On neuro examination, mental status is normal.  Cranial nerves are significant for full visual fields and pupils are equal and reactive.  However, extraocular movements are very limited.  She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move.  Face is symmetric.  Sensation is intact.  Tongue and uvula are in midline.  Palate is elevated symmetrically.  Shoulder shrug is strong.  The patient's muscle exam shows normal bulk and tone throughout.  She has no weakness of the left upper extremity.  In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5.  There is no drift or orbit.  Reflexes are absent throughout.  Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal.  There is no dysmetria.  Gait is somewhat limited possibly by her vision and possibly also by her balance problems.,PERTINENT DATA:,  As reviewed previously.,DISCUSSION: , This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.  The patient has shown some improvement with IVIG and continues to show some gradual improvement.  I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.,I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now.  She is scheduled to see an ophthalmologist.  I think it is reasonable for close followup of her visual symptoms progress.  However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually.,I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further.  I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week.  She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.,She was apparently given some baclofen by her internist and I think this is not unreasonable.  I definitely hope to get her off the Percocet in the future.,IMPRESSION:,1.  Guillain-Barre Miller-Fisher variant.,2.  Hypertension.,3.  Diabetes mellitus.,4.  Stroke.,RECOMMENDATIONS:,1.  The patient is to start taking aspirin 162 mg per day.,2.  Followup with ophthalmology.,3.  Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.,4.  Followup by phone in three to four weeks.,5.  Followup in this clinic in approximately two months' time.,6.  Call for any questions or problems.
---
DESCRIPTION: This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.

The patient's follow-up concerns a serious neurological condition, Guillain-Barre syndrome (Miller-Fisher variant), with complications including vision issues and muscle weakness. Given the combination of pre-existing conditions such as hypertension, diabetes, and a history of stroke, the patient is at significant risk for serious complications. The need for close monitoring and potential medication adjustments further emphasizes the high stakes, as Guillain-Barre syndrome can lead to severe health impacts if not properly managed.


Medical Specialty: Neurology
Sample Name: Essential Tremor & Torticollis

REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade.  She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam.  She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better.  She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity.  Since around 6 to 7 years, she has had a head tremor, which is mainly "no- no" and occasional voice tremor also.  Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart.  She also has some stress incontinence.  Last MRI brain was done in 2001 reportedly normal.,CURRENT MEDICATIONS:,1.  Klonopin 0.5 mg twice a day.,2.  Primidone 100 mg b.i.d.,3.  Propranolol long-acting 80 mg once in the morning.,PAST MEDICAL HISTORY: , Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,PAST SURGICAL HISTORY: , L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,FAMILY HISTORY: , Both parents have ET and hypertension.  Maternal cousin with lupus.,SOCIAL HISTORY: , Denies any smoking or alcohol.  She is married since 44 years, has 3 children.  She used to work as a labor and delivery nurse up until early 2001 when she retired.,REVIEW OF SYSTEMS: , No fever, chills, nausea or vomiting.  No visual complaints.  She complains of hearing decreased on the left.  No chest pain or shortness of breath.  No constipation.  She does give a history of urge incontinence.  No rashes.  No depressive symptoms.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg.  HEENT:  PERRLA.  EOMI.  CARDIOVASCULAR:  S1 and S2 normal.  Regular rate and rhythm.  She does have a rash over the right ankle with a prior basal cell carcinoma was resected.  NEUROLOGIC:  Alert and oriented x4.  Speech shows a voice tremor occasionally.  Language is intact.  Cranial nerves II through XII intact.  Motor examination showed 5/5 power in all extremities with minimal increased tone.  Sensory examination was intact to light touch.  Reflexes were brisk bilaterally, but they were equal and both toes were downgoing.  Her coordination showed minimal intentional component to bilateral finger-to-nose.  Gait was intact.  Lot of swing on Romberg's.  The patient did have a tremor both upper extremities, right more than left.  She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,ASSESSMENT AND PLAN: , This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.  The patient did not wish to change any of her medication doses at this point.  We will go ahead and check MRI brain, and we will get the films later.  We will see her back in 3 months.  Also, the patient declined any possible Botox for the mild torticollis she has at this point.
---
DESCRIPTION: This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.

neurology, clonazepam, difficulty writing, head tremor, voice tremor, migraine headaches, mri brain, essential tremor, torticollis, carcinoma,

The situation involves a patient's ongoing management of essential tremor and mild torticollis. While these conditions impact the patient's writing ability, they do not significantly affect other activities of daily living. Additionally, the patient is not currently in distress, experiencing severe symptoms, or requiring immediate changes to management such as medication adjustments or invasive procedures. Therefore, the situation is primarily a matter of monitoring and routine follow-up rather than an urgent or life-threatening scenario.


Medical Specialty: Neurology
Sample Name: Epidural Fluid Collection

CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired.
---
DESCRIPTION: Fall/loss of consciousness.

Fall/loss of consciousness.

neurology, loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone,

This case involves a serious traumatic brain injury resulting from a high fall, which led to extensive brain and skull injuries. The situation required immediate medical intervention, including surgery and life support measures, and ended in the patient's death. Given the life's threat posed by the injuries, and the subsequent decisions made about life-sustaining treatments, it is a high-stakes scenario involving critical and urgent medical decision-making.


Medical Specialty: Neurology
Sample Name: EMG/Nerve Conduction Study - 5

She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome.  She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine.  She has full strength in upper and lower extremities.  Normal straight leg raising.  Reflexes are 2 and symmetric throughout.  No Babinski.  She has numbness to light touch in her right big toe.,NERVE CONDUCTION STUDIES:  The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude.  Bilateral tibial motor nerves could not be obtained (technical).  The remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, F-waves, and H. reflexes.,NEEDLE EMG:  Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI.  It revealed 2+ spontaneous activity in the right APB and FDI and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres.  There was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,IMPRESSION:  This electrical study is abnormal.  It reveals the following:,1.  An active right C8/T1 radiculopathy.  Electrical abnormalities are moderate.,2.  An active right C6/C7 radiculopathy.  Electrical abnormalities are mild.,3.  Evidence of chronic left C8/T1 denervation.  No active denervation.,4.  Mild right lumbosacral radiculopathies.  This could not be further localized because of normal EMG testing in the lower extremity muscles.,5.  There is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,Results were discussed with the patient.  It appears that she has failed conservative therapy and I have recommended to her that she return to Dr. X for his assessment for possible surgery to her C-spine.  She will continue with conservative therapy for the mild lumbosacral radiculopathies.
---
DESCRIPTION: The patient is status post C3-C4 anterior cervical discectomy and fusion.

neurology, emg, nerve conduction study, needle emg, paraspinal muscles, radiculopathy, electrical abnormalities, carpal tunnel release, evoked response, lumbosacral radiculopathies, conservative therapy, carpal tunnel, conduction, emg/nerve,

The situation involves the interpretation of nerve conduction and EMG studies which have identified multiple radiculopathies and past medical procedures that have failed conservative management. The patient is being considered for possible cervical spine surgery which can have significant consequences if not appropriately managed. Any surgical intervention carries weight and potential risks such as neurological damage. However, the recommendation for surgery is a common step in radiculopathy management after conservative methods fail.


Medical Specialty: Neurology
Sample Name: EMG/Nerve Conduction Study - 7

HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.
---
DESCRIPTION: Patient had movor vehicle accirdent and may have had a brief loss of consciousness.  Shortly thereafter she had some blurred vision,  Since that time she has had right low neck pain and left low back pain.

neurology, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction,

The patient's symptoms following a motor vehicle accident, particularly the sudden onset of neurological symptoms (e.g., left-side numbness and pain) raise concerns about a potential central nervous system event, such as a transient ischemic attack (TIA) or stroke. The normal results from the EMG and MRI of the spine suggest no peripheral neuropathy or radiculopathy, pushing the investigation toward potential central causes. An upcoming MRI with contrast will further clarify the situation, making this a high-stakes scenario due to the potential for serious central nervous system issues. Early diagnosis and intervention are critical in such cases to prevent further complications.


Medical Specialty: Neurology
Sample Name: Electroencephalography

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

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

The EEG findings indicate significant abnormalities such as tremors suggesting possible Parkinson’s and left temporal sharps that could indicate seizures or structural abnormalities. Additionally, slowing in the right frontal region might point to serious conditions like a stroke or subdural hematoma. These findings are critical for determining the patient’s treatment plan and have potential implications for their health. Therefore, the situation involves crucial decision-making based on the findings, impacting the patient's quality of life and outcomes, hence it is high-stakes.


Medical Specialty: Neurology
Sample Name: Electroencephalogram - 2

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

neurology, referential electrodes, scalp, hyperventilation, photic stimulation, electroencephalogram

The EEG report indicates that the findings are essentially within normal limits, and clinical correlation is recommended. There is no immediate indication of a severe neurologic condition based on this EEG. However, the patient is experiencing dizziness, which could potentially indicate underlying issues that might need further investigation, but the current report does not indicate an immediate high-stakes situation.


Medical Specialty: Neurology
Sample Name: Electroencephalogram - 3

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

neurology, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The electroencephalogram (EEG) results indicate abnormalities in the brain's electrical activity, such as generalized slowing and sharp wave activity, which could signify neurological issues such as epilepsy, brain injury, or other disorders. While the immediate situation is not emergent, it requires medical evaluation and potential intervention, making it somewhat high-stakes as it pertains to diagnosing and managing potential neurological conditions.


Medical Specialty: Neurology
Sample Name: Dizziness - Recurrent

CHIEF COMPLAINT:,  Recurrent dizziness x1 month.,HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness.  She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  She is not able to describe what direction she feels like she is spinning.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.  She does note that it is worse when she turns to the right and when she turns to the left.  She also complains that she gets similar sensations when she looks up.  She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches.  She also notes occasional tinnitus to her right ear.,PAST MEDICAL HISTORY:,1.  CHF (uses portable oxygen).,2.  Atrial fibrillation.,3.  Gout.,4.  Arthritis (DJD/rheumatoid).,5.  Diabetes mellitus.,6.  Hypothyroidism.,7.  Hypertension.,8.  GERD.,9.  Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , She is married.  She does not smoke, use alcohol or use illicit drugs.,MEDICATIONS: , Please see medication sheet in the chart.  It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness).,REVIEW OF SYSTEMS:,  Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented.  Tinnitus in the right ear.  Diabetes and hypothyroidism.  Chronic nausea.  Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back.  Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking.  She says her mood is sad and may be depressed and she is also extremely anxious.  She has chronic shortness of breath and coughs easily when has to breathe deeply.  She also endorses poor sleep.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66.  Respiratory rate is 20.  Weight is 257 pounds.  Pain scale is 7.,GENERAL:  This is a somewhat anxious elderly African-American female who tends to amplify findings on examination.  It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw.  She is obese.,HEENT:  She is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  Tympanic membranes were visualized bilaterally.  There is tenderness to palpation of any sinus region.  There are no palpable cervical nodes.,NECK:  Supple although she complains of pain when rotating her neck.,CHEST:  Clear to auscultation bilaterally.,HEART:  Heart sounds are distant.  There are no carotid bruits.,EXTREMITIES:  She has 1-2+ pitting edema to the mid shins bilaterally.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  She is alert and oriented x3.  Her speech is fluent; however, she is extremely tangential.  She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation.,CRANIAL NERVES:  Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline.,MOTOR:  This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity.  There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout.  Her tone is normal throughout.,SENSORY:  She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg.  She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact.,COORDINATION:  There is no obvious dysmetria.,GAIT:  She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker.  There are some mild right lower extremity circumduction present.,REFLEXES:  Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent.  Toes are equivocal.,OTHER:  Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, "Oh my back, oh my back", and was unable to complete the maneuver.  Brief inspection of her eyes failed to show any nystagmus at that time.,IMPRESSION AND PLAN:,  This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology.  Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings.  I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise.  I agree with symptomatic treatment with Antivert.,We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency.  In addition, we will attempt to get further objective data by ENG testing.  I will see the patient again after these tests are completed and she has a trial of the Antivert.
---
DESCRIPTION: Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place.  She gets similar symptoms when she rolls over in bed.  At times, she also feels as though she is going to pass out.  These sensations stop if she just sits in one place or lies down for several minutes.

The patient presents with recurrent dizziness and possible benign positional vertigo. Although the symptoms are significant, this seems not to be immediately life-threatening, especially since there is no nystagmus observed and symptoms are temporarily relieved by lying down. However, given the patient's extensive medical history, including possible previous stroke and heart conditions, there is a necessary concern for underlying vascular issues such as vertebrobasilar insufficiency. Imaging and further testing have been planned, but at the moment, it does not appear to be critically high-stakes. The situation could escalate depending on the results of the tests, which is why it requires monitoring.


Medical Specialty: Neurology
Sample Name: CVA - Discharge Summary

DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.
---
DESCRIPTION: Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.

neurology, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident

The discharge summary for a patient with a cerebrovascular accident (CVA) indicates a situation that is medically significant and requires careful attention. The CVA itself is a serious medical condition, often associated with long-term outcomes, including potential disability. Although the patient's condition improved during the hospital stay, the presence of additional complications such as atherosclerotic cardiovascular disease, thrombocytopenia, and acute bronchitis adds complexity to their care. The medical practitioner must carefully manage these overlapping issues to prevent further complications. While the discharge prognosis is good, and the patient has shown improvement, the initial situation when admitted was high-stakes due to the potential severity of a stroke and its impact on the patient's recovery and well-being.


Medical Specialty: Neurology
Sample Name: CT Head, Facial Bones, Cervical Spine

EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.
---
DESCRIPTION: CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.

neurology, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical

This situation involves a 68-year-old patient who recently experienced a fall and is undergoing CT scans to assess potential injuries. The scans reveal subtle hemorrhagic contusions in the brain, sinus congestion, and degenerative changes in the cervical spine. These findings suggest non-life-threatening but significant injuries that could impact the patient's health and quality of life, particularly given the patient's age and the potential for falls to cause serious complications, such as brain contusions and spinal issues. While there's no immediate life-threatening condition identified, close monitoring and possibly additional imaging are recommended, which elevates the stakes to moderate due to the potential for complications if not properly addressed.


Medical Specialty: Neurology
Sample Name: CT Head - 3

REASON FOR EXAM:  ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS:  ,There is an approximately 5-mm shift of the midline towards the right side.  Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes.  There is loss of the cortical sulci on the right side.  These findings are compatible with edema.  Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact.  The visualized paranasal sinuses are clear.,IMPRESSION:  ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes.  A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density.  A postcontrast MRI is required for further characterization of this mass.  Gradient echo imaging should be obtained.
---
DESCRIPTION: Left arm and hand numbness.  CT head without contrast.  Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.

neurology, numbness, head, ct images, frontal, parietal, temporal, axial ct images, parietal and temporal, ct head, slice thickness, white matter, frontal parietal, temporal lobes, parietal lobe, edema, intact, noncontrast, mass, ct, lobes, arm,

The findings from the CT scan indicate a 5 mm midline shift and a significant edema in the right hemisphere of the brain. Additionally, a 1.8 cm hyperintense mass suggests the possibility of hemorrhage. These neurological findings could lead to severe consequences including increased intracranial pressure and potential for significant neurological impairment or life-threatening conditions. Immediate further investigation is crucial.


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

Medical Specialty: Neurology
Sample Name: CT Head and C Spine

CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:,  Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  There is no calvarial fracture.  The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE:  ,Noncontrast axial CT images of the cervical spine were obtained.  Sagittal and coronal images were obtained.,FINDINGS:,  Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms.  No fracture or subluxation is seen.  Anterior and posterior osteophyte formation is seen at C5-C6.  No abnormal anterior cervical soft tissue swelling is seen.  No spinal compression is noted.  The atlanto-dens interval is normal.  There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1.  Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2.  Degenerative disk and joint disease at C5-C6.,3.  Retention cyst versus polyp of the right maxillary sinus.
---
DESCRIPTION: Motor vehicle collision.  CT head without contrast and CT cervical spine without contrast.  Noncontrast axial CT images of the head were obtained.

neurology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast

This CT scan report is from a patient who was involved in a motor vehicle collision, which is potentially a high-stakes situation due to the possibility of serious injury. However, the CT head and cervical spine scans show no acute intracranial issues or fractures. While there are findings of degenerative changes and a possible retention cyst or polyp, these do not suggest immediate life-threatening conditions. The stakes are moderate because although the findings are not of acute concern, monitoring and follow-up care for the degenerative changes and the retention cyst are recommended.


Medical Specialty: Neurology
Sample Name: CT Head - 4

EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration.  There are no comparison studies.,FINDINGS:  ,There are no abnormal extraaxial fluid collections.  There is no midline shift or mass effect.  Ventricular system demonstrates no dilatation.  There is no evidence of acute intracranial hemorrhage.  The calvarium is intact.  There is a laceration in the left parietal region of the scalp without underlying calvarial fractures.  The mastoid air cells are clear.,IMPRESSION:  ,No acute intracranial process.
---
DESCRIPTION: CT head without contrast.  Assaulted, positive loss of consciousness, rule out bleed.  CT examination of the head was performed without intravenous contrast administration.

neurology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast,

The patient experienced a loss of consciousness following an assault, necessitating a CT scan to rule out serious conditions like intracranial hemorrhage. The results indicate no acute intracranial process, which is reassuring. While initially high-stakes due to the potential for serious brain injury, the findings alleviate immediate concern.


Medical Specialty: Neurology
Sample Name: CT Brain: Subdural hematoma

CC:, Progressive unsteadiness following head trauma.,HX:,  A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery.
---
DESCRIPTION: CT of Brain - Subacute SDH.

CT of Brain - Subacute SDH.

neurology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis,

The case involves a 77-year-old male with a subdural hematoma following a head injury, demonstrating progressive neurological symptoms including unsteadiness, facial weakness, and hemiparesis. Emergent medical intervention was required, a surgical evacuation was performed, and there was significant anatomical impact (midline shift). This represents a high-stakes situation due to the potential for severe outcomes like permanent neurological damage or life-threatening complications if not treated promptly.


Medical Specialty: Neurology
Sample Name: CT Brain - Calcification of Basal Ganglia

CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been "stumbling," when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand.  2) Hospitalized for an unknown "nervous" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell "world" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: "normal" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with "severe" aortic stenosis in the face of "normal" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia.
---
DESCRIPTION: CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).

neurology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain,

The situation involves a 78-year-old patient with significant neurological symptoms, including episodic mental status changes, right upper extremity numbness, and choreiform movements, alongside noticeable cognitive decline. The CT scan indicating basal ganglia calcification complicates the clinical picture, which includes suspected senile chorea and dementia. The stakes are high because of the potential for these symptoms to severely impact quality of life, the need for accurate diagnosis, and appropriate management of multiple complex conditions. Given the age and complex medical history, this patient's situation requires careful handling and possibly urgent intervention, elevating the situation to high-stakes.


Medical Specialty: Neurology
Sample Name: Creutzfeldt-Jakob Disease

CC:, Progressive memory and cognitive decline.,HX:, This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.,Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play "Murder She Wrote" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the "assassin." Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a "chuckle.",While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing "Murder She Wrote." She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.,She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.,Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was "Dementia of the Alzheimer's Type.",One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.,MEDS:, None.,PMH:, Unremarkable.,FHX:, Father and mother died in their 80's of "old age." There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.,SHX: ,She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.,EXAM:, Vitals signs were within normal limits.,MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared "child-like" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.,CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.,Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.,Station: No sign of Romberg or pronator drift. There was no truncal ataxia.,Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.,Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.,COURSE:,  CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD).
---
DESCRIPTION: Heidenhain variant of Creutzfeldt-Jakob Disease (CJD)

The case involves a diagnosis of Creutzfeldt-Jakob Disease (CJD), a rare and fatal neurodegenerative disorder. It is high-stakes due to its serious nature, rapid progression, and lack of effective treatment. The case study highlights the complexity and severity of symptoms leading to the eventual diagnosis. Such cases require careful handling, accurate diagnosis, and sensitive management, especially considering the terminal outcome for the patient.


Medical Specialty: Neurology
Sample Name: Craniotomy & Neuronavigation

PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.
---
DESCRIPTION: Right frontal craniotomy with resection of right medial frontal brain tumor.  Stereotactic image-guided neuronavigation and  microdissection and micro-magnification for resection of brain tumor.

neurology, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection,

The situation described involves a complex neurosurgical procedure, a right frontal craniotomy with resection of a brain tumor. This is a high-stakes situation because the procedure directly impacts the patient's brain, a critical organ, and involves risks such as bleeding, infection, neurological deficits, or even death. The stakes are further heightened by the patient's age, medical history of lung carcinoma, and symptoms suggestive of brain metastases. The use of advanced techniques such as neuronavigation and microdissection underscores the complexity and precision required, indicating the procedure's high-stakes nature.


Medical Specialty: Neurology
Sample Name: Consult - Seizures - 1

CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS:  ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.  The patient stated she was in her normal state of well being when she was experiencing having frequent seizures.  She lives in assisted living.  She has been falling more frequently.  The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this.  There was no head trauma, but apparently she was doing that many times and there was no responsiveness.  The patient has no memory of the event.  She is now back to her baseline.  She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred.  She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems.  The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY:  ,Include dyslipidemia and hypertension.,FAMILY HISTORY:  ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking.  No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:,  The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning.  The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL:  Normal.,NEUROLOGICAL:  As follows.  Right-handed female, normal orientation, normal recollection to 3 objects.  The patient has underlying MR. Speech, no aphasia, no dysarthria.  Cranial nerves, funduscopic intact without papilledema.  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  No nystagmus.  Her mood is intact.  Symmetric face sensation.  Symmetric smile and forehead.  Intact hearing.  Symmetric palate elevation.  Symmetric shoulder shrug and tongue midline.  Motor 5/5 proximal and distal.  The patient does have limp on the right lower extremity.  Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left.  Sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  The patient has trouble with ambulation.  She does have ataxia and uses a walker to ambulate.  There is no bradykinesia.  Romberg is positive to the left.  Cerebellar, finger-nose-finger is intact.  Rapid alternating movements are intact.  Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding.  Neck more than 16 to 17 inches, BMI elevated above 33.  Head and neck circumference very high.,IMPRESSION:,1.  Cerebral palsy, worsening seizures.,2.  Hypertension.,3.  Dyslipidemia.,4.  Obstructive sleep apnea.,5.  Obesity.,RECOMMENDATIONS:,1.  Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity.  Initial time of admission is 3 nights and 3 days.,2.  Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated.  Continue her other medications.,3.  Consult Dr. X for hypertension, internal medicine management.,4.  I will follow this patient per EMU protocol.
---
DESCRIPTION: Cerebral palsy, worsening seizures.  A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.

The situation involves a patient with a complex medical history, including cerebral palsy, worsening seizures, hypertension, dyslipidemia, obesity, and possible obstructive sleep apnea. Seizures are a particularly serious concern because they can lead to injury, loss of consciousness, and other complications. The patient is admitted for EMU monitoring to better characterize her seizures and adjust her treatment, indicating the critical nature of her condition. Additionally, her frequent falls and episodes of unresponsiveness while operating a scooter underscore the potential risks to personal safety. Overall, this is a high-stakes situation due to the direct implications for the patient's health and well-being, the need for precise medical intervention, and the risk of uncontrolled seizures.