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GENERAL REVIEW OF SYSTEMS,General: No fevers, chills, or sweats. No weight loss or weight gain.,Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.,Neurologic: No paresis, paresthesias, or syncope.,Eyes: No double vision or blurred vision.,Ears: No tinnitus or decreased auditory acuity.,ENT: No allergy symptoms, such as rhinorrhea or sneezing.,GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits.,GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream.,Psych: No symptoms of depression or anxiety.,Pulmonary: No wheezing, cough, or sputum production.,Skin: No skin lesions or nonhealing lesions.,Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints.,Endocrine: No heat or cold intolerance. No polydipsia.,Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears: TMs intact bilaterally. Throat is clear without hyperemia.,Mouth: Mucous membranes normal. Tongue normal.,Neck: Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest: Clear to auscultation; no dullness to percussion.,Heart: Revealed a regular rhythm, normal S1 and S2. No murmurs, clicks or gallops.,Abdomen: Soft to palpation without guarding or rebound. No masses or hepatosplenomegaly palpable. Bowel sounds are normoactive.,Extremities: bilaterally symmetrical. Peripheral pulses 2+ in all extremities. No pedal edema.,Neurologic examination: Essentially intact including cranial nerves II through XII intact bilaterally. Deep tendon reflexes 2+ and symmetrical.,Genitalia: Bilaterally descended testes without tenderness or masses. No hernias palpable. Rectal examination revealed normal sphincter tone, no rectal mass. Prostate was *. Stool was Hemoccult negative.

general review systemsgeneral fevers chills sweats weight loss weight gaincardiovascular exertional chest pain orthopnea pnd pedal edema palpitationsneurologic paresis paresthesias syncopeeyes double vision blurred visionears tinnitus decreased auditory acuityent allergy symptoms rhinorrhea sneezinggi indigestion heartburn diarrhea blood stools black stools change bowel habitsgu dysuria hematuria pyuria polyuria nocturia denies slow urinary streampsych symptoms depression anxietypulmonary wheezing cough sputum productionskin skin lesions nonhealing lesionsmusculoskeletal joint pain bone pain back pain erythema jointsendocrine heat cold intolerance polydipsiahematologic easy bruising easy bleeding swollen lymph nodesphysical examvital blood pressure today heart rate respiratory rate ears tms intact bilaterally throat clear without hyperemiamouth mucous membranes normal tongue normalneck supple carotids bilaterally without bruits lymphadenopathy thyromegalychest clear auscultation dullness percussionheart revealed regular rhythm normal murmurs clicks gallopsabdomen soft palpation without guarding rebound masses hepatosplenomegaly palpable bowel sounds normoactiveextremities bilaterally symmetrical peripheral pulses extremities pedal edemaneurologic examination essentially intact including cranial nerves ii xii intact bilaterally deep tendon reflexes symmetricalgenitalia bilaterally descended testes without tenderness masses hernias palpable rectal examination revealed normal sphincter tone rectal mass prostate stool hemoccult negative

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL REVIEW OF SYSTEMS,General: No fevers, chills, or sweats. No weight loss or weight gain.,Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.,Neurologic: No paresis, paresthesias, or syncope.,Eyes: No double vision or blurred vision.,Ears: No tinnitus or decreased auditory acuity.,ENT: No allergy symptoms, such as rhinorrhea or sneezing.,GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits.,GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream.,Psych: No symptoms of depression or anxiety.,Pulmonary: No wheezing, cough, or sputum production.,Skin: No skin lesions or nonhealing lesions.,Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints.,Endocrine: No heat or cold intolerance. No polydipsia.,Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears: TMs intact bilaterally. Throat is clear without hyperemia.,Mouth: Mucous membranes normal. Tongue normal.,Neck: Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest: Clear to auscultation; no dullness to percussion.,Heart: Revealed a regular rhythm, normal S1 and S2. No murmurs, clicks or gallops.,Abdomen: Soft to palpation without guarding or rebound. No masses or hepatosplenomegaly palpable. Bowel sounds are normoactive.,Extremities: bilaterally symmetrical. Peripheral pulses 2+ in all extremities. No pedal edema.,Neurologic examination: Essentially intact including cranial nerves II through XII intact bilaterally. Deep tendon reflexes 2+ and symmetrical.,Genitalia: Bilaterally descended testes without tenderness or masses. No hernias palpable. Rectal examination revealed normal sphincter tone, no rectal mass. Prostate was *. Stool was Hemoccult negative. ### Response: General Medicine

GENERAL REVIEW OF SYSTEMS,General: No fevers, chills, or sweats. No weight loss or weight gain.,Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.,Neurologic: No paresis, paresthesias, or syncope.,Eyes: No double vision or blurred vision.,Ears: No tinnitus or decreased auditory acuity.,ENT: No allergy symptoms, such as rhinorrhea or sneezing.,GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits.,GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream.,Psych: No symptoms of depression or anxiety.,Pulmonary: No wheezing, cough, or sputum production.,Skin: No skin lesions or nonhealing lesions.,Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints.,Endocrine: No heat or cold intolerance. No polydipsia.,Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.,PHYSICAL EXAM,Vitals: Blood pressure today was *, heart rate *, respiratory rate *.,Ears: TMs intact bilaterally. Throat is clear without hyperemia.,Mouth: Mucous membranes normal. Tongue normal.,Neck: Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest: Clear to auscultation; no dullness to percussion.,Heart: Revealed a regular rhythm, normal S1 and S2. No murmurs, clicks or gallops.,Abdomen: Soft to palpation without guarding or rebound. No masses or hepatosplenomegaly palpable. Bowel sounds are normoactive.,Extremities: Bilaterally symmetrical. Peripheral pulses 2+ in all extremities. No pedal edema.,Neurologic examination: Essentially intact including cranial nerves II through XII intact bilaterally. Deep tendon reflexes 2+ and symmetrical.,Breasts: Bilaterally symmetrical without tenderness, masses. No axillary tenderness or masses.,Pelvic examination: Revealed normal external genitalia. Pap smear obtained without difficulty. Bimanual examination revealed no pelvic tenderness or masses. No uterine enlargement. Rectal examination revealed normal sphincter tone, no rectal masses. Stool is Hemoccult negative.

