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DESCRIPTION OF PROCEDURE:, After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture.

description procedure appropriate operative consent obtained patient brought supine operating room placed operating room table intravenous sedation administered retrobulbar block consisting xylocaine marcaine wydase administered right eye without difficulty patients right eye prepped draped sterile ophthalmic fashion procedure begun wire lid speculum inserted right eye limited conjunctival peritomy performed limbus temporally superonasally infusion line set inferotemporal quadrant two additional sclerotomies made superonasal superotemporal quadrants lens ring secured eye using vicryl suture

### Instruction: find the medical speciality for this medical test. ### Input: DESCRIPTION OF PROCEDURE:, After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture. ### Response: Ophthalmology, Surgery

DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.

description record tracing obtained utilizing pasteon goldplated surface disc electrodes placed according international system electrode impedances measured reported less kiloohms eachfindings general background rhythms bilaterally symmetrical resting awake state composed moderate amounts low amplitude fast activity intermixed moderate amounts wellmodulated hz alpha activity best seen posteriorly alpha activity attenuates eye openingduring portions tracing patient enters drowsy state background rhythms composed predominantly moderate amounts low amplitude fast activity intermixed moderate amounts low medium amplitude polymorphic theta activitythere evidence focal slowing paroxysmal activityimpression normal awake drowsy stage sleep eeg patients age

### Instruction: find the medical speciality for this medical test. ### Input: DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age. ### Response: Neurology

DESCRIPTION:, The patient was placed in the supine position and was prepped and draped in the usual manner. The left vas was grasped in between the fingers. The skin and vas were anesthetized with local anesthesia. The vas was grasped with an Allis clamp. Skin was incised and the vas deferens was regrasped with another Allis clamp. The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens. The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side. The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side. Dry sterile dressings were applied and the patient put on a scrotal supporter. The procedure was then terminated.

description patient placed supine position prepped draped usual manner left vas grasped fingers skin vas anesthetized local anesthesia vas grasped allis clamp skin incised vas deferens regrasped another allis clamp sheath incised scalpel elevated using iris scissors clamps used ligate vas deferens portion clamps excised ends vas clamped using hemoclips two testicular side one proximal side incision inspected hemostasis closed chromic catgut interrupted fashiona similar procedure carried right side dry sterile dressings applied patient put scrotal supporter procedure terminated

### Instruction: find the medical speciality for this medical test. ### Input: DESCRIPTION:, The patient was placed in the supine position and was prepped and draped in the usual manner. The left vas was grasped in between the fingers. The skin and vas were anesthetized with local anesthesia. The vas was grasped with an Allis clamp. Skin was incised and the vas deferens was regrasped with another Allis clamp. The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens. The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side. The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side. Dry sterile dressings were applied and the patient put on a scrotal supporter. The procedure was then terminated. ### Response: Surgery, Urology

DESCRIPTION:,1. Normal cardiac chambers size.,2. Normal left ventricular size.,3. Normal LV systolic function. Ejection fraction estimated around 60%.,4. Aortic valve seen with good motion.,5. Mitral valve seen with good motion.,6. Tricuspid valve seen with good motion.,7. No pericardial effusion or intracardiac masses.,DOPPLER:,1. Trace mitral regurgitation.,2. Trace tricuspid regurgitation.,IMPRESSION:,1. Normal LV systolic function.,2. Ejection fraction estimated around 60%.,

description normal cardiac chambers size normal left ventricular size normal lv systolic function ejection fraction estimated around aortic valve seen good motion mitral valve seen good motion tricuspid valve seen good motion pericardial effusion intracardiac massesdoppler trace mitral regurgitation trace tricuspid regurgitationimpression normal lv systolic function ejection fraction estimated around

### Instruction: find the medical speciality for this medical test. ### Input: DESCRIPTION:,1. Normal cardiac chambers size.,2. Normal left ventricular size.,3. Normal LV systolic function. Ejection fraction estimated around 60%.,4. Aortic valve seen with good motion.,5. Mitral valve seen with good motion.,6. Tricuspid valve seen with good motion.,7. No pericardial effusion or intracardiac masses.,DOPPLER:,1. Trace mitral regurgitation.,2. Trace tricuspid regurgitation.,IMPRESSION:,1. Normal LV systolic function.,2. Ejection fraction estimated around 60%., ### Response: Cardiovascular / Pulmonary, Radiology

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.

diagnoses admission cerebrovascular accident cva right arm weakness bronchitis atherosclerotic cardiovascular disease hyperlipidemia thrombocytopeniadiagnoses discharge cerebrovascular accident right arm weakness mri indicating acutesubacute infarct involving left posterior parietal lobe without mass effect old coronary infarct anterior aspect right external capsule acute bronchitis reactive airway disease thrombocytopenia likely due old coronary infarct anterior aspect right external capsule atherosclerotic cardiovascular disease hyperlipidemiahospital course patient admitted emergency room plavix started addition baby aspirin kept oral zithromax cough given xopenex treatment respiratory distress carotid ultrasound reviewed revealed obstruction left internal carotid dr x saw consultation recommended ct angiogram showed significant obstructive lesion known ultrasound head mri done revealed findings patient begun pt improved discharge much improved strength right arm progressions cough improved oral zithromax nebulizer treatments platelets also improved well discharge platelets hh stable white count normal differential chest xray revealed mild elevated right hemidiaphragm infiltrate last chemistry panel december sodium potassium chloride co glucose bun creatinine calcium ptinr admission ptt time discharge patients cough much improved right arm weakness much improved lung examination occasional rhonchi changed metered dose inhaler albuterol discharged home echocardiogram revealed mild concentric lvh normal left ventricular function ef moderate left atrial enlargement diastolic dysfunction mild mitral regurgitation follow office week start pt ot outpatient avoid driving car notify symptoms doses zithromax home complete prognosis good

### Instruction: find the medical speciality for this medical test. ### Input: 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. ### Response: Cardiovascular / Pulmonary, Discharge Summary, Neurology

DIAGNOSES PROBLEMS:,1. Orthostatic hypotension.,2. Bradycardia.,3. Diabetes.,4. Status post renal transplant secondary polycystic kidney disease in 1995.,5. Hypertension.,6. History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7. History of renal osteodystrophy.,8. Iron deficiency anemia.,9. Cataract status post cataract surgery.,10. Chronic left lower extremity pain.,11. Hyperlipidemia.,12. Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:, Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine. She briefly was on Cymbalta; however, this was discontinued when she was transferred back. She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued. She was able to maintain her pressures then was able to ambulate without difficulty. We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1. CellCept - 500 mg twice a daily.,2. Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3. Prednisone - 5 mg once daily.,4. Hydralazine - 10 mg four times a day.,5. Pantoprazole - 40 mg once daily.,6. Glipizide - 5 mg every morning.,7. Aspirin - 81 mg once daily.,FOLLOWUP CARE: ,The patient is to follow up with Dr. X in about 1 week's time.

diagnoses problems orthostatic hypotension bradycardia diabetes status post renal transplant secondary polycystic kidney disease hypertension history basal cell ganglia cerebrovascular event left residual history renal osteodystrophy iron deficiency anemia cataract status post cataract surgery chronic left lower extremity pain hyperlipidemia status post hysterectomy secondary uterine fibroidsprocedures telemetry monitoringhistory findings hospital course patient originally hospitalized secondary dizziness disequilibrium extensive workup first hospitalization negative prominent feature blunted affect real anhedonia transferred briefly psychiatry however second day psychiatry became orthostatic transferred acutely back medicine briefly cymbalta however discontinued transferred back monitored back medicine hours given intravenous fluids discontinued able maintain pressures able ambulate without difficulty wanted pursue workup possible causes autonomic dysfunction however patient interested remaining hospital anymore left really recommendationsdischarge medications cellcept mg twice daily cyclosporine mg morning mg evening prednisone mg daily hydralazine mg four times day pantoprazole mg daily glipizide mg every morning aspirin mg dailyfollowup care patient follow dr x weeks time

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSES PROBLEMS:,1. Orthostatic hypotension.,2. Bradycardia.,3. Diabetes.,4. Status post renal transplant secondary polycystic kidney disease in 1995.,5. Hypertension.,6. History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7. History of renal osteodystrophy.,8. Iron deficiency anemia.,9. Cataract status post cataract surgery.,10. Chronic left lower extremity pain.,11. Hyperlipidemia.,12. Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:, Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine. She briefly was on Cymbalta; however, this was discontinued when she was transferred back. She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued. She was able to maintain her pressures then was able to ambulate without difficulty. We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1. CellCept - 500 mg twice a daily.,2. Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3. Prednisone - 5 mg once daily.,4. Hydralazine - 10 mg four times a day.,5. Pantoprazole - 40 mg once daily.,6. Glipizide - 5 mg every morning.,7. Aspirin - 81 mg once daily.,FOLLOWUP CARE: ,The patient is to follow up with Dr. X in about 1 week's time. ### Response: Cardiovascular / Pulmonary

DIAGNOSES,1. Term pregnancy.,2. Possible rupture of membranes, prolonged.,PROCEDURE:, Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:, The patient is a 20-year-old female, gravida 4, para 0, who presented to the office. She had small amount of leaking since last night. On exam, she was positive Nitrazine, no ferning was noted. On ultrasound, her AFI was about 4.7 cm. Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin. Once she was in her regular pattern, we ruptured her bag of water; fluid was clear. She went rapidly to completion over the next hour and a half. She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation. Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications. The baby was vigorous, moving all extremities. The cord was clamped and cut. The baby was handed off to mom with nurse present. Apgars were 8 and 9. Placenta was delivered spontaneously, intact. Three-vessel cord with no retained placenta. Estimated blood loss was about 150 mL. There were no tears.

diagnoses term pregnancy possible rupture membranes prolongedprocedure induction vaginal delivery viable male apgars hospital course patient yearold female gravida para presented office small amount leaking since last night exam positive nitrazine ferning noted ultrasound afi cm variable cervix oligohydramnios possible ruptured membranes recommended inductionshe brought hospital begun pitocin regular pattern ruptured bag water fluid clear went rapidly completion next hour half pushed hours delivering viable male intact perineum oa presentation upon delivery head anterior posterior arms delivered remainder baby without complications baby vigorous moving extremities cord clamped cut baby handed mom nurse present apgars placenta delivered spontaneously intact threevessel cord retained placenta estimated blood loss ml tears

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSES,1. Term pregnancy.,2. Possible rupture of membranes, prolonged.,PROCEDURE:, Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:, The patient is a 20-year-old female, gravida 4, para 0, who presented to the office. She had small amount of leaking since last night. On exam, she was positive Nitrazine, no ferning was noted. On ultrasound, her AFI was about 4.7 cm. Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin. Once she was in her regular pattern, we ruptured her bag of water; fluid was clear. She went rapidly to completion over the next hour and a half. She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation. Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications. The baby was vigorous, moving all extremities. The cord was clamped and cut. The baby was handed off to mom with nurse present. Apgars were 8 and 9. Placenta was delivered spontaneously, intact. Three-vessel cord with no retained placenta. Estimated blood loss was about 150 mL. There were no tears. ### Response: Obstetrics / Gynecology, Surgery

DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program. Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.

diagnoses traumatic brain injury cervical musculoskeletal straindischarge summary patient seen evaluation followed treatment sessions treatment consisted neuromuscular reeducation including therapeutic exercise improve range motion strength coordination functional mobility training selfcare training cognitive retraining caregiver instruction home exercise program goals achieved patient admitted inpatient rehabilitation centerrecommendations discharged ot date patient admitted inpatient rehabilitation centerthank referral

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program. Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral. ### Response: Discharge Summary

DIAGNOSES:,1. Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2. Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion. She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis. She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness. She was treated per pathway orders. However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission. There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained. We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe. However, the rest of the lungs were normal and the heart was also normal. There were no complications during her hospitalization and she continued to be stable and eating better. On day 2 of the admission, it was decided she was okay to go home. Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this. During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care. The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Vital signs were stable within normal limits on room air.,GENERAL: She is sleeping and in no acute distress.,HEENT: Her anterior fontanelle was soft and flat. She does have some upper airway congestion.,CARDIOVASCULAR: Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES: Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS: Her lungs did show some slight coarseness, but good air movement with equal breath sounds. She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases. She did not have any respiratory distress while she was asleep.,ABDOMEN: Normal bowel sounds. Soft and nondistended.,GENITOURINARY: She is Tanner I female.,DISCHARGE WEIGHT:, Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY: No one should smoke near The patient. She should also avoid all other exposures to smoke such as from fireplaces and barbecues. She is to avoid contact with other infants since she is sick and they are to limit travel. There should be frequent hand washings.,DIET: Regular diet. Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS: She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:, Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,

diagnoses bronchiolitis respiratory syncytial virus positive improved stable innocent heart murmur stablehospital course patient admitted acute onset congestion checked rsv positive admitted hospital acute bronchiolitis always stable room air however age early diagnosis admitted observation rsv bronchiolitis typically worsens third fourth day illness treated per pathway orders however second day admission patient quite eating well parents live far away little bit trouble first night admission heart murmur heard sounded innocent yet chest xray obtained obtain chest xray show slight perihilar infiltrate right upper lobe however rest lungs normal heart also normal complications hospitalization continued stable eating better day admission decided okay go home mother advised regarding signs symptoms increased respiratory distress includes tachypnea increased retractions grunting nasal flaring etc comfortable looking hospitalization albuterol mdi given patient mom learn outpatient care patient receive couple doses significant respiratory distress discharged improved conditiondischarge physical examinationvital signs afebrile vital signs stable within normal limits room airgeneral sleeping acute distressheent anterior fontanelle soft flat upper airway congestioncardiovascular regular rate rhythm systolic murmur radiates bilateral axilla backextremities femoral pulses extremities warm well perfused good capillary refilllungs lungs show slight coarseness good air movement equal breath sounds wheezes time scattered crackles bilateral bases respiratory distress asleepabdomen normal bowel sounds soft nondistendedgenitourinary tanner femaledischarge weight weight discharge kg grams admissiondischarge instructions activity one smoke near patient also avoid exposures smoke fireplaces barbecues avoid contact infants since sick limit travel frequent hand washingsdiet regular diet continue breastfeeding much possible encourage oral intakemedications sent home albuterol mdi used needed cough wheezes dyspneaadditional instructions mom quite comfortable bulb suctioning nose saline know return immediately starts difficulty breathing stops breathing decides want eat

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSES:,1. Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2. Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion. She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis. She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness. She was treated per pathway orders. However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission. There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained. We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe. However, the rest of the lungs were normal and the heart was also normal. There were no complications during her hospitalization and she continued to be stable and eating better. On day 2 of the admission, it was decided she was okay to go home. Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this. During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care. The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Vital signs were stable within normal limits on room air.,GENERAL: She is sleeping and in no acute distress.,HEENT: Her anterior fontanelle was soft and flat. She does have some upper airway congestion.,CARDIOVASCULAR: Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES: Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS: Her lungs did show some slight coarseness, but good air movement with equal breath sounds. She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases. She did not have any respiratory distress while she was asleep.,ABDOMEN: Normal bowel sounds. Soft and nondistended.,GENITOURINARY: She is Tanner I female.,DISCHARGE WEIGHT:, Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY: No one should smoke near The patient. She should also avoid all other exposures to smoke such as from fireplaces and barbecues. She is to avoid contact with other infants since she is sick and they are to limit travel. There should be frequent hand washings.,DIET: Regular diet. Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS: She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:, Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat., ### Response: Cardiovascular / Pulmonary, Discharge Summary

DIAGNOSES:,1. Cervical dystonia.,2. Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone. The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:, The patient is appropriate. She is well dressed and oriented x3. She still smells of some cigarette smoke. Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles. There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved. On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding. This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:, After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles. A total of 400 units of Botox is anticipated. The procedure is being scheduled. The patient's medications are refilled. She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.

diagnoses cervical dystonia post cervical laminectomy pain syndromems xyz states pain shifted left side noticed marked improvement right side subject botulinum toxin injection two weeks ago side effects botox injection feels activities daily living increased still oxycodone methadone patients husband confirms fact lot better active still issues yet regarding anxiety depression frustration regarding pain neckphysical examination patient appropriate well dressed oriented x still smells cigarette smoke examination neck shows excellent reduction muscle spasm right paraspinals trapezius splenius capitis muscles trigger points felt range motion neck still somewhat guarded much improved left side however significant muscle spasm tight bands involving multifidus muscle trigger point activity lot tenderness guarding extends trapezius muscle splenius capitis seems involvedtreatment plan long discussion patient husband decided go ahead botulinum toxin injection left multifidustrapezius muscles total units botox anticipated procedure scheduled patients medications refilled continue see dr berry continue therapy mary hotchkinson victoria

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSES:,1. Cervical dystonia.,2. Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone. The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:, The patient is appropriate. She is well dressed and oriented x3. She still smells of some cigarette smoke. Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles. There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved. On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding. This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:, After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles. A total of 400 units of Botox is anticipated. The procedure is being scheduled. The patient's medications are refilled. She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria. ### Response: Orthopedic, Pain Management, SOAP / Chart / Progress Notes

DIAGNOSES:,1. Disseminated intravascular coagulation.,2. Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy.,PAST MEDICAL HISTORY: ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY: ,There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY: ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place.,NECK: No jugular venous pressure distention.,CHEST: Coarse breath sounds bilaterally.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line.,EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES: ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN: ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time.

diagnoses disseminated intravascular coagulation streptococcal pneumonia sepsischief complaint unobtainable patient intubated respiratory failurecurrent history present illness yearold female presented symptoms pneumonia developed rapid sepsis respiratory failure requiring intubation time treated aggressively mechanical ventilation supportive measures developed disseminated intravascular coagulation prolonged partial thromboplastin time prothrombin time low fibrinogen elevated ddimer time consulted evaluation recommendations treatment nurses report actually improved clinically last hours bleeding problem however seems abrogated time factor replacement well platelet infusion prior history coagulopathypast medical history otherwise nondescript past surgical historysocial history possible illicit drugs family present discussed case mother sisterfamily history otherwise noncontributoryreview systems otherwise pertinentphysical examinationgeneral sedated young black female acute distress lying bed intubatedvital signs rate blood pressure respiratory rate per ventilator approximately heent sclerae showed conjunctival hemorrhage petechiae nasal vestibules clear oropharynx et tube placeneck jugular venous pressure distentionchest coarse breath sounds bilaterallyheart regular rate rhythmabdomen soft nontender good bowel sounds oozing around site central lineextremities clubbing cyanosis edema evidence compromise arterial blood flow digits hands feetlaboratory studies dic parameters platelet count approximately inr normal ptt time fibrinogen ddimer impressionplan time disseminated intravascular coagulation sepsis pneumococcal disease recommendation patient continue factor replacement seems clinical course reversing simple factor replacement probably best measure time indication point xigris however coagulopathy resolve within next hours continue improve elevated fibrinogen normalization coagulation times would consider lowdose continuous infusion heparin abrogation consumption coagulation routines continued supportive infusions repeat laboratory studies morning give recommendations time

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSES:,1. Disseminated intravascular coagulation.,2. Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy.,PAST MEDICAL HISTORY: ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY: ,There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY: ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place.,NECK: No jugular venous pressure distention.,CHEST: Coarse breath sounds bilaterally.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line.,EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES: ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN: ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time. ### Response: Consult - History and Phy., General Medicine, Hematology - Oncology

DIAGNOSES:,1. Juvenile myoclonic epilepsy.,2. Recent generalized tonic-clonic seizure.,MEDICATIONS:,1. Lamictal 250 mg b.i.d.,2. Depo-Provera.,INTERIM HISTORY: , The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She has not had a generalized seizure. She is very concerned that this will occur. Most of the myoclonus is in the mornings. Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left. She states that she has been very compliant with the medications and is getting a good amount of sleep. She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal. Pupils are equal and reactive to light. Extraocular movements are intact. There is no nystagmus. Visual fields are full. Demeanor is normal. Facial sensation and symmetry is normal. No myoclonic jerks noted during this examination. No myoclonic jerks provoked by tapping on her upper extremity muscles. Negative orbit. Deep tendon reflexes are 2 and symmetric. Gait is normal. Tandem gait is normal. Romberg negative.,IMPRESSION AND PLAN:, Recurrence of early morning myoclonus despite high levels of Lamictal. She is tolerating the medication well and has not had a generalized tonic-clonic seizure. She is concerned that this is a precursor for another generalized seizure. She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra. This was thought secondary to severe insomnia when her baby was very young. Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d. Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.

diagnoses juvenile myoclonic epilepsy recent generalized tonicclonic seizuremedications lamictal mg bid depoproverainterim history patient returns followup since last consultation tolerated lamictal well recurrence myoclonic jerking generalized seizure concerned occur myoclonus mornings recent eeg show polyspike slow wave complexes bilaterally prominent left states compliant medications getting good amount sleep continues drivesocial history review systems discussed documented chartphysical examination vital signs normal pupils equal reactive light extraocular movements intact nystagmus visual fields full demeanor normal facial sensation symmetry normal myoclonic jerks noted examination myoclonic jerks provoked tapping upper extremity muscles negative orbit deep tendon reflexes symmetric gait normal tandem gait normal romberg negativeimpression plan recurrence early morning myoclonus despite high levels lamictal tolerating medication well generalized tonicclonic seizure concerned precursor another generalized seizure states compliant medications normal sleepwake cyclelooking back notes initially responded well keppra breakthrough seizure keppra thought secondary severe insomnia baby young tolerated medication well least partially affective recommended adding keppra mg bid side effect profile medication discussed patienti see followup three months

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSES:,1. Juvenile myoclonic epilepsy.,2. Recent generalized tonic-clonic seizure.,MEDICATIONS:,1. Lamictal 250 mg b.i.d.,2. Depo-Provera.,INTERIM HISTORY: , The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She has not had a generalized seizure. She is very concerned that this will occur. Most of the myoclonus is in the mornings. Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left. She states that she has been very compliant with the medications and is getting a good amount of sleep. She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal. Pupils are equal and reactive to light. Extraocular movements are intact. There is no nystagmus. Visual fields are full. Demeanor is normal. Facial sensation and symmetry is normal. No myoclonic jerks noted during this examination. No myoclonic jerks provoked by tapping on her upper extremity muscles. Negative orbit. Deep tendon reflexes are 2 and symmetric. Gait is normal. Tandem gait is normal. Romberg negative.,IMPRESSION AND PLAN:, Recurrence of early morning myoclonus despite high levels of Lamictal. She is tolerating the medication well and has not had a generalized tonic-clonic seizure. She is concerned that this is a precursor for another generalized seizure. She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra. This was thought secondary to severe insomnia when her baby was very young. Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d. Side effect profile of this medication was discussed with the patient.,I will see in followup in three months. ### Response: Neurology

DIAGNOSES:,1. Pneumonia.,2. Crohn disease.,3. Anasarca.,4. Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY: ,The patient is a 41-year-old gentleman with a long history of Crohn disease. He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months. He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers. This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital. He has been treated with IV antibiotics and is growing Streptococcus. At this time, he seems relatively stable although slightly dyspneic. Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities. At this time, he continues to have symptoms consistent with diarrhea and malabsorption. He also has some episodes of nausea and vomiting at times. He currently has a cough and symptoms of dyspnea. Further review of systems was not otherwise contributory.,MEDICATIONS:,1. Prednisone.,2. Effexor.,3. Folic acid.,4. Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1. Small bowel resections.,2. Appendectomy.,3. A vasectomy.,ALLERGIES: ,He has no known drug allergies.,SOCIAL HISTORY: ,He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter.,FAMILY HISTORY: ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL: He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS: His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT: Sclerae anicteric. Conjunctivae normal. Nasal and oropharynx are clear.,NECK: Supple. No jugular venous pressure distention is noted. There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST: Reveals some crackles in the right chest, in the base, and in the upper lung fields. His left is relatively clear with decreased breath sounds.,HEART: Regular rate and rhythm.,ABDOMEN: Slightly protuberant. Bowel sounds are present. He is slightly tender and it is diffuse. There is no organomegaly and no ascites appreciable.,EXTREMITIES: There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC: Shows thin skin. No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3. There is no M-spike observed. His B12 is 500 with a folic acid of 11. His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1. Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate. I believe that he needs a calorie count. We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered. I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist. I will help in anyway that I can to improve the patient's laboratory abnormalities. However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time. I have explained this in detail to the patient and his family. Everybody expresses understanding and all questions were answered. At this time, follow him up during his hospital stay and plan to see him in the office as well.

diagnoses pneumonia crohn disease anasarca anemiachief complaint lot swelling legshistory patient yearold gentleman long history crohn disease followed dr abc primary care doctor states multiple gastroenterology doctors seen one past year months treated multiple different medications crohn disease recently taking pulses steroids felt like symptoms consistent crampy abdominal pain increased diarrhea lowgrade fevers helped past developed symptoms consistent pneumonia admitted hospital treated iv antibiotics growing streptococcus time seems relatively stable although slightly dyspneic symptoms include lower extremity edema pain ankles knees actually symptoms edema entire body including face upper extremities time continues symptoms consistent diarrhea malabsorption also episodes nausea vomiting times currently cough symptoms dyspnea review systems otherwise contributorymedications prednisone effexor folic acid norco painpast medical history mentioned also anxiety depressionpast surgical history small bowel resections appendectomy vasectomyallergies known drug allergiessocial history smoke two packs cigarettes per day alcohol drug use painterfamily history significant father died ipf irritable bowel syndromereview systems mentioned history present illness review systems otherwise contributoryphysical examinationgeneral thin appearing man mild respiratory distress oxygen offvital signs respiratory rate approximately blood pressure pulse regular afebrile currently weight approximately poundsheent sclerae anicteric conjunctivae normal nasal oropharynx clearneck supple jugular venous pressure distention noted adenopathy cervical supraclavicular axillary areaschest reveals crackles right chest base upper lung fields left relatively clear decreased breath soundsheart regular rate rhythmabdomen slightly protuberant bowel sounds present slightly tender diffuse organomegaly ascites appreciableextremities mild scrotal edema lower extremities edema pretibial lateral feetdermatologic shows thin skin ecchymosis petechiaelaboratory studies laboratory studies pertinent total protein albumin mspike observed b folic acid white count hemoglobin platelet count impression time pneumonia face fairly severe crohn disease proteinlosing enteropathy severe malnutrition anasarca also anemia leukocytosis may related crohn disease well underlying pneumoniaassessment plan time believe evaluation protein intake dietary supplement appropriate believe needs calorie count check sedimentation rate creactive protein ldh prealbumin thyroid iron studies morning laboratory studies already ordered recommended strongly hospital return care gastroenterologist help anyway improve patients laboratory abnormalities however lower extremity edema primarily due marked hypoalbuminemia believe diuretics help time explained detail patient family everybody expresses understanding questions answered time follow hospital stay plan see office well

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSES:,1. Pneumonia.,2. Crohn disease.,3. Anasarca.,4. Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY: ,The patient is a 41-year-old gentleman with a long history of Crohn disease. He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months. He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers. This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital. He has been treated with IV antibiotics and is growing Streptococcus. At this time, he seems relatively stable although slightly dyspneic. Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities. At this time, he continues to have symptoms consistent with diarrhea and malabsorption. He also has some episodes of nausea and vomiting at times. He currently has a cough and symptoms of dyspnea. Further review of systems was not otherwise contributory.,MEDICATIONS:,1. Prednisone.,2. Effexor.,3. Folic acid.,4. Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1. Small bowel resections.,2. Appendectomy.,3. A vasectomy.,ALLERGIES: ,He has no known drug allergies.,SOCIAL HISTORY: ,He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter.,FAMILY HISTORY: ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL: He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS: His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT: Sclerae anicteric. Conjunctivae normal. Nasal and oropharynx are clear.,NECK: Supple. No jugular venous pressure distention is noted. There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST: Reveals some crackles in the right chest, in the base, and in the upper lung fields. His left is relatively clear with decreased breath sounds.,HEART: Regular rate and rhythm.,ABDOMEN: Slightly protuberant. Bowel sounds are present. He is slightly tender and it is diffuse. There is no organomegaly and no ascites appreciable.,EXTREMITIES: There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC: Shows thin skin. No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3. There is no M-spike observed. His B12 is 500 with a folic acid of 11. His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1. Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate. I believe that he needs a calorie count. We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered. I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist. I will help in anyway that I can to improve the patient's laboratory abnormalities. However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time. I have explained this in detail to the patient and his family. Everybody expresses understanding and all questions were answered. At this time, follow him up during his hospital stay and plan to see him in the office as well. ### Response: Consult - History and Phy., General Medicine

DIAGNOSIS AT ADMISSION: , Congestive heart failure (CHF) with left pleural effusion.,DIAGNOSES AT DISCHARGE,1. Congestive heart failure (CHF) with pleural effusion.,2. Hypertension.,3. Prostate cancer.,4. Leukocytosis.,5. Anemia of chronic disease.,HOSPITAL COURSE: ,The patient was admitted to the emergency room by Dr. X. He has diuresed with IV Lasix. He was placed on Prinivil, aspirin, oxybutynin, docusate, and Klor-Con. Chest x-rays were followed. He did have free flowing fluid in his left chest. Radiology consultation was obtained for thoracentesis. The patient was seen by Dr. Y. An echocardiogram was done. This revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3. An adenosine sestamibi was done in March 2000, with a small fixed apical defect, but no ischemia. Cardiac enzymes were negative. Dr. Y recommended a beta-blocker with an ACE inhibitor; therefore, the lisinopril was discontinued. The patient felt much better after the thoracentesis. I do not have the details of this, i.e., the volumes. No fluid was sent for routine studies.,LABORATORY AT DISCHARGE: , Sodium 134, potassium 4.2, chloride 99, CO2 26, glucose 182, BUN 17, and creatinine 1.0. Glucose was elevated because of several doses of Solu-Medrol given to him because of bronchospams. Magnesium was 1.8, calcium was 8.1. Liver enzymes were unremarkable. Cardiac enzymes were normal as mentioned. PT/INR is 1.02, PTT 31.3, white blood cell count 15, 000 with a left shift. This was presumed due to the corticosteroids. H&H was 32.3/11.3 and platelets 352,000, and MCV was 99. The patient's O2 saturations on room air were normal.,Vital signs were stable.,DISCHARGE MEDICATIONS: , He is being discharged home on Lasix 40 mg daily, potassium chloride 10 mEq daily, atenolol 25 mg daily, aspirin 5 grains daily, Ditropan 5 mg b.i.d., and Colace 100 mg b.i.d.,FOLLOWUP: , He will be followed in my office in 1 week. He is to notify if recurrent fever or chills.,PROGNOSIS: ,Guarded.

diagnosis admission congestive heart failure chf left pleural effusiondiagnoses discharge congestive heart failure chf pleural effusion hypertension prostate cancer leukocytosis anemia chronic diseasehospital course patient admitted emergency room dr x diuresed iv lasix placed prinivil aspirin oxybutynin docusate klorcon chest xrays followed free flowing fluid left chest radiology consultation obtained thoracentesis patient seen dr echocardiogram done revealed ejection fraction diastolic dysfunction periaortic stenosis opening cm adenosine sestamibi done march small fixed apical defect ischemia cardiac enzymes negative dr recommended betablocker ace inhibitor therefore lisinopril discontinued patient felt much better thoracentesis details ie volumes fluid sent routine studieslaboratory discharge sodium potassium chloride co glucose bun creatinine glucose elevated several doses solumedrol given bronchospams magnesium calcium liver enzymes unremarkable cardiac enzymes normal mentioned ptinr ptt white blood cell count left shift presumed due corticosteroids hh platelets mcv patients saturations room air normalvital signs stabledischarge medications discharged home lasix mg daily potassium chloride meq daily atenolol mg daily aspirin grains daily ditropan mg bid colace mg bidfollowup followed office week notify recurrent fever chillsprognosis guarded

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS AT ADMISSION: , Congestive heart failure (CHF) with left pleural effusion.,DIAGNOSES AT DISCHARGE,1. Congestive heart failure (CHF) with pleural effusion.,2. Hypertension.,3. Prostate cancer.,4. Leukocytosis.,5. Anemia of chronic disease.,HOSPITAL COURSE: ,The patient was admitted to the emergency room by Dr. X. He has diuresed with IV Lasix. He was placed on Prinivil, aspirin, oxybutynin, docusate, and Klor-Con. Chest x-rays were followed. He did have free flowing fluid in his left chest. Radiology consultation was obtained for thoracentesis. The patient was seen by Dr. Y. An echocardiogram was done. This revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3. An adenosine sestamibi was done in March 2000, with a small fixed apical defect, but no ischemia. Cardiac enzymes were negative. Dr. Y recommended a beta-blocker with an ACE inhibitor; therefore, the lisinopril was discontinued. The patient felt much better after the thoracentesis. I do not have the details of this, i.e., the volumes. No fluid was sent for routine studies.,LABORATORY AT DISCHARGE: , Sodium 134, potassium 4.2, chloride 99, CO2 26, glucose 182, BUN 17, and creatinine 1.0. Glucose was elevated because of several doses of Solu-Medrol given to him because of bronchospams. Magnesium was 1.8, calcium was 8.1. Liver enzymes were unremarkable. Cardiac enzymes were normal as mentioned. PT/INR is 1.02, PTT 31.3, white blood cell count 15, 000 with a left shift. This was presumed due to the corticosteroids. H&H was 32.3/11.3 and platelets 352,000, and MCV was 99. The patient's O2 saturations on room air were normal.,Vital signs were stable.,DISCHARGE MEDICATIONS: , He is being discharged home on Lasix 40 mg daily, potassium chloride 10 mEq daily, atenolol 25 mg daily, aspirin 5 grains daily, Ditropan 5 mg b.i.d., and Colace 100 mg b.i.d.,FOLLOWUP: , He will be followed in my office in 1 week. He is to notify if recurrent fever or chills.,PROGNOSIS: ,Guarded. ### Response: Discharge Summary

DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE: ,The patient was admitted through the emergency room. He was admitted to the Intensive Care Unit. He was rewarmed and had blood, sputum, and urine cultures done. He was placed on IV Rocephin. His usual medications of Dilantin and Depakene were given. The patient's hypertension was treated with fluid boluses. The patient was empirically placed on Synthroid and hydrocortisone by Dr. X. Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins. H&H was stable at 33.3/10.9 and platelets of 80,000. White blood cell counts were normal, differential was normal. TSH was 3.41. Free T4 was 0.9. Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement. A cortisol level was obtained prior to administration of hydrocortisone. This was 10.9 and that was not a fasting level. Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef. The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday. The patient was started back on his tube feeds. He tolerated these poorly with residuals. Reglan was increased to 10 mg q.6 h. and erythromycin is being added. The patient's temperature has been stable in the 94 to 95 range. Other vital signs have been stable. His urine output has been diminished. An external jugular line was placed in the Intensive Care Unit. The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there. As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him. He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque. His prognosis is poor.

diagnosis admission hypothermiadiagnoses discharge hypothermia rule sepsis negative blood cultures sputum cultures urine cultures negative organic brain syndrome seizure disorder adrenal insufficiency hypothyroidism anemia chronic diseasehospital course patient admitted emergency room admitted intensive care unit rewarmed blood sputum urine cultures done placed iv rocephin usual medications dilantin depakene given patients hypertension treated fluid boluses patient empirically placed synthroid hydrocortisone dr x blood work consisted chemistry panel unremarkable except decreased proteins hh stable platelets white blood cell counts normal differential normal tsh free dr x felt consistent secondary hypothyroidism recommended synthroid replacement cortisol level obtained prior administration hydrocortisone fasting level dr x felt hypothyroidism hypothermia secondary adrenal insufficiency recommended hydrocortisone florinef patient eventually changed prednisone mg bid addition florinef mg monday wednesday friday patient started back tube feeds tolerated poorly residuals reglan increased mg q h erythromycin added patients temperature stable range vital signs stable urine output diminished external jugular line placed intensive care unit patients legal guardian janet sanchez albuquerque requested transported per several physicians albuquerque dr internist accept nursing home available transported back nursing home today discharge planners working getting nursing home albuquerque prognosis poor

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE: ,The patient was admitted through the emergency room. He was admitted to the Intensive Care Unit. He was rewarmed and had blood, sputum, and urine cultures done. He was placed on IV Rocephin. His usual medications of Dilantin and Depakene were given. The patient's hypertension was treated with fluid boluses. The patient was empirically placed on Synthroid and hydrocortisone by Dr. X. Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins. H&H was stable at 33.3/10.9 and platelets of 80,000. White blood cell counts were normal, differential was normal. TSH was 3.41. Free T4 was 0.9. Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement. A cortisol level was obtained prior to administration of hydrocortisone. This was 10.9 and that was not a fasting level. Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef. The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday. The patient was started back on his tube feeds. He tolerated these poorly with residuals. Reglan was increased to 10 mg q.6 h. and erythromycin is being added. The patient's temperature has been stable in the 94 to 95 range. Other vital signs have been stable. His urine output has been diminished. An external jugular line was placed in the Intensive Care Unit. The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there. As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him. He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque. His prognosis is poor. ### Response: Discharge Summary, General Medicine

DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypothyroidism.,6. Chronic oxygen dependent.,7. Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload.,The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS: ,Guarded.

diagnosis admission chronic obstructive pulmonary disease copd exacerbation acute bronchitisdiagnoses discharge chronic obstructive pulmonary disease exacerbation acute bronchitis congestive heart failure atherosclerotic cardiovascular disease mild seniletype dementia hypothyroidism chronic oxygen dependent resuscitatedo intubatehospital course patient admitted office dr x placed usual medications included synthroid mg day enalapril mg day imdur mg day lanoxin mg day aspirin mg day albuterol atrovent nebulizers q h potassium chloride meq tablets per day lasix mg day humibid la mg bid placed oral levaquin load mg mg day given oxygen encouraged eat suctioned neededlaboratory data included urinalysis wbcs per high power field urine culture negative blood cultures x negative tsh chem sodium potassium chloride co glucose bun creatinine calcium digoxin white blood cell count normal differential hh platelets chest xray thought prominent interstitial lung changes without acute infiltrate question mild fluid overloadthe patient improved regimen discharge lungs fell back baseline significant shortness breath saturations stable vital signs stableshe discharged home follow week halfher daughter spoken phone notify worsens problemsprognosis guarded

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypothyroidism.,6. Chronic oxygen dependent.,7. Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload.,The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS: ,Guarded. ### Response: Cardiovascular / Pulmonary, Discharge Summary

DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:, Colonoscopy.,FINDINGS:, Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE: ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood. Dr. Y Miller saw him in consultation and recommended a colonoscopy. A bowel prep was done. H&Hs were stable. His most recent H&H was 38.6/13.2 that was this morning. His H&H at admission was 41/14.3. The patient had the bowel prep that revealed no significant bleeding. His vital signs are stable. He is continuing on his usual medications of Imdur, metoprolol, and Synthroid. His Plavix is discontinued. He is given IV Protonix. I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8. Chemistry panel was unremarkable. The patient was given a regular diet after his colonoscopy today. He tolerated it well and is being discharged home. He will be followed closely as an outpatient. He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission. He will hold his Plavix for now. They will call me for further dark stools and will avoid Pepto-Bismol. They will follow up in the office on Thursday.

diagnosis admission gastrointestinal bleeddiagnoses discharge gastrointestinal bleed source undetermined possibly due internal hemorrhoids atherosclerotic cardiovascular disease hypothyroidismprocedure colonoscopyfindings poor prep friable internal hemorrhoids gross lesions source bleedhospital course patient admitted emergency room dr x apparently ng tube placed emergency room gastric aspirate revealing blood dr miller saw consultation recommended colonoscopy bowel prep done hhs stable recent hh morning hh admission patient bowel prep revealed significant bleeding vital signs stable continuing usual medications imdur metoprolol synthroid plavix discontinued given iv protonix hesitant use prilosec protonix history pancreatitis associated prilosecthe patients ptinr ptt chemistry panel unremarkable patient given regular diet colonoscopy today tolerated well discharged home followed closely outpatient continue pepcid mg night imdur synthroid metoprolol prior admission hold plavix call dark stools avoid peptobismol follow office thursday

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:, Colonoscopy.,FINDINGS:, Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.,HOSPITAL COURSE: ,The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood. Dr. Y Miller saw him in consultation and recommended a colonoscopy. A bowel prep was done. H&Hs were stable. His most recent H&H was 38.6/13.2 that was this morning. His H&H at admission was 41/14.3. The patient had the bowel prep that revealed no significant bleeding. His vital signs are stable. He is continuing on his usual medications of Imdur, metoprolol, and Synthroid. His Plavix is discontinued. He is given IV Protonix. I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec.,The patient's PT/INR was 1.03, PTT 25.8. Chemistry panel was unremarkable. The patient was given a regular diet after his colonoscopy today. He tolerated it well and is being discharged home. He will be followed closely as an outpatient. He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission. He will hold his Plavix for now. They will call me for further dark stools and will avoid Pepto-Bismol. They will follow up in the office on Thursday. ### Response: Discharge Summary, Gastroenterology

DIAGNOSIS: ,Shortness of breath. Fatigue and weakness. Hypertension. Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,

diagnosis shortness breath fatigue weakness hypertension hyperlipidemiaindication evaluate coronary artery disease

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: ,Shortness of breath. Fatigue and weakness. Hypertension. Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease., ### Response: Cardiovascular / Pulmonary, Radiology

DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is "dormant.",MEDICATIONS:,1. Hydrochlorothiazide.,2. Lisinopril.,3. Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain. The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional. The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities. The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time. The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY: ,The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot. Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention. When compared to right ankle edema, it is approximately equal. There is no evidence of discoloration or temperature. The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows: Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees. Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful. The patient was tearful during this activity. Eversion is 3 degrees and inversion is 25 degrees. The patient states this movement was difficult, but not painful. Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:, A 6-minute walk test. The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT: ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to complete work task and functional activities in the home.,5. Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1. The patient will demonstrate independence with home exercise program.,2. The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3. The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4. The patient will demonstrate 3/5 strength of the left ankle.,5. The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1. The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2. The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:, Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:

diagnosis ankle sprain left anklehistory patient yearold female referred physical therapy secondary fall patient states tripped dog toy fell left foot inverted patient states received series xrays mris unremarkable approximately month patient continued significant debilitating pain left ankle received walking boot boot past monthpast medical history significant hypertension asthma cervical cancer cervical cancer diagnosed years old patient states cancer dormantmedications hydrochlorothiazide lisinopril percocetthe patient states percocet helps take edge pain completely eliminate itsubjective patient rates pain pain analog scale patient states elevation rest pain subsidesfunctional activitieshobbies currently limited including basic household chores activities increases pain patient states also recently joined weight watchers involved walking routine currently unable participate activitywork status patient currently medical leave paraprofessional patient states works teachers aide school system required complete extensive walking standing activities patient states primarily feet work rarely sitting break extensive period time patients goal able stand walk without painsocial history patient lives private home children father patient states stairs negotiate without use railing states able manage stairs however slow movement patient smokes packs cigarettes day history regular exercise routineobjective upon observation patient obese female ambulating significant antalgic gait pattern altered normal gait due pain well walking boot upon inspection left ankle appears swelling unsure swelling secondary injury water retention patient states significant water retention compared right ankle edema approximately equal evidence discoloration temperature patient states bruising time injuryactive range motion left ankle follows dorsiflexion degrees past neutral plantar flexion degrees eversion degrees inversion degrees left ankle dorsiflexion lacks degrees neutral plantar flexion degrees motion painful patient tearful activity eversion degrees inversion degrees patient states movement difficult painful strength testing right lower extremity grossly left ankle patient unable obtain full range motionpalpation patient tender palpation primarily along lateral malleolus left anklejoint play unable assessed secondary patients extreme tenderness guarding ankle jointspecial tests minute walk test patient able ambulate approximately feet wearing walking boot prior pain significantly increasing ankle requiring test stoppedassessment patient would benefit skilled physical therapy intervention trial treatment order address following problem list increased pain decreased range motion decreased strength decreased ability complete work task functional activities home decreased gait patternshortterm goals completed weeks patient demonstrate independence home exercise program patient ambulate without boot hours order decrease reliance upon boot ankle stabilization patient achieve left ankle dorsiflexion neutral plantar flexion degrees without significant increase pain patient demonstrate strength left ankle patient tolerate completion minute walk test without use boot minimal increase painlongterm goals completed weeks patient report pain hour period without use medication without wearing boot patient return go work without use walking boot report minimal increase pain discomfortprognosis fair abovestated goals full compliance home exercise program therapy treatment well patient motivationplan patient seen three times week weeks following

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is "dormant.",MEDICATIONS:,1. Hydrochlorothiazide.,2. Lisinopril.,3. Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain. The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional. The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities. The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time. The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY: ,The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot. Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention. When compared to right ankle edema, it is approximately equal. There is no evidence of discoloration or temperature. The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows: Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees. Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful. The patient was tearful during this activity. Eversion is 3 degrees and inversion is 25 degrees. The patient states this movement was difficult, but not painful. Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:, A 6-minute walk test. The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT: ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to complete work task and functional activities in the home.,5. Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1. The patient will demonstrate independence with home exercise program.,2. The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3. The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4. The patient will demonstrate 3/5 strength of the left ankle.,5. The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1. The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2. The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:, Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following: ### Response: Orthopedic

DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure. The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes. The patient was found to have moderately stenotic aortic valve. In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system. It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion. It is a tricuspid type of valve. The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery. Flow was excellent. Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches. On the angiogram these vessels appeared to be quite small. Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken. The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position. A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs nearly three hundred pounds. There was concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory. The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner. The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released. The patient was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples.

diagnosis aortic valve stenosis coronary artery disease associated congestive heart failure patient diabetes morbidly obeseprocedures aortic valve replacement using mechanical valve twovessel coronary artery bypass grafting procedure using saphenous vein graft first obtuse marginal artery left radial artery graft left anterior descending arteryanesthesia general endotrachealincision median sternotomyindications patient presented severe congestive heart failure associated patients severe diabetes patient found moderately stenotic aortic valve addition patient significant coronary artery disease consisting chronically occluded right coronary artery important large obtuse marginal artery coming main circumflex system patient also left anterior descending artery moderate disease supplies quite bit collateral patients right system decided perform valve replacement well coronary artery bypass grafting procedurefindings left ventricle certainly hypertrophied aortic valve leaflet calcified severe restrictive leaflet motion tricuspid type valve coronary artery consists large left anterior descending artery associated stenosis large obtuse marginal artery tight proximal stenosisthe radial artery used left anterior descending artery flow excellent looking targets posterior descending artery territory appear large branches angiogram vessels appeared quite small chronically occluded vessel patient limited conduit due patients massive obesity attempt bypass area undertaken patient brought operating roomprocedure patient brought operating room placed supine position median sternotomy incision carried conduits taken left arm well right thigh patient weighs nearly three hundred pounds concern taking left internal mammary artery radial artery appeared good conduit patient would arterial graft left anterior descending artery territory patient cannulated aorta atrium exposed full heparinizationthe patient went cardiopulmonary bypass aortic crossclamp applied cardioplegia delivered coronary sinuses retrograde manner patient cooled degrees iced slush applied heart aortic valve exposed aortic root transverse incision valve leaflets removed st jude mechanical valve secured position circumferential pledgeted sutures point aortotomy closedthe first obtuse marginal artery large target vein graft target indeed produced excellent amount flow proximal anastomosis carried foot aorta left anterior descending artery severe disease also good target radial artery anastomosed target endtoside manner two proximal anastomoses carried root aortathe patient came cardiopulmonary bypass aortic crossclamp released patient adequately warmed protamine given without adverse effect sternal closure done using wires subcutaneous layers closed using vicryl suture skin approximated using staples

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure. The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes. The patient was found to have moderately stenotic aortic valve. In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system. It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion. It is a tricuspid type of valve. The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery. Flow was excellent. Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches. On the angiogram these vessels appeared to be quite small. Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken. The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position. A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs nearly three hundred pounds. There was concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory. The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner. The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released. The patient was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. ### Response: Cardiovascular / Pulmonary, Surgery

DIAGNOSIS: , Bilateral hypomastia.,NAME OF OPERATION:, Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,ANESTHESIA:, General.,PROCEDURE: , After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and solution. Sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts. Following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5% Xylocaine with 1:200,000 units of epinephrine.,After a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia. Blunt dissection was then used to form a bilateral subpectoral pocket. Through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.,Following completion of irrigation, 350-cc saline-filled implants were introduced. They were first filled with 60 cc of saline and checked for gross leakage; none was evident. They were over filled to 400 cc of saline each. The patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.,Following completion of the filling of the implants and checking the breasts for symmetry, the patient's wounds were closed with interrupted vertical mattress sutures of 4-0 Prolene. Flexan dressings were applied followed by the patient's bra.,She seemed to tolerate the procedure well.

diagnosis bilateral hypomastianame operation bilateral transaxillary subpectoral mammoplasty salinefilled implantsanesthesia generalprocedure first obtaining suitable level general anesthesia patient supine position breasts prepped betadine scrub solution sterile towels sheets drapes placed usual fashion surgery breasts following prepping draping anterior axillary folds inframammary folds infiltrated total cc xylocaine units epinephrineafter suitable hemostatic waiting period transaxillary incisions made dissection carried edge pectoralis fascia blunt dissection used form bilateral subpectoral pocket subpectoral pocket sterile suction tip introduced copious irrigation sterile saline solution used irrigant clearfollowing completion irrigation cc salinefilled implants introduced first filled cc saline checked gross leakage none evident filled cc saline patient placed seated position left breast needed cc additional fluid symmetryfollowing completion filling implants checking breasts symmetry patients wounds closed interrupted vertical mattress sutures prolene flexan dressings applied followed patients brashe seemed tolerate procedure well

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Bilateral hypomastia.,NAME OF OPERATION:, Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,ANESTHESIA:, General.,PROCEDURE: , After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and solution. Sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts. Following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5% Xylocaine with 1:200,000 units of epinephrine.,After a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia. Blunt dissection was then used to form a bilateral subpectoral pocket. Through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.,Following completion of irrigation, 350-cc saline-filled implants were introduced. They were first filled with 60 cc of saline and checked for gross leakage; none was evident. They were over filled to 400 cc of saline each. The patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.,Following completion of the filling of the implants and checking the breasts for symmetry, the patient's wounds were closed with interrupted vertical mattress sutures of 4-0 Prolene. Flexan dressings were applied followed by the patient's bra.,She seemed to tolerate the procedure well. ### Response: Surgery

DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY: ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene. The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions. The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,SHORT-TERM GOALS:,1. To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2. He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3. We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4. To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation. However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1. The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2. The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.

diagnosis chronic laryngitis hoarsenesshistory patient yearold male referred medical centers outpatient rehabilitation department skilled speech therapy secondary voicing difficulties patient attended initial evaluation plus outpatient speech therapy sessions focused training patient complete resonant voice activities improve vocal hygiene patient attended therapy one time week given numerous home activities therapy sessions patient made great progress came discuss appointment stating voice finally returned normalshortterm goals independent relaxation stretching exercises lessacmadsen resonant voice therapy protocol also met shortterm goal therapy independent resonant voice therapy tasks complete __________ ratio last session unsure met shortterm goal number referred videostroboscopy time patient need evaluation however future hoarseness returns strongly recommended referred videostroboscopy prior returning additional outpatient therapylongterm goals patient reach longterm goal improved vocal quality return prior level function utilize voice settings without vocal hoarseness difficulty patient appears pleased return normal voice feels longer needs outpatient skilled speech therapythe patient discharged services time home program continue promote normal voicing

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY: ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene. The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions. The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,SHORT-TERM GOALS:,1. To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2. He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3. We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4. To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation. However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1. The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2. The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing. ### Response: Discharge Summary

DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:, 5,HOSPITAL COURSE: ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge.

diagnosis cognitive linguistic impairment secondary strokenumber sessions completed hospital course patient yearold female referred medical centers outpatient rehabilitation department skilled speech therapy secondary cognitive linguistic deficits based initial evaluation completed patient mild difficulty generative naming auditory comprehension recall patients skilled speech therapy recommended three times week weeks improve overall cognitive linguistic abilities time patient accomplished shortterm therapy goals able complete functional mass tasks accuracy independently able listen narrative recall main idea plus least five details minute delay independentlyshe able read newspaper article recall main idea plus five details minute delay independently able state items broad category within minute half independently patient also able complete deductive reasoning tasks promote mental flexibility accuracy independently patient also met longterm therapy goal functional cognitive linguistic abilities return teaching improve independence safety home patient longer need skilled speech therapy discharged services quite well therapy also agreed discharge

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:, 5,HOSPITAL COURSE: ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge. ### Response: Discharge Summary

DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care.

diagnosis left breast adenocarcinoma stage nb stage iiiashe found recently stage iv disease metastatic deposits recurrence involving chest wall lower left neck lymph nodescurrent medications glucosamine complex toprol xl alprazolam hydrochlorothiazide dyazide centrumdr x given carboplatin taxol recently feels would benefit electron beam radiotherapy left chest wall well neck previously received total gy fractions external beam radiotherapy left supraclavicular area feel could safely retreat lower neck weight increased complain coughing fatiguephysical examinationneck physical examination palpable lymphadenopathy present left lower neck supraclavicular area cervical lymphadenopathy supraclavicular lymphadenopathy presentrespiratory good air entry bilaterally examination chest wall reveals small lesion chest wall recurrence resected lumps bumps evidence disease involving right breast presentabdomen normal bowel sounds hepatomegaly tenderness deep palpation started last cycle chemotherapy today wishes visit daughter brooklyn new york return approximately weeks begin radiotherapy treatment timei look forward keeping informed progress thank allowed participate care

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care. ### Response: Hematology - Oncology, Obstetrics / Gynecology, SOAP / Chart / Progress Notes

DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. Since that time, the patient has only been performing transverse and has been unable to ambulate. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS: ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:, The patient reports that when seated and at rest, her knee pain is 0/10. The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity. There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY: ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT: ,The patient is a 58-year-old female with left knee osteoarthritis. Examination indicates deficits in pain, muscle endurance, and functional mobility. The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1. Modalities including electrical stimulation, ultrasound, heat, and ice.,2. Therapeutic exercise.,3. Functional mobility training.,4. Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1. The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. The patient is to perform standby assist transfer using a pickup walker.,3. The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to be independent with the home exercise program.,2. The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:, Fair to good.,The above treatment plan has been discussed with the patient. She is in agreement.

diagnosis left knee osteoarthritishistory patient yearold female referred therapy due left knee osteoarthritis patient states approximately years ago fell ground thereafter blood clots knee area patient transferred hospital nursing home lived year prior incident patient ambulating independently pickup walker throughout home since time patient performing transverse unable ambulate patient states primary concern left knee pain desire walk short distances homepast medical history high blood pressure obesity right patellar fracture pin history blood clotsmedications naproxen plavix stool softenermedical diagnostics patient states xray knee diagnosed osteoarthritissubjective patient reports seated rest knee pain patient states active motion left knee pain anterior portion increases patients goal transfer better walk feet bed couchinspection right knee large inch long wide tight scar adhesions underlying connective tissue due patellar fracture surgery following mva bilateral knees large due obesity scars bruising increased temperature noted left kneerange motion active passive range motion right knee degrees left knee degrees pain elicited active range motion left kneepalpation palpation left knee elicits pain around patellar tendon side areafunctional mobility patient reports transfers standby contactguard assist home bed wheelchair return patient able stand modified independent wheelchair level tolerates least seconds standing prior needing sit due left knee painassessment patient yearold female left knee osteoarthritis examination indicates deficits pain muscle endurance functional mobility patient would benefit skilled physical therapy address impairmentstreatment plan patient seen two times per week initial weeks reassessment time additional weeks neededinterventions include modalities including electrical stimulation ultrasound heat ice therapeutic exercise functional mobility training gait traininglongterm goals achieved weeks patient increased endurance bilateral lower extremities demonstrated able perform repetitions lower extremity exercises seated supine positions minimum pound weight patient perform standby assist transfer using pickup walker patient demonstrate steps ambulation using forward backward using pickup walker frontwheeled walker patient report maximum pain weightbearing minutes left kneelongterm goals achieved weeks patient independent home exercise program patient tolerate reps standing exercises pain maximum patient ambulate feet appropriate assistive deviceprognosis abovestated goals fair goodthe treatment plan discussed patient agreement

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. Since that time, the patient has only been performing transverse and has been unable to ambulate. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS: ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:, The patient reports that when seated and at rest, her knee pain is 0/10. The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity. There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY: ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT: ,The patient is a 58-year-old female with left knee osteoarthritis. Examination indicates deficits in pain, muscle endurance, and functional mobility. The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1. Modalities including electrical stimulation, ultrasound, heat, and ice.,2. Therapeutic exercise.,3. Functional mobility training.,4. Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1. The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. The patient is to perform standby assist transfer using a pickup walker.,3. The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to be independent with the home exercise program.,2. The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:, Fair to good.,The above treatment plan has been discussed with the patient. She is in agreement. ### Response: Orthopedic

DIAGNOSIS: , Left sciatica.,ANESTHESIA: , Intravenous sedation,NAME OF OPERATION:,1. Left L5-S1 transforaminal epidural steroid block with fluoroscopy.,2. Left L4-5 transforaminal epidural steroid block with fluoroscopy.,3. Monitored intravenous Versed sedation.,PROCEDURE: , The patient was taken to the block room. He was placed prone on the fluoroscopy table. He was monitored appropriately. He was administered Versed 2 mg IV. His O2 saturation remained greater than 90%. His back was prepped and draped. The C-arm was brought in. The endplates at L5-S1 were squared off. The C-arm was rotated to the left. The L5 pedicle, the superior articular process of the L5-S1 facet, and the "neck of the scotty dog" were all visualized. After adequate local anesthesia, a 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique. The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle. No paresthesias were noted. One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected. The needle was flushed and removed.,I then went up to the L4-5 level, and using a similar technique, injected the patient transforaminally at the L4-5 level. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected at the L4-5 level just as at the L5-S1 level. The patient had pain down his left leg during the injection, primarily at the L5-S1 level similar to what he normally experiences. He was awake and alert, and taken to the recovery room in good condition. His left leg pain was relieved.

diagnosis left sciaticaanesthesia intravenous sedationname operation left ls transforaminal epidural steroid block fluoroscopy left l transforaminal epidural steroid block fluoroscopy monitored intravenous versed sedationprocedure patient taken block room placed prone fluoroscopy table monitored appropriately administered versed mg iv saturation remained greater back prepped draped carm brought endplates ls squared carm rotated left l pedicle superior articular process ls facet neck scotty dog visualized adequate local anesthesia gauge inch spinal needle inserted using downthebarreloftheneedle technique needle advanced posterior aspect foramen advanced anteriorly toward oclock position pedicle paresthesias noted onehalf cc contrast injected spread medially around pedicle epidural space l nerve root visualized depomedrol mg plus cc preservativefree lidocaine injected needle flushed removedi went l level using similar technique injected patient transforaminally l level depomedrol mg plus cc preservativefree lidocaine injected l level ls level patient pain left leg injection primarily ls level similar normally experiences awake alert taken recovery room good condition left leg pain relieved

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Left sciatica.,ANESTHESIA: , Intravenous sedation,NAME OF OPERATION:,1. Left L5-S1 transforaminal epidural steroid block with fluoroscopy.,2. Left L4-5 transforaminal epidural steroid block with fluoroscopy.,3. Monitored intravenous Versed sedation.,PROCEDURE: , The patient was taken to the block room. He was placed prone on the fluoroscopy table. He was monitored appropriately. He was administered Versed 2 mg IV. His O2 saturation remained greater than 90%. His back was prepped and draped. The C-arm was brought in. The endplates at L5-S1 were squared off. The C-arm was rotated to the left. The L5 pedicle, the superior articular process of the L5-S1 facet, and the "neck of the scotty dog" were all visualized. After adequate local anesthesia, a 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique. The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle. No paresthesias were noted. One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected. The needle was flushed and removed.,I then went up to the L4-5 level, and using a similar technique, injected the patient transforaminally at the L4-5 level. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected at the L4-5 level just as at the L5-S1 level. The patient had pain down his left leg during the injection, primarily at the L5-S1 level similar to what he normally experiences. He was awake and alert, and taken to the recovery room in good condition. His left leg pain was relieved. ### Response: Pain Management

DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:, The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:, Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1. TriCor.,2. Vytorin.,3. Estradiol.,4. Levothyroxine.,5. The patient is also taking ibuprofen 800 mg occasionally as needed for pain management. The patient states she rarely takes this and does not like to take pain medication if at all possible. The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:, The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with. The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption. The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day. However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain. The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:, The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation. The patient states she is able to bring the report in upon next visit.,SUBJECTIVE: ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:, The patient reports having occasional shooting pains into the lower extremities. However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device. However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity. The patient does have mild difficulty transferring from the seated position to standing. However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE: ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5. The patient denies any significant tenderness to palpation. However, does have mild increase in tenderness on the right versus left. A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking. The patient was able to continue; however, stopped after 700 feet. There were two minutes remaining in the six-minute walk test. The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1. Increased pain.,2. Decreased ability to complete tasks and hobbies.,3

diagnosis low back pain degenerative lumbar diskhistory patient yearold female referred physical therapy secondary low back pain degenerative disk disease patient states cauterization sort nerves low back help alleviate painful symptoms patient states occurred october well november patient history low back pain secondary fall originally occurred patient states slipped newly waxed floor fell tailbone low back region patient second fall march patient states qualifying range handgun lost footing states fell due weakness lower extremities rather loss balancepast medical history past medical history significant allergies thyroid problemspast surgical history patient past surgical history appendectomy hysterectomymedications tricor vytorin estradiol levothyroxine patient also taking ibuprofen mg occasionally needed pain management patient states rarely takes like take pain medication possible patient states uncomplicated pregnancies pastsocial history patient states lives singlelevel home husband good health able assist tasks activities patient difficulty patient rates general health excellent denies smoking reports occasional alcohol consumption patient state completed exercises daily basis one one half hours day however able complete exercise routine since approximately june secondary back pain patient working fulltime project manager required extensive walking various periods workdaymedical imaging patient states mri recently performed however results available time evaluation patient states able bring report upon next visitsubjective patient rates pain pain analog scale worse patient describes pain deep aching primarily right lower back gluteal region aggravating factors include stairs prolonged driving well general limitations home tasks projects patient states active individual noticing extreme limitations ability complete home tasks projects used able completeneurological symptoms patient reports occasional shooting pains lower extremities however occurring less frequently occurring frequently right versus left lower extremity occurfunctional activities hobbies include exercising general activitiespatients goal patient would like improve overall body movements return daily exercise routine able well maintaining safetyobjective upon observation patient ambulates independently without use assistive device however present mild limp favoring left lower extremity extensive standing walking activity patient mild difficulty transferring seated position standing however upright patient denies increased pain symptomsactive range motion lumbar spine forward flexion cm fingertip floor lateral side bend fingertip floor cm bilaterallystrength strength grossly patient denies significant tenderness palpation however mild increase tenderness right versus left sixminute walk test revealed painful symptoms achiness occurring approximately feet walking patient able continue however stopped feet two minutes remaining sixminute walk test patient tight hamstrings well negative slump testassessment patient would benefit skilled physical therapy intervention order address following problem listproblem list increased pain decreased ability complete tasks hobbies

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:, The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:, Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1. TriCor.,2. Vytorin.,3. Estradiol.,4. Levothyroxine.,5. The patient is also taking ibuprofen 800 mg occasionally as needed for pain management. The patient states she rarely takes this and does not like to take pain medication if at all possible. The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:, The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with. The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption. The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day. However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain. The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:, The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation. The patient states she is able to bring the report in upon next visit.,SUBJECTIVE: ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:, The patient reports having occasional shooting pains into the lower extremities. However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device. However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity. The patient does have mild difficulty transferring from the seated position to standing. However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE: ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5. The patient denies any significant tenderness to palpation. However, does have mild increase in tenderness on the right versus left. A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking. The patient was able to continue; however, stopped after 700 feet. There were two minutes remaining in the six-minute walk test. The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1. Increased pain.,2. Decreased ability to complete tasks and hobbies.,3 ### Response: Orthopedic

DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:, None.,FINDINGS: ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position. After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined. She was found to have an anteverted uterus and no adnexal mass. She was prepped and draped in the usual fashion. The Foley catheter was placed. A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife. A Veress needle was inserted into the abdomen. Intraperitoneal location was verified with approximately 10 cc of sterile solution. A pneumoperitoneum was created. The Veress needle was then removed, and a trocar was inserted directly without difficulty. Intraperitoneal location was verified visually with the laparoscope. There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization. An attempt was made to close the fascia with a figure-of-eight suture. However, this was felt to be more subcutaneous. The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.

diagnosis multiparous female desires permanent sterilizationname operation laparoscopic bilateral tubal ligation falope ringsanesthesia general et tubecomplications nonefindings normal female anatomy except mild clitoromegaly posterior uterine fibroidprocedure patient taken operating room placed table supine position adequate general anesthesia obtained placed lithotomy position examined found anteverted uterus adnexal mass prepped draped usual fashion foley catheter placed hulka cannula inserted cervix attached anterior lip cervixan infraumbilical incision made knife veress needle inserted abdomen intraperitoneal location verified approximately cc sterile solution pneumoperitoneum created veress needle removed trocar inserted directly without difficulty intraperitoneal location verified visually laparoscope evidence intraabdominal traumaeach fallopian tube elevated falope ring applicator falope ring placed tube cm cm portion tube falope ringthe pneumoperitoneum evacuated trocar removed direct visualization attempt made close fascia figureofeight suture however felt subcutaneous skin closed subcuticular fashion patient taken recovery room awake vital signs stable

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:, None.,FINDINGS: ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position. After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined. She was found to have an anteverted uterus and no adnexal mass. She was prepped and draped in the usual fashion. The Foley catheter was placed. A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife. A Veress needle was inserted into the abdomen. Intraperitoneal location was verified with approximately 10 cc of sterile solution. A pneumoperitoneum was created. The Veress needle was then removed, and a trocar was inserted directly without difficulty. Intraperitoneal location was verified visually with the laparoscope. There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization. An attempt was made to close the fascia with a figure-of-eight suture. However, this was felt to be more subcutaneous. The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable. ### Response: Obstetrics / Gynecology, Surgery

DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:, A 16-month-old with history of penile swelling for 4 days. The patient was transferred for higher level of care. This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent. Apparently, the patient developed adhesions and the patient had surgery for 2 more occasions for removal of the adhesions. This time, the patient developed fevers 3 days after the surgery with edema and erythema around the circumcision and it has spread to the pubic area. The patient became febrile with 102 to 103 fever, treated with Tylenol with Codeine and topical antibiotics. The patient was transferred to Children's Hospital for higher level of care.,REVIEW OF SYSTEMS: , ,ENT: Denies any runny nose. ,EYES: No apparent discharge. ,FEEDING: Good feeding. ,CARDIOVASCULAR: There is no cyanosis or edema. ,RESPIRATORY: Denies any cough or wheezing. ,GI: Positive for constipation, no bowel movements for 2 days. ,GU: Positive dysuria for the last 2 days and penile discharge for the last 2 days with foul smelling. ,NEUROLOGIC: Denies any lethargy or seizure. ,MUSCULOSKELETAL: No pain or swelling. ,SKIN: Erythema and edema in the pubic area for the last 3 days. All the rest of systems are negative except as noted above.,At the emergency room, the patient had a second dose of clindamycin. The transfer labs are as follows: 15.7 for WBC, H&H 12.0 and 36. One blood culture. We will follow the results. He is status post Rocephin and Cleocin.,PAST MEDICAL HISTORY: , Denied. ,PAST SURGICAL HISTORY:, The patient underwent 3 circumcisions since birth, the last 2 had been for possible removal of adhesions.,IMMUNIZATIONS: , He is behind with his immunizations. He is due for his 16-month-old immunizations.,ACTIVITY: , NKDA.,BIRTH HISTORY: , Born to a 21-year-old, first baby, born NSVD, 8 pounds 10 ounces, no complications.,DEVELOPMENTAL:, He is walking and speaking about 15 words.,FAMILY HISTORY: , Noncontributory.,MEDICATIONS: , Tylenol with Codeine q.6h.,SOCIAL HISTORY: , He lives with both parents and both of them smoke. There are no pets.,SICK CONTACTS: , Mom has some upper respiratory infection.,DIET: , Regular diet.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Temperature max at ER is 102, heart rate 153.,GENERAL: This patient is alert, arousable, big boy.,HEENT: Head: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Mucous membranes are moist.,NECK: Supple.,CHEST: Clear to auscultation bilaterally. Good air exchange.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: Full range of movement. No deformities.

diagnosis pubic cellulitishistory present illness monthold history penile swelling days patient transferred higher level care monthold circumcision week ago third circumcision patient underwent apparently patient developed adhesions patient surgery occasions removal adhesions time patient developed fevers days surgery edema erythema around circumcision spread pubic area patient became febrile fever treated tylenol codeine topical antibiotics patient transferred childrens hospital higher level carereview systems ent denies runny nose eyes apparent discharge feeding good feeding cardiovascular cyanosis edema respiratory denies cough wheezing gi positive constipation bowel movements days gu positive dysuria last days penile discharge last days foul smelling neurologic denies lethargy seizure musculoskeletal pain swelling skin erythema edema pubic area last days rest systems negative except noted aboveat emergency room patient second dose clindamycin transfer labs follows wbc hh one blood culture follow results status post rocephin cleocinpast medical history denied past surgical history patient underwent circumcisions since birth last possible removal adhesionsimmunizations behind immunizations due monthold immunizationsactivity nkdabirth history born yearold first baby born nsvd pounds ounces complicationsdevelopmental walking speaking wordsfamily history noncontributorymedications tylenol codeine qhsocial history lives parents smoke petssick contacts mom upper respiratory infectiondiet regular dietphysical examination vital signs temperature max er heart rate general patient alert arousable big boyheent head normocephalic atraumatic pupils equal round reactive light mucous membranes moistneck supplechest clear auscultation bilaterally good air exchangeabdomen soft nontender nondistendedextremities full range movement deformities

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Pubic cellulitis.,HISTORY OF PRESENT ILLNESS:, A 16-month-old with history of penile swelling for 4 days. The patient was transferred for higher level of care. This 16-month-old had circumcision 1 week ago and this is the third circumcision this patient underwent. Apparently, the patient developed adhesions and the patient had surgery for 2 more occasions for removal of the adhesions. This time, the patient developed fevers 3 days after the surgery with edema and erythema around the circumcision and it has spread to the pubic area. The patient became febrile with 102 to 103 fever, treated with Tylenol with Codeine and topical antibiotics. The patient was transferred to Children's Hospital for higher level of care.,REVIEW OF SYSTEMS: , ,ENT: Denies any runny nose. ,EYES: No apparent discharge. ,FEEDING: Good feeding. ,CARDIOVASCULAR: There is no cyanosis or edema. ,RESPIRATORY: Denies any cough or wheezing. ,GI: Positive for constipation, no bowel movements for 2 days. ,GU: Positive dysuria for the last 2 days and penile discharge for the last 2 days with foul smelling. ,NEUROLOGIC: Denies any lethargy or seizure. ,MUSCULOSKELETAL: No pain or swelling. ,SKIN: Erythema and edema in the pubic area for the last 3 days. All the rest of systems are negative except as noted above.,At the emergency room, the patient had a second dose of clindamycin. The transfer labs are as follows: 15.7 for WBC, H&H 12.0 and 36. One blood culture. We will follow the results. He is status post Rocephin and Cleocin.,PAST MEDICAL HISTORY: , Denied. ,PAST SURGICAL HISTORY:, The patient underwent 3 circumcisions since birth, the last 2 had been for possible removal of adhesions.,IMMUNIZATIONS: , He is behind with his immunizations. He is due for his 16-month-old immunizations.,ACTIVITY: , NKDA.,BIRTH HISTORY: , Born to a 21-year-old, first baby, born NSVD, 8 pounds 10 ounces, no complications.,DEVELOPMENTAL:, He is walking and speaking about 15 words.,FAMILY HISTORY: , Noncontributory.,MEDICATIONS: , Tylenol with Codeine q.6h.,SOCIAL HISTORY: , He lives with both parents and both of them smoke. There are no pets.,SICK CONTACTS: , Mom has some upper respiratory infection.,DIET: , Regular diet.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Temperature max at ER is 102, heart rate 153.,GENERAL: This patient is alert, arousable, big boy.,HEENT: Head: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Mucous membranes are moist.,NECK: Supple.,CHEST: Clear to auscultation bilaterally. Good air exchange.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: Full range of movement. No deformities. ### Response: Consult - History and Phy., Urology

DIAGNOSIS: , Status post brain tumor with removal.,SUBJECTIVE: ,The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy. The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness. The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling. The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. The patient also complains of difficulty with word retrieval and slurring of speech. The patient denies any difficulty with swallowing at this time.,OBJECTIVE: ,Portions of the cognitive linguistic quick test was administered. An oral mechanism exam was performed. A motor speech protocol was completed.,The cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.,The patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming. She had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult. In the storytelling task, she scored within normal limits. She was also within normal limits for generative naming. She did have difficulty with the design, memory, and mazes subtests. She was unable to complete the second maze during the allotted time. The design generation subtest was also completed. She was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.,ORAL MECHANISM EXAMINATION:, The patient has mild left facial droop with decreased nasolabial fold. Tongue is at midline, and lingual range of motion and strength are within functional limit. The patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks. Her AMRs are judged to be within functional limit. Her rate of speech is decreased with a monotonous vocal quality. The decreased rate may be a compensation for decreased word retrieval ability. The patient's speech is judged to be 100% intelligible without background noise.,DIAGNOSTIC IMPRESSION: ,The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.,PLAN OF CARE:, Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.,SHORT-TERM GOALS (THREE WEEKS):,1. The patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.,2. The patient will complete perspective memory test with 100% accuracy using compensatory strategy.,3. The patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.,4. The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.,PATIENT'S GOAL: ,To improve functional independence and cognitive abilities.,LONG-TERM GOAL (FOUR WEEKS): ,Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver.,

diagnosis status post brain tumor removalsubjective patient yearold female previous medical history breast cancer metastasized lung liver spleen brain status post radiation therapy patient stated brain tumor removed subsequent leftsided weakness patient readmitted abc hospital found massive swelling brain second surgery performed reduce swelling patient remained acute rehab abc discharged home patient receive skilled speech therapy acute rehab focused higher level cognitive linguistic skills attention memory mental flexibility improvement executive function patient also complains difficulty word retrieval slurring speech patient denies difficulty swallowing timeobjective portions cognitive linguistic quick test administered oral mechanism exam performed motor speech protocol completedthe cognitive linguistic subtests recalling personal facts symbol cancellation confrontational naming clock drawing story retelling generative naming design memory completion mazes administeredthe patient accurate recalling personal facts completion symbol cancellation tasks confrontational naming difficulty clock drawing task however considerable hand tremors makes writing difficult storytelling task scored within normal limits also within normal limits generative naming difficulty design memory mazes subtests unable complete second maze allotted time design generation subtest also completed able draw four unique designs toward end tasks longer able recall stated directionoral mechanism examination patient mild left facial droop decreased nasolabial fold tongue midline lingual range motion strength within functional limit patient complain biting tongue occasion denied biting inside cheeks amrs judged within functional limit rate speech decreased monotonous vocal quality decreased rate may compensation decreased word retrieval ability patients speech judged intelligible without background noisediagnostic impression patient mild cognitive linguistic deficits areas higher level cognitive function seen mental flexibility memory executive functionplan care outpatient skilled speech therapy two times week four weeks include cognitive linguistic treatmentshortterm goals three weeks patient complete deductive reasoning mental flexibility tasks greater accuracy independently patient complete perspective memory test accuracy using compensatory strategy patient complete visual perceptual activities focus scanning flexibility problem solving greater accuracy minimal cueing patient listen andor read lengthy narrative able recall least details minute delay independentlypatients goal improve functional independence cognitive abilitieslongterm goal four weeks functional cognitive linguistic abilities improve safety independence home decrease burden care caregiver

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , Status post brain tumor with removal.,SUBJECTIVE: ,The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy. The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness. The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling. The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09. The patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. The patient also complains of difficulty with word retrieval and slurring of speech. The patient denies any difficulty with swallowing at this time.,OBJECTIVE: ,Portions of the cognitive linguistic quick test was administered. An oral mechanism exam was performed. A motor speech protocol was completed.,The cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.,The patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming. She had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult. In the storytelling task, she scored within normal limits. She was also within normal limits for generative naming. She did have difficulty with the design, memory, and mazes subtests. She was unable to complete the second maze during the allotted time. The design generation subtest was also completed. She was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.,ORAL MECHANISM EXAMINATION:, The patient has mild left facial droop with decreased nasolabial fold. Tongue is at midline, and lingual range of motion and strength are within functional limit. The patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks. Her AMRs are judged to be within functional limit. Her rate of speech is decreased with a monotonous vocal quality. The decreased rate may be a compensation for decreased word retrieval ability. The patient's speech is judged to be 100% intelligible without background noise.,DIAGNOSTIC IMPRESSION: ,The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.,PLAN OF CARE:, Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.,SHORT-TERM GOALS (THREE WEEKS):,1. The patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.,2. The patient will complete perspective memory test with 100% accuracy using compensatory strategy.,3. The patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.,4. The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.,PATIENT'S GOAL: ,To improve functional independence and cognitive abilities.,LONG-TERM GOAL (FOUR WEEKS): ,Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver., ### Response: Consult - History and Phy.

DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:, 0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well. He is working. He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics. Overall when he compares his strength to six or eight months ago he notes that he feels much stronger. He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs: Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT: Extraocular muscles intact. Sclerae not icteric. Oral cavity free of exudate or ulceration. Dry mouth noted.,Lymph: No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs: Clear.,Cardiac: Rhythm regular.,Abdomen: Soft, nondistended. Neither liver, spleen, nor other masses palpable.,Lower Extremities: Without edema.,Neurologic: Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1. This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal. I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. He has made a good recovery. We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up. We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.

diagnosis n cancer nasopharynx status post radiation therapy cycles high dose cisplatin radiation completed june status post cycles carboplatinfu given adjuvant therapy completed september hearing loss related chemotherapy radiation xerostomia history left upper extremity deep venous thrombosisperformance status interval history interim since last visit done quite well working episode upper respiratory infection fever end april got better antibiotics overall compares strength six eight months ago notes feels much stronger complaints mild xerostomia treatment related hearing lossphysical examinationvital signs height inches weight pulse blood pressure temperature respirations heent extraocular muscles intact sclerae icteric oral cavity free exudate ulceration dry mouth notedlymph palpable adenopathy cervical supraclavicular axillary areaslungs clearcardiac rhythm regularabdomen soft nondistended neither liver spleen masses palpablelower extremities without edemaneurologic awake alert ambulatory oriented cognitively intacti reviewed ct images report study done may showed evidence metabolically active malignancymost recent laboratory studies performed last september tsh normal asked repeat tsh one year anniversaryhe current medicationsin summary yearold man presented n cancer nasopharynx months post completion therapy made good recovery continue follow thyroid function asked obtain tsh one year anniversary september cbc follow see six months time petcthe returns general care direction dr abc

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:, 0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well. He is working. He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics. Overall when he compares his strength to six or eight months ago he notes that he feels much stronger. He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs: Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT: Extraocular muscles intact. Sclerae not icteric. Oral cavity free of exudate or ulceration. Dry mouth noted.,Lymph: No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs: Clear.,Cardiac: Rhythm regular.,Abdomen: Soft, nondistended. Neither liver, spleen, nor other masses palpable.,Lower Extremities: Without edema.,Neurologic: Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1. This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal. I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. He has made a good recovery. We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up. We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC. ### Response: Consult - History and Phy., ENT - Otolaryngology, Hematology - Oncology

DIAGNOSIS:, Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:, General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic. No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound. Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two. He tolerated the procedure well. A sterile dressing was applied. He was awakened and transferred to the recovery room in stable condition.

diagnosis desires vasectomyname operation vasectomyanesthesia generalhistory patient desires vasectomyprocedure midline scrotal incision right vas identified separated surrounding tissues clamped transected tied chromic bleeding identifiedthrough incision left side identified transected tied dropped back wound bleeding notedthe wound closed vicryl times two tolerated procedure well sterile dressing applied awakened transferred recovery room stable condition

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:, Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:, General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic. No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound. Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two. He tolerated the procedure well. A sterile dressing was applied. He was awakened and transferred to the recovery room in stable condition. ### Response: Surgery, Urology

DIAGNOSIS:, Nuclear sclerotic and cortical cataract, right eye.,OPERATION:, Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:, The patient was taken to the operating room and placed on the table in the supine position. Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff. Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage. The patient was then prepped and draped in the usual sterile fashion for eye surgery. With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle. With Westcott scissors, a fornix-based conjunctival flap was made. The surgical limbus was identified and hemostasis obtained with wet-field cautery. With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea. A stab incision was made at 2 o'clock with a 15-degree blade. With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber. Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique. Hydrodissection was performed with Balanced Salt Solution. Phacoemulsification was performed in a two-headed nuclear fracture technique. The remaining cortical material was removed with irrigation and aspiration handpiece. The posterior capsule remained intact and vacuumed with minimal suction. The posterior chamber intraocular lens was obtained. It was inspected, irrigated, inserted into the posterior chamber without difficulty. Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound. There was no aqueous leak even with digital pressure. The conjunctiva was pulled back into position with wet-field cautery. A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given. Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture. The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.

diagnosis nuclear sclerotic cortical cataract right eyeoperation phacoemulsification extracapsular cataract extraction intraocular lens implantation right eyeprocedure patient taken operating room placed table supine position cardiac monitor oxygen liters per minute connected nursing staff local anesthesia obtained using lidocaine marcaine cc wydase cc solution used paribulbar injection followed ten minutes digital massage patient prepped draped usual sterile fashion eye surgery zeiss operating microscopy position lid speculum inserted black silk bridal suture placed superior rectus muscle westcott scissors fornixbased conjunctival flap made surgical limbus identified hemostasis obtained wetfield cautery beaver blade corneoscleral groove made shelved clear cornea stab incision made oclock degree blade mm keratome shelved groove attended anterior chamber viscoelastic inserted anterior chamber anterior capsulotomy performed continuoustear technique hydrodissection performed balanced salt solution phacoemulsification performed twoheaded nuclear fracture technique remaining cortical material removed irrigation aspiration handpiece posterior capsule remained intact vacuumed minimal suction posterior chamber intraocular lens obtained inspected irrigated inserted posterior chamber without difficulty inspection revealed intraocular lens good position intact capsule wellapproximated wound aqueous leak even digital pressure conjunctiva pulled back position wetfield cautery subconjunctival injection mg gatamycine cc celestone given tobradex ointment instilled eye patched shielded appropriately removing lid speculum bridle suture patient tolerated procedure well sent recovery room good condition followed attending physician office next day

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:, Nuclear sclerotic and cortical cataract, right eye.,OPERATION:, Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:, The patient was taken to the operating room and placed on the table in the supine position. Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff. Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage. The patient was then prepped and draped in the usual sterile fashion for eye surgery. With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle. With Westcott scissors, a fornix-based conjunctival flap was made. The surgical limbus was identified and hemostasis obtained with wet-field cautery. With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea. A stab incision was made at 2 o'clock with a 15-degree blade. With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber. Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique. Hydrodissection was performed with Balanced Salt Solution. Phacoemulsification was performed in a two-headed nuclear fracture technique. The remaining cortical material was removed with irrigation and aspiration handpiece. The posterior capsule remained intact and vacuumed with minimal suction. The posterior chamber intraocular lens was obtained. It was inspected, irrigated, inserted into the posterior chamber without difficulty. Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound. There was no aqueous leak even with digital pressure. The conjunctiva was pulled back into position with wet-field cautery. A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given. Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture. The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day. ### Response: Ophthalmology, Surgery

DIAGNOSIS:, Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped.,The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS: He is afebrile. Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute. GENERAL: He is in no acute distress. HEENT: There is no pallor, icterus or cervical adenopathy that is noted. Oral cavity is normal to exam. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. ABDOMEN: Soft and nontender with no hepatomegaly. Spleen is palpable 4 fingerbreadths below the left costal margin. There is no guarding, tenderness, rebound or rigidity noted. Bowel sounds are present. EXTREMITIES: Reveal no edema. Palpation of the left tibia revealed some mild tenderness. However, I do not palpate any bony abnormalities. There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1. JAK-2 positive myeloproliferative disorder. The patient has failed pretty much all available options. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial. Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2. I am concerned about the risk of thrombosis with his elevated white count. He is on aspirin prophylaxis. The patient has been told to call me with any complaints.,3. Left shin pain. I have ordered x-rays of the left tibia and knee today. The patient will return to the clinic in 3 weeks. He is to call me in the interim for any problems.

diagnosis polycythemia vera secondary myelofibrosisreason visit followup conditionchief complaint left shin painhistory present illness yearold white male carries diagnosis polycythemia vera secondary myelofibrosis diagnosis made time initially underwent phlebotomy subsequently transferred care past hydroxyurea interferon tolerate jak positive siblings matchrelated transplant seen consideration mud transplant deemed candidate social support well reasonably good healthat institution patient received trial lenalidomide prednisone short period well combination subsequently developed intolerance lenalidomide complained severe fatigue diarrhea subsequently stoppedthe patient reports injury left leg last week left leg apparently swollen took steroids days stopped left leg swelling disappeared patient denies complaints point time admits smoking marijuana says gives great appetite actually gained weight performance status ecog scale physical examinationvital signs afebrile blood pressure pulse weight kg respiratory rate per minute general acute distress heent pallor icterus cervical adenopathy noted oral cavity normal exam chest clear auscultation cardiovascular normal regular rate rhythm abdomen soft nontender hepatomegaly spleen palpable fingerbreadths left costal margin guarding tenderness rebound rigidity noted bowel sounds present extremities reveal edema palpation left tibia revealed mild tenderness however palpate bony abnormalities history deep venous thrombosislaboratory data cbc today significant white count absolute neutrophil count hemoglobin mcv platelet count assessment plan jak positive myeloproliferative disorder patient failed pretty much available options candidate chlorambucil radioactive phosphorus young age concern secondary malignancy emailed dr x see whether candidate lbh trial hopefully get jak inhibitor trial quickly board concerned risk thrombosis elevated white count aspirin prophylaxis patient told call complaints left shin pain ordered xrays left tibia knee today patient return clinic weeks call interim problems

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:, Polycythemia vera with secondary myelofibrosis.,REASON FOR VISIT:, Followup of the above condition.,CHIEF COMPLAINT: , Left shin pain.,HISTORY OF PRESENT ILLNESS: , A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped.,The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS: He is afebrile. Blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute. GENERAL: He is in no acute distress. HEENT: There is no pallor, icterus or cervical adenopathy that is noted. Oral cavity is normal to exam. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 normal with regular rate and rhythm. ABDOMEN: Soft and nontender with no hepatomegaly. Spleen is palpable 4 fingerbreadths below the left costal margin. There is no guarding, tenderness, rebound or rigidity noted. Bowel sounds are present. EXTREMITIES: Reveal no edema. Palpation of the left tibia revealed some mild tenderness. However, I do not palpate any bony abnormalities. There is no history of deep venous thrombosis.,LABORATORY DATA: , CBC from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an MCV of 56.7, and platelet count 235,000.,ASSESSMENT AND PLAN:,1. JAK-2 positive myeloproliferative disorder. The patient has failed pretty much all available options. He is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy. I have e-mailed Dr. X to see whether he will be a candidate for the LBH trial. Hopefully, we can get a JAK-2 inhibitor trial quickly on board.,2. I am concerned about the risk of thrombosis with his elevated white count. He is on aspirin prophylaxis. The patient has been told to call me with any complaints.,3. Left shin pain. I have ordered x-rays of the left tibia and knee today. The patient will return to the clinic in 3 weeks. He is to call me in the interim for any problems. ### Response: Hematology - Oncology, SOAP / Chart / Progress Notes

DIAGNOSIS:, Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically. A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session. Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions. Hyperventilation was not performed. No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study. The findings are suggestive of a generalized cerebral disorder. Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated. Clinical correlation is recommended.

diagnosis possible cerebrovascular accidentdescription eeg obtained using electrodes placed scalptoscalp scalptovertex montages background activity appears consist fairly organized somewhat pleomorphic low occasional medium amplitude cycle per second activity seen mostly posteriorly bilaterally symmetrically large amount movement artifacts electromyographic effects noted intermixed throughout recording session transient periods drowsiness occurred naturally producing irregular cycle per second activity mostly anterior regions hyperventilation performed epileptiform activity definite lateralizing findings seenimpression mildly abnormal study findings suggestive generalized cerebral disorder due abundant amount movement artifacts lateralizing findings cannot well appreciated clinical correlation recommended

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:, Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically. A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session. Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions. Hyperventilation was not performed. No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study. The findings are suggestive of a generalized cerebral disorder. Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated. Clinical correlation is recommended. ### Response: Neurology, Radiology

DIAGNOSIS:, Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY: ,Diabetes.,PAST SURGICAL HISTORY:, Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.,FAMILY HISTORY:, Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.,VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.,HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.,NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC: Noncontributory.,DERMATOLOGIC: Noncontributory.,CARDIOVASCULAR: Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS: ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.

diagnosis refractory anemia transfusion dependentchief complaint needed blood transfusionhistory patient yearold gentleman substantial past medical history except diabetes denies comorbid complications diabetes including kidney disease heart disease stroke vision loss neuropathy time admitted anemia hemoglobin requiring transfusion reports signs symptom bleeding blood transfusion approximately two months ago actually several weeks blood transfusion transfusion anemia placed b oral iron procrit time asked evaluate causes treatment anemia denies constitutional complaints except fatigue malaise dyspnea adenopathy reports fevers night sweats bone pain rash arthralgias myalgiaspast medical history diabetespast surgical history hernia repairallergies allergiesmedications listed chart include coumadin lasix metformin folic acid diltiazem b prevacid feosolsocial history tobacco user drink lives alone family social support look himfamily history negative blood cancer disorders according patientphysical examinationgeneral elderly gentleman acute distress sitting bed eating breakfast alert oriented answering questions appropriatelyvital signs blood pressure pulse respiratory rate temperature inches tall weighs poundsheent sclerae show mild arcus senilis right left clear pupils equally round reactive light extraocular movements intact oropharynx clearneck supple trachea midline jugular venous pressure distention noted adenopathy cervical supraclavicular axillary areaschest clearheart regular rate rhythmabdomen soft nontender may fullness left upper quadrant although appreciate true spleen inspirationextremities clubbing edema cyanosisneurologic noncontributorydermatologic noncontributorycardiovascular noncontributoryimpression time refractory anemia transfusion dependent b iron folic acid procrit sign symptom blood loss recent esophagogastroduodenoscopy negative creatinine impression time probably underlying myelodysplastic syndrome bone marrow failure creatinine hospitalization slightly may contribute anemiarecommendations time recommendation patient undergoes serologic evaluation reticulocyte count serum protein electrophoresis ldh b folate erythropoietin level undergo bone marrow aspiration biopsy discussed procedure detail patient discussed risks benefits successes treatment usefulness bone marrow predicting cause refractory anemia therapeutic interventions might beneficial willing proceed studies described order ultrasound abdomen possible fullness spleen probably see follow hospitalizationas always greatly appreciate able participate care patient appreciate consultation patient

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:, Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY: ,Diabetes.,PAST SURGICAL HISTORY:, Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.,FAMILY HISTORY:, Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.,VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.,HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.,NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC: Noncontributory.,DERMATOLOGIC: Noncontributory.,CARDIOVASCULAR: Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS: ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient. ### Response: Consult - History and Phy., General Medicine, Hematology - Oncology

DIAGNOSIS:, Stasis ulcers of the lower extremities,OPERATION:, Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:, This 84-year old female presented recently with large ulcers of the lower extremities. These were representing on the order of 50% or more of the circumference of her lower leg. They were in a distribution to be consistent with stasis ulcers. They were granulating nicely and she was scheduled for surgery.,FINDINGS:, Large ulcers of lower extremities with size as described above. These are irregular in shape and posterior and laterally on the lower legs. There was no evidence of infection. The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes. The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin. The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed. Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch. This was meshed 1:1.5 and then stapled into position on the wounds. The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels. The donor site was dressed with Op-Site. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.

diagnosis stasis ulcers lower extremitiesoperation splitthickness skin grafting total area approximately x cm right leg x cm left legindications year old female presented recently large ulcers lower extremities representing order circumference lower leg distribution consistent stasis ulcers granulating nicely scheduled surgeryfindings large ulcers lower extremities size described irregular shape posterior laterally lower legs evidence infection ultimate skin grafting quite satisfactoryprocedure obtained adequate general endotracheal anesthesia patient prepped pubis toes legs examined wounds pulsavaced bilaterally liters saline bacitracin wounds inspected adequate hemostasis minimal fibrinous debris needed removed accomplished skin harvested right thigh approximately inch meshed stapled position wounds wounds dressed fine mesh gauze stapled position well kerlix soaked sulfamylon solutionshe dressed additional kerlix followed webril splints fashioned spiral fashion avoided foot drop stabilized time put pressure across heels donor site dressed opsite patient tolerated procedure well returned recovery room satisfactory condition

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:, Stasis ulcers of the lower extremities,OPERATION:, Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:, This 84-year old female presented recently with large ulcers of the lower extremities. These were representing on the order of 50% or more of the circumference of her lower leg. They were in a distribution to be consistent with stasis ulcers. They were granulating nicely and she was scheduled for surgery.,FINDINGS:, Large ulcers of lower extremities with size as described above. These are irregular in shape and posterior and laterally on the lower legs. There was no evidence of infection. The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes. The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin. The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed. Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch. This was meshed 1:1.5 and then stapled into position on the wounds. The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels. The donor site was dressed with Op-Site. The patient tolerated the procedure well and returned to the recovery room in satisfactory condition. ### Response: Surgery

DIAGNOSIS:, Status post brain tumor removal.,HISTORY:, The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications. The patient reports that she was admitted to Hospital on 12/05/08. At that time, they found massive swelling on the brain and a second surgery was performed. The patient then remained in acute rehab until she was discharged to home on 01/05/09. The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS: ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time. The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL: ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION: Bilateral lower extremities are within normal limits.,STRENGTH: Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE: The patient's balance was assessed with a Berg balance test. The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT: The patient ambulates with contact guard assist. The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance. However, the patient has been reports that with increased fatigue, left footdrop tends to occur. A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery. Examination indicates deficits in strength, balance, and ambulation. The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks. Interventions include:,1. Therapeutic exercise.,2. Balance training.,3. Gait training.,4. Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1. The patient is to tolerate 30 repetitions of all lower extremity exercises.,2. The patient is to improve balance with a score of 50/56 points.,3. The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to ambulate independently within her home and standby to general supervision within the community.,2. Berg balance test to be 52/56.,3. The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4. The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good. The above treatment plan has been discussed with the patient and her husband. They are in agreement.

diagnosis status post brain tumor removalhistory patient yearold female referred physical therapy following complications related brain tumor removal patient reports brain tumor removed leftsided weakness patient seen physical therapy began complications patient reports admitted hospital time found massive swelling brain second surgery performed patient remained acute rehab discharged home patients husband al also present reports rehabilitation patient dvt left calf since resolvedpast medical history unremarkablemedications coumadin keppra decadron glucophagesubjective patient reports pain issue time patient states primary concern leftsided weakness related balance walking left arm weaknesspatient goal increase strength left leg better balance walkingobjectiverange motion bilateral lower extremities within normal limitsstrength bilateral lower extremities grossly one repetition except left hip reflexion balance patients balance assessed berg balance test patient got points places moderate risk fallsgait patient ambulates contact guard assist patient ambulates reciprocal gait pattern good bilateral foot clearance however patient reports increased fatigue left footdrop tends occur minute walk test performed next visit due time constraintsassessment patient yearold female referred physical therapy status post brain surgery examination indicates deficits strength balance ambulation patient benefit skilled physical therapy address impairmentstreatment plan patient seen three times per week weeks reduce two times per week additional weeks interventions include therapeutic exercise balance training gait training functional mobility trainingshort term goal completed weeks patient tolerate repetitions lower extremity exercises patient improve balance score points patient ambulate feet minute walk test standby assistlong term goal achieved weeks patient ambulate independently within home standby general supervision within community berg balance test patient ambulate minute walk test feet independently including safe negotiation corners busy areas patient demonstrate safely stepping around objects without loss balanceprognosis abovestated goals good treatment plan discussed patient husband agreement

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:, Status post brain tumor removal.,HISTORY:, The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications. The patient reports that she was admitted to Hospital on 12/05/08. At that time, they found massive swelling on the brain and a second surgery was performed. The patient then remained in acute rehab until she was discharged to home on 01/05/09. The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS: ,Coumadin, Keppra, Decadron, and Glucophage.,SUBJECTIVE: , The patient reports that the pain is not an issue at this time. The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,PATIENT GOAL: ,To increase strength in her left leg for better balance and walking.,OBJECTIVE:,RANGE OF MOTION: Bilateral lower extremities are within normal limits.,STRENGTH: Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,BALANCE: The patient's balance was assessed with a Berg balance test. The patient has got 46/56 points, which places her at moderate risk for falls.,GAIT: The patient ambulates with contact guard assist. The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance. However, the patient has been reports that with increased fatigue, left footdrop tends to occur. A 6-minute walk test will be performed at the next visit due to time constraints.,ASSESSMENT: , The patient is a 64-year-old female referred to Physical Therapy status post brain surgery. Examination indicates deficits in strength, balance, and ambulation. The patient will benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: , The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks. Interventions include:,1. Therapeutic exercise.,2. Balance training.,3. Gait training.,4. Functional mobility training.,SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS:,1. The patient is to tolerate 30 repetitions of all lower extremity exercises.,2. The patient is to improve balance with a score of 50/56 points.,3. The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to ambulate independently within her home and standby to general supervision within the community.,2. Berg balance test to be 52/56.,3. The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4. The patient is to demonstrate safely stepping over and around objects without loss of balance.,Prognosis for the above-stated goals is good. The above treatment plan has been discussed with the patient and her husband. They are in agreement. ### Response: Neurology

DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs. The report was available at the time of the evaluation. The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1. Tramadol.,2. Diclofenac.,3. Advil.,4. Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES: ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE: ,Upon observation, the patient is ambulating with a significant antalgic gait pattern. However, he is not using any assistive device. The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion. Right knee active range of motion is 0 to 126 degrees.,STRENGTH: ,Strength is 3/5 for left knee, 4+/5 for right knee. The patient denies any pain upon light and deep palpation at the knee joints. There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint. The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS: ,The patient performed a six-minute walk test. He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:, The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to perform functional activities and work tasks.,5. Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1. Patient will demonstrate independence with the home exercise program.,2. Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3. The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4. The patient will demonstrate 4/5 strength for the left knee.,5. The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1. The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2. The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3. Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4. The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS: ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1. Therapeutic exercise with home exercise program.

diagnosis synovitisanterior cruciate ligament tear left kneehistory patient yearold male referred physical therapy secondary left knee pain patient states patient fell grocery store reports slipping grape floor patient states went emergency room followed primary care physician patient ultimately referred physical therapy receiving knee brace history information received translator patient spanish speaking onlypast medical history past medical history unremarkablemedical imaging medical imaging significant xrays mris report available time evaluation patient reports abnormal posterior horn medial meniscus consistent knee degenerative change possibly tearsmedications tramadol diclofenac advil tylenolsubjective patient rates pain pain analog scale primarily ambulation patient deny pain night patient present knee brace exterior __________ leg appears backboardfunctional activities hobbies functional activities hobbies currently limited include work patient currently unemployed looking job however primary skills laborer street broker new homesobjective upon observation patient ambulating significant antalgic gait pattern however using assistive device knee brace corrected patient wife demonstrated understanding knowledge place knee brace correctlyactive range motion active range motion left knee degrees pain range motion right knee active range motion degreesstrength strength left knee right knee patient denies pain upon light deep palpation knee joints evidence temperature change increased swelling discoloration left knee joint patient appear instability time formal tests left knee jointspecial tests patient performed sixminute walk test able complete feet however stop test approximately five minutes secondary significant increase painassessment patient would benefit skilled physical therapy intervention order address following problem list increased pain decreased range motion decreased strength decreased ability perform functional activities work tasks decreased ambulation toleranceshortterm goals completed three weeks patient demonstrate independence home exercise program patient report maximum pain pain analog scale within hour period patient demonstrate left knee active range motion degrees without significant increase pain motion patient demonstrate strength left knee patient complete feet sixminute walk test without significant increase painlongterm goals completed six weeks patient demonstrate bilateral knee active range motion degrees patient demonstrate lower extremity strength bilaterally without significant increase pain patient complete feet sixminute walk test without increase pain tolerate full completion six minutes patient improve confidence ability perform work activity situation improves resolvesprognosis prognosis good abovestated goals compliance home exercise program treatmentsession plan patient seen two three times week six weeks following therapeutic exercise home exercise program

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs. The report was available at the time of the evaluation. The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1. Tramadol.,2. Diclofenac.,3. Advil.,4. Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES: ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE: ,Upon observation, the patient is ambulating with a significant antalgic gait pattern. However, he is not using any assistive device. The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion. Right knee active range of motion is 0 to 126 degrees.,STRENGTH: ,Strength is 3/5 for left knee, 4+/5 for right knee. The patient denies any pain upon light and deep palpation at the knee joints. There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint. The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS: ,The patient performed a six-minute walk test. He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:, The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to perform functional activities and work tasks.,5. Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1. Patient will demonstrate independence with the home exercise program.,2. Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3. The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4. The patient will demonstrate 4/5 strength for the left knee.,5. The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1. The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2. The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3. Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4. The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS: ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1. Therapeutic exercise with home exercise program. ### Response: Orthopedic

DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.

diagnosis broadbased endocervical poly broad based pigmented raised nevus right thighoperation leep procedure endocervical polyp electrical excision pigmented mole inner right thighfindings x cm broadbased pigmented nevus inner thigh excised wire loop also buttbased cm long endocervical polyp posterior lip cervix slightly canalprocedure patient supine position general anesthesia administered patient put dorsal lithotomy position prepped draped dilatation curettage routine fashionan insulated posterior weighted retractor put using leep tenaculum able grasp anterior lip cervix large wire loop cutting coagulation endocervical polyp posterior lip cervix excisedthen changing coagulation cutting base polyp electrocoagulated controlled bleeding wire loop attached pigmented raised nevus inner thigh excised wire loop cautery base done closed figureofeight vicryl sutures bandaid applied thisrechecking cervix bleeding noted patient laid flat table awakened moved recovery room bed sent recovery room satisfactory condition

### Instruction: find the medical speciality for this medical test. ### Input: DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition. ### Response: Obstetrics / Gynecology, Surgery

DISCHARGE DATE: MM/DD/YYYY,HISTORY OF PRESENT ILLNESS: Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. He underwent a resection there. He was to be admitted to the Day Hospital for cystectomy. He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE: Mr. ABC presented to the Day Hospital in anticipation for Urology surgery. On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained. A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia. In addition, inducible ischemia seen in the inferior lateral septum. Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease. The RCA, proximal was 95% stenosed and the distal 80% stenosed. The mid LAD was 85% stenosed and the distal LAD was 85% stenosed. There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%. Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ. Mr. ABC had a noncomplicated post-intervention hospital course. He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS: Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: Obese, soft, nontender. Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN: Dry and intact, no bruit, no ecchymosis, no hematoma. Distal pulses are intact.,DISCHARGE LABS: CBC: White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1. BMP: Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211. Lipid profile: Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1. On MM/DD/YYYY, cardiac MRI adenosine stress.,2. On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS: Mr. ABC is discharged home. He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet. He should follow post-coronary artery intervention restrictions. He should not lift greater than 10 pounds for seven days. He should not drive for two days. He should not immerse in water for two weeks. Groin site care reviewed with patient prior to being discharged home. He should check groin for bleeding, edema, and signs of infection. Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him. He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1. Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2. Bladder cancer.,3. Diabetes.,4. Dyslipidemia.,5. Hypertension.,6. Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7. Multiple resections of the bladder tumor.,8. Distant history of appendectomy.,9. Distant history of ankle surgery.

discharge date mmddyyyyhistory present illness mr abc yearold white male veteran multiple comorbidities history bladder cancer diagnosed approximately two years ago va hospital underwent resection admitted day hospital cystectomy seen urology clinic radiology clinic mmddyyyyhospital course mr abc presented day hospital anticipation urology surgery evaluation ekg echocardiogram abnormal cardiology consult obtained cardiac adenosine stress mri proceeded positive inducible ischemia mildtomoderate inferolateral subendocardial infarction periinfarct ischemia addition inducible ischemia seen inferior lateral septum mr abc underwent left heart catheterization revealed two vessel coronary artery disease rca proximal stenosed distal stenosed mid lad stenosed distal lad stenosed four multilink vision bare metal stents placed decrease four lesions following intervention mr abc admitted ardmore tower cardiology service direction dr xyz mr abc noncomplicated postintervention hospital course stable discharge home mmddyyyy instructions take plavix daily one month urology aware samedischarge examvital signs temperature heart rate respirations blood pressure heart regular rate rhythmlungs clear auscultationabdomen obese soft nontender lower abdomen tender touched due bladder cancerright groin dry intact bruit ecchymosis hematoma distal pulses intactdischarge labs cbc white count hemoglobin hematocrit platelet count hemoglobin ac bmp sodium potassium bun creatinine glucose lipid profile cholesterol triglycerides hdl ldl procedures mmddyyyy cardiac mri adenosine stress mmddyyyy left heart catheterization coronary angiogram left ventriculogram coronary angioplasty four multilink vision bare metal stents two placed lad two placed rcadischarge instructions mr abc discharged home follow lowfat lowsalt lowcholesterol heart healthy diabetic diet follow postcoronary artery intervention restrictions lift greater pounds seven days drive two days immerse water two weeks groin site care reviewed patient prior discharged home check groin bleeding edema signs infection mr abc see primary care physician within one two weeks return dr xyzs clinic four six weeks appointment card mailed follow urology clinic mmddyyyy oclock scheduled ct scan timedischarge diagnoses coronary artery disease status post percutaneous coronary artery intervention right coronary artery lad bladder cancer diabetes dyslipidemia hypertension carotid artery stenosis status post right carotid endarterectomy multiple resections bladder tumor distant history appendectomy distant history ankle surgery

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DATE: MM/DD/YYYY,HISTORY OF PRESENT ILLNESS: Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. He underwent a resection there. He was to be admitted to the Day Hospital for cystectomy. He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY.,HOSPITAL COURSE: Mr. ABC presented to the Day Hospital in anticipation for Urology surgery. On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained. A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia. In addition, inducible ischemia seen in the inferior lateral septum. Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease. The RCA, proximal was 95% stenosed and the distal 80% stenosed. The mid LAD was 85% stenosed and the distal LAD was 85% stenosed. There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%. Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ. Mr. ABC had a noncomplicated post-intervention hospital course. He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same.,DISCHARGE EXAM:,VITAL SIGNS: Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: Obese, soft, nontender. Lower abdomen tender when touched due to bladder cancer.,RIGHT GROIN: Dry and intact, no bruit, no ecchymosis, no hematoma. Distal pulses are intact.,DISCHARGE LABS: CBC: White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1. BMP: Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211. Lipid profile: Cholesterol 157, triglycerides 146, HDL 22, LDL 106.,PROCEDURES:,1. On MM/DD/YYYY, cardiac MRI adenosine stress.,2. On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA.,DISCHARGE INSTRUCTIONS: Mr. ABC is discharged home. He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet. He should follow post-coronary artery intervention restrictions. He should not lift greater than 10 pounds for seven days. He should not drive for two days. He should not immerse in water for two weeks. Groin site care reviewed with patient prior to being discharged home. He should check groin for bleeding, edema, and signs of infection. Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him. He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time.,DISCHARGE DIAGNOSES:,1. Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.,2. Bladder cancer.,3. Diabetes.,4. Dyslipidemia.,5. Hypertension.,6. Carotid artery stenosis, status post right carotid endarterectomy in 2004.,7. Multiple resections of the bladder tumor.,8. Distant history of appendectomy.,9. Distant history of ankle surgery. ### Response: Discharge Summary, General Medicine

DISCHARGE DIAGNOSES,1. Multiple extensive subcutaneous abscesses, right thigh.,2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2. Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3. Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE: ,The patient was admitted on 03/05/08 by Dr. X. He was taken to the operating room. He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip. This led to a prolonged hospital course. The patient initially was treated with local wound care. He was treated with broad spectrum antibiotics. He ended up growing out different species of Clostridium. Infectious Disease consult was obtained from Dr. Z. He assisted in further antibiotic coverage throughout the rest of his hospitalization. The patient also had significant hypoalbuminemia, decreased nutrition. Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing. The patient had this superior area what appeared to be further necrotic, infected soft tissue. He went back to the OR on 03/16/08 and further resection done by Dr. X. After this, his wound appeared to be free of infection. He is treated with a wound VAC. He slowly, but progressively had significant progress in his wound. I went from a very poor-looking wound to a red granulated wound throughout its majority. He was thought ready for skin grafting. Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity. These were negative. He was treated with SCDs to help decrease his risk. On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting. He underwent skin grafting to his right thigh and hip massive open wound. Donor sites were truncated. Postoperatively, the patient ended up with a vast majority of skin graft taking. To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip. He is continued on VAC dressing. Graft progressively improved with this therapy. Had another ultrasound, which was negative for DVT. The patient was mobilized up out of his bed. Infectious Disease recommendations were obtained. Plan was to complete additional 10 days of antibiotics at discharge. This will be oral antibiotics. I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage. So, decision was not made to excise this, but instead monitor. By 04/11/08, his graft looked good. It was pink and filling in. He looked stable for discharge. The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written. He is okay to shower. Donor site and graft site dressing instruction orders were given for Home Health and the patient. His followup was arranged with Dr. X and myself.

discharge diagnoses multiple extensive subcutaneous abscesses right thigh massive open wound right thigh status post right excision multiple subcutaneous abscesses right thighprocedures performed dr x massive debridement soft tissue right lateral thigh hip soft tissue debridement right thigh hip dr x split thickness skin graft right thigh right hip massive open wound dr yreason admission patient yearold male history drug use history injection heroin bilateral thighs unfortunately developed chronic abscesses open wounds bilateral thighs much worse right left decision made radical excision followed reconstructionhospital course patient admitted dr x taken operating room underwent massive resection multiple subcutaneous abscesses heroin remnants left massive huge open wounds right thigh hip led prolonged hospital course patient initially treated local wound care treated broad spectrum antibiotics ended growing different species clostridium infectious disease consult obtained dr z assisted antibiotic coverage throughout rest hospitalization patient also significant hypoalbuminemia decreased nutrition given large wounds end getting feeding tube placement prior grafting received significant feeding tube supplementation help achieve adequate nutrition healing patient superior area appeared necrotic infected soft tissue went back resection done dr x wound appeared free infection treated wound vac slowly progressively significant progress wound went poorlooking wound red granulated wound throughout majority thought ready skin grafting note patient serial ultrasounds given high risk dvt massive wound need decreased activity negative treated scds help decrease risk patient taken operating room thought adequate ________ grafting underwent skin grafting right thigh hip massive open wound donor sites truncated postoperatively patient ended vast majority skin graft taking unable take kept iv antibiotics strict bed rest limited range motion hip continued vac dressing graft progressively improved therapy another ultrasound negative dvt patient mobilized bed infectious disease recommendations obtained plan complete additional days antibiotics discharge oral antibiotics would monitor left side significantly decreased inflammation irritation infection given antibiotic coverage decision made excise instead monitor graft looked good pink filling looked stable discharge patient discharged homedischarge instructions discharge homecondition stableantibiotic augmentin xr script written okay shower donor site graft site dressing instruction orders given home health patient followup arranged dr x

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES,1. Multiple extensive subcutaneous abscesses, right thigh.,2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2. Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3. Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE: ,The patient was admitted on 03/05/08 by Dr. X. He was taken to the operating room. He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip. This led to a prolonged hospital course. The patient initially was treated with local wound care. He was treated with broad spectrum antibiotics. He ended up growing out different species of Clostridium. Infectious Disease consult was obtained from Dr. Z. He assisted in further antibiotic coverage throughout the rest of his hospitalization. The patient also had significant hypoalbuminemia, decreased nutrition. Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing. The patient had this superior area what appeared to be further necrotic, infected soft tissue. He went back to the OR on 03/16/08 and further resection done by Dr. X. After this, his wound appeared to be free of infection. He is treated with a wound VAC. He slowly, but progressively had significant progress in his wound. I went from a very poor-looking wound to a red granulated wound throughout its majority. He was thought ready for skin grafting. Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity. These were negative. He was treated with SCDs to help decrease his risk. On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting. He underwent skin grafting to his right thigh and hip massive open wound. Donor sites were truncated. Postoperatively, the patient ended up with a vast majority of skin graft taking. To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip. He is continued on VAC dressing. Graft progressively improved with this therapy. Had another ultrasound, which was negative for DVT. The patient was mobilized up out of his bed. Infectious Disease recommendations were obtained. Plan was to complete additional 10 days of antibiotics at discharge. This will be oral antibiotics. I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage. So, decision was not made to excise this, but instead monitor. By 04/11/08, his graft looked good. It was pink and filling in. He looked stable for discharge. The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written. He is okay to shower. Donor site and graft site dressing instruction orders were given for Home Health and the patient. His followup was arranged with Dr. X and myself. ### Response: Discharge Summary, General Medicine

DISCHARGE DIAGNOSES: ,1. Suspected mastoiditis ruled out.,2. Right acute otitis media.,3. Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blood draining from the right ear. The child had a temperature maximum of 101.4 in the ER. The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control. In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. The patient was evaluated by Dr. X from the ENT while in house. After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis. The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge. At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL: The patient is alert, in no respiratory distress.,VITAL SIGNS: His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT: Right ear shows no redness. The area behind his ear is nontender. There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK: Supple.,CHEST: Clear breath sounds.,CARDIAC: Normal S1, S2 without murmur.,ABDOMEN: Soft. There is no hepatosplenomegaly or tenderness.,SKIN: Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:, Regular as tolerated.,DISCHARGE MEDICATIONS: ,1. Ciprodex Otic Solution in the right ear twice daily.,2. Augmentin 500 mg three times daily x10 days.,FOLLOW UP: ,1. Dr. Y in one week (ENT).,2. The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.

discharge diagnoses suspected mastoiditis ruled right acute otitis media severe ear pain resolvinghistory present illness patient yearold male admitted er ct scan suggested child mastoiditis child severe ear pain blood draining right ear child temperature maximum er patient admitted started iv unasyn tolerated well required morphine vicodin pain control first hours admission patients pain decreased also swelling cervical area decreased patient evaluated dr x ent house reviewing ct scan felt ct scan consistent mastoiditis child continued iv fluid narcotics pain well unasyn time discharge time discharge pain markedly decreased swelling area improved patient also able take po welldischarge physical examinationgeneral patient alert respiratory distressvital signs temperature heart rate blood pressure respiratory rate room airheent right ear shows redness area behind ear nontender large posterior chains node nontender swelling area decreased markedlyneck supplechest clear breath soundscardiac normal without murmurabdomen soft hepatosplenomegaly tendernessskin warm well perfuseddischarge weight kgdischarge condition gooddischarge diet regular tolerateddischarge medications ciprodex otic solution right ear twice daily augmentin mg three times daily x daysfollow dr one week ent primary care physician daystime spent approximate discharge time minutes

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES: ,1. Suspected mastoiditis ruled out.,2. Right acute otitis media.,3. Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blood draining from the right ear. The child had a temperature maximum of 101.4 in the ER. The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control. In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. The patient was evaluated by Dr. X from the ENT while in house. After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis. The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge. At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL: The patient is alert, in no respiratory distress.,VITAL SIGNS: His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT: Right ear shows no redness. The area behind his ear is nontender. There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK: Supple.,CHEST: Clear breath sounds.,CARDIAC: Normal S1, S2 without murmur.,ABDOMEN: Soft. There is no hepatosplenomegaly or tenderness.,SKIN: Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:, Regular as tolerated.,DISCHARGE MEDICATIONS: ,1. Ciprodex Otic Solution in the right ear twice daily.,2. Augmentin 500 mg three times daily x10 days.,FOLLOW UP: ,1. Dr. Y in one week (ENT).,2. The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes. ### Response: Discharge Summary, ENT - Otolaryngology, Emergency Room Reports, Pediatrics - Neonatal

DISCHARGE DIAGNOSES:, BRCA-2 mutation. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION: ,The chest was clear. The abdomen was nontender. Pelvic examination shows no masses. No heart murmur. ,HOSPITAL COURSE: ,The patient underwent surgery on the day of admission. In the postoperative course she was afebrile and unremarkable. The patient regained bowel function and was discharged on the morning of the fourth postoperative day.,OPERATIONS AND PROCEDURES: , Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.,PATHOLOGY: , A 105-gram uterus without dysplasia or cancer.,CONDITION ON DISCHARGE: , Stable.,PLAN: ,The patient will remain at rest initially with progressive ambulation after. She will avoid lifting, driving or intercourse. She will call me if any fevers, drainage, bleeding, or pain. Follow up in my office in four weeks. Family history, social history, psychosocial needs per the social worker.,DISCHARGE MEDICATIONS: , Percocet 5 #40 one every 3 hours p.r.n. pain.

discharge diagnoses brca mutation history present illness patient yearold brca mutation sister died breast cancer age daughter breast cancer age physical examination chest clear abdomen nontender pelvic examination shows masses heart murmur hospital course patient underwent surgery day admission postoperative course afebrile unremarkable patient regained bowel function discharged morning fourth postoperative dayoperations procedures total abdominal hysterectomybilateral salpingooophorectomy resection ovarian fossa peritoneum en bloc july pathology gram uterus without dysplasia cancercondition discharge stableplan patient remain rest initially progressive ambulation avoid lifting driving intercourse call fevers drainage bleeding pain follow office four weeks family history social history psychosocial needs per social workerdischarge medications percocet one every hours prn pain

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:, BRCA-2 mutation. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,PHYSICAL EXAMINATION: ,The chest was clear. The abdomen was nontender. Pelvic examination shows no masses. No heart murmur. ,HOSPITAL COURSE: ,The patient underwent surgery on the day of admission. In the postoperative course she was afebrile and unremarkable. The patient regained bowel function and was discharged on the morning of the fourth postoperative day.,OPERATIONS AND PROCEDURES: , Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006.,PATHOLOGY: , A 105-gram uterus without dysplasia or cancer.,CONDITION ON DISCHARGE: , Stable.,PLAN: ,The patient will remain at rest initially with progressive ambulation after. She will avoid lifting, driving or intercourse. She will call me if any fevers, drainage, bleeding, or pain. Follow up in my office in four weeks. Family history, social history, psychosocial needs per the social worker.,DISCHARGE MEDICATIONS: , Percocet 5 #40 one every 3 hours p.r.n. pain. ### Response: Discharge Summary, Hematology - Oncology

DISCHARGE DIAGNOSES:,1. Acute respiratory failure, resolved.,2. Severe bronchitis leading to acute respiratory failure, improving.,3. Acute on chronic renal failure, improved.,4. Severe hypertension, improved.,5. Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1. Hyperlipidemia.,2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3. Remote history of carcinoma of the breast.,4. Remote history of right nephrectomy.,5. Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1. Metoprolol 25 mg p.o. b.i.d.,2. Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1. Prednisone 20 mg p.o. daily for seven days.,2. Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:, The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time.

discharge diagnoses acute respiratory failure resolved severe bronchitis leading acute respiratory failure improving acute chronic renal failure improved severe hypertension improved diastolic dysfunctionxray discharge show congestion probnp normalsecondary diagnoses hyperlipidemia recent evaluation treatment including cardiac catheterization show coronary artery disease remote history carcinoma breast remote history right nephrectomy allergic rhinitishospital course yearold patient cold symptoms treated bronchitis antibiotics long patient returned mexico patient started progressive shortness breath came emergency room severe bilateral wheezing crepitations xrays however show congestion infiltrates probnp within normal limits patient however hypoxic required l nasal cannula admitted intensive care unit patient improved remarkably night iv steroids empirical iv lasix initial swab positive mrsa colonization discussed infectious disease dr x decided treatment required decolonization patients breathing improved wheezing crepitations saturation room air patient yet go exercise oximetry main complaint nasal congestion steroid nasal spray patient seen cardiology dr z advised continuation beta blockers diastolic dysfunction patient weaned iv steroids currently oral steroids seven daysdisposition patient discharged homedischarge medications metoprolol mg po bid simvastatin mg po dailynew medications prednisone mg po daily seven days flonase nasal spray daily daysresults oximetry pending evaluate patient need home oxygenfollow patient follow pulmonology dr one weeks time cardiologist dr x two three weeks time

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:,1. Acute respiratory failure, resolved.,2. Severe bronchitis leading to acute respiratory failure, improving.,3. Acute on chronic renal failure, improved.,4. Severe hypertension, improved.,5. Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1. Hyperlipidemia.,2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3. Remote history of carcinoma of the breast.,4. Remote history of right nephrectomy.,5. Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1. Metoprolol 25 mg p.o. b.i.d.,2. Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1. Prednisone 20 mg p.o. daily for seven days.,2. Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:, The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time. ### Response: Cardiovascular / Pulmonary, Discharge Summary

DISCHARGE DIAGNOSES:,1. Advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,2. Respiratory failure secondary to above.,3. Likely postobstructive pneumonia.,4. Gastrointestinal bleed.,5. Thrombocytopenia.,6. Acute renal failure.,7. Hyponatremia.,8. Hypercalcemia, likely secondary to paraneoplastic syndrome from the non-small cell lung CA, possible metastases to the bones.,9. Leukemoid reaction, likely secondary to malignancy.,10. Elevated liver function tests.,HOSPITAL COURSE:, This is a 53-year-old African American male patient of Dr. X who was admitted through the emergency room. He has been having some right hip pain and cough. The patient had a CT scan of the chest, which revealed a left pleural effusion, extensive mediastinal mass, left hilar adenopathy, causing complete obstruction of the left lower lobe and the lingula and the left pulmonary vein, and the multiple nodules on the right side of his chest. These were all consistent with metastatic disease. He was thus also a suspicion for osseous metastatic disease involving the right scapula with a left large pleural effusion. The patient had severe shortness of breath, chest pain, a left-sided chest tube was inserted, and pleural effusion was positive for malignant cells. The history of right hip pain could be secondary to metastatic disease. The patient underwent bronchoscopy, which is positive for non-small cell lung CA. The patient was seen by various consultants. The patient underwent respiratory failure, requiring intubation, mechanical ventilatory support. He was extubated, but had to be re-intubated because of respiratory failure. Had a long discussion with the patient's wife and other family members. The patient was seen by Dr. Y. The patient was not in a condition to undergo any kind of chemotherapy, being on the ventilator. The patient progressively got deteriorated. The patient's family requested for DNR, withdrawal of the life support. The patient was extubated, and he was pronounced expired on 08/21/08 at 01:40 hours.,I appreciate all consultants' input.

discharge diagnoses advanced nonsmall cell lung carcinoma left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis respiratory failure secondary likely postobstructive pneumonia gastrointestinal bleed thrombocytopenia acute renal failure hyponatremia hypercalcemia likely secondary paraneoplastic syndrome nonsmall cell lung ca possible metastases bones leukemoid reaction likely secondary malignancy elevated liver function testshospital course yearold african american male patient dr x admitted emergency room right hip pain cough patient ct scan chest revealed left pleural effusion extensive mediastinal mass left hilar adenopathy causing complete obstruction left lower lobe lingula left pulmonary vein multiple nodules right side chest consistent metastatic disease thus also suspicion osseous metastatic disease involving right scapula left large pleural effusion patient severe shortness breath chest pain leftsided chest tube inserted pleural effusion positive malignant cells history right hip pain could secondary metastatic disease patient underwent bronchoscopy positive nonsmall cell lung ca patient seen various consultants patient underwent respiratory failure requiring intubation mechanical ventilatory support extubated reintubated respiratory failure long discussion patients wife family members patient seen dr patient condition undergo kind chemotherapy ventilator patient progressively got deteriorated patients family requested dnr withdrawal life support patient extubated pronounced expired hoursi appreciate consultants input

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:,1. Advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,2. Respiratory failure secondary to above.,3. Likely postobstructive pneumonia.,4. Gastrointestinal bleed.,5. Thrombocytopenia.,6. Acute renal failure.,7. Hyponatremia.,8. Hypercalcemia, likely secondary to paraneoplastic syndrome from the non-small cell lung CA, possible metastases to the bones.,9. Leukemoid reaction, likely secondary to malignancy.,10. Elevated liver function tests.,HOSPITAL COURSE:, This is a 53-year-old African American male patient of Dr. X who was admitted through the emergency room. He has been having some right hip pain and cough. The patient had a CT scan of the chest, which revealed a left pleural effusion, extensive mediastinal mass, left hilar adenopathy, causing complete obstruction of the left lower lobe and the lingula and the left pulmonary vein, and the multiple nodules on the right side of his chest. These were all consistent with metastatic disease. He was thus also a suspicion for osseous metastatic disease involving the right scapula with a left large pleural effusion. The patient had severe shortness of breath, chest pain, a left-sided chest tube was inserted, and pleural effusion was positive for malignant cells. The history of right hip pain could be secondary to metastatic disease. The patient underwent bronchoscopy, which is positive for non-small cell lung CA. The patient was seen by various consultants. The patient underwent respiratory failure, requiring intubation, mechanical ventilatory support. He was extubated, but had to be re-intubated because of respiratory failure. Had a long discussion with the patient's wife and other family members. The patient was seen by Dr. Y. The patient was not in a condition to undergo any kind of chemotherapy, being on the ventilator. The patient progressively got deteriorated. The patient's family requested for DNR, withdrawal of the life support. The patient was extubated, and he was pronounced expired on 08/21/08 at 01:40 hours.,I appreciate all consultants' input. ### Response: Discharge Summary

DISCHARGE DIAGNOSES:,1. Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2. Prostatic hypertrophy with bladder outlet obstruction.,3. Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks. He will be followed in the office.,HISTORY OF PRESENT ILLNESS:, This is a pleasant 62-year-old male with cerebral palsy. The patient was recently admitted to Hospital with lower extremity cellulitis. This resolved, however, recurred in both legs. Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:, As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION: ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000. Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8. Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria. Blood culture and wound cultures were unremarkable. Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin. On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine. A Foley catheter was inserted and was productive of approximately 500 cc of urine. The patient was prescribed Flomax 0.4 mg daily. 24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.

discharge diagnoses bilateral lower extremity cellulitis secondary bilateral tinea pedis prostatic hypertrophy bladder outlet obstruction cerebral palsydischarge instructions patient would discharged usual valium mg bedtime spasticity flomax mg daily cefazolin mg qid lotrimin cream toes bid additional two weeks followed officehistory present illness pleasant yearold male cerebral palsy patient recently admitted hospital lower extremity cellulitis resolved however recurred legs examination time admission demonstrated peeling skin excoriation toes feet consistent tinea pedispast medicalfamilysocial history per admission recordreview systems per admission recordphysical examination per admission recordlaboratory studies time admission white blood cell count normal differential hemoglobin hematocrit normal indices platelet count comprehensive metabolic profile unremarkable except nonfasting blood sugar lactic acid urine demonstrated red blood cells per highpowered field bacteria blood culture wound cultures unremarkable chest xray unremarkablehospital course patient admitted general medical floor treated intravenous ceftriaxone topical lotrimin regimen lower extremity edema erythema resolved quite rapidlybecause urinary frequency bladder scan done suggesting cc residual urine foley catheter inserted productive approximately cc urine patient prescribed flomax mg daily hours later foley catheter removed bladder scan demonstrated cc residual urine approximately eight hoursat time dictation patient ambulating minimally however sufficiently resume independent living

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:,1. Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2. Prostatic hypertrophy with bladder outlet obstruction.,3. Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks. He will be followed in the office.,HISTORY OF PRESENT ILLNESS:, This is a pleasant 62-year-old male with cerebral palsy. The patient was recently admitted to Hospital with lower extremity cellulitis. This resolved, however, recurred in both legs. Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:, As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION: ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000. Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8. Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria. Blood culture and wound cultures were unremarkable. Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin. On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine. A Foley catheter was inserted and was productive of approximately 500 cc of urine. The patient was prescribed Flomax 0.4 mg daily. 24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living. ### Response: Discharge Summary, Neurology

DISCHARGE DIAGNOSES:,1. Central nervous system lymphoma.,2. Gram-negative bacteremia.,3. Pancytopenia.,4. Hypertension.,5. Perianal rash.,6. Diabetes mellitus.,7. Hypoxia.,8. Seizure prophylaxis.,9. Acute kidney injury.,PROCEDURES DURING HOSPITALIZATION:,1. Cycle five high-dose methotrexate.,2. Rituxan weekly.,3. Chest x-ray.,4. Wound consult.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a pleasant 60-year-old Caucasian female who was diagnosed in April 2008 with diffuse large B-cell lymphoma after she developed visual saltation, changes, and confusion. Further staging revealed borderline mediastinal pretracheal lymphadenopathy but was otherwise unremarkable. She began high-dose methotrexate in mid May 2008; courses of methotrexate have been complicated by prolonged methotrexate levels, mental confusion, and mania. During cycle three, repeat MRI showed interval worsening of disease, and Rituxan was added to her regimen. Ms. ABC had a repeat MRI on July 24, 2008 prior to this admission, which showed significant improvement in her CNS disease.,HOSPITAL COURSE: , Ms. ABC was admitted to the Hematology B Service under attending Dr. Z.,1. CNS lymphoma. Upon admission, she was started on her Rituxan, which she tolerated well. She was then hydrated with bicarbonate solution to a urine pH of 8. She received methotrexate 5 g/m2. 24-hour creatinine was 0.9, 48-hour methotrexate level was elevated at 2.08. This was likely secondary to the need to initiate treatment with antibiotics secondary to infection. Her leucovorin was increased to 100 mg/m2. 72-hour methotrexate level was 0.58. 96-hour methotrexate was 0.16, and 19-hour was 0.08. She continued additional four doses of oral leucovorin. Her creatinine improved. On day prior to discharge, she received her weekly dose of Rituxan. She will return for Rituxan next week and then return for an appointment with Dr. X on August 18, 2008 with plans for admission for next cycle of methotrexate.,2. Gram-negative bacteremia. On the morning of June 27, 2008, Ms. ABC did spike a fever. She was started on empiric antibiotics with cefepime and vancomycin. Cultures were drawn peripherally and from the Port-A-Cath which both grew out Gram-negative rods within 12 hours. After being initiated on IV antibiotics, she remained afebrile for the remainder of the hospitalization. Both cultures eventually grew out Proteus mirabilis, which was pansensitive. She had three additional blood cultures, which were all negative. On the day prior to discharge, she was transitioned to oral Cipro and remained afebrile. We had intended to send her home with oral antibiotics; however, by day of discharge, she was pancytopenic and it was decided that she should be discharged to complete a 14-day course of IV antibiotics with cefepime. She will continue this with the assistance of home health services. She was advised to follow neutropenic precautions and labs will be followed closely as an outpatient. She understands if she develops a fever greater than 100.5, she should call to return immediately for admission.,3. Pancytopenia. On the day of discharge, the patient was pancytopenic with white count of 0.7, ANC of 500, hemoglobin 8.5, hematocrit 24.8, and platelet count 38, 000. Her labs will be followed closely as an outpatient. During the admission, we did obtain a HIT antibody, which was negative. Heparin was held until this level was returned. She was placed on Arixtra for prophylaxis against thrombus. It is thought that her decreasing counts may be secondary to infection; however, if she continues to be pancytopenic, she will have a repeat bone marrow as an outpatient.,4. Hypertension. Blood pressure remained stable throughout the admission. She will continue lisinopril daily.,5. Perianal rash. Upon admission, she was found to have worsening of a candidal rash in the perianal region. A wound consult was obtained. They recommended Aloe Vesta foam and Silver gel to the area topically. She was also continued on Diflucan 200 mg daily. She will complete a 10-day course.,6. Diabetes mellitus. At the time of admission, she was found to have hyperglycemia. She was started on sliding scale insulin and eventually started on long-acting Lantus insulin. She will be discharged with the regimen of Lantus 35 units at bedtime and continue the sliding scale as needed.,7. Hypoxia. She did have evidence of decreased saturations. There was concern that she may have a pneumonia, which was treated with vancomycin for possible hospital acquired pneumonia; however, upon further review of the blood cultures improved, chest x-ray consistent with atelectasis and normal saturations that this was likely secondary to increased fluids associated with methotrexate and atelectasis from being confined to bed.,8. Seizure prophylaxis. She will continue Keppra twice daily.,9. Acute kidney injury. She did have a bump in the creatinine when methotrexate level was elevated. This resolved by the time of discharge. Creatinine on day of discharge is 0.9. This will be followed as an outpatient.,DISPOSITION: , To home in stable condition with home health services.,DISCHARGE MEDICATIONS: , See separate sheet attached.,DIET:, Neutropenic diabetic.,ACTIVITY: , Resume same activity.,FOLLOWUP: , With weekly lab work and plans for admission on August 18, 2008. Ms. ABC was advised if she has any problems or concerns in the interim and needs to be seen sooner, she should call.

discharge diagnoses central nervous system lymphoma gramnegative bacteremia pancytopenia hypertension perianal rash diabetes mellitus hypoxia seizure prophylaxis acute kidney injuryprocedures hospitalization cycle five highdose methotrexate rituxan weekly chest xray wound consulthistory present illness ms abc pleasant yearold caucasian female diagnosed april diffuse large bcell lymphoma developed visual saltation changes confusion staging revealed borderline mediastinal pretracheal lymphadenopathy otherwise unremarkable began highdose methotrexate mid may courses methotrexate complicated prolonged methotrexate levels mental confusion mania cycle three repeat mri showed interval worsening disease rituxan added regimen ms abc repeat mri july prior admission showed significant improvement cns diseasehospital course ms abc admitted hematology b service attending dr z cns lymphoma upon admission started rituxan tolerated well hydrated bicarbonate solution urine ph received methotrexate gm hour creatinine hour methotrexate level elevated likely secondary need initiate treatment antibiotics secondary infection leucovorin increased mgm hour methotrexate level hour methotrexate hour continued additional four doses oral leucovorin creatinine improved day prior discharge received weekly dose rituxan return rituxan next week return appointment dr x august plans admission next cycle methotrexate gramnegative bacteremia morning june ms abc spike fever started empiric antibiotics cefepime vancomycin cultures drawn peripherally portacath grew gramnegative rods within hours initiated iv antibiotics remained afebrile remainder hospitalization cultures eventually grew proteus mirabilis pansensitive three additional blood cultures negative day prior discharge transitioned oral cipro remained afebrile intended send home oral antibiotics however day discharge pancytopenic decided discharged complete day course iv antibiotics cefepime continue assistance home health services advised follow neutropenic precautions labs followed closely outpatient understands develops fever greater call return immediately admission pancytopenia day discharge patient pancytopenic white count anc hemoglobin hematocrit platelet count labs followed closely outpatient admission obtain hit antibody negative heparin held level returned placed arixtra prophylaxis thrombus thought decreasing counts may secondary infection however continues pancytopenic repeat bone marrow outpatient hypertension blood pressure remained stable throughout admission continue lisinopril daily perianal rash upon admission found worsening candidal rash perianal region wound consult obtained recommended aloe vesta foam silver gel area topically also continued diflucan mg daily complete day course diabetes mellitus time admission found hyperglycemia started sliding scale insulin eventually started longacting lantus insulin discharged regimen lantus units bedtime continue sliding scale needed hypoxia evidence decreased saturations concern may pneumonia treated vancomycin possible hospital acquired pneumonia however upon review blood cultures improved chest xray consistent atelectasis normal saturations likely secondary increased fluids associated methotrexate atelectasis confined bed seizure prophylaxis continue keppra twice daily acute kidney injury bump creatinine methotrexate level elevated resolved time discharge creatinine day discharge followed outpatientdisposition home stable condition home health servicesdischarge medications see separate sheet attacheddiet neutropenic diabeticactivity resume activityfollowup weekly lab work plans admission august ms abc advised problems concerns interim needs seen sooner call

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:,1. Central nervous system lymphoma.,2. Gram-negative bacteremia.,3. Pancytopenia.,4. Hypertension.,5. Perianal rash.,6. Diabetes mellitus.,7. Hypoxia.,8. Seizure prophylaxis.,9. Acute kidney injury.,PROCEDURES DURING HOSPITALIZATION:,1. Cycle five high-dose methotrexate.,2. Rituxan weekly.,3. Chest x-ray.,4. Wound consult.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a pleasant 60-year-old Caucasian female who was diagnosed in April 2008 with diffuse large B-cell lymphoma after she developed visual saltation, changes, and confusion. Further staging revealed borderline mediastinal pretracheal lymphadenopathy but was otherwise unremarkable. She began high-dose methotrexate in mid May 2008; courses of methotrexate have been complicated by prolonged methotrexate levels, mental confusion, and mania. During cycle three, repeat MRI showed interval worsening of disease, and Rituxan was added to her regimen. Ms. ABC had a repeat MRI on July 24, 2008 prior to this admission, which showed significant improvement in her CNS disease.,HOSPITAL COURSE: , Ms. ABC was admitted to the Hematology B Service under attending Dr. Z.,1. CNS lymphoma. Upon admission, she was started on her Rituxan, which she tolerated well. She was then hydrated with bicarbonate solution to a urine pH of 8. She received methotrexate 5 g/m2. 24-hour creatinine was 0.9, 48-hour methotrexate level was elevated at 2.08. This was likely secondary to the need to initiate treatment with antibiotics secondary to infection. Her leucovorin was increased to 100 mg/m2. 72-hour methotrexate level was 0.58. 96-hour methotrexate was 0.16, and 19-hour was 0.08. She continued additional four doses of oral leucovorin. Her creatinine improved. On day prior to discharge, she received her weekly dose of Rituxan. She will return for Rituxan next week and then return for an appointment with Dr. X on August 18, 2008 with plans for admission for next cycle of methotrexate.,2. Gram-negative bacteremia. On the morning of June 27, 2008, Ms. ABC did spike a fever. She was started on empiric antibiotics with cefepime and vancomycin. Cultures were drawn peripherally and from the Port-A-Cath which both grew out Gram-negative rods within 12 hours. After being initiated on IV antibiotics, she remained afebrile for the remainder of the hospitalization. Both cultures eventually grew out Proteus mirabilis, which was pansensitive. She had three additional blood cultures, which were all negative. On the day prior to discharge, she was transitioned to oral Cipro and remained afebrile. We had intended to send her home with oral antibiotics; however, by day of discharge, she was pancytopenic and it was decided that she should be discharged to complete a 14-day course of IV antibiotics with cefepime. She will continue this with the assistance of home health services. She was advised to follow neutropenic precautions and labs will be followed closely as an outpatient. She understands if she develops a fever greater than 100.5, she should call to return immediately for admission.,3. Pancytopenia. On the day of discharge, the patient was pancytopenic with white count of 0.7, ANC of 500, hemoglobin 8.5, hematocrit 24.8, and platelet count 38, 000. Her labs will be followed closely as an outpatient. During the admission, we did obtain a HIT antibody, which was negative. Heparin was held until this level was returned. She was placed on Arixtra for prophylaxis against thrombus. It is thought that her decreasing counts may be secondary to infection; however, if she continues to be pancytopenic, she will have a repeat bone marrow as an outpatient.,4. Hypertension. Blood pressure remained stable throughout the admission. She will continue lisinopril daily.,5. Perianal rash. Upon admission, she was found to have worsening of a candidal rash in the perianal region. A wound consult was obtained. They recommended Aloe Vesta foam and Silver gel to the area topically. She was also continued on Diflucan 200 mg daily. She will complete a 10-day course.,6. Diabetes mellitus. At the time of admission, she was found to have hyperglycemia. She was started on sliding scale insulin and eventually started on long-acting Lantus insulin. She will be discharged with the regimen of Lantus 35 units at bedtime and continue the sliding scale as needed.,7. Hypoxia. She did have evidence of decreased saturations. There was concern that she may have a pneumonia, which was treated with vancomycin for possible hospital acquired pneumonia; however, upon further review of the blood cultures improved, chest x-ray consistent with atelectasis and normal saturations that this was likely secondary to increased fluids associated with methotrexate and atelectasis from being confined to bed.,8. Seizure prophylaxis. She will continue Keppra twice daily.,9. Acute kidney injury. She did have a bump in the creatinine when methotrexate level was elevated. This resolved by the time of discharge. Creatinine on day of discharge is 0.9. This will be followed as an outpatient.,DISPOSITION: , To home in stable condition with home health services.,DISCHARGE MEDICATIONS: , See separate sheet attached.,DIET:, Neutropenic diabetic.,ACTIVITY: , Resume same activity.,FOLLOWUP: , With weekly lab work and plans for admission on August 18, 2008. Ms. ABC was advised if she has any problems or concerns in the interim and needs to be seen sooner, she should call. ### Response: Discharge Summary

DISCHARGE DIAGNOSES:,1. Chest pain. The patient ruled out for myocardial infarction on serial troponins. Result of nuclear stress test is pending.,2. Elevated liver enzymes, etiology uncertain for an outpatient followup.,3. Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia. The patient ruled out for myocardial infarction with serial troponins. Nuclear stress test has been done, results of which are pending. The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations. He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks. Discharge medications will depend on results of nuclear stress test.

discharge diagnoses chest pain patient ruled myocardial infarction serial troponins result nuclear stress test pending elevated liver enzymes etiology uncertain outpatient followup acid reflux diseasetest done nuclear stress test results pendinghospital course yearold family history premature coronary artery disease came evaluation recurrent chest pain saturation atypical typical features ischemia patient ruled myocardial infarction serial troponins nuclear stress test done results pending patient stable discharged pending results nuclear stress test cardiologists recommendations follow cardiologist dr x two weeks primary physician two four weeks discharge medications depend results nuclear stress test

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:,1. Chest pain. The patient ruled out for myocardial infarction on serial troponins. Result of nuclear stress test is pending.,2. Elevated liver enzymes, etiology uncertain for an outpatient followup.,3. Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia. The patient ruled out for myocardial infarction with serial troponins. Nuclear stress test has been done, results of which are pending. The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations. He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks. Discharge medications will depend on results of nuclear stress test. ### Response: Cardiovascular / Pulmonary

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

discharge diagnoses endstage renal disease hemodialysis history vertebral fracture diskitis thrombocytopenia congestive heart failure ejection fraction approximately diabetes type protein malnourishment history anemiahistory hospital course patient yearold white male presented hospital bossier april patient found lumbar diskitis going require extensive antibiotic therapy cause need continued hospitalization also needed continue dialysis needed improve rehabilitation patient tolerated medication well going rehab fairly well without significant troubles bouts issues constipation throughout hospitalization seemed come control aggressive management patient remained afebrile also bout episodic confusion problems appeared sundownertype problem cleared stay promise day discharge may patient good spirits clear lucid denied complaints pain trouble sleep night times think mainly tied fact sleeps lot day patient increased appetite eating vital signs remain stable blood pressure discharge heart rate respiratory rate temperature ppd negative sms form filled plan discharge sent medications receiving promisethe patient family understood plan agreed thanked us care received promise thought fantastic job taking care acute questions going next step care would discuss length prior date discharge

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

DISCHARGE DIAGNOSES:,1. Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2. History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3. History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal. Transesophageal echocardiogram July 27, 2007, that was normal. No evidence of vegetations. CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm. There were 2-3 additional tiny cysts in the right lobe. The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers. For further details of the admission, please see the previously dictated history and physical. ,HOSPITAL COURSE:, Gram-negative rod bacteremia. The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers. The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations. The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides. The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade. We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver. There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned. I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah. Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with. I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet. The patient, however, appeared to be responding well to levofloxacin. I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime. Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return. A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin. In addition, I told the patient that it would be my recommendation to get rid of the rats. I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection. I told her very clearly that she should, indeed, get rid of the animals. The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following., ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated. Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases. I gave the patient the phone number to call on Monday for an appointment. Additional followup is also with Dr. XYZ, her primary care physician. Please note that 40 minutes was spent in the discharge.

discharge diagnoses gramnegative rod bacteremia final identification susceptibilities still pending history congenital genitourinary abnormalities multiple surgeries th grade history urinary tract infections pyelonephritisoperations performed chest xray july normal transesophageal echocardiogram july normal evidence vegetations ct scan abdomen pelvis july revealed multiple small cysts liver largest measuring mm additional tiny cysts right lobe remainder ct scan normalhistory present illness briefly patient yearold white female history fevers details admission please see previously dictated history physical hospital course gramnegative rod bacteremia patient admitted hospital suspicion endocarditis given fact fever septicemia osler nodes fingers patient transthoracic echocardiogram outpatient equivocal transesophageal echocardiogram hospital normal evidence vegetations microbiology laboratory stated gramnegative rod appeared anaerobic thus raising possibility organisms like bacteroides patient history congenital genitourinary abnormalities surgically corrected fifth grade ct scan abdomen pelvis showed benign appearing cysts liver nothing remarkable far kidneys ureters bladder concerned spoke dr xyz infectious diseases dr xyz asked talk patient contact animals given fact recent outbreak tularemia utah much surprise patient told multiple pet rats home constantly contact ordered tularemia leptospirosis serologies advice dr xyz day discharge results microbiology still back yet patient however appeared responding well levofloxacin gave week course mg day levofloxacin instructed follow dr xyz meantime hopefully final identification susceptibility organism tularemia leptospirosis serologies return thought add doxycycline patient clinically appeared responding levofloxacin addition told patient would recommendation get rid rats told indeed rats carriers infection received zoonotic infection exposure rats could ongoing continuing danger children could also potentially exposed potentially lethal infection told clearly indeed get rid animals patient seemed reluctant first believe coercion family finally came realization recommendation worth following dispositiondischarge instructions activity tolerated diet toleratedmedications levaquin mg daily x daysfollowup dr xyz infectious diseases gave patient phone number call monday appointment additional followup also dr xyz primary care physician please note minutes spent discharge

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:,1. Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2. History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3. History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal. Transesophageal echocardiogram July 27, 2007, that was normal. No evidence of vegetations. CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm. There were 2-3 additional tiny cysts in the right lobe. The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers. For further details of the admission, please see the previously dictated history and physical. ,HOSPITAL COURSE:, Gram-negative rod bacteremia. The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers. The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations. The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides. The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade. We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver. There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned. I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah. Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with. I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet. The patient, however, appeared to be responding well to levofloxacin. I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime. Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return. A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin. In addition, I told the patient that it would be my recommendation to get rid of the rats. I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection. I told her very clearly that she should, indeed, get rid of the animals. The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following., ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated. Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases. I gave the patient the phone number to call on Monday for an appointment. Additional followup is also with Dr. XYZ, her primary care physician. Please note that 40 minutes was spent in the discharge. ### Response: Discharge Summary, General Medicine

DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient.,3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids.,4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses.,4. IV contrast CT scan of the head is unremarkable.,5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary.,6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.,7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left.,HISTORY AND PHYSICAL: ,This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery.,The patient was admitted to the MICU.,HOSPITAL COURSE PER PROBLEM LIST:,1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT, OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.,2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.,3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.,4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.,CONDITION ON DISCHARGE:, Stable.,ACTIVITY: ,As tolerated.,DIET:, Low-fat, low-salt, cardiac diet.,DISCHARGE INSTRUCTIONS:,1. Take medications regularly.,2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital.,3. Continue Cipro for an additional two days for his UTI.,DISCHARGE MEDICATIONS:,1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.,2. Aggrenox, one tablet p.o. b.i.d.,3. Docusate sodium 100 mg, one cap p.o. b.i.d.,4. Zocor 20 mg, one tablet p.o. at bedtime.,5. Prevacid 30 mg p.o. once a day.,FOLLOW UP:,1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.,2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance.

discharge diagnoses acute cerebrovascular accidentleft basal ganglia deep white matter left parietal lobe hypertension urinary tract infection hypercholesterolemiaprocedures portable chest single view impression atherosclerotic change aortic knob chest portable single view impression mild tortuosity thoracic aorta maybe secondary hypertension right lateral costophrenic angle evaluated due positioning patient march swallowing study normal swallowing study minimal penetration thin liquids march head ct without contrast airfluid level right maxillary sinus suggestive acute sinusitis cm oval low density mass dependent portion left maxillary sinus consistent retention cyst mucoparietal cell thickening right maxillary sinus ethmoid sinuses iv contrast ct scan head unremarkable mrimra neck brain without contrast changes consistent infarct involving right basal ganglia deep white matter left parietal lobe described diffuse smooth narrowing left middle cerebral artery may congenital abnormality clinical correlation necessary march th echocardiogram bubble study impression normal left ventricular systolic function estimated left ventricular ejection fraction mild concentric left ventricular hypertrophy left atrial size normal negative bubble study march carotid duplex ultrasound showed grade carotid stenosis right evidence carotid stenosis lefthistory physical yearold white male history hypertension years untreated patient woke march sudden onset rightsided weakness arm hand leg foot also right facial droop right hand numbness dorsal side left face numbness slurred speech patient brought ems emergency room patient normal went bed prior night given aspirin er ct brain without contrast show changes could ct contrast machine broken went ahead mrimra brain neck showed infarct involving right basal ganglia deep white matter left parietal lobe also diffuse smooth narrowing left middle cerebral arterythe patient admitted micuhospital course per problem list acute cerebrovascular accident patient candidate tissue plasminogen activator neurology consult obtained dr agrees treatment patient patient aspirin mg also zocor mg day also ordered fasting blood lipids showed cholesterol triglycerides hdl cholesterol ldl cholesterol dr farber agreed treat risk factors treat blood pressure first two weeks stroke put patient prn labetalol systolic blood pressure greater diastolic blood pressure greater patients blood pressure stable need blood pressure medications right leg kept improving increased muscle strength however right upper extremity improve much slurred speech improved little bit patient started pt ot speech therapy second day hospitalization patient transferred regular floor day admission based stable neurologic exam also added aggrenox secondary stroke prevention suggested dr f echocardiogram ordered showed normal left ventricular function bubble study negative carotid ultrasound showed mild stenosis right side ekg show changes patient transferred siskin rehabilitation hospital today aggrenox secondary stroke prevention need blood pressure treatment unless systolic greater diastolic greater first week stroke discharge neurologic exam right facial palsy eye right upper extremity weakness muscle strength right leg improved slurred speech hypertension mentioned item see blood pressure stable need treatment urinary tract infection patient urinalysis march th showed large amount leukocyte esterase small amount blood red blood cells white blood cells moderate amount bacteria patient started cipro mg po bid march th needs finish seven days antibiotic treatment uti urine culture sensitivity negative hypercholesterolemia patient put zocor mg po daily goal ldl patient less ldl currently hdl triglycerides cholesterol condition discharge stableactivity tolerateddiet lowfat lowsalt cardiac dietdischarge instructions take medications regularly pt ot speech therapist evaluate treat siskin rehab hospital continue cipro additional two days utidischarge medications cipro mg one tablet po bid additional two days aggrenox one tablet po bid docusate sodium mg one cap po bid zocor mg one tablet po bedtime prevacid mg po dayfollow patient needs follow rehabilitation hospital discharged patient call clinic needs follow appointment us patient find primary care physician since insurance

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient.,3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids.,4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses.,4. IV contrast CT scan of the head is unremarkable.,5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary.,6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.,7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left.,HISTORY AND PHYSICAL: ,This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery.,The patient was admitted to the MICU.,HOSPITAL COURSE PER PROBLEM LIST:,1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT, OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.,2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.,3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.,4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.,CONDITION ON DISCHARGE:, Stable.,ACTIVITY: ,As tolerated.,DIET:, Low-fat, low-salt, cardiac diet.,DISCHARGE INSTRUCTIONS:,1. Take medications regularly.,2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital.,3. Continue Cipro for an additional two days for his UTI.,DISCHARGE MEDICATIONS:,1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.,2. Aggrenox, one tablet p.o. b.i.d.,3. Docusate sodium 100 mg, one cap p.o. b.i.d.,4. Zocor 20 mg, one tablet p.o. at bedtime.,5. Prevacid 30 mg p.o. once a day.,FOLLOW UP:,1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.,2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance. ### Response: Discharge Summary, General Medicine

DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF PRESENT ILLNESS:, Details are present in the dictated report.,BRIEF HOSPITAL COURSE:, The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy.,DISCHARGE MEDICATIONS:, Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily.,TRANSFER INSTRUCTIONS:, The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required.

discharge diagnoses chronic obstructive pulmonary disease acute hypercapnic respiratory failure chronic atrial fibrillation prior ablation done coumadin treatment mitral stenosis remote history lung cancer prior resection left upper lobe anxiety depressionhistory present illness details present dictated reportbrief hospital course patient yearold lady came increased shortness breath one day duration denied history chest pain fevers cough purulent sputum time empirically treated course antibiotics avelox ten days also received steroids prednisolone mg breathing treatments albuterol ipratropium bronchodilator therapy also optimized theophylline continued receive coumadin chronic atrial fibrillation heart rate controlled maintained ss third day admission developed worsening respiratory failure fatigue hence required intubated ventilated put mechanical ventilation extubated put bipap pressures gradually increased bipap epap fio time transfer kindred bronchospasm also responded aggressive bronchodilation steroid therapydischarge medications prednisolone mg orally daily albuterol mg nebulized every hours atrovent respules nebulized every hours pulmicort micrograms nebulized twice every hours coumadin mg orally daily magnesium oxide mg orally dailytransfer instructions patient strictly kept bilevel pap ipapepap cm fio times day may put nasal cannula liters per minute saturation meal times limited hours every meal admission potassium risen slightly hence ace inhibitor discontinued may restart later date blood pressure control better required

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF PRESENT ILLNESS:, Details are present in the dictated report.,BRIEF HOSPITAL COURSE:, The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy.,DISCHARGE MEDICATIONS:, Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily.,TRANSFER INSTRUCTIONS:, The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required. ### Response: Discharge Summary, General Medicine

DISCHARGE DIAGNOSIS: ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1. Chronic pain.,2. Tobacco use.,3. History of hepatitis C.,REASON FOR ADMISSION:, The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. He has had prolonged hospitalizations because of this problem. He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg. Examination in the emergency room revealed significant concern for significant cellulitis. Decision was made to admit him to the hospital.,HOSPITAL COURSE:, The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking. The patient had edema of his bilateral lower extremities. The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C. Hospital consult was obtained. This included an ultrasound of his abdomen, which showed just mild cirrhosis. His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well. The patient eventually grew MRSA in a moderate amount. He was treated with IV vancomycin. Local wound care and elevation. The patient had slow progress. He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression. The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days. He was also given prescription for Percocet and OxyContin, picked up at my office. He is instructed to do daily wound care and also wrap his leg with an Ace wrap. Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.

discharge diagnosis complex open wound right lower extremity complicated methicillinresistant staphylococcus aureus cellulitisadditional discharge diagnoses chronic pain tobacco use history hepatitis creason admission patient yearold male complex course secondary right lower extremity complex open wound prolonged hospitalizations problem recently discharged noted develop outpatient swollen red tender leg examination emergency room revealed significant concern significant cellulitis decision made admit hospitalhospital course patient admitted started iv antibiotics elevation also counseled minimizing cigarette smoking patient edema bilateral lower extremities hospital consult also obtained address edema issue question related liver hepatitis c hospital consult obtained included ultrasound abdomen showed mild cirrhosis leg swelling thought secondary chronic venostasis likely contribution liver well patient eventually grew mrsa moderate amount treated iv vancomycin local wound care elevation patient slow progress started compression leg got much improved minimal redness swelling compression patient thought safe discharge homedischarge instructions patient discharged doxycycline mg po bid x days also given prescription percocet oxycontin picked office instructed daily wound care also wrap leg ace wrap followup arranged couple weeksdischarge condition stable

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSIS: ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1. Chronic pain.,2. Tobacco use.,3. History of hepatitis C.,REASON FOR ADMISSION:, The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound. He has had prolonged hospitalizations because of this problem. He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg. Examination in the emergency room revealed significant concern for significant cellulitis. Decision was made to admit him to the hospital.,HOSPITAL COURSE:, The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking. The patient had edema of his bilateral lower extremities. The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C. Hospital consult was obtained. This included an ultrasound of his abdomen, which showed just mild cirrhosis. His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well. The patient eventually grew MRSA in a moderate amount. He was treated with IV vancomycin. Local wound care and elevation. The patient had slow progress. He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression. The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days. He was also given prescription for Percocet and OxyContin, picked up at my office. He is instructed to do daily wound care and also wrap his leg with an Ace wrap. Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable. ### Response: Discharge Summary, General Medicine

DISCHARGE DIAGNOSIS:,1. Epigastric pain. Questionable gastritis, questionable underlying myocardial ischemia.,2. Congestive heart failure exacerbation.,3. Small pericardial effusion with no tamponade.,4. Hypothyroidism.,5. Questionable subacute infarct versus neoplasm in the pons.,6. History of coronary artery disease, status post angioplasty and stent.,7. Hypokalemia.,CLINICAL RESUME: , This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago. She has had abdominal CAT scan and gastric emptying studies which was normal.,A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon. Otherwise unremarkable. The patient follows with Dr. XYZ as an outpatient. The patient had some worsening of her symptoms over the last few days and then came to the ER. She was admitted. Please refer to Dr. XYZ initial H&P for complete details.,HOSPITAL COURSE:,1. Epigastric pain, nausea, and vomiting. The patient was restituted with antiemetics and her symptoms improved. It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin. A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct. However, brain neoplasm could not be excluded. Other workup including a CT angio did not show any evidence of acute pulmonary emboli. It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion. The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive. She refused to complete the stress test. She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2. Congestive heart failure exacerbation. The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved. An echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade. There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV.,3. Small pericardial effusion. The patient did not have any clinical or echocardiographic evidence of tamponade.,4. Hypothyroidism. TSH was quite elevated at 19.,5. Questionable subacute infarct versus neoplasm in the pons on an MRI of the head.,6. History of coronary artery disease/angioplasty and stents.,7. Hyperkalemia.,8. Patient was doing well. She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,MEDICATIONS AND ADVICE ON DISCHARGE:,1. She is to continue taking Coreg 12.5 mg p.o. b.i.d.,2. Cozaar 50 mg p.o. daily.,3. Aldactone 25 mg p.o. daily.,4. Synthroid 0.075 mg p.o. daily.,5. Carafate 1 gram p.o. 4 times a day.,6. Claritin 10 mg p.o. daily.,7. Lasix 20 mg p.o. daily.,8. K-Dur 20 mEq p.o. daily.,9. Prilosec 40 mg p.o. daily.,10. Zofran 4 mg p.o. q.4-6 hourly p.r.n.,She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time. She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time. She is to follow up with Dr. XYZ from GI as scheduled. The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient. She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time. She will also need repeat echocardiogram done in one month for a pericardial effusion. This can be arranged by her primary care physician. Repeat TSH to be done in 6 weeks' time.,Over 35 minutes were spent in the patient discharged.

discharge diagnosis epigastric pain questionable gastritis questionable underlying myocardial ischemia congestive heart failure exacerbation small pericardial effusion tamponade hypothyroidism questionable subacute infarct versus neoplasm pons history coronary artery disease status post angioplasty stent hypokalemiaclinical resume yearold woman presented er complaints nausea vomiting epigastric discomfort ongoing months extensive work gallbladder removed april endoscopy demonstrative gastric ulcer disease apparently year ago abdominal cat scan gastric emptying studies normala ct scan abdomen done may showed bilateral peripelvic renal cysts redundant sigmoid colon otherwise unremarkable patient follows dr xyz outpatient patient worsening symptoms last days came er admitted please refer dr xyz initial hp complete detailshospital course epigastric pain nausea vomiting patient restituted antiemetics symptoms improved clear whether nausea abdominal pain due gastritis peptic ulcer diseasegastric ischemia cardiac origin brain mri also done basically showed tiny focus abnormal enhancement pons could subacute like infarct however brain neoplasm could excluded workup including ct angio show evidence acute pulmonary emboli showed moderate cardiomegaly bilateral pleural effusions small pericardial effusion patient underwent cardiolite stress test finished resting studies inconclusive refused complete stress test seen dr xyz consultation recommended patient small bowel follow eventually angiogram outpatient congestive heart failure exacerbation patient treated ace inhibitors diuretics aldactone lasix improved echocardiogram done showed ejection fraction mild water decrease lv systolic function multiple segmental wall motion abnormalities small anterior pericardial effusion electrocardiographic signs cardiac tamponade pseudo normal pattern filling mild mr global hypokinesis lv small pericardial effusion patient clinical echocardiographic evidence tamponade hypothyroidism tsh quite elevated questionable subacute infarct versus neoplasm pons mri head history coronary artery diseaseangioplasty stents hyperkalemia patient well back baseline refusing workup patient stable felt could safely discharged home testing done outpatientmedications advice discharge continue taking coreg mg po bid cozaar mg po daily aldactone mg po daily synthroid mg po daily carafate gram po times day claritin mg po daily lasix mg po daily kdur meq po daily prilosec mg po daily zofran mg po q hourly prnshe follow primary care physician dr xyz days time follow dr xyz cardiologist days time follow dr xyz gi scheduled patient advised need small bowel follow angiogram arranged gastroenterologist outpatient also advised would need repeat mri head months time also need repeat echocardiogram done one month pericardial effusion arranged primary care physician repeat tsh done weeks timeover minutes spent patient discharged

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSIS:,1. Epigastric pain. Questionable gastritis, questionable underlying myocardial ischemia.,2. Congestive heart failure exacerbation.,3. Small pericardial effusion with no tamponade.,4. Hypothyroidism.,5. Questionable subacute infarct versus neoplasm in the pons.,6. History of coronary artery disease, status post angioplasty and stent.,7. Hypokalemia.,CLINICAL RESUME: , This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago. She has had abdominal CAT scan and gastric emptying studies which was normal.,A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon. Otherwise unremarkable. The patient follows with Dr. XYZ as an outpatient. The patient had some worsening of her symptoms over the last few days and then came to the ER. She was admitted. Please refer to Dr. XYZ initial H&P for complete details.,HOSPITAL COURSE:,1. Epigastric pain, nausea, and vomiting. The patient was restituted with antiemetics and her symptoms improved. It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin. A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct. However, brain neoplasm could not be excluded. Other workup including a CT angio did not show any evidence of acute pulmonary emboli. It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion. The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive. She refused to complete the stress test. She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2. Congestive heart failure exacerbation. The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved. An echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade. There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV.,3. Small pericardial effusion. The patient did not have any clinical or echocardiographic evidence of tamponade.,4. Hypothyroidism. TSH was quite elevated at 19.,5. Questionable subacute infarct versus neoplasm in the pons on an MRI of the head.,6. History of coronary artery disease/angioplasty and stents.,7. Hyperkalemia.,8. Patient was doing well. She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,MEDICATIONS AND ADVICE ON DISCHARGE:,1. She is to continue taking Coreg 12.5 mg p.o. b.i.d.,2. Cozaar 50 mg p.o. daily.,3. Aldactone 25 mg p.o. daily.,4. Synthroid 0.075 mg p.o. daily.,5. Carafate 1 gram p.o. 4 times a day.,6. Claritin 10 mg p.o. daily.,7. Lasix 20 mg p.o. daily.,8. K-Dur 20 mEq p.o. daily.,9. Prilosec 40 mg p.o. daily.,10. Zofran 4 mg p.o. q.4-6 hourly p.r.n.,She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time. She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time. She is to follow up with Dr. XYZ from GI as scheduled. The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient. She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time. She will also need repeat echocardiogram done in one month for a pericardial effusion. This can be arranged by her primary care physician. Repeat TSH to be done in 6 weeks' time.,Over 35 minutes were spent in the patient discharged. ### Response: Discharge Summary, General Medicine

DISCHARGE DIAGNOSIS:,1. Respiratory failure improved.,2. Hypotension resolved.,3. Anemia of chronic disease stable.,4. Anasarca improving.,5. Protein malnourishment improving.,6. End-stage liver disease.,HISTORY AND HOSPITAL COURSE: ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction. His bowel function started to improve. He was on TPN prior to coming to Hospital. He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some. The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine. At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty. The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia. This has been treated successfully with Zyvox and Levaquin and Diflucan. He seems to be currently doing much better. He is only using BiPAP in the evening. As stated above, he is eating better. He had some evidence of redness and exquisite swelling around his genital and lower abdominal region. This may be mainly dependent edema versus anasarca. The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling. This morning, the patient denies any acute distress. He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation. He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:, He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily. The patient is going to require physical therapy to help with assistance in strength training. He is also going to need respiratory care to work with his BiPAP. His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%. The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS: On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL: A well-developed white male who appears in no apparent distress.,HEENT: Unremarkable.,CARDIOVASCULAR: Positive S1, S2 without murmur, rubs, or gallops.,LUNGS: Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN: Positive for bowel sounds. Soft, nondistended. He does have some generalized redness around his abdominal region and groin. This does appear improved compared to presentation last week. The swelling in this area also appears improved.,EXTREMITIES: Show no clubbing or cyanosis. He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC: The patient is alert and oriented to person and place. He is alert and aware of surroundings. We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL: The patient moves all extremities without difficulty. He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following: White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000. Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4. Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN: ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning. Hopefully, long-term planning will be discharge home. He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge. The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.

discharge diagnosis respiratory failure improved hypotension resolved anemia chronic disease stable anasarca improving protein malnourishment improving endstage liver diseasehistory hospital course patient admitted undergoing drawn process small bowel obstruction bowel function started improve tpn prior coming hospital remained tpn throughout time appetite po intake improved patient episode blood pressure bottomed requiring spend multiple days intensive care unit dopamine one point unsuccessful weaning dopamine approximately days finally started tolerate weaning parameters successfully removed dopamine maintained blood pressure without difficulty patient also requiring bipap help oxygenation appeared developed leftsided pneumonia treated successfully zyvox levaquin diflucan seems currently much better using bipap evening stated eating better evidence redness exquisite swelling around genital lower abdominal region may mainly dependent edema versus anasarca patient diuresed aggressively last days seems made improvement swelling morning patient denies acute distress states feeling good understands discharged another facility continued care rehabilitation discharged garden court skilled nursing facilitydischarge medicationsinstructions going going protonix mg daily metoclopramide mg every hours zyvox mg daily days diflucan mg po daily days bumex mg po daily megace mg po bid ensure tid meals miralax gm po daily patient going require physical therapy help assistance strength training also going need respiratory care work bipap initial settings rate pressure support peep fio patient need sleep study nursing home able set upphysical examinationvital signs day discharge heart rate respiratory rate blood pressure temperature sat general welldeveloped white male appears apparent distressheent unremarkablecardiovascular positive without murmur rubs gallopslungs clear auscultation bilaterally without wheezes cracklesabdomen positive bowel sounds soft nondistended generalized redness around abdominal region groin appear improved compared presentation last week swelling area also appears improvedextremities show clubbing cyanosis lower extremity edema distal pedal pulses presentneurologic patient alert oriented person place alert aware surroundings difficulties confusion latelymusculoskeletal patient moves extremities without difficulty weak generallaboratory data lab work done today shows following white count hemoglobin hematocrit platelet count electrolytes show sodium potassium chloride co glucose bun creatinine calcium phosphorus little high magnesium albumin plan discharge gentleman hospital admit garden court snf continue rehab conditioning hopefully longterm planning discharge home history endstage liver disease cirrhosis may make candidate hospice upon discharge family initially wanted bring patient home weak requires much assistance adequately consider option time

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DIAGNOSIS:,1. Respiratory failure improved.,2. Hypotension resolved.,3. Anemia of chronic disease stable.,4. Anasarca improving.,5. Protein malnourishment improving.,6. End-stage liver disease.,HISTORY AND HOSPITAL COURSE: ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction. His bowel function started to improve. He was on TPN prior to coming to Hospital. He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some. The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine. At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty. The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia. This has been treated successfully with Zyvox and Levaquin and Diflucan. He seems to be currently doing much better. He is only using BiPAP in the evening. As stated above, he is eating better. He had some evidence of redness and exquisite swelling around his genital and lower abdominal region. This may be mainly dependent edema versus anasarca. The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling. This morning, the patient denies any acute distress. He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation. He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:, He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily. The patient is going to require physical therapy to help with assistance in strength training. He is also going to need respiratory care to work with his BiPAP. His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%. The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS: On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL: A well-developed white male who appears in no apparent distress.,HEENT: Unremarkable.,CARDIOVASCULAR: Positive S1, S2 without murmur, rubs, or gallops.,LUNGS: Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN: Positive for bowel sounds. Soft, nondistended. He does have some generalized redness around his abdominal region and groin. This does appear improved compared to presentation last week. The swelling in this area also appears improved.,EXTREMITIES: Show no clubbing or cyanosis. He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC: The patient is alert and oriented to person and place. He is alert and aware of surroundings. We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL: The patient moves all extremities without difficulty. He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following: White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000. Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4. Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN: ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning. Hopefully, long-term planning will be discharge home. He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge. The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time. ### Response: Cardiovascular / Pulmonary, Discharge Summary

DISCHARGE DISPOSITION:, The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I: Schizoaffective disorder, bipolar type.,AXIS II: Deferred.,AXIS III: Hepatitis C.,AXIS IV: Severe.,AXIS V: 19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized. The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP: ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy: Seroquel 25 mg p.o. nightly. Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:, Attitude was cooperative. Appearance showed fair hygiene and grooming. Psychomotor behavior showed restlessness. No EPS or TD was noted. Affect was restricted. Mood remained anxious and speech was pressured. Thoughts remained tangential, and the patient endorsed paranoid delusions. The patient denied auditory hallucinations. The patient denied suicidal or homicidal ideation, was oriented to person and place. Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors. The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants. The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others. The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment. The patient on admission interview was noted to be labile and disorganized. The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD. The patient remained labile and suspicious during her hospital stay. The patient continued to be sexually preoccupied and had poor insight into her need for treatment. The patient denied further auditory hallucinations. The patient was treated with Seroquel for persistent mood lability and psychosis. The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge. The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010. The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies. The patient was thus discharged in symptomatic condition.

discharge disposition patient discharged court voluntary drop prosecution ama hospital advicedischarge diagnosesaxis schizoaffective disorder bipolar typeaxis ii deferredaxis iii hepatitis caxis iv severeaxis v condition patient discharge patient remained disorganized patient suffering prolactinemia secondary medicationsdischarge followup arranged per patient patient discharged courtdischarge medications week supply following phoned patients pharmacy seroquel mg po nightly zyprexa mg po bidmental status time discharge attitude cooperative appearance showed fair hygiene grooming psychomotor behavior showed restlessness eps td noted affect restricted mood remained anxious speech pressured thoughts remained tangential patient endorsed paranoid delusions patient denied auditory hallucinations patient denied suicidal homicidal ideation oriented person place overall insight illness remained impairedhistory hospital course patient yearold female history bipolar affective disorder initially admitted evaluation increasing mood lability disorganization inappropriate behaviors patient reportedly asking father sex tried pull mothers pants patient took clothing noted disorganized sexually religiously preoccupied endorsed auditory hallucinations voices telling calm others patient history depression versus bipolar disorder last hospitalized pierce county without recent treatment patient admission interview noted labile disorganized patient initiated risperdal mtab mg po bid psychosis mood lability also medically evaluated rebecca richardson md patient remained labile suspicious hospital stay patient continued sexually preoccupied poor insight need treatment patient denied auditory hallucinations patient treated seroquel persistent mood lability psychosis patient noted develop prolactinemia risperdal changed zyprexa prior discharge patient remained disorganized given voluntary drop prosecution medical advice went court patient discharged return home parents referred community mental health agencies patient thus discharged symptomatic condition

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE DISPOSITION:, The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I: Schizoaffective disorder, bipolar type.,AXIS II: Deferred.,AXIS III: Hepatitis C.,AXIS IV: Severe.,AXIS V: 19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized. The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP: ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy: Seroquel 25 mg p.o. nightly. Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:, Attitude was cooperative. Appearance showed fair hygiene and grooming. Psychomotor behavior showed restlessness. No EPS or TD was noted. Affect was restricted. Mood remained anxious and speech was pressured. Thoughts remained tangential, and the patient endorsed paranoid delusions. The patient denied auditory hallucinations. The patient denied suicidal or homicidal ideation, was oriented to person and place. Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors. The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants. The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others. The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment. The patient on admission interview was noted to be labile and disorganized. The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD. The patient remained labile and suspicious during her hospital stay. The patient continued to be sexually preoccupied and had poor insight into her need for treatment. The patient denied further auditory hallucinations. The patient was treated with Seroquel for persistent mood lability and psychosis. The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge. The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010. The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies. The patient was thus discharged in symptomatic condition. ### Response: Discharge Summary

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.

discharge summarysummary treatment planning discharge familys requestidentified problemsoutcomes

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1. ### Response: Discharge Summary

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.

discharge summarysummary treatment planningtwo major problems identified admission adolescent

### Instruction: find the medical speciality for this medical test. ### Input: DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1. ### Response: Discharge Summary

DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2. Negative EKG criteria for ischemia.,3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management.

dobutamine stress echocardiogramreason exam chest discomfort evaluation coronary artery diseaseprocedure detail patient brought cardiac center cardiac images rest obtained parasternal long short axis apical four apical two views followed starting dobutamine drip usual fashion mcgkg per minute low dose increased every minutes mcgkg per minute patient maximized mcgkg per minute images obtained level adding mg atropine reach maximal heart rate maximal images obtained windows parasternal long short axis apical four apical two windowswall motion assessed levels well recoverythe patient got nauseated mild shortness breath angina procedure maximal amount dobutamine mcgkg per minutethe resting heart rate resting blood pressure heart rate reduced vasodilator effects dobutamine maximal heart rate achieved agepredicted heart ratethe ekg rest showed sinus rhythm stt wave depression suggestive ischemia injury incomplete right bundlebranch block seen maximal stress test ekg showed sinus tachycardia subtle upsloping st depression iii avf normal response tachycardia dobutamine significant depression suggestive ischemia st elevation seenno ventricular tachycardia ventricular ectopy seen test heart rate recovered normal fashion using metoprolol mgthe heart images somewhat suboptimal evaluate obesity problems short axis windows mainly peak exercisethe ef rest appeared normal normal wall motion including anterior anteroseptal inferior lateral septal walls low dose walls mentioned augmented normal fashion maximum dose walls augmented views except short axis foreshortened uncertain anterolateral wall peak exercise however views lateral wall showing normal thickening normal augmentation ef improved wall motion score unchangedimpression maximal dobutamine stress echocardiogram test achieving agepredicted heart rate negative ekg criteria ischemia normal augmentation low maximum stress test uncertainty anterolateral wall peak exercise short axis view considered negative dobutamine stress echocardiogram test medical management

### Instruction: find the medical speciality for this medical test. ### Input: DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2. Negative EKG criteria for ischemia.,3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management. ### Response: Cardiovascular / Pulmonary, Radiology

DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer: "I would rather not go there. Well, since we were talking, "I will tell you that my mother really does not understand. She is very worried. She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor. I don't think my mom really understands, and I know that she really needs a kidney. I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother. I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all. I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact. I am away from my children and my husband a lot because of I travel with my job. So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process. I work as a contract nursing all over the country. I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks. I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine. It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now. I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant. We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC. I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child. I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not. I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried? Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS: LENGTH OF TIME MARRIED: "I live with my family, my husband, and my two children with good relationship. We have been married for 29 years.",NAME OF SPOUSE/PARTNER: "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER: He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter. Our elder child has just finished college.",CHILDREN: I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend. He lives in the Houston area. I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse. I go on assignments all over the country, and I work until the contract is over. This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage: "None.",SUPPORTIVE ENVIRONMENT:, "Yes."

donors perception recipients illnesswhat understanding recipients illness need kidney kidney mother dialysis mother suffering long enough want relieve suffering able kidney transplantwhen subject donation arise mom talked together familyrecipients reaction offerwhat recipients reaction offer would rather go well since talking tell mother really understand worried afraid something might happen would feel terrible problems result donor dont think mom really understands know really needs kidney think coming around acceptingfamilys reaction offerwhat family feelings donor well children fine husband supportivecandidates motivation donatehow arrive decision donor brothers sisters got together decided since schedule flexible used traveling seem like best candidatehow would family friends react decided donor dont think going happencandidates motivation donatehow would feel cannot donor reason would feel upset know best mother want badly mother hoping headache away blood pressure comes start feel better workupcandidates description relationship recipientwhat relationship recipient motherhow relationship recipient change donate kidney sure change know feel better mother mother always sacrificing helping otherswith donor affect relationships life dont think much impact away children husband lot travel job dont think donor really dramatic affectdo understanding process transplant yes good understanding transplant process work contract nursing country able see patients different things different places feel like realistic perceptive processcandidates understanding transplantation risk rejectiondo understand risk rejection kidney recipient yes understand risks long conversation coordinator talked thingshave thought might feel kidney rejected guess sure wont rejected sure everything fine part way managing stress thisdo doubts concerns donating dont doubts concerns right wish headache would go awaydo understand pain transplant course dowhat expectations recuperation planning staying mom three months houston area transplant live outside tampa florida adventure usdo need speak transplant team members long talk abc feel pretty comfortable conversation well conversation nephrologistmedical historywhat previous illnesses surgeries one cesarian section also suffered asthma child otherwise good healthare currently medication yes folic acidpsychiatric historyhave ever spoken counselor therapist psychiatrist good supportive system lot people talk need toalcohol nicotine drug usedo smoke noany typical drinks prefer nondrinkerwhat kinds recreational drugs tried used recently nonefamily support systemsmarital status length time married live family husband two children good relationship married yearsname spousepartner name xyzage health spousepartner healthy lives outside tampo yearold daughter elder child finished collegechildren two children ages also postsurgical housing planwith stay discharge stay friend lives houston area staying friend right workupcurrent occupationwhat current occupation currently work contract basis nurse go assignments country work contract allowed flexible best candidate donation momdo support employer absolutelypaid timepaid leave nonedisability coverage nonesupportive environment yes

### Instruction: find the medical speciality for this medical test. ### Input: DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer: "I would rather not go there. Well, since we were talking, "I will tell you that my mother really does not understand. She is very worried. She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor. I don't think my mom really understands, and I know that she really needs a kidney. I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother. I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all. I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact. I am away from my children and my husband a lot because of I travel with my job. So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process. I work as a contract nursing all over the country. I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks. I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine. It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now. I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant. We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC. I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child. I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not. I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried? Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS: LENGTH OF TIME MARRIED: "I live with my family, my husband, and my two children with good relationship. We have been married for 29 years.",NAME OF SPOUSE/PARTNER: "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER: He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter. Our elder child has just finished college.",CHILDREN: I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend. He lives in the Houston area. I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse. I go on assignments all over the country, and I work until the contract is over. This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage: "None.",SUPPORTIVE ENVIRONMENT:, "Yes." ### Response: Nephrology

DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.

duplex ultrasound legsright leg duplex imaging carried according normal protocol mhz imaging probe using bmode ultrasound deep veins imaged level common femoral popliteal veins deep veins demonstrated compressibility without evidence intraluminal thrombus increased echogenicitythe long saphenous system displayed compressibility without evidence thrombosis long saphenous vein measured cm proximal thigh reflux seconds release distal compression cm knee reflux seconds release distal compression small saphenous system measured cm proximal calf reflux seconds release distal compressionleft leg duplex imaging carried according normal protocol mhz imaging probe using bmode ultrasound deep veins imaged level common femoral popliteal veins deep veins demonstrated compressibility without evidence intraluminal thrombus increased echogenicitythe long saphenous system displayed compressibility without evidence thrombosis long saphenous vein measured cm proximal thigh reflux seconds release distal compression cm knee reflux seconds release distal compression small saphenous system measured cm proximal calf reflux seconds release distal compression

### Instruction: find the medical speciality for this medical test. ### Input: DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression. ### Response: Cardiovascular / Pulmonary, Radiology

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

dear sample doctorthank referring mr sample patient cardiac evaluation yearold obese male history therapycontrolled hypertension borderline diabetes obesity family history coronary heart disease denies symptoms angina pectoris effort intolerance specifically chest discomfort kind dyspnea exertion unless extreme exertion performed orthopnea pnd known mother coronary heart disease never smoker never syncopal episode mi cva gallbladder removed bleeding tendencies history dvt pulmonary embolism patient retired rarely consumes alcohol consumes coffee moderately apparently sleep disorder according wife office patient snores stops breathing sleep allergic codeine aspirin angioedemaphysical exam revealed middleaged man weighing pounds height feet inches heart rate beats per minute regular blood pressure mmhg right arm sitting position mmhg standing position distress venous pressure normal carotid pulsations normal without bruits lungs clear cardiac exam normal abdomen obese organomegaly palpated pulsatile masses bruits femoral pulses character symmetrical distribution dorsalis pedis posterior tibiales character peripheral edema chemistry profile suggests diabetes mellitus fasting blood sugar mgdl renal function normal lipid profile showed slight increase triglycerides normal total cholesterol hdl acceptable range ldl sodium little bit increased ac hemoglobin increased spirometry reported normal resting electrocardiogram december also normal treadmill cardiolite performed stage terminated supervising physician patient achieved predicted maximum heart rate symptoms ischemia ekg suggestion inferior wall ischemia normal wall motion cardiolite imagingin summary yearold gentleman risk factors coronary heart disease concerned possible diabetes likely metabolic syndrome gentleman truncal obesity hypertension possible insulin resistance degree fasting hyperglycemia well slight triglyceride elevation denies symptoms coronary heart disease probably degree coronary atherosclerosis possibly affecting inferior wall functional testings view absence symptoms medical therapy indicated present time aggressive risk factor modification explained discussed extensively patient benefits regular exercise walking program given patient also start aggressively losing weight requested additional testing today include apolipoprotein b lpa lipoprotein well homocystine cardio crp assess risk atherosclerosis terms medication changed verapamil long acting betablocker continue ace inhibitor plavix patient allergic aspirin also probably start statin studies recommended come back abnormal furthermore confirmed diabetes along line perhaps consider obtaining advice endocrinologist decide whether gentleman needs treatment diabetes believe however leave entirely decide indeed considered diabetic much aggressive program entertained reducing risks atherosclerosis general coronary artery disease particulari find indication point time proceed testing coronary angiography absence symptomsif questions please hesitate let knowthank kind referralsincerelysample doctor md

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

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

doctors addressdear doctorthis letter introduction patient seeing near future pleasant gentleman history wilsons disease treated penicillamine diagnosed age way south carolina trip developed shortness breath palpitations chest discomfort went closest hospital near randolph north carolina found atrial fibrillation rapid rate admitted observed converted normal sinus rhythm spontaneously required interventions started lopressor tolerated well echocardiogram performed revealed mildtomoderate left atrial enlargement normal ejection fraction significant valvular abnormality reported physicians cirrhosis related wilsons disease therefore hepatologist consulted recommendation avoid coumadin secondary questionable significant liver disease therefore placed aspirin mg dayin discussion mr review chart available unclear status liver disease however never liver biopsy diagnosis cirrhosis concerned north carolina doubt lfts remained normal copper level undetectable current dose penicillaminei would appreciate input long term management anticoagulation also recommendations would rhythm control normal sinus rhythm evaluation tolerating metoprolol aspirin without difficulty guess big question remains level risk entailed placing coumadin therapy due potentially paroxysmal atrial fibrillation evidence left atrial enlargement would place increased risk recurrent episodesi appreciate input regarding friendly gentleman current medicines include penicillamine mg po four times day metoprolol mg twice day aspirin mg dayif questions regarding care please feel free call discuss case otherwise look forward hearing back regarding evaluation thank always care patient

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

Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008. As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities. His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg. He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this. He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain. He was seen by Dr. Y at Orthopedic Associates for review of this. However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation. Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds. As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain. He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain. He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain. He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation. Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion. He has been evaluated by Dr. X for rehab concerns to determine. He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation. If you have any questions regarding his care please feel free to call me at my office. Otherwise, I look forward to hearing back from you shortly after your evaluation. Please feel free to call me if it is possible or if you have any questions about anything.

doctors addressdear doctorthis letter serves reintroduction patient seeing thursday know unfortunate gentleman reflex sympathetic dystrophy lower extremities current symptoms severe right persisting wound failed heal right leg wound clinic try help heal intolerant compression dressings unable get satisfactory healing seen dr x pain management considered possibility amputation therapeutic option help reduce pain seen dr orthopedic associates review however discussion dr z evaluation mr felt may imprudent path take given lack likelihood reduction pain rst questionable healing wound given noninvasive studies reveal tenuous oxygenation right lower leg concerns worsening rst symptoms left leg would amputation based results transcutaneous oxygen levels dramatic improvement oxygen therapy test dr z felt course hyperbaric oxygen may utility help improving wounds may may know certainly pursued aggressive significant measures try improve mr pain cleveland clinic implantable stimulator unsuccessful dramatically improving pain currently taking methadone eight tablets four times day morphine mg three times day dilaudid two tablets mouth every two hours help reduce pain also currently taking neurontin mg three times day effexor xr mg day cytomel mcg day seroquel mg po q day levothyroxine mcg po q day prinivil mg po q day mevacor mg po q dayi appreciate assistance determining hyperbaric oxygen reasonable treatment course unfortunate situation dr z tried stress fact amputation may abrupt irreversible treatment course may reach significant conclusion evaluated dr x rehab concerns determine agrees less aggressive form therapy may appropriatei thank kindly prompt evaluation kind gentleman unfortunate situation questions regarding care please feel free call office otherwise look forward hearing back shortly evaluation please feel free call possible questions anything

### Instruction: find the medical speciality for this medical test. ### Input: Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008. As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities. His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg. He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this. He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain. He was seen by Dr. Y at Orthopedic Associates for review of this. However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation. Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds. As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain. He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain. He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain. He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation. Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion. He has been evaluated by Dr. X for rehab concerns to determine. He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation. If you have any questions regarding his care please feel free to call me at my office. Otherwise, I look forward to hearing back from you shortly after your evaluation. Please feel free to call me if it is possible or if you have any questions about anything. ### Response: Neurology

Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. She also noted and confirmed that he has significant tonsillar hypertrophy. The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day. He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms. He does have an allergy to penicillin.,I appreciate your input on his care. If you have any questions regarding, please feel free to call me through my office. Otherwise, I look forward to hearing back from you regarding his evaluation.

doctors addressdear doctorthis letter serves introduction patient seeing near future pleasant young man diagnosis bulbar cerebral palsy hypotonia treated dr x pediatric neurology clinic saw dr x recently noted difficulty mouth breathing contributing speech problems also noted confirmed significant tonsillar hypertrophy concern whether may benefit surgery remove tonsils improve mouth breathing swallowing speech therefore ask opinion matterfor chronic allergic rhinitis symptoms currently flonase two sprays nostril day also taking zyrtec mg day partial relief symptoms allergy penicillini appreciate input care questions regarding please feel free call office otherwise look forward hearing back regarding evaluation

### Instruction: find the medical speciality for this medical test. ### Input: Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. She also noted and confirmed that he has significant tonsillar hypertrophy. The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day. He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms. He does have an allergy to penicillin.,I appreciate your input on his care. If you have any questions regarding, please feel free to call me through my office. Otherwise, I look forward to hearing back from you regarding his evaluation. ### Response: Neurology

EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling. The tympanic membranes are without disruption or infection. Hearing intact bilaterally to normal level speech. Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation. The septum is without acute traumatic lesions or disruption. The turbinates are without abnormal swelling. There is no unusual rhinorrhea or bleeding. ,LIPS/TEETH/GUMS: ,The lips are without infection, mass lesion or traumatic lesions. The teeth are intact without obvious signs of infection. The gingivae are normal to palpation and inspection. ,OROPHARYNX: ,The oral mucosa is normal. The salivary glands are without swelling. The hard and soft palates are intact. The tongue is without masses or swelling with normal movement. The tonsils are without inflammation. The posterior pharynx is without mass lesion with good patent oropharyngeal airway.

ears nose mouth throatearsnose auricles normal palpation inspection without surrounding lymphadenitis signs acute trauma nose normal palpation inspection externally without evidence acute trauma otoscopic examination auditory canals tympanic membranes reveals auditory canals without signs mass lesion inflammation swelling tympanic membranes without disruption infection hearing intact bilaterally normal level speech nasal mucosa septum turbinate examination reveals normal mucous membranes without disruption inflammation septum without acute traumatic lesions disruption turbinates without abnormal swelling unusual rhinorrhea bleeding lipsteethgums lips without infection mass lesion traumatic lesions teeth intact without obvious signs infection gingivae normal palpation inspection oropharynx oral mucosa normal salivary glands without swelling hard soft palates intact tongue without masses swelling normal movement tonsils without inflammation posterior pharynx without mass lesion good patent oropharyngeal airway

### Instruction: find the medical speciality for this medical test. ### Input: EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling. The tympanic membranes are without disruption or infection. Hearing intact bilaterally to normal level speech. Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation. The septum is without acute traumatic lesions or disruption. The turbinates are without abnormal swelling. There is no unusual rhinorrhea or bleeding. ,LIPS/TEETH/GUMS: ,The lips are without infection, mass lesion or traumatic lesions. The teeth are intact without obvious signs of infection. The gingivae are normal to palpation and inspection. ,OROPHARYNX: ,The oral mucosa is normal. The salivary glands are without swelling. The hard and soft palates are intact. The tongue is without masses or swelling with normal movement. The tonsils are without inflammation. The posterior pharynx is without mass lesion with good patent oropharyngeal airway. ### Response: Consult - History and Phy., ENT - Otolaryngology, General Medicine

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex. Hearing is grossly intact to finger rubbing and whisper. The nasal mucosa is moist. The septum is midline. There is no evidence of septal hematoma. The turbinates are without abnormality. No obvious abnormalities to the lips. The teeth are unremarkable. The gingivae are without any obvious evidence of infection. The oral mucosa is moist and pink. There are no obvious masses to the hard or soft palate. The uvula is midline. The salivary glands appear unremarkable. The tongue is midline. The posterior pharynx is without erythema or exudate. The tonsils are normal appearing.

ears nose mouth throat nose without evidence deformity ears normalappearing pinna examination canals normal appearing bilaterally drainage erythema noted tympanic membranes normal appearing pearly color normalappearing landmarks normal light reflex hearing grossly intact finger rubbing whisper nasal mucosa moist septum midline evidence septal hematoma turbinates without abnormality obvious abnormalities lips teeth unremarkable gingivae without obvious evidence infection oral mucosa moist pink obvious masses hard soft palate uvula midline salivary glands appear unremarkable tongue midline posterior pharynx without erythema exudate tonsils normal appearing

### Instruction: find the medical speciality for this medical test. ### Input: EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex. Hearing is grossly intact to finger rubbing and whisper. The nasal mucosa is moist. The septum is midline. There is no evidence of septal hematoma. The turbinates are without abnormality. No obvious abnormalities to the lips. The teeth are unremarkable. The gingivae are without any obvious evidence of infection. The oral mucosa is moist and pink. There are no obvious masses to the hard or soft palate. The uvula is midline. The salivary glands appear unremarkable. The tongue is midline. The posterior pharynx is without erythema or exudate. The tonsils are normal appearing. ### Response: Consult - History and Phy., ENT - Otolaryngology, General Medicine

ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter. The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy. The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter. Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function.

endovascular brachytherapy ebtthe patient undergo course angioplasty instent restenosis radiotherapy planned using simulation films novoste system catheter markers placed either side coronary artery injury site calculation take place determine length time strontium sources left place deliver adequate dose given reference vessel diameter rationale treatment based radiobiological principles make type therapy effective blade atherectomy laser atherectomy per fraction individualized patient according radiobiological principles reference vessel diameter given high dose rate source chances severe acute toxicity cardiac ischemia machine malfunction present imperative patient followed closely monitored st segment elevation correct machine function

### Instruction: find the medical speciality for this medical test. ### Input: ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter. The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy. The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter. Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function. ### Response: Cardiovascular / Pulmonary, Radiology

EPIDIDYMECTOMY,OPERATIVE NOTE: ,The patient was placed in the supine position and prepped and draped in the usual manner. A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened. A small amount of clear fluid was expressed. The tunica vaginalis was opened and the testicle was brought out through this incision. The epididymis was separated off the surface of the testicle using a scalpel. With blunt and sharp dissection, the epididymis was dissected off the testicle. Bovie was used for hemostasis. The vessels going to the testicle were preserved without any obvious injury, and a nice viable testicle was present after the epididymis was removed from this. The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also. There was no obvious bleeding. The cord was infiltrated with 0.25% Marcaine, as was the dartos tissue in the scrotum. The testicle was replaced in the scrotum. Skin was closed in two layers using 3-0 chromic catgut for the dartos and a subcuticular closure with the same material. A dry sterile dressing and compression were applied, and he was sent to the recovery room in stable condition.

epididymectomyoperative note patient placed supine position prepped draped usual manner transverse scrotal incision made carried tunica vaginalis opened small amount clear fluid expressed tunica vaginalis opened testicle brought incision epididymis separated surface testicle using scalpel blunt sharp dissection epididymis dissected testicle bovie used hemostasis vessels going testicle preserved without obvious injury nice viable testicle present epididymis removed blood supply epididymis cauterized using bovie vas divided cautery also obvious bleeding cord infiltrated marcaine dartos tissue scrotum testicle replaced scrotum skin closed two layers using chromic catgut dartos subcuticular closure material dry sterile dressing compression applied sent recovery room stable condition

### Instruction: find the medical speciality for this medical test. ### Input: EPIDIDYMECTOMY,OPERATIVE NOTE: ,The patient was placed in the supine position and prepped and draped in the usual manner. A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened. A small amount of clear fluid was expressed. The tunica vaginalis was opened and the testicle was brought out through this incision. The epididymis was separated off the surface of the testicle using a scalpel. With blunt and sharp dissection, the epididymis was dissected off the testicle. Bovie was used for hemostasis. The vessels going to the testicle were preserved without any obvious injury, and a nice viable testicle was present after the epididymis was removed from this. The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also. There was no obvious bleeding. The cord was infiltrated with 0.25% Marcaine, as was the dartos tissue in the scrotum. The testicle was replaced in the scrotum. Skin was closed in two layers using 3-0 chromic catgut for the dartos and a subcuticular closure with the same material. A dry sterile dressing and compression were applied, and he was sent to the recovery room in stable condition. ### Response: Surgery, Urology

EXAM: ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder. The patient has a family history of breast cancer within her mother at age 58. Patient denies personal history of breast cancer.,TECHNIQUE AND FINDINGS: ,Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy. An additional lateromedial projection of the right breast was obtained. The breasts demonstrate heterogeneously-dense fibroglandular tissue. Within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter. No additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen. Multiple additional benign-appearing calcifications are visualized bilaterally. Skin overlying both breasts is unremarkable.,Bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder. This mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow. This may represent benign fibrous tissue or a lipoma.,Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter. At this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast. Informed consent was obtained. The lesion was re-localized under ultrasound guidance. The left breast was prepped and draped in the usual sterile fashion. 2% lidocaine was administered locally for anesthesia. Additional lidocaine with epinephrine was administered around the distal aspect of the lesion. A small skin nick was made. Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides. The lateral to medial approach was performed with an 11-gauge Mammotome device. The device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture. Two core biopsies were obtained. The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma. Arterial blood was visualized exiting the access site. A biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage. Therefore, the Mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved. Postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter. The left breast was re-cleansed with a ChloraPrep, and a pressure bandage and ice packing were applied to the left breast. The patient was observed in the ultrasound department for the following 30 minutes without complaints. The patient was subsequently discharged with information and instructions on utilizing the ice bandage. The obtained specimens were sent to pathology for further analysis.,IMPRESSION:,1. A mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument, and multiple core biopsies were obtained. Transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma. Pressure was applied until hemostasis was achieved. The patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition. The core biopsies were submitted to pathology for further analysis.,2. Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3. Suspicious mammographic findings. The circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied. Further pathologic analysis is pending.,BIRADS Classification 4 - Suspicious findings.,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.

exam bilateral diagnostic mammogram left breast ultrasound biopsyhistory yearold female presents digital bilateral mammography secondary soft tissue lump palpated patient upper right shoulder patient family history breast cancer within mother age patient denies personal history breast cancertechnique findings craniocaudal mediolateral oblique projections bilateral breasts obtained mmddyy additional lateromedial projection right breast obtained breasts demonstrate heterogeneouslydense fibroglandular tissue within upper outer aspect left breast evidence circumscribed density measuring approximately cm x cm diameter additional dominant mass areas architectural distortion malignanttype calcifications seen multiple additional benignappearing calcifications visualized bilaterally skin overlying breasts unremarkablebilateral breast ultrasound subsequently performed demonstrated ovoid mass measuring approximately x x cm diameter located within anteromedial aspect left shoulder mass demonstrates isoechoic echotexture adjacent muscle evidence internal color flow may represent benign fibrous tissue lipomaadditional ultrasonographic imaging left breast demonstrates complex circumscribed solid cystic lesion hypervascular properties oclock position measuring x x cm diameter time lesion determined amenable ultrasoundguided core biopsythe risks complications procedure discussed patient biopsy solid cystic lesion oclock position left breast informed consent obtained lesion relocalized ultrasound guidance left breast prepped draped usual sterile fashion lidocaine administered locally anesthesia additional lidocaine epinephrine administered around distal aspect lesion small skin nick made color doppler surrounding lesion demonstrates multiple vessels surrounding lesion sides lateral medial approach performed gauge mammotome device device advanced ultrasound guidance superior aspect lesion placed within aperture two core biopsies obtained third core biopsy demonstrated evidence expanding hypoechoic area surrounding lesion consistent rapidlyexpanding hematoma arterial blood visualized exiting access site biopsy clip attempted placed however could performed secondary active hemorrhage therefore mammotome removed direct pressure access site biopsy location applied approximately minutes hemostasis achieved postprocedural imaging oclock position left breast demonstrates evidence hematoma measuring approximately x x cm diameter left breast recleansed chloraprep pressure bandage ice packing applied left breast patient observed ultrasound department following minutes without complaints patient subsequently discharged information instructions utilizing ice bandage obtained specimens sent pathology analysisimpression mixed solid cystic lesion oclock position left breast accessed ultrasound guidance utilizing mammotome core biopsy instrument multiple core biopsies obtained transient arterial hemorrhage noted biopsy site resulting localized cm hematoma pressure applied hemostasis achieved patient monitored approximately minutes procedure ultimately discharged good condition core biopsies submitted pathology analysis small isoechoic ovoid mass within anteromedial aspect left shoulder demonstrate color flow likely represents fibrotic changes lipoma suspicious mammographic findings circumscribed density measuring approximately mm oclock position left breast subsequently biopsied pathologic analysis pendingbirads classification suspicious findingsmammography information certain percentage cancers probably identified mammography lack radiographic evidence malignancy delay biopsy clinically suspicious mass present images obtained fdaapproved digital mammography equipment icad secondlook software version utilized

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder. The patient has a family history of breast cancer within her mother at age 58. Patient denies personal history of breast cancer.,TECHNIQUE AND FINDINGS: ,Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy. An additional lateromedial projection of the right breast was obtained. The breasts demonstrate heterogeneously-dense fibroglandular tissue. Within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter. No additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen. Multiple additional benign-appearing calcifications are visualized bilaterally. Skin overlying both breasts is unremarkable.,Bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder. This mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow. This may represent benign fibrous tissue or a lipoma.,Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter. At this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast. Informed consent was obtained. The lesion was re-localized under ultrasound guidance. The left breast was prepped and draped in the usual sterile fashion. 2% lidocaine was administered locally for anesthesia. Additional lidocaine with epinephrine was administered around the distal aspect of the lesion. A small skin nick was made. Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides. The lateral to medial approach was performed with an 11-gauge Mammotome device. The device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture. Two core biopsies were obtained. The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma. Arterial blood was visualized exiting the access site. A biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage. Therefore, the Mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved. Postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter. The left breast was re-cleansed with a ChloraPrep, and a pressure bandage and ice packing were applied to the left breast. The patient was observed in the ultrasound department for the following 30 minutes without complaints. The patient was subsequently discharged with information and instructions on utilizing the ice bandage. The obtained specimens were sent to pathology for further analysis.,IMPRESSION:,1. A mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument, and multiple core biopsies were obtained. Transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma. Pressure was applied until hemostasis was achieved. The patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition. The core biopsies were submitted to pathology for further analysis.,2. Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3. Suspicious mammographic findings. The circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied. Further pathologic analysis is pending.,BIRADS Classification 4 - Suspicious findings.,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized. ### Response: Obstetrics / Gynecology, Radiology

EXAM: ,CT KUB.,REASON FOR EXAM: , Flank pain.,TECHNIQUE:, Noncontrast CT abdomen and pelvis per renal stone protocol.,Correlation is made with the prior examination dated 01/16/09.,FINDINGS: , There is no intrarenal stone or obstruction bilaterally. There is no hydronephrosis, ureteral dilatation. There are calcifications about the pelvis including one in the left upper pelvis, but these are stable from the prior study and there is no upstream ureteral dilatation, the findings therefore are favored to represent phleboliths. The bladder is nearly completely decompressed. There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction.,The appendix is normal. There is no evidence for a pericolonic inflammatory process or small bowel obstruction.,Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths. There is no pelvic free fluid or adenopathy.,Lung bases appear clear. Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas appear grossly unremarkable. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. No renal stone or evidence of obstruction. Stable appearing pelvic calcifications likely indicate phleboliths.,2. Normal appendix.

exam ct kubreason exam flank paintechnique noncontrast ct abdomen pelvis per renal stone protocolcorrelation made prior examination dated findings intrarenal stone obstruction bilaterally hydronephrosis ureteral dilatation calcifications pelvis including one left upper pelvis stable prior study upstream ureteral dilatation findings therefore favored represent phleboliths bladder nearly completely decompressed asymmetric renal enlargement perinephric stranding secondary evidence obstructionthe appendix normal evidence pericolonic inflammatory process small bowel obstructiondedicated scan pelvis disclosed aforementioned presumed phleboliths pelvic free fluid adenopathylung bases appear clear given lack contrast liver spleen adrenal glands pancreas appear grossly unremarkable gallbladder resected abdominal free fluid pathologic adenopathyimpression renal stone evidence obstruction stable appearing pelvic calcifications likely indicate phleboliths normal appendix

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: ,CT KUB.,REASON FOR EXAM: , Flank pain.,TECHNIQUE:, Noncontrast CT abdomen and pelvis per renal stone protocol.,Correlation is made with the prior examination dated 01/16/09.,FINDINGS: , There is no intrarenal stone or obstruction bilaterally. There is no hydronephrosis, ureteral dilatation. There are calcifications about the pelvis including one in the left upper pelvis, but these are stable from the prior study and there is no upstream ureteral dilatation, the findings therefore are favored to represent phleboliths. The bladder is nearly completely decompressed. There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction.,The appendix is normal. There is no evidence for a pericolonic inflammatory process or small bowel obstruction.,Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths. There is no pelvic free fluid or adenopathy.,Lung bases appear clear. Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas appear grossly unremarkable. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. No renal stone or evidence of obstruction. Stable appearing pelvic calcifications likely indicate phleboliths.,2. Normal appendix. ### Response: Nephrology, Radiology

EXAM: ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims. The ethmoid, sphenoid, and frontal sinuses are clear. There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally. There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally. The nasal bones appear intact. The zygomatic arches are intact. The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes. The mandible and maxilla are intact. There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1. Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally. There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2. Mild soft tissue swelling about the right cheek.

exam ct maxillofacial traumafindings ct examination maxillofacial bones performed without contrast coronal reconstructions obtained better anatomical localizationthere normal appearance orbital rims ethmoid sphenoid frontal sinuses clear polypoid mucosal thickening involving floor maxillary sinuses bilaterally soft tissue fluid opacification ostiomeatal complexes bilaterally nasal bones appear intact zygomatic arches intact temporomandibular joints intact demonstrate dislocations significant degenerative changes mandible maxilla intact soft tissue swelling seen involving right cheekimpression mucosal thickening versus mucous retention cyst involving maxillary sinuses bilaterally also soft tissue fluid opacification ostiomeatal complexes bilaterally mild soft tissue swelling right cheek

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims. The ethmoid, sphenoid, and frontal sinuses are clear. There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally. There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally. The nasal bones appear intact. The zygomatic arches are intact. The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes. The mandible and maxilla are intact. There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1. Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally. There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2. Mild soft tissue swelling about the right cheek. ### Response: ENT - Otolaryngology, Radiology

EXAM: ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involving the thoracic spine. There is a suggestion of generalized osteoporosis. The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis.

exam thoracic spinereason exam injuryinterpretation thoracic spine examined ap lateral swimmers projections mild chronicappearing anterior wedging believed represent vertebral bodies mild amount anterior osteophytic lipping seen involving thoracic spine suggestion generalized osteoporosis intervertebral disc spaces appear generally well preservedthe pedicles appear intactimpression mild chronicappearing anterior wedging believed represent vertebral bodies mild degenerative changes thoracic spine osteoporosis

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involving the thoracic spine. There is a suggestion of generalized osteoporosis. The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis. ### Response: Neurology, Orthopedic, Radiology

EXAM: ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained. There are no comparison studies. There is no evidence of fractures or dislocations. No significant degenerative changes or obstructive osseous lesions were identified. There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.

exam three views right footreason exam right foot traumafindings three views right foot obtained comparison studies evidence fractures dislocations significant degenerative changes obstructive osseous lesions identified radiopaque foreign bodiesimpression negative right foot

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained. There are no comparison studies. There is no evidence of fractures or dislocations. No significant degenerative changes or obstructive osseous lesions were identified. There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot. ### Response: Orthopedic, Radiology

EXAM: ,Ultrasound left lower extremity, duplex venous,REASON FOR EXAM: , Swelling and rule out DVT.,FINDINGS: , Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed. Compressibility, augmentation, and color flow as well as Doppler flow was demonstrated within the common femoral vein, superficial femoral vein, and popliteal vein. The posterior tibial vein also demonstrated flow along its proximal visualized extent.,IMPRESSION: , No evidence of left lower extremity deep venous thrombosis.

exam ultrasound left lower extremity duplex venousreason exam swelling rule dvtfindings duplex color doppler interrogation left lower extremity deep venous system performed compressibility augmentation color flow well doppler flow demonstrated within common femoral vein superficial femoral vein popliteal vein posterior tibial vein also demonstrated flow along proximal visualized extentimpression evidence left lower extremity deep venous thrombosis

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: ,Ultrasound left lower extremity, duplex venous,REASON FOR EXAM: , Swelling and rule out DVT.,FINDINGS: , Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed. Compressibility, augmentation, and color flow as well as Doppler flow was demonstrated within the common femoral vein, superficial femoral vein, and popliteal vein. The posterior tibial vein also demonstrated flow along its proximal visualized extent.,IMPRESSION: , No evidence of left lower extremity deep venous thrombosis. ### Response: Radiology

EXAM: ,Ultrasound neck/soft tissue, head.,HISTORY: , Right-sided facial swelling and draining wound.,TECHNIQUE AND FINDINGS:, Ultrasound of the right mandibular region was performed.,No focal collection is identified. This whole region appears to be phlegmonous. It is hard to adequately delineate the exact margins of this region.,IMPRESSION: ,Abnormal appearing right mandibular region has more phlegmonous changes. No focal fluid collection.,Had a discussion with Dr. xx. Consider CT for further evaluation.

exam ultrasound necksoft tissue headhistory rightsided facial swelling draining woundtechnique findings ultrasound right mandibular region performedno focal collection identified whole region appears phlegmonous hard adequately delineate exact margins regionimpression abnormal appearing right mandibular region phlegmonous changes focal fluid collectionhad discussion dr xx consider ct evaluation

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: ,Ultrasound neck/soft tissue, head.,HISTORY: , Right-sided facial swelling and draining wound.,TECHNIQUE AND FINDINGS:, Ultrasound of the right mandibular region was performed.,No focal collection is identified. This whole region appears to be phlegmonous. It is hard to adequately delineate the exact margins of this region.,IMPRESSION: ,Abnormal appearing right mandibular region has more phlegmonous changes. No focal fluid collection.,Had a discussion with Dr. xx. Consider CT for further evaluation. ### Response: Radiology

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

exam ap abdomen ultrasound kidneyhistory ureteral strictureap abdomen findings comparison made study month dd yyyy left lower quadrant ostomy dilated bowel loops suggesting obstruction doublej right ureteral stent appears place several pelvic calcifications likely vascular definite pathologic calcifications seen overlying regions kidneys obstructing course ureters overall findings stable versus recent examimpression properly positioned doublej right ureteral stent evidence calcified renal ureteral stonesultrasound kidneysfindings right kidney normal cortical echogenicity solid mass stone hydronephrosis measuring x x cm right renalureteral stent identified perinephric fluid collectionthe left kidney demonstrates moderatetosevere hydronephrosis stone solid masses seen cortex normalthe bladder decompressedimpression leftsided hydronephrosis visible renal ureteral calculi right ureteral stent

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

EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE: ,A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images. A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:, The scout radiograph demonstrates a nonobstructive gastrointestinal pattern. There are no suspicious calcifications seen or evidence of gross free intraperitoneal air. The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course. There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum. A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image. There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.

exam barium enemaclinical history yearold male history encopresis constipationtechnique single frontal scout radiograph abdomen performed rectal tube inserted usual sterile fashion retrograde instillation barium contrast followed via spot fluoroscopic images postevacuation overhead radiograph abdomen performedfindings scout radiograph demonstrates nonobstructive gastrointestinal pattern suspicious calcifications seen evidence gross free intraperitoneal air visualized lung bases osseous structures within normal limitsthe rectum colon normal caliber throughout course evidence obstruction contrast seen flow without difficulty right colon cecum small amount contrast seen opacify small bowel loops postevacuation image also opacification normalappearing appendix documentedimpression normal barium enema

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE: ,A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images. A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:, The scout radiograph demonstrates a nonobstructive gastrointestinal pattern. There are no suspicious calcifications seen or evidence of gross free intraperitoneal air. The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course. There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum. A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image. There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema. ### Response: Gastroenterology, Radiology

EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast. Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. Right breast ultrasound was performed. Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue. No new mass or architectural distortion is evident. Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged. There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1. Stable mammographic appearance from mm/dd/yy.,2. No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality. The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign

exam bilateral diagnostic mammogram right breast ultrasoundhistory palpable abnormality oclock right breast family history sister breast cancer age technique cc mlo views breasts obtained spot compression views palpable area also obtained right breast ultrasound performed comparison made mmddyyfindings breast parenchymal pattern stable heterogeneous scattered areas fibroglandular tissue new mass architectural distortion evident asymmetric density upper outer posterior left breast nodule upper outer right breast unchanged suspicious cluster microcalcificationsdirected ultrasonography upper outer quadrant right breast revealed cystic hypoechoic solid massimpression stable mammographic appearance mmddyy sonographic evidence mass oclock right breast correspond palpable abnormality need assessment palpable abnormality determined clinicallybirads classification benign

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast. Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. Right breast ultrasound was performed. Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue. No new mass or architectural distortion is evident. Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged. There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1. Stable mammographic appearance from mm/dd/yy.,2. No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality. The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benign ### Response: Obstetrics / Gynecology, Radiology

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

exam bilateral lower extremity ultrasound deep venous thrombusreason exam lower extremity edema bilaterallytechnique colored grayscale doppler imaging employedfindings examination limited prominent edema bilaterally large body habitus two limit assessment especially right lower extremityas visualized gross evidence dvt right leg grayscale images limited obvious clot identified color flow doppler images left leg better visualized right limited definite clot seenimpression limited study secondary body habitus edema obvious dvt visualized

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

EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS: ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm. The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm. There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections. The bladder is of normal size and contour. The bladder contains approximately 13 mL of urine after recent voiding. This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound. Small postvoid residual.

exam bilateral renal ultrasoundclinical indication utitechnique transverse longitudinal sonograms kidneys obtainedfindings right kidney normal size echotexture measures x x cm left kidney normal size echotexture measures x x cm evidence hydronephrosis perinephric fluid collections bladder normal size contour bladder contains approximately ml urine recent voiding small postvoid residualimpression normal renal ultrasound small postvoid residual

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS: ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm. The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm. There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections. The bladder is of normal size and contour. The bladder contains approximately 13 mL of urine after recent voiding. This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound. Small postvoid residual. ### Response: Nephrology, Radiology

EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT, the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Unremarkable exam; specifically no evidence for acute appendicitis. ,2. No acute nephro-/ureterolithiasis. ,3. No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.

exam ct abdomen pelvis contrast reason exam nausea vomiting diarrhea one day fever right upper quadrant pain one day comparison none technique ct abdomen pelvis performed without approximately ml isovue contrast enhancement ct abdomen lung bases clear liver gallbladder spleen pancreas bilateral adrenalkidneys unremarkable aorta normal caliber retroperitoneal lymphadenopathy ct pelvis appendix visualized along length diffusely unremarkable surrounding inflammatory change per ct colon small bowel unremarkable bladder distended free fluidair visualized osseous structures demonstrate definite evidence acute fracture malalignment dislocationimpression unremarkable exam specifically evidence acute appendicitis acute nephroureterolithiasis secondary evidence acute cholecystitisresults communicated er time dictation

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT, the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Unremarkable exam; specifically no evidence for acute appendicitis. ,2. No acute nephro-/ureterolithiasis. ,3. No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation. ### Response: Gastroenterology, Nephrology, Radiology

EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally. However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right. The right renal pelvis is not dilated. There is no stone along the course of the ureter. I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised. There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder. No pelvic free fluid or adenopathy.,There are few scattered diverticula. There is a moderate amount of stool throughout the colon. There are scattered diverticula, but no CT evidence of acute diverticulitis. The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. The gallbladder is present. There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding. There is no stone identified along the course of the left ureter or in the bladder. Could this patient be status post recent stone passage? Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix.

exam ct abdomen pelvis without contrast stone protocol reconstructionreason exam flank paintechnique noncontrast ct abdomen pelvis coronal reconstructionsfindings intrarenal stone bilaterally however mild left renal pelvis proximal ureteral dilatation small amount left perinephric stranding asymmetric right right renal pelvis dilated stone along course ureter cannot exclude possibility recent stone passage although findings ultimately technically indeterminate clinical correlation advised obvious solidappearing mass given lack contrastscans pelvis disclose evidence stone within decompressed bladder pelvic free fluid adenopathythere scattered diverticula moderate amount stool throughout colon scattered diverticula ct evidence acute diverticulitis appendix normalthere mild bibasilar atelectatic changesgiven lack contrast visualized portions liver spleen adrenal glands pancreas grossly unremarkable gallbladder present abdominal free fluid pathologic adenopathythere degenerative changes lumbar spineimpressionvery mild left renal pelvic dilatation proximal ureteral dilatation mild left perinephric stranding stone identified along course left ureter bladder could patient status post recent stone passage clinical correlation adviseddiverticulosismoderate amount stool throughout colonnormal appendix

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally. However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right. The right renal pelvis is not dilated. There is no stone along the course of the ureter. I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised. There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder. No pelvic free fluid or adenopathy.,There are few scattered diverticula. There is a moderate amount of stool throughout the colon. There are scattered diverticula, but no CT evidence of acute diverticulitis. The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. The gallbladder is present. There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding. There is no stone identified along the course of the left ureter or in the bladder. Could this patient be status post recent stone passage? Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix. ### Response: Gastroenterology, Nephrology, Radiology

EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE: ,Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal. There is a moderate amount of stool throughout the colon. There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process. Examination of the extreme lung bases appear clear, no pleural effusions. The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast. There is a small hiatal hernia. There is no intrarenal stone or evidence of obstruction bilaterally. There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast. This can be correlated with a followup ultrasound if necessary. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy. There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy. There are surgical clips present. There is a tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. The report was faxed upon dictation.

exam ct abdomen without contrast pelvis without contrast reconstructionreason exam right lower quadrant pain rule appendicitistechnique noncontrast ct abdomen pelvis intravenous line could obtained use intravenous contrast materialfindings appendix normal moderate amount stool throughout colon evidence small bowel obstruction evidence pericolonic inflammatory process examination extreme lung bases appear clear pleural effusions visualized portions liver spleen adrenal glands pancreas appear normal given lack contrast small hiatal hernia intrarenal stone evidence obstruction bilaterally questionable vague region low density left anterior mid pole region may indicate tiny cyst well seen given lack contrast correlated followup ultrasound necessary gallbladder resected abdominal free fluid pathologic adenopathy abdominal atherosclerosis without evidence aneurysmdedicated scans pelvis disclosed phleboliths free fluid adenopathy surgical clips present tiny airdrop within bladder patient recent catheterization correlate signs symptoms urinary tract infectionimpressionnormal appendixmoderate stool throughout colonno intrarenal stonestiny airdrop within bladder patient recent catheterization correlate signs symptoms urinary tract infection report faxed upon dictation

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE: ,Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal. There is a moderate amount of stool throughout the colon. There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process. Examination of the extreme lung bases appear clear, no pleural effusions. The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast. There is a small hiatal hernia. There is no intrarenal stone or evidence of obstruction bilaterally. There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast. This can be correlated with a followup ultrasound if necessary. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy. There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy. There are surgical clips present. There is a tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. The report was faxed upon dictation. ### Response: Gastroenterology, Nephrology, Radiology

EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:, Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:, There is reversal of the normal cervical curvature at the vertebral body heights. The intervertebral disk spaces are otherwise maintained. There is no prevertebral soft tissue swelling. The facets are aligned. The tip of the clivus and occiput appear intact. On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact. There is no evidence of a posterior element fracture. Included portions of the mastoid air cells appear clear. There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.

exam ct cervical spinereason exam mva feeling sleepy headache shoulder rib paintechnique axial images cervical spine coronal sagittal reconstructionsfindings reversal normal cervical curvature vertebral body heights intervertebral disk spaces otherwise maintained prevertebral soft tissue swelling facets aligned tip clivus occiput appear intact coronal reconstructed sequence satisfactory alignment c c evidence base dens fracturethe included portions first second ribs intact evidence posterior element fracture included portions mastoid air cells appear clear ct evidence moderate highgrade stenosisimpression acute process cervical spine

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:, Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:, There is reversal of the normal cervical curvature at the vertebral body heights. The intervertebral disk spaces are otherwise maintained. There is no prevertebral soft tissue swelling. The facets are aligned. The tip of the clivus and occiput appear intact. On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact. There is no evidence of a posterior element fracture. Included portions of the mastoid air cells appear clear. There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine. ### Response: Neurology, Orthopedic, Radiology

EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.

exam ct chest contrasthistory abnormal chest xray demonstrated region consolidation versus mass right upper lobetechnique post contrastenhanced spiral images obtained chestfindings several discrete patchy airspace opacities right upper lobe appearance compatible infiltrates remainder lung parenchyma clear pneumothorax effusion heart size pulmonary vessels appear unremarkable axillary hilar mediastinal lymphadenopathyimages upper abdomen unremarkableosseous windows without acute pathologyimpression several discrete patchy airspace opacities right upper lobe compatible pneumonia

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia. ### Response: Cardiovascular / Pulmonary, Radiology

EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are linear fibrotic or atelectatic changes associated with this. Recommend followup to ensure resolution. There is left apical scarring. There is no pleural effusion or pneumothorax. There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid. Cardiac and aortic contours are unremarkable aside from mild atherosclerosis. The heart is not enlarged. There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation. Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis.

exam ct chest contrastreason exam pneumonia chest pain short breath coughing bloodtechnique postcontrast ct chest ml isovue contrastfindings study demonstrates small region coalescent infiltratesconsolidation anterior right upper lobe linear fibrotic atelectatic changes associated recommend followup ensure resolution left apical scarring pleural effusion pneumothorax lingular right middle lobe mild atelectasis fibrosisexamination mediastinal windows disclosed normal inferior thyroid cardiac aortic contours unremarkable aside mild atherosclerosis heart enlarged pathologic adenopathy identified chest including bilateral axillary hilar regionsvery limited assessment upper abdomen demonstrates definite abnormalitiesthere mild degenerative changes thoracic spineimpressionanterior small right upper lobe infiltrateconsolidation recommend followup ensure resolution given consolidated appearancebilateral atelectasis versus fibrosis

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are linear fibrotic or atelectatic changes associated with this. Recommend followup to ensure resolution. There is left apical scarring. There is no pleural effusion or pneumothorax. There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid. Cardiac and aortic contours are unremarkable aside from mild atherosclerosis. The heart is not enlarged. There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation. Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis. ### Response: Cardiovascular / Pulmonary, Radiology

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.

exam ct head without contrast ct facial bones without contrast ct cervical spine without contrastreason exam yearold status post fall multifocal paincomparisons nonetechnique sequential axial ct images obtained vertex thoracic inlet without contrast additional highresolution sagittal andor coronal reconstructed images obtained facial bones cervical spine better visualization osseous structuresinterpretationsheadthere mild generalized atrophy scattered patchy foci decreased attenuation seen subcortical periventricular white matter consistent chronic small vessel ischemic changes subtle areas increased attenuation seen within frontal lobes bilaterally given patients clinical presentation likely represent small hemorrhagic contusions differential considerations include cortical calcifications less likely brain parenchyma otherwise normal attenuation without evidence mass midline shift hydrocephalus extraaxial fluid acute infarction visualized paranasal sinuses mastoid air cells clear bony calvarium skull base unremarkablefacial bonesthe osseous structures face grossly intact without acute fracture dislocation orbits extraocular muscles within normal limits diffuse mucosal thickening ethmoid right maxillary sinuses remaining visualized paranasal sinuses mastoid air cells clear diffuse soft tissue swelling noted right orbit right facial bones without underlying fracturecervical spinethere mild generalized osteopenia diffuse multilevel degenerative changes identified extending cc disk space narrowing sclerosis marginal osteophyte formation remaining cervical vertebral body heights maintained without acute fracture dislocation spondylolisthesis central canal grossly patent pedicles posterior elements appear intact multifocal facet degenerative changes prevertebral paravertebral soft tissue masses identified atlantodens interval dens maintainedimpressionsubtle areas increased attenuation identified within frontal lobes bilaterally suggesting small hemorrhagic contusions associated shift mass effect time less likely finding could secondary cortical calcifications patient may benefit repeat ct scan head mri additional evaluation clinically indicatedatrophy chronic small vessel ischemic changes brainethmoid right maxillary sinus congestion diffuse soft tissue swelling right side face without underlying fractureosteopenia multilevel degenerative changes cervical spine described abovefindings discussed dr x emergency department time interpretation

### Instruction: find the medical speciality for this medical test. ### Input: 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. ### Response: Neurology, Orthopedic, Radiology

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.

exam ct head without contrastindications assaulted positive loss consciousness rule bleedtechnique ct examination head performed without intravenous contrast administration comparison studiesfindings abnormal extraaxial fluid collections midline shift mass effect ventricular system demonstrates dilatation evidence acute intracranial hemorrhage calvarium intact laceration left parietal region scalp without underlying calvarial fractures mastoid air cells clearimpression acute intracranial process

### Instruction: find the medical speciality for this medical test. ### Input: 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. ### Response: Neurology, Radiology

EXAM: , CT of abdomen with and without contrast. CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts. There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration. This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole. No other enhancing renal masses were seen. The visualized liver, spleen, pancreas, and adrenal glands were unremarkable. There are changes of cholecystectomy. Mild prominence of the common bile duct is likely secondary to cholecystectomy. There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear. No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described. Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion. The patient was placed in the decubitus position. The region overlying the left renal mass of note was marked. Area was prepped and draped in usual sterile fashion. Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate. The Versed and fentanyl were given to achieve conscious sedation. Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis. Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia. No perinephric fluid/hematoma was identified. The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described.

exam ct abdomen without contrast ctguided needle placement biopsyhistory left renal masstechnique pre postcontrast enhanced images acquired kidneysfindings comparison made prior mri redemonstration multiple bilateral cystic renal lesions several demonstrate high attenuation precontrast phase exam suggesting hemorrhagic cysts however one cyst seen lower pole left kidney demonstrated apparent enhancement hounsfield units post contrast administration measured approximately x cm exophytic half lower pole enhancing renal masses seen visualized liver spleen pancreas adrenal glands unremarkable changes cholecystectomy mild prominence common bile duct likely secondary cholecystectomy abdominal lymphadenopathy masses fluid collection asciteslung bases clear acute bony pathology notedimpression solitary apparently enhancing left renal mass lower pole described renal cell carcinoma cannot excludedctguided needle biopsy left kidney mass following discussion risks benefits alternatives patient wished proceed ctguided biopsy left renal lesion patient placed decubitus position region overlying left renal mass note marked area prepped draped usual sterile fashion local anesthesia achieved approximately ml lidocaine bicarbonate versed fentanyl given achieve conscious sedation utilizing x gauge coaxial system core biopsies obtained mass question sent pathology analysis following procedure scans region demonstrate small subcutaneous hematoma region superficial anesthesia perinephric fluidhematoma identified patient tolerated procedure without immediate complicationsimpression three core biopsies region left renal tumor described

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT of abdomen with and without contrast. CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts. There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration. This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole. No other enhancing renal masses were seen. The visualized liver, spleen, pancreas, and adrenal glands were unremarkable. There are changes of cholecystectomy. Mild prominence of the common bile duct is likely secondary to cholecystectomy. There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear. No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described. Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion. The patient was placed in the decubitus position. The region overlying the left renal mass of note was marked. Area was prepped and draped in usual sterile fashion. Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate. The Versed and fentanyl were given to achieve conscious sedation. Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis. Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia. No perinephric fluid/hematoma was identified. The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described. ### Response: Radiology, Surgery

EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:, Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis. There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs. Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed. There is calcification within the right lobe of the liver likely related to granulomatous changes. Subtle irregularity of the liver contour is noted, suggestive of cirrhosis. There is splenomegaly seen. There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst. The pancreas appears atrophic. There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding. There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma. There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination. Bilateral ureters appear normal in caliber along their visualized course. The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted. There are pelvic phlebolith seen. There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed. The appendix is within normal limits. The small bowel is unremarkable. There is an anterior abdominal wall hernia noted containing herniated mesenteric fat. The hernia neck measures approximately 2.7 cm. There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis. Degenerative changes of the spine are observed.,IMPRESSION:,1. Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2. Nodule in the left lower lobe, recommend follow up in 3 months.,3. Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4. Hepatomegaly with changes suggestive of cirrhosis. There is also splenomegaly observed.,5. Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6. Fat density lesion in the left kidney, likely represents angiomyolipoma.,7. Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.

exam ct abdomen pelvis without contrasthistory lower abdominal painfindings limited views lung bases demonstrate linear density likely representing dependent atelectasis cm nodular density left posterior sulcusnoncontrast technique limits evaluation solid abdominal organs cardiomegaly atherosclerotic calcifications seenhepatomegaly observed calcification within right lobe liver likely related granulomatous changes subtle irregularity liver contour noted suggestive cirrhosis splenomegaly seen two lowattenuation lesions seen posterior aspect spleen incompletely characterized may represent splenic cyst pancreas appears atrophic left renal nodule seen measures cm hounsfield unit density approximately indeterminatethere mild bilateral perinephric stranding mm fat density lesion anterior inner polar region left kidney compatible appearance angiomyolipoma cm lowattenuation lesion upper pole right kidney likely representing cyst incompletely characterized examination bilateral ureters appear normal caliber along visualized course bladder partially distended urine otherwise unremarkablepostsurgical changes hysterectomy noted pelvic phlebolith seen calcified soft tissue density lesion right pelvis may represent ovary calcification appears continuous right gonadal veinscattered colonic diverticula observed appendix within normal limits small bowel unremarkable anterior abdominal wall hernia noted containing herniated mesenteric fat hernia neck measures approximately cm stranding fat within hernia sacthere extensive degenerative changes right hip noted changes suggestive avascular necrosis degenerative changes spine observedimpression anterior abdominal wall hernia mesenteric fatcontaining stranding suggestive incarcerated fat nodule left lower lobe recommend follow months indeterminate left adrenal nodule could assessed dedicated adrenal protocol ct mri hepatomegaly changes suggestive cirrhosis also splenomegaly observed lowattenuation lesions spleen may represent cyst incompletely characterized examination fat density lesion left kidney likely represents angiomyolipoma fat density soft tissue lesion region right adnexa contains calcifications may represent ovary possibly dermoid cyst

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:, Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis. There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs. Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed. There is calcification within the right lobe of the liver likely related to granulomatous changes. Subtle irregularity of the liver contour is noted, suggestive of cirrhosis. There is splenomegaly seen. There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst. The pancreas appears atrophic. There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding. There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma. There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination. Bilateral ureters appear normal in caliber along their visualized course. The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted. There are pelvic phlebolith seen. There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed. The appendix is within normal limits. The small bowel is unremarkable. There is an anterior abdominal wall hernia noted containing herniated mesenteric fat. The hernia neck measures approximately 2.7 cm. There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis. Degenerative changes of the spine are observed.,IMPRESSION:,1. Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2. Nodule in the left lower lobe, recommend follow up in 3 months.,3. Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4. Hepatomegaly with changes suggestive of cirrhosis. There is also splenomegaly observed.,5. Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6. Fat density lesion in the left kidney, likely represents angiomyolipoma.,7. Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst. ### Response: Gastroenterology, Nephrology, Radiology

EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis.

exam ct pelvis contrast ct abdomen without contrastindications abnormal liver enzymes diarrheatechnique ct examination abdomen pelvis performed ml intravenous contrast administration oral contrast administration precontrast images abdomen also obtainedcomparison comparison studiesfindings lung bases clearthe liver demonstrates mild intrahepatic biliary ductal dilatation findings may secondary patients post cholecystectomy state pancreas spleen adrenal glands kidneys unremarkablethere mm peripheralenhancing fluid collection anterior pararenal space uncertain etiology numerous nonspecific retroperitoneal mesenteric lymph nodes may reactive however early neoplastic process would difficult totally excludethere right inguinal hernia containing loop small bowel may produce partial obstruction mild fluid distention several small bowel loops particularly right lower quadrant large bowel demonstrates significant diverticulosis coli sigmoid distal descending colon without evidence diverticulitisthere diffuse osteopenia along significant degenerative changes lower lumbar spinethe urinary bladder unremarkable uterus visualizedimpression right inguinal hernia containing small bowel partial obstruction suspected nonspecific retroperitoneal mesenteric lymph nodes thirteen millimeter circumscribed fluid collection anterior pararenal space uncertain etiology diverticulosis without evidence diverticulitis status post cholecystectomy mild intrahepatic biliary ductal dilatation osteopenia degenerative changes spine pelvis

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis. ### Response: Gastroenterology, Nephrology, Radiology

EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained. 5-mm slices were acquired after injection of 125 cc of Omnipaque IV. In addition, oral ReadiCAT was given. Reformatted sagittal and coronal images were obtained.,DISCUSSION:, There are numerous subcentimeter nodules seen within the lung bases. The largest measures up to 6 mm. No hiatal hernia is identified. Consider chest CT for further evaluation of the pulmonary nodules. The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits. No dilated loops of bowel. There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat. In addition, there is soft tissue stranding seen of the lower pelvis. In addition, the uterus is not identified. Correlate with history of recent surgery. There is no free fluid or lymphadenopathy seen within the abdomen or pelvis. The bladder is within normal limits for technique.,No acute bony abnormalities appreciated. No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1. Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2. Numerous subcentimeter nodules seen within the lung bases. Consider chest CT for further characterization.

exam ct scan abdomen pelvis contrastreason exam abdominal paincomparison exam nonetechnique multiple axial images abdomen pelvis obtained mm slices acquired injection cc omnipaque iv addition oral readicat given reformatted sagittal coronal images obtaineddiscussion numerous subcentimeter nodules seen within lung bases largest measures mm hiatal hernia identified consider chest ct evaluation pulmonary nodules liver gallbladder pancreas spleen adrenal glands kidneys within normal limits dilated loops bowel punctate foci air seen within nondependent portions peritoneal cavity well anterior subcutaneous fat addition soft tissue stranding seen lower pelvis addition uterus identified correlate history recent surgery free fluid lymphadenopathy seen within abdomen pelvis bladder within normal limits techniqueno acute bony abnormalities appreciated suspicious osteoblastic osteolytic lesionsimpression postoperative changes seen within pelvis without appreciable evidence free fluid numerous subcentimeter nodules seen within lung bases consider chest ct characterization

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained. 5-mm slices were acquired after injection of 125 cc of Omnipaque IV. In addition, oral ReadiCAT was given. Reformatted sagittal and coronal images were obtained.,DISCUSSION:, There are numerous subcentimeter nodules seen within the lung bases. The largest measures up to 6 mm. No hiatal hernia is identified. Consider chest CT for further evaluation of the pulmonary nodules. The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits. No dilated loops of bowel. There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat. In addition, there is soft tissue stranding seen of the lower pelvis. In addition, the uterus is not identified. Correlate with history of recent surgery. There is no free fluid or lymphadenopathy seen within the abdomen or pelvis. The bladder is within normal limits for technique.,No acute bony abnormalities appreciated. No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1. Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2. Numerous subcentimeter nodules seen within the lung bases. Consider chest CT for further characterization. ### Response: Gastroenterology, Nephrology, Radiology

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

exam ct scan abdomen pelvis without intravenous contrastclinical indication left lower quadrant abdominal paincomparison nonefindings ct scan abdomen pelvis performed without intravenous contrast total ml isovue administered intravenously oral contrast also administeredthe lung bases clear liver enlarged decreased attenuation focal liver massesthere intra extrahepatic ductal dilatationthe gallbladder slightly distendedthe adrenal glands pancreas spleen left kidney normala mm simple cyst present inferior pole right kidney hydronephrosis hydroureterthe appendix normalthere multiple diverticula rectosigmoid evidence focal wall thickening sigmoid colon image adjacent fat stranding association diverticulum findings consistent diverticulitis pneumoperitoneum identified ascites focal fluid collectionthe aorta normal contour caliberthere adenopathydegenerative changes present lumbar spineimpression findings consistent diverticulitis please see report

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

EXAM: , CT stone protocol.,REASON FOR EXAM:, History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally. These are unchanged. There is no hydronephrosis or significant ureteral dilatation. There is no stone along the expected course of the ureters or within the bladder. There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith. There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal. There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. The gallbladder is present. There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.

exam ct stone protocolreason exam history stones rule stonestechnique noncontrast ct abdomen pelvis per renal stone protocolfindings correlation made prior examination dated identified small intrarenal stones bilaterally unchanged hydronephrosis significant ureteral dilatation stone along expected course ureters within bladder calcification low left pelvis line ureter finding stable compatible phlebolith asymmetric renal enlargement perinephric strandingthe appendix normal evidence pericolonic inflammatory process small bowel obstructionscans pelvis disclose free fluid adenopathylung bases aside mild dependent atelectasis appear cleargiven lack contrast liver spleen adrenal glands pancreas grossly unremarkable gallbladder present abdominal free fluid pathologic adenopathyimpression bilateral intrarenal stones obstruction normal appendix

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CT stone protocol.,REASON FOR EXAM:, History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally. These are unchanged. There is no hydronephrosis or significant ureteral dilatation. There is no stone along the expected course of the ureters or within the bladder. There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith. There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal. There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. The gallbladder is present. There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix. ### Response: Nephrology, Radiology

EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. However, there is considerable change in the appearance of the lung fields. There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. There are also extensive right lung consolidations, all new or increased significantly from the prior examination. Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. There is aortic root and arch and descending thoracic aortic calcification. There are scattered regions of soft plaque intermixed with this. The heart is not enlarged. The left axilla is intact in regards to adenopathy. The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. Spleen, adrenal glands, and upper kidneys appear unremarkable. Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass. There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1. Again demonstrated is a large right chest wall mass.,2. No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3. New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4. See above regarding other findings.

exam cta chest pulmonary angioreason exam evaluate pulmonary embolismtechnique postcontrast ct chest pulmonary embolism protocol ml isovue contrast utilizedfindings filling defects main main right left pulmonary arteries central embolism proximal subsegmental pulmonary arteries free embolus distal subsegmental segmental arteries especially right limited extensive pulmonary parenchymal findings would discussed detail evidence central embolismas seen prior examination large heterogeneous right chest wall mass measures least x cm based axial image superior mass second heterogeneous focus neoplasm measuring x cm given short interval time course prior exam dated finding significantly changed however considerable change appearance lung fields bilateral pleural effusions small right moderate left associated atelectasis also extensive right lung consolidations new increased significantly prior examination identified somewhat spiculated region increased density right lung apex may indicate fibrosis scarring possibility primary metastatic disease cannot excluded pneumothorax intervalon mediastinal windows presumed subcarinal adenopathy one lymph node measuring roughly mm suggestive metastatic disease aortic root arch descending thoracic aortic calcification scattered regions soft plaque intermixed heart enlarged left axilla intact regards adenopathy inferior thyroid appears unremarkablelimited assessment upper abdomen discloses region lower density within right hepatic lobe finding indeterminate need additional imaging regards hepatic metastatic disease follow ultrasound spleen adrenal glands upper kidneys appear unremarkable visualized portions pancreas unremarkablethere extensive rib destruction region chest wall mass changes suggesting prior trauma right clavicleimpression demonstrated large right chest wall mass central embolus distal subsegmental segmental pulmonary artery branches part obscured pulmonary parenchymal findings well assessed new bilateral pleural effusions extensive increasing consolidations infiltrates right lung see regarding findings

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. However, there is considerable change in the appearance of the lung fields. There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. There are also extensive right lung consolidations, all new or increased significantly from the prior examination. Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. There is aortic root and arch and descending thoracic aortic calcification. There are scattered regions of soft plaque intermixed with this. The heart is not enlarged. The left axilla is intact in regards to adenopathy. The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. Spleen, adrenal glands, and upper kidneys appear unremarkable. Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass. There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1. Again demonstrated is a large right chest wall mass.,2. No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3. New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4. See above regarding other findings. ### Response: Cardiovascular / Pulmonary, Radiology

EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1. Left heart catheterization, coronary angiography, left ventriculography.,2. PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1. IV Valium.,2. IV Benadryl.,3. Subcutaneous lidocaine.,4. IV heparin.,5. IV ReoPro.,6. Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST: ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG. She was prepped and draped in the usual sterile fashion. The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained. The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed. The needle was exchanged for 6 French sheath. The wire was removed. The sheath was washed with sterile saline. Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed. A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD. The patient had an ACT check, received additional IV heparin and IV ReoPro. The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures. The balloon was deflated and angiography demonstrated establishment of flow. Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres. The balloon was deflated, reinflated at 12 atmospheres, deflated and removed. Final angiography demonstrated excellent clinical result. Additional angiography was performed with a wire out. Following this, the wire and the catheter was removed. Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views. This catheter was removed. The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve. At the end of procedure, wires and catheter were removed. Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site. There was no hematoma. Peripheral pulses _______ procedure. The patient tolerated the procedure well. Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1. Coronary angiography.,A. Left main free of obstruction.,B. LAD, subtotal proximal stenosis.,C. Circumflex large vessel with three large obtuse marginal branches. No high-grade obstruction, evidence of minimal plaquing.,D. Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2. Left ventriculogram. Left ventricular ejection fraction estimated at 45% to 50%. There was an akinetic apical wall.,3. Hemodynamics. Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1. Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2. Two-vessel coronary disease.,3. Mild-to-moderate impaired LV systolic function.,4. Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN: ,Overnight observation in ICU. Start aspirin, Plavix, beta-blocker and ACE inhibitor. Check serial cardiac enzymes. Further recommendations to follow. Check fasting lipid panel, in addition add a statin. Further recommendations to follow.

exam cardiac catheterization coronary intervention reportprocedures left heart catheterization coronary angiography left ventriculography ptcaendeavor stent proximal ladindications acute anterior stelevation miaccess right femoral artery frenchmedications iv valium iv benadryl subcutaneous lidocaine iv heparin iv reopro intracoronary nitroglycerinestimated blood loss mlcontrast mlcomplications noneprocedure patient brought cardiac catheterization laboratory acute stelevation mi ekg prepped draped usual sterile fashion right femoral region infiltrated subcutaneous lidocaine adequate anesthesia obtained right femoral artery entered _______ modified seldinger technique j wire passed needle exchanged french sheath wire removed sheath washed sterile saline following left coronary attempted cannulated xp catheter however catheter folded could reach left main removed second french jl guiding catheter used cannulate left main initial guiding shots demonstrated occlusion proximal lad patient act check received additional iv heparin iv reopro lesion crossed bmw wire redilated x mm balloon nominal pressures balloon deflated angiography demonstrated establishment flow following lesion stented x mm endeavor stent atmospheres balloon deflated reinflated atmospheres deflated removed final angiography demonstrated excellent clinical result additional angiography performed wire following wire catheter removed following right coronary selectively cannulated diagnostic catheter angiographic views obtained multiple views catheter removed pigtail catheter placed left ventricle left ventriculography performed pullback pressures across aortic valve end procedure wires catheter removed right femoral angiography performed right femoral angioseal kit deployed right femoral arteriotomy site hematoma peripheral pulses _______ procedure patient tolerated procedure well symptoms chest pain resolved end procedure complicationsresults coronary angiographya left main free obstructionb lad subtotal proximal stenosisc circumflex large vessel three large obtuse marginal branches highgrade obstruction evidence minimal plaquingd right coronary mid vessel stenosis mid distal stenosis giving rise right dominant posterior lateral posterior descending artery left ventriculogram left ventricular ejection fraction estimated akinetic apical wall hemodynamics aortic pressure left ventricular pressure left ventricular enddiastolic pressure mmhgimpression acute stelevation myocardial infarction culprit lesion left anterior descending occlusion twovessel coronary disease mildtomoderate impaired lv systolic function successful stent left anterior descending occlusion residual stenosisplan overnight observation icu start aspirin plavix betablocker ace inhibitor check serial cardiac enzymes recommendations follow check fasting lipid panel addition add statin recommendations follow

### Instruction: find the medical speciality for this medical test. ### Input: EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1. Left heart catheterization, coronary angiography, left ventriculography.,2. PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1. IV Valium.,2. IV Benadryl.,3. Subcutaneous lidocaine.,4. IV heparin.,5. IV ReoPro.,6. Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST: ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG. She was prepped and draped in the usual sterile fashion. The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained. The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed. The needle was exchanged for 6 French sheath. The wire was removed. The sheath was washed with sterile saline. Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed. A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD. The patient had an ACT check, received additional IV heparin and IV ReoPro. The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures. The balloon was deflated and angiography demonstrated establishment of flow. Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres. The balloon was deflated, reinflated at 12 atmospheres, deflated and removed. Final angiography demonstrated excellent clinical result. Additional angiography was performed with a wire out. Following this, the wire and the catheter was removed. Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views. This catheter was removed. The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve. At the end of procedure, wires and catheter were removed. Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site. There was no hematoma. Peripheral pulses _______ procedure. The patient tolerated the procedure well. Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1. Coronary angiography.,A. Left main free of obstruction.,B. LAD, subtotal proximal stenosis.,C. Circumflex large vessel with three large obtuse marginal branches. No high-grade obstruction, evidence of minimal plaquing.,D. Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2. Left ventriculogram. Left ventricular ejection fraction estimated at 45% to 50%. There was an akinetic apical wall.,3. Hemodynamics. Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1. Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2. Two-vessel coronary disease.,3. Mild-to-moderate impaired LV systolic function.,4. Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN: ,Overnight observation in ICU. Start aspirin, Plavix, beta-blocker and ACE inhibitor. Check serial cardiac enzymes. Further recommendations to follow. Check fasting lipid panel, in addition add a statin. Further recommendations to follow. ### Response: Cardiovascular / Pulmonary, Surgery

EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measured at 20%.,3. Patent bilateral vertebral arteries.,4. No significant disease was identified of the anterior cerebral vessels.,DISCUSSION: ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home.