general review systemsgeneral fevers chills sweats weight loss weight gaincardiovascular exertional chest pain orthopnea pnd pedal edema palpitationsneurologic paresis paresthesias syncopeeyes double vision blurred visionears tinnitus decreased auditory acuityent allergy symptoms rhinorrhea sneezinggi indigestion heartburn diarrhea blood stools black stools change bowel habitsgu dysuria hematuria pyuria polyuria nocturia denies slow urinary streampsych symptoms depression anxietypulmonary wheezing cough sputum productionskin skin lesions nonhealing lesionsmusculoskeletal joint pain bone pain back pain erythema jointsendocrine heat cold intolerance polydipsiahematologic easy bruising easy bleeding swollen lymph nodesphysical examvitals blood pressure today heart rate respiratory rate ears tms intact bilaterally throat clear without hyperemiamouth mucous membranes normal tongue normalneck supple carotids bilaterally without bruits lymphadenopathy thyromegalychest clear auscultation dullness percussionheart revealed regular rhythm normal murmurs clicks gallopsabdomen soft palpation without guarding rebound masses hepatosplenomegaly palpable bowel sounds normoactiveextremities bilaterally symmetrical peripheral pulses extremities pedal edemaneurologic examination essentially intact including cranial nerves ii xii intact bilaterally deep tendon reflexes symmetricalbreasts bilaterally symmetrical without tenderness masses axillary tenderness massespelvic examination revealed normal external genitalia pap smear obtained without difficulty bimanual examination revealed pelvic tenderness masses uterine enlargement rectal examination revealed normal sphincter tone rectal masses stool hemoccult negative

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL REVIEW OF SYSTEMS,General: No fevers, chills, or sweats. No weight loss or weight gain.,Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.,Neurologic: No paresis, paresthesias, or syncope.,Eyes: No double vision or blurred vision.,Ears: No tinnitus or decreased auditory acuity.,ENT: No allergy symptoms, such as rhinorrhea or sneezing.,GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits.,GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream.,Psych: No symptoms of depression or anxiety.,Pulmonary: No wheezing, cough, or sputum production.,Skin: No skin lesions or nonhealing lesions.,Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints.,Endocrine: No heat or cold intolerance. No polydipsia.,Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.,PHYSICAL EXAM,Vitals: Blood pressure today was *, heart rate *, respiratory rate *.,Ears: TMs intact bilaterally. Throat is clear without hyperemia.,Mouth: Mucous membranes normal. Tongue normal.,Neck: Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest: Clear to auscultation; no dullness to percussion.,Heart: Revealed a regular rhythm, normal S1 and S2. No murmurs, clicks or gallops.,Abdomen: Soft to palpation without guarding or rebound. No masses or hepatosplenomegaly palpable. Bowel sounds are normoactive.,Extremities: Bilaterally symmetrical. Peripheral pulses 2+ in all extremities. No pedal edema.,Neurologic examination: Essentially intact including cranial nerves II through XII intact bilaterally. Deep tendon reflexes 2+ and symmetrical.,Breasts: Bilaterally symmetrical without tenderness, masses. No axillary tenderness or masses.,Pelvic examination: Revealed normal external genitalia. Pap smear obtained without difficulty. Bimanual examination revealed no pelvic tenderness or masses. No uterine enlargement. Rectal examination revealed normal sphincter tone, no rectal masses. Stool is Hemoccult negative. ### Response: General Medicine

GENERAL: ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.,HEAD: , Normocephalic. Negative lesions, negative masses.,EYES: , PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.,ENT:, Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers. No tattoos.,NECK:, Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:, Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.,LUNGS:, Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.,MUSCULOSKELETAL:, Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.,GENITOURINARY: ,Deferred.,

general xxxvital signs blood pressure xxx pulse xxx temperature xxx respirations xxx height xxx weight xxxhead normocephalic negative lesions negative masseseyes perla eomi sclerae clear negative icterus negative conjunctivitisent negative nasal hemorrhages negative nasal obstructions negative nasal exudates negative ear obstructions negative exudates negative inflammation external auditory canals negative throat inflammation massesskin negative rashes negative masses negative ulcers tattoosneck negative palpable lymphadenopathy negative palpable thyromegaly negative bruitsheart regular rate rhythm negative rubs negative gallops negative murmurslungs clear auscultation negative rales negative rhonchi negative wheezingabdomen soft nontender adequate bowel sounds negative palpable masses negative hepatosplenomegaly negative abdominal bruitsextremities negative inflammation negative tenderness negative swelling negative edema negative cyanosis negative clubbing pulses adequate bilaterallymusculoskeletal negative muscle atrophy negative masses strength adequate bilaterally negative movement restriction negative joint crepitus negative deformityneurologic cranial nerves xii intact negative gait disturbance balance coordination intact negative romberg negative babinski dtrs equal bilaterallygenitourinary deferred

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL: ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.,HEAD: , Normocephalic. Negative lesions, negative masses.,EYES: , PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.,ENT:, Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers. No tattoos.,NECK:, Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:, Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.,LUNGS:, Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.,MUSCULOSKELETAL:, Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.,GENITOURINARY: ,Deferred., ### Response: Consult - History and Phy., General Medicine

GENERAL: Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC: Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT: Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC: Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY: Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL: Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY: Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY: Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC: Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC: Negative for any abnormal bruising, frequent infections or bleeding.

general negative nausea vomiting fevers chills weight lossneurologic negative blurry vision blind spots double vision facial asymmetry dysphagia dysarthria hemiparesis hemisensory deficits vertigo ataxiaheent negative head trauma neck trauma neck stiffness photophobia phonophobia sinusitis rhinitiscardiac negative chest pain dyspnea exertion paroxysmal nocturnal dyspnea peripheral edemapulmonary negative shortness breath wheezing copd tb exposuregastrointestinal negative abdominal pain nausea vomiting bright red blood per rectum melenagenitourinary negative dysuria hematuria incontinenceintegumentary negative rashes cuts insect bitesrheumatologic negative joint pains photosensitive rashes history vasculitis kidney problemshematologic negative abnormal bruising frequent infections bleeding

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL: Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC: Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT: Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC: Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY: Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL: Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY: Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY: Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC: Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC: Negative for any abnormal bruising, frequent infections or bleeding. ### Response: Consult - History and Phy., General Medicine

GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS: ,Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.,HEENT: ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:, Clear to auscultation.,HEART:, Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral.,ABDOMEN:, Soft with bowel sounds present. No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC: ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash.

general welldeveloped infant acute respiratory distressvital signs initial temperature xx pulse xx respirations xx weight xx grams length xx cm head circumference xx cmheent head normocephalic anterior fontanelle open soft nonbulging eyes red reflex elicited bilaterally tms occluded vernix well visualized nose throat patent without palatal defectneck supple without clavicular fracturelungs clear auscultationheart regular rate without murmur click gallop present pulses brachial femoralabdomen soft bowel sounds present masses organomegalygenitalia normalextremities without evidence hip defectsneurologic infant good moro grasp suck reflexesskin warm dry without evidence rash

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL: , A well-developed infant in no acute respiratory distress.,VITAL SIGNS: ,Initial temperature was XX, pulse XX, respirations XX. Weight XX grams, length XX cm, head circumference XX cm.,HEENT: ,Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect.,NECK: , Supple without clavicular fracture.,LUNGS:, Clear to auscultation.,HEART:, Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral.,ABDOMEN:, Soft with bowel sounds present. No masses or organomegaly.,GENITALIA: , Normal.,EXTREMITIES: , Without evidence of hip defects.,NEUROLOGIC: ,The infant has good Moro, grasp, and suck reflexes.,SKIN: , Warm and dry without evidence of rash. ### Response: Consult - History and Phy., General Medicine, Pediatrics - Neonatal

GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age. Oriented to time, place and person. No recent loss of memory. Affect appropriate for age.,EYES: ,Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist. Ears and nose without masses, lesions or deformities. Tympanic membranes clear bilaterally. Trachea midline. No lymph node swelling or tenderness.,RESPIRATORY: ,Clear to auscultation and percussion. No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended. No pulsatile mass, no flank tenderness or suprapubic tenderness. No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact. No focal neurological deficits. Deep tendon reflexes +2 bilaterally. Babinski negative. Moves all extremities spontaneously. Sensation intact bilaterally.,SKIN: , No rashes or lesions. No petechia. No purpura. Good turgor. No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing. No gross deformities. Capable of free range of motion without pain or crepitation. No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone.,MUSCLE: ,No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.,LYMPHATIC:, Palpation of neck reveals no swelling or tenderness of neck nodes. Palpation of groin reveals no swelling or tenderness of groin nodes.

general alert well developed acute distressmental status judgment insight appropriate age oriented time place person recent loss memory affect appropriate ageeyes pupils equal reactive light hemorrhages exudates extraocular muscles intactear nose throat oropharynx clean mucous membranes moist ears nose without masses lesions deformities tympanic membranes clear bilaterally trachea midline lymph node swelling tendernessrespiratory clear auscultation percussion wheezing rales rhonchicardiovascular heart sounds normal thrills regular rate rhythm murmurs rubs gallopsgastrointestinal abdomen soft nondistended pulsatile mass flank tenderness suprapubic tenderness hepatosplenomegalyneurologic cranial nerves iixii grossly intact focal neurological deficits deep tendon reflexes bilaterally babinski negative moves extremities spontaneously sensation intact bilaterallyskin rashes lesions petechia purpura good turgor edemamusculoskeletal cyanosis clubbing gross deformities capable free range motion without pain crepitation laxity instability dislocationbone misalignment asymmetry defect tenderness effusion capable joint bonemuscle crepitation defect tenderness masses swellings loss muscle tone strengthlymphatic palpation neck reveals swelling tenderness neck nodes palpation groin reveals swelling tenderness groin nodes

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age. Oriented to time, place and person. No recent loss of memory. Affect appropriate for age.,EYES: ,Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist. Ears and nose without masses, lesions or deformities. Tympanic membranes clear bilaterally. Trachea midline. No lymph node swelling or tenderness.,RESPIRATORY: ,Clear to auscultation and percussion. No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended. No pulsatile mass, no flank tenderness or suprapubic tenderness. No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact. No focal neurological deficits. Deep tendon reflexes +2 bilaterally. Babinski negative. Moves all extremities spontaneously. Sensation intact bilaterally.,SKIN: , No rashes or lesions. No petechia. No purpura. Good turgor. No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing. No gross deformities. Capable of free range of motion without pain or crepitation. No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone.,MUSCLE: ,No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.,LYMPHATIC:, Palpation of neck reveals no swelling or tenderness of neck nodes. Palpation of groin reveals no swelling or tenderness of groin nodes. ### Response: Consult - History and Phy., General Medicine

GENERAL: , Vital signs and temperature as documented in nursing notes. The patient appears stated age and is adequately developed.,EYES:, Pupils are equal, round, reactive to light and accommodation. Lids and conjunctivae reveal no gross abnormality.,ENT: ,Hearing appears adequate. No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline. Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:, The patient has normal and symmetric respiratory effort. Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender. Bowel sounds are active. No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL: ,The patient is ambulatory with normal and symmetric gait. There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions. Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:, Mental status, judgment and affect are grossly intact and normal for age.

general vital signs temperature documented nursing notes patient appears stated age adequately developedeyes pupils equal round reactive light accommodation lids conjunctivae reveal gross abnormalityent hearing appears adequate obvious asymmetry deformity ears noseneck trachea midline symmetric obvious deformity mass thyromegaly evidentrespiratory patient normal symmetric respiratory effort lungs clear auscultationcardiovascular without significant murmurabdomen abdomen flat soft nontender bowel sounds active masses pulsations presentextremities extremities reveal remarkable dependent edema varicositiesmusculoskeletal patient ambulatory normal symmetric gait adequate range motion without significant pain deformityskin essentially clear significant rash lesions adequate skin turgorneurological acute focal neurologic changespsychiatric mental status judgment affect grossly intact normal age

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL: , Vital signs and temperature as documented in nursing notes. The patient appears stated age and is adequately developed.,EYES:, Pupils are equal, round, reactive to light and accommodation. Lids and conjunctivae reveal no gross abnormality.,ENT: ,Hearing appears adequate. No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline. Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:, The patient has normal and symmetric respiratory effort. Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender. Bowel sounds are active. No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL: ,The patient is ambulatory with normal and symmetric gait. There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions. Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:, Mental status, judgment and affect are grossly intact and normal for age. ### Response: Consult - History and Phy., General Medicine

GENERAL: , Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetrical, undilated. Funduscopic exam reveals no hemorrhages or discopathy. Ears, Nose, Mouth, and throat: External ears without lesions. Nares patent. Septum midline. Tympanic membranes without erythema, bulging or retraction. Canals without lesion. Hearing is grossly intact. Lips, teeth, gums, palate without lesion. Posterior oropharynx: No erythema. No tonsillar enlargement, crypt formation or abscess.,NECK: ,Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain.,RESPIRATORY: , Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.,CARDIOVASCULAR:, Regular rate and rhythm. No murmur, gallops, clicks, heaves or rub. Cardiac palpation within normal limits. Pulses equal at carotid. Femoral and pedal pulses: No peripheral edema.,GASTROINTESTINAL: ,No tenderness or mass. No hepatosplenomegaly. No hernia. Bowel sounds equal times four quadrants. Abdomen is nondistended. No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline. Full range of motion with flexion, extension and sidebending.,SKIN:, Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.,LYMPH:, Cervical lymph nodes. No lymphadenopathy.,NEUROLOGICAL: ,Cranial nerves II-XII grossly intact. DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle. Motor strength 4/4 bilateral upper and lower extremity. Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate. Alert and oriented times three. Memory and mood within normal limits. No delusions, hallucinations. No suicidal or homicidal ideation.

general well developed well nourished alert acute distress gcs nontoxicvital signs blood pressure pulse respirations temperature degrees f pulse oximetry heent eyes lids conjunctiva lesions pupils equal round reactive light accommodation irises symmetrical undilated funduscopic exam reveals hemorrhages discopathy ears nose mouth throat external ears without lesions nares patent septum midline tympanic membranes without erythema bulging retraction canals without lesion hearing grossly intact lips teeth gums palate without lesion posterior oropharynx erythema tonsillar enlargement crypt formation abscessneck supple symmetric masses thyroid midline non enlarged jvd neck nontender full range motion without painrespiratory good respiratory effort clear auscultation clear percussion chest symmetrical rise fall symmetrical expansion egophony tactile fremituscardiovascular regular rate rhythm murmur gallops clicks heaves rub cardiac palpation within normal limits pulses equal carotid femoral pedal pulses peripheral edemagastrointestinal tenderness mass hepatosplenomegaly hernia bowel sounds equal times four quadrants abdomen nondistended rebound guarding rigidity ecchymosismusculoskeletal normal gait station pathology digits nails extremities move times four tenderness effusion range motion adequate strength tone equal bilaterally stableback nontender midline full range motion flexion extension sidebendingskin inspection within normal limits well hydrated diaphoresis obvious woundlymph cervical lymph nodes lymphadenopathyneurological cranial nerves iixii grossly intact dtrs symmetric bilateral upper lower extremity elbow patella ankle motor strength bilateral upper lower extremity straight leg raise negative bilaterallypsychiatric judgment insight adequate alert oriented times three memory mood within normal limits delusions hallucinations suicidal homicidal ideation

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL: , Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetrical, undilated. Funduscopic exam reveals no hemorrhages or discopathy. Ears, Nose, Mouth, and throat: External ears without lesions. Nares patent. Septum midline. Tympanic membranes without erythema, bulging or retraction. Canals without lesion. Hearing is grossly intact. Lips, teeth, gums, palate without lesion. Posterior oropharynx: No erythema. No tonsillar enlargement, crypt formation or abscess.,NECK: ,Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain.,RESPIRATORY: , Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.,CARDIOVASCULAR:, Regular rate and rhythm. No murmur, gallops, clicks, heaves or rub. Cardiac palpation within normal limits. Pulses equal at carotid. Femoral and pedal pulses: No peripheral edema.,GASTROINTESTINAL: ,No tenderness or mass. No hepatosplenomegaly. No hernia. Bowel sounds equal times four quadrants. Abdomen is nondistended. No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline. Full range of motion with flexion, extension and sidebending.,SKIN:, Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.,LYMPH:, Cervical lymph nodes. No lymphadenopathy.,NEUROLOGICAL: ,Cranial nerves II-XII grossly intact. DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle. Motor strength 4/4 bilateral upper and lower extremity. Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate. Alert and oriented times three. Memory and mood within normal limits. No delusions, hallucinations. No suicidal or homicidal ideation. ### Response: Consult - History and Phy., General Medicine

GENERAL:, Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.,EYES:, Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT: ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:, No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs.,MUSCULOSKELETAL:, Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.

general negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergiesintegumentary negative rash negative jaundicehematopoietic negative bleeding negative lymph node enlargement negative bruisabilityneurologic negative headaches negative syncope negative seizures negative weakness negative tremor history strokes history neurologic conditionseyes negative visual changes negative diplopia negative scotomata negative impaired visionears negative tinnitus negative vertigo negative hearing impairmentnose throat negative postnasal drip negative sore throatcardiovascular negative chest pain negative dyspnea exertion negative palpations negative edema history heart attack history arrhythmias history hypertensionrespiratory history shortness breath history asthma history chronic obstructive pulmonary disease history obstructive sleep apneagastrointestinal negative dysphagia negative nausea negative vomiting negative hematemesis negative abdominal paingenitourinary negative frequency negative urgency negative dysuria negative incontinence history stdsmusculoskeletal negative myalgia negative joint pain negative stiffness negative weakness negative back painpsychiatric see psychiatric evaluationendocrine history diabetes mellitus history thyroid problems history endocrinologic abnormalities

### Instruction: find the medical speciality for this medical test. ### Input: GENERAL:, Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.,EYES:, Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT: ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:, No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs.,MUSCULOSKELETAL:, Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities. ### Response: Consult - History and Phy., General Medicine

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

gross description specimen labeled right ovarian cyst received fresh frozen section consists smoothwalled clear fluid filled cyst measuring xx cm weighing grams fluid surfaces wall pinktan smooth grossly unremarkable firm thick areas papillary structures noted cyst wall externally internally removal fluid cyst weight grams fluid transparent slightly mucoid frozen section submitteddiagnosis benign cystic ovary

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

GROSS DESCRIPTION: , Specimen labeled "sesamoid bone left foot" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm. The specimen is entirely submitted, after decalcification.,DIAGNOSIS:, Acute Osteomyelitis, with foci of marrow fibrosis.,Focal acute and chronic inflammation of fascia and soft tissue. Arteriosclerosis, severely occlusive.

gross description specimen labeled sesamoid bone left foot received formalin consists three irregular fragments greybrown hard bony tissue admixed multiple fragments browntan rubbery fibrocollagenous soft tissue altogether measuring x x cm specimen entirely submitted decalcificationdiagnosis acute osteomyelitis foci marrow fibrosisfocal acute chronic inflammation fascia soft tissue arteriosclerosis severely occlusive

### Instruction: find the medical speciality for this medical test. ### Input: GROSS DESCRIPTION: , Specimen labeled "sesamoid bone left foot" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm. The specimen is entirely submitted, after decalcification.,DIAGNOSIS:, Acute Osteomyelitis, with foci of marrow fibrosis.,Focal acute and chronic inflammation of fascia and soft tissue. Arteriosclerosis, severely occlusive. ### Response: Orthopedic

GROSS DESCRIPTION:,A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B. Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.,D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.,C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma,(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.,E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.,COMMENTS:, Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.

gross descriptiona received fresh labeled patients name designated right upper lobe wedge x x cm wedge lung cm staple line x x cm sessile tumor surrounding pleural puckeringb received fresh labeled patients name designated lymph node cm possible lymph node anthracotic pigmentc received fresh labeled patients name designated right upper lobe x x cm lobe lung lung inflated formalin cm staple line lateral surface inked blue x x cm subpleural firm illdefined mass cm bronchial margin cm previously described staple line overlying pleura puckeredd received fresh labeled patients name designated lymph nodes x x cm aggregate lymphoid material anthracotic pigment adipose tissuee received fresh labeled patients name designated subcarinal lymph node x x cm aggregate lymphoid material anthracotic pigment final diagnosisa right upper lobe wedge lung biopsy poorly differentiated nonsmall cell carcinoma tumor size cm arterial large vessel invasion seen small vessel lymphatic invasion seen pleural invasion identified margins excision negative malignancyb biopsy r lymph node anthracotically pigmented lymphoid tissue negative malignancyc right upper lobe lung moderately differentiated nonsmall cell carcinomaadenocarcinoma tumor size cm arterial large vessel invasion present small vessel lymphatic invasion seen pleural invasion identified margins excision negative malignancyd biopsy r lymph nodes lymphoid tissue negative malignancye biopsy subcarinal lymph node lymphoid tissue negative malignancycomments pathologic examination reveals two separate tumors right upper lobe appear histologically distinct suggesting separate primary tumors pt right upper lobe wedge biopsy part shows poorly differentiated nonsmall cell carcinoma solid growth pattern without definite glandular differentiation light microscopy right upper lobe carcinoma identified resection part c moderately differentiated adenocarcinoma obvious gland formation

### Instruction: find the medical speciality for this medical test. ### Input: GROSS DESCRIPTION:,A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B. Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.,D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.,C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma,(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.,E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.,COMMENTS:, Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation. ### Response: Cardiovascular / Pulmonary

Grade II: Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III: Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV: The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease. The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.,IMPRESSION:, Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.

grade ii atherosclerotic plaques seen appear causing obstructiongrade iii atherosclerotic plaques seen appear causing greater obstructiongrade iv vessel pulsating artery appears totally obstructed blood flow itright carotid system common carotid artery bulb area shows mild intimal thickening increase velocity evidence obstructive disease internal carotid artery shows intimal thickening mixed plaques increase velocity evidence significant obstructive disease external carotid artery shows disease vertebral present antegradeleft carotid system common carotid artery bulb area shows mild intimal thickening increase velocity evidence significant obstructive disease internal carotid artery shows intimal thickening mixed plaques increase velocity evidence significant obstructive disease external carotid artery shows disease vertebral present antegradeimpression bilateral atherosclerotic changes evidence significant obstructive disease

### Instruction: find the medical speciality for this medical test. ### Input: Grade II: Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III: Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV: The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease. The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.,IMPRESSION:, Bilateral atherosclerotic changes with no evidence for any significant obstructive disease. ### Response: Cardiovascular / Pulmonary, Radiology

HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified. Simulation films were obtained, documenting its positioning. The 3-dimensional treatment planning process was accomplished utilizing the CT derived data. A treatment plan was selected utilizing sequential dwell positions within a single catheter. The patient was taken to the treatment area. The patient was appropriately positioned and the position of the intracavitary device was checked. Catheter length measurements were taken. Appropriate measurements of the probe dimensions and assembly were also performed. The applicator was attached to the HDR after-loader device. The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication. The brachytherapy source was appropriately removed back to the brachytherapy safe within the device. Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty. The patient was in no apparent distress and was discharged home.

hdr brachytherapythe intracavitary brachytherapy applicator placed appropriately secured patient identified simulation films obtained documenting positioning dimensional treatment planning process accomplished utilizing ct derived data treatment plan selected utilizing sequential dwell positions within single catheter patient taken treatment area patient appropriately positioned position intracavitary device checked catheter length measurements taken appropriate measurements probe dimensions assembly also performed applicator attached hdr afterloader device device ran checking sequences appropriately brachytherapy delivered without difficulty complication brachytherapy source appropriately removed back brachytherapy safe within device radiation screening performed geigermuller counter prior brachytherapy procedure completed results deemed appropriatefollowing completion procedure intracavitary device removed without difficulty patient apparent distress discharged home

### Instruction: find the medical speciality for this medical test. ### Input: HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified. Simulation films were obtained, documenting its positioning. The 3-dimensional treatment planning process was accomplished utilizing the CT derived data. A treatment plan was selected utilizing sequential dwell positions within a single catheter. The patient was taken to the treatment area. The patient was appropriately positioned and the position of the intracavitary device was checked. Catheter length measurements were taken. Appropriate measurements of the probe dimensions and assembly were also performed. The applicator was attached to the HDR after-loader device. The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication. The brachytherapy source was appropriately removed back to the brachytherapy safe within the device. Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty. The patient was in no apparent distress and was discharged home. ### Response: Hematology - Oncology, Radiology

HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:, No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:, No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.

heent history headaches migraines vertigo syncope visual loss tinnitus sinusitis sore mouth hoarseness swelling goiterrespiratory shortness breath wheezing dyspnea pulmonary disease tuberculosis past pneumoniascardiovascular history palpitations irregular rhythm chest pain hypertension hyperlipidemia diaphoresis congestive heart failure heart catheterization stress test recent cardiac testsgastrointestinal history rectal bleeding appetite change abdominal pain hiatal hernia ulcer jaundice change bowel habits liver problems history inflammatory bowel problemsgenitourinary dysuria hematuria frequency incontinence colicnervous system gait problems strokes numbness muscle weaknesspsychiatric history emotional lability depression sleep disturbancesoncologic history cancer change moles rashes history weight loss patient good energy levelallergiclymph history systemic allergy abnormal lymph nodes swellingmusculoskeletal fractures motor weakness arthritis joint pains

### Instruction: find the medical speciality for this medical test. ### Input: HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:, No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:, No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains. ### Response: Consult - History and Phy., General Medicine

HISTORY AND CLINICAL DATA: ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,He reports no clear-cut chest discomfort or difficulty with angina. He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.,REVIEW OF SYSTEMS:, General review of system is significant for difficulty with intermittent constipation, which has been problematic recently. He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.,PAST MEDICAL HISTORY:, Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,SOCIAL HISTORY: , Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,MEDICATIONS AT HOME:, Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily.,ALLERGIES: ,He has known history of allergy to clonidine, Medifast does fatigue.,DIAGNOSTIC AND LABORATORY DATA: , Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes. Low voltage in the limb leads.,WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000. Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179. Low total protein 5.7. Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200.,PHYSICAL EXAMINATION: ,He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular. JVD difficult to assess. Normal carotids with obvious bruits. Conjunctivae pink. Oropharynx clear. Mild kyphosis. Diffusely depressed breath sounds halfway up both posterior lung fields. No active wheezing. Cardiac Exam: Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base. Abdomen: Soft, nontender, protuberant, benign. Extremities: 2+ bilateral pitting edema to the level of the knees. Neuro Exam: Appears alert, oriented x3. Appropriate manner and affect, exceedingly hard of hearing.,OVERALL IMPRESSION:, An 88-year-old white male with the following major medical issues:,1. Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2. Hypertension with suboptimal controlled currently.,3. Diabetes.,4. Prostate CA, status post radium seed implant.,5. COPD, on metered-dose inhaler.,6. CLL followed by Dr. Y.,7. Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8. Hearing loss, anxiety.,9. Significant degenerative joint disease.,PLAN:,1. Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2. Strict I&O, Foley catheter has already been placed.,3. Daily BMP.,4. Two-dimensional echocardiogram to assess left ventricular systolic function. Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event. Further recommendations will be forthcoming pending his clinical course and hospital.

history clinical data patient yearold gentleman followed dr x primary care physician dr indication cll dr z cardiovascular issues presents care center earlier today approximately oneweek history increased progressive shortness breath orthopnea course past nights mild increase peripheral edema active wheezing dyspnea presenting morninghe reports clearcut chest discomfort difficulty angina dizziness lightheadedness near true syncope nothing supportive cva tia peripheral vascular claudicationreview systems general review system significant difficulty intermittent constipation problematic recently reports fever shaking chills nothing supportive gi gu blood loss productive nonproductive coughpast medical history remarkable hypertension diabetes prostate cancer status post radium seed implant copd single vessel coronary disease esophageal reflux cll osteopenia significant hearing loss anxiety degenerative joint diseasesocial history remarkable married retired quit smoking rare use alcohol lives locally wifemedications home include lortab mg three times daily chronic arthritic discomfort miacalcin nasal spray daily omeprazole mg daily diovan mg daily combivent two puffs tid folate one adult aspirin daily glyburide mg daily atenolol mg daily furosemide mg daily amlodipine mg daily hydralazine mg po tid addition tekturna mg daily zoloft mg dailyallergies known history allergy clonidine medifast fatiguediagnostic laboratory data chest xray upon presentation ellis emergency room evening demonstrate significant congestive heart failure moderatesized bilateral pleural effusionsa lead ekg sinus rhythm rate per minute right bundlebranch block type ivcv moderate nonspecific st changes low voltage limb leadswbc hemoglobin hematocrit platelets low serum sodium potassium bun creatinine random glucose low total protein magnesium level troponin bnatriuretic peptide physical examination elderly gentleman appears acute distress lying comfortably flat degrees measured pressure pulse regular jvd difficult assess normal carotids obvious bruits conjunctivae pink oropharynx clear mild kyphosis diffusely depressed breath sounds halfway posterior lung fields active wheezing cardiac exam regular soft early systolic ejection murmur best heard base abdomen soft nontender protuberant benign extremities bilateral pitting edema level knees neuro exam appears alert oriented x appropriate manner affect exceedingly hard hearingoverall impression yearold white male following major medical issues presentation consists subclinical congestive heart failure possibly systolic recent echocardiogram available review hypertension suboptimal controlled currently diabetes prostate ca status post radium seed implant copd metereddose inhaler cll followed dr singlevessel coronary disease recent anginal quality chest pain changes ecg suggestive acute ischemia however initial troponin followed serial enzyme determinations telemetry hearing loss anxiety significant degenerative joint diseaseplan admit telemetry congestive heart failure pathway intravenous diuretic therapy strict io foley catheter already placed daily bmp twodimensional echocardiogram assess left ventricular systolic function serum iron determination exclude possibility subclinical ischemic cardiac event recommendations forthcoming pending clinical course hospital

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY AND CLINICAL DATA: ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,He reports no clear-cut chest discomfort or difficulty with angina. He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.,REVIEW OF SYSTEMS:, General review of system is significant for difficulty with intermittent constipation, which has been problematic recently. He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.,PAST MEDICAL HISTORY:, Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,SOCIAL HISTORY: , Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,MEDICATIONS AT HOME:, Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily.,ALLERGIES: ,He has known history of allergy to clonidine, Medifast does fatigue.,DIAGNOSTIC AND LABORATORY DATA: , Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes. Low voltage in the limb leads.,WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000. Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179. Low total protein 5.7. Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200.,PHYSICAL EXAMINATION: ,He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular. JVD difficult to assess. Normal carotids with obvious bruits. Conjunctivae pink. Oropharynx clear. Mild kyphosis. Diffusely depressed breath sounds halfway up both posterior lung fields. No active wheezing. Cardiac Exam: Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base. Abdomen: Soft, nontender, protuberant, benign. Extremities: 2+ bilateral pitting edema to the level of the knees. Neuro Exam: Appears alert, oriented x3. Appropriate manner and affect, exceedingly hard of hearing.,OVERALL IMPRESSION:, An 88-year-old white male with the following major medical issues:,1. Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2. Hypertension with suboptimal controlled currently.,3. Diabetes.,4. Prostate CA, status post radium seed implant.,5. COPD, on metered-dose inhaler.,6. CLL followed by Dr. Y.,7. Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8. Hearing loss, anxiety.,9. Significant degenerative joint disease.,PLAN:,1. Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2. Strict I&O, Foley catheter has already been placed.,3. Daily BMP.,4. Two-dimensional echocardiogram to assess left ventricular systolic function. Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event. Further recommendations will be forthcoming pending his clinical course and hospital. ### Response: Consult - History and Phy., General Medicine

HISTORY AND PHYSICAL: ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block. He is on the pacemaker. He had a coarctation of the aorta and that was repaired when he was an infant. He was followed in our Cardiology Clinic here and has been doing well. However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up. He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal. Thus, his dad put him in the car and transported him here. He has been evaluated here. He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced. It was 2 a.m. when he woke, and again, he was brought here by private vehicle. He was well prior to going to bed. No cough, cold, runny nose, fever. No trauma has been noted.,PAST MEDICAL HISTORY:, Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:, He has no allergies.,IMMUNIZATIONS:, Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL: This is an awake, alert male, who appears to be in mild distress.,HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. His TMs are clear. His nares are clear. The mucous membranes are pink and moist. Throat is clear.,NECK: Supple without lymphadenopathy or masses. Trachea is midline.,LUNGS: Clear.,HEART: Shows bradycardia at 53. He has good distal pulses.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding, no rebound. No rashes are seen.,HOSPITAL COURSE:, Initial blood pressure is 164/90. He was moved in room 1. He was placed on nasal cannula. Pulse ox was 100%, which is normal. We placed him on a monitor. We did an EKG; it has not appear to be capturing his pacemaker at this time. Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker. Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation. As noted, he was transferred to room 1, placed on a monitor, pulse ox. An IV was placed. A standard blood work was sent. A chest x-ray was done showing normal heart size, lead appeared to be in placed. There was no evidence of pulmonary edema. His pacemaker did not appear to be capturing. We placed him on transthoracic leads. However, it is difficult to get good placement with these because of the area where his pacemaker was placed. The Medtronic technician initially turned off his defibrillation mode and turned down his sensor. However, we could not get our transthoracic pacer to capture his heart. When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s. The patient appeared to be in pain. We placed it back on a rate of 60 at that time. He has remained in sinus bradycardia, but no evidence of ectopic beats. No widening of his QRS complex. I spoke with Cardiology. Cardiology service has come in, has evaluated him at bedside with me. Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker. So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed. I accompanied the patient up to the ICU. He remained awake and alert. Initially, he was complaining of a lot of chest pain. Once the defibrillator was turned off, he had no more pain. He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal. Chem-20 was normal as well.,IMPRESSION: ,Complete heart block with pacemaker malfunction.,PLAN: ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient. I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.

history physical patient yearold history shone complex complete heart block pacemaker coarctation aorta repaired infant followed cardiology clinic well however last night sleeping states felt dream thunder dream woke felt defibrillator going continued feels like heart rate normal thus dad put car transported evaluated scar tissue one point internal pacemaker working properly replaced woke brought private vehicle well prior going bed cough cold runny nose fever trauma notedpast medical history shone complex pacemaker dependentmedications medications timeallergies allergiesimmunizations datesocial history lives parentsfamily history negativereview system twelve asked negative except noted abovephysical examinationgeneral awake alert male appears mild distressheent pupils equal round reactive light extraocular movements intact tms clear nares clear mucous membranes pink moist throat clearneck supple without lymphadenopathy masses trachea midlinelungs clearheart shows bradycardia good distal pulsesabdomen soft nontender positive bowel sounds guarding rebound rashes seenhospital course initial blood pressure moved room placed nasal cannula pulse ox normal placed monitor ekg appear capturing pacemaker time shortly patients arrival medtronic technician came worked pacemaker medtronic representative informed lead place recalled prone microfractures oversensing automatic defibrillation noted transferred room placed monitor pulse ox iv placed standard blood work sent chest xray done showing normal heart size lead appeared placed evidence pulmonary edema pacemaker appear capturing placed transthoracic leads however difficult get good placement area pacemaker placed medtronic technician initially turned defibrillation mode turned sensor however could get transthoracic pacer capture heart medtronic representative turned pacemaker heart rate seemed drop patient appeared pain placed back rate time remained sinus bradycardia evidence ectopic beats widening qrs complex spoke cardiology cardiology service come evaluated bedside turned transthoracic pacer seem picking heart rate still going medtronics internal pacemaker icu physician call dr x agreed taking young man icuan hour presentation icu ready bed accompanied patient icu remained awake alert initially complaining lot chest pain defibrillator turned pain transported pediatrics picu delivered stable conditionlaboratory data cbc normal chem normal wellimpression complete heart block pacemaker malfunctionplan admitted icutime seen critical care time outside billable procedures minutes patient note lead ekg done showing sinus bradycardia normal intervals otherwise

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY AND PHYSICAL: ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block. He is on the pacemaker. He had a coarctation of the aorta and that was repaired when he was an infant. He was followed in our Cardiology Clinic here and has been doing well. However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up. He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal. Thus, his dad put him in the car and transported him here. He has been evaluated here. He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced. It was 2 a.m. when he woke, and again, he was brought here by private vehicle. He was well prior to going to bed. No cough, cold, runny nose, fever. No trauma has been noted.,PAST MEDICAL HISTORY:, Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:, He has no allergies.,IMMUNIZATIONS:, Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL: This is an awake, alert male, who appears to be in mild distress.,HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. His TMs are clear. His nares are clear. The mucous membranes are pink and moist. Throat is clear.,NECK: Supple without lymphadenopathy or masses. Trachea is midline.,LUNGS: Clear.,HEART: Shows bradycardia at 53. He has good distal pulses.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding, no rebound. No rashes are seen.,HOSPITAL COURSE:, Initial blood pressure is 164/90. He was moved in room 1. He was placed on nasal cannula. Pulse ox was 100%, which is normal. We placed him on a monitor. We did an EKG; it has not appear to be capturing his pacemaker at this time. Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker. Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation. As noted, he was transferred to room 1, placed on a monitor, pulse ox. An IV was placed. A standard blood work was sent. A chest x-ray was done showing normal heart size, lead appeared to be in placed. There was no evidence of pulmonary edema. His pacemaker did not appear to be capturing. We placed him on transthoracic leads. However, it is difficult to get good placement with these because of the area where his pacemaker was placed. The Medtronic technician initially turned off his defibrillation mode and turned down his sensor. However, we could not get our transthoracic pacer to capture his heart. When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s. The patient appeared to be in pain. We placed it back on a rate of 60 at that time. He has remained in sinus bradycardia, but no evidence of ectopic beats. No widening of his QRS complex. I spoke with Cardiology. Cardiology service has come in, has evaluated him at bedside with me. Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker. So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed. I accompanied the patient up to the ICU. He remained awake and alert. Initially, he was complaining of a lot of chest pain. Once the defibrillator was turned off, he had no more pain. He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal. Chem-20 was normal as well.,IMPRESSION: ,Complete heart block with pacemaker malfunction.,PLAN: ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient. I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise. ### Response: Cardiovascular / Pulmonary, Emergency Room Reports

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation.

history reason consultation evaluation patient colon cancer screeninghistory present illness mr yearold gentleman referred colon cancer screening patient said occasionally gets loose stools medical problems past medical history patient serious medical problems denies hypertension diabetes problems take medicationspast surgical history surgery deviated nasal septum allergies known drug allergiessocial history smoke drinks occasionally last five yearsfamily history history colon cancer familyreview systems denies significant diarrhea sometimes gets loose stools occasionally constipation stools caliber changed blood stool mucus stool weight loss appetite good nausea vomiting difficulty swallowing occasional heartburnphysical examination patient alert oriented x vital signs weight pounds blood pressure pulse per minute respiratory rate heent negative neck supple thyromegaly cardiovascular heart sounds heard rhythm regular murmur lungs clear percussion auscultation abdomen soft nontender masses felt bowel sounds heard extremities free edemaimpression routine colorectal cancer screeningrecommendations colonoscopy explained procedure colonoscopy benefits risks particular risk perforation hemorrhage infection patient agreed proceed also explained patient conscious sedation agreed conscious sedation

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation. ### Response: Consult - History and Phy., Gastroenterology, Hematology - Oncology

HISTORY OF PRESENT ILLNESS: ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD. Unfortunately over the past few months he has returned to pipe smoking. At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy. COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click. Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES: ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7. Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol. The patient improved on this regimen. Chest x-ray did not show any CHF. The cortisone was tapered. The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES: ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. To follow up with me in the office in 4-5 days.

history present illness yearold male copd history bronchospasm presents day history increased cough respiratory secretions wheezings shortness breath seen office day admission noted dyspneic audible wheezing admitted acute asthmatic bronchitis superimposed upon longstanding copd unfortunately past months returned pipe smoking time admission denied fever diaphoresis nausea chest pain systemic symptomspast medical history status post artificial aortic valve implantation summer chronic coumadin therapy copd described history hypertension history elevated cholesterolphysical examination heart tones regular easily audible mechanical click breath sounds greatly diminished rales rhonchi lung fieldslaboratory studies sodium potassium bun creatinine hemoglobin hematocrit hospital course started intravenous antibiotics vigorous respiratory therapy intravenous solumedrol patient improved regimen chest xray show chf cortisone tapered patients oxygenation improved able discharged homedischarge diagnoses chronic obstructive pulmonary disease acute asthmatic bronchitiscomplications nonedischarge condition guardeddischarge plan prednisone mg times day days times day days one daily keflex mg times day resume preadmission medication given pneumococcal vaccination discharge follow office days

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD. Unfortunately over the past few months he has returned to pipe smoking. At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy. COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click. Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES: ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7. Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol. The patient improved on this regimen. Chest x-ray did not show any CHF. The cortisone was tapered. The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES: ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. To follow up with me in the office in 4-5 days. ### Response: Cardiovascular / Pulmonary, Discharge Summary

HISTORY OF PRESENT ILLNESS: ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form. Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56. Standing up blood pressure was 160/80 with a pulse rate of 56. His general exam and neurological exam were detailed on our H&P form. Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN: ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. He states this is more of a lightheaded type feeling. He did have a mild blood pressure drop here in the office. We are also concerned that bradycardia might be contributing to his feeling of lightheadedness. We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist.

history present illness patient comes today feeling lightheaded difficulty keeping balance denies spinning sensation past vertigo describes feeling lightheaded usually occurs position changes stands sitting position stands lying position tends ease sits totally resolve another minutes feels shaky weak lorazepam help sensation blood pressure lately dose metoprolol increased feel symptoms gotten worse since metoprolol increasedpast medical history detailed hp form positive elevated cholesterol diabetes glaucoma cataracts hypertension heart disease vertigo stroke may congestive heart failure cabg cataract removed right eyecurrent medications detailed hp formphysical examination blood pressure sitting pulse rate standing blood pressure pulse rate general exam neurological exam detailed hp form pertinent positives neurological exam decreased sensation left face left arm legimpression plan lightheaded exquisitely denies vertigo vertigo past states lightheaded type feeling mild blood pressure drop office also concerned bradycardia might contributing feeling lightheadedness going suggest gets holter monitor speak general practitioner well cardiologist regarding lightheaded feelingwe schedule holter monitor refer back cardiologist

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form. Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56. Standing up blood pressure was 160/80 with a pulse rate of 56. His general exam and neurological exam were detailed on our H&P form. Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN: ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. He states this is more of a lightheaded type feeling. He did have a mild blood pressure drop here in the office. We are also concerned that bradycardia might be contributing to his feeling of lightheadedness. We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist. ### Response: Consult - History and Phy., Neurology

HISTORY OF PRESENT ILLNESS: ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.,PAST MEDICAL HISTORY: ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES: ,The patient has no known drug allergies.,SOCIAL HISTORY: ,The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:, X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:, After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed.

history present illness patient yearold woman presenting clinic first time evaluation hip pain right greater left greater years duration patient states began right hip pain getting steadily worse last years developed pain left hip pain located laterally well anteriorly groin states pain present activities walking get painful popping clicking right hip evaluation first time sought previous medical attention thispast medical history significant depression reflux diseasepast surgical history cesarean section x current medications listed chart reviewed patientallergies patient known drug allergiessocial history patient married employed office manager smoke cigarettes one pack per day last years consumes alcohol drinks daily uses illicit drugs exercises monthly mainly walking low impact aerobics also likes play softballreview systems significant occasional indigestion nausea well anxiety depression remainder systems negativephysical examination patient foot inches tall weighs pounds patient ambulates independently without assist device normal stance gait inspection hips reveals normal contour appearance good symmetry patient able active straight leg raise gravity resistance bilaterally significant trochanteric tenderness however tenderness groin bilaterally crepitus present passive active range motion hips grossly neurologically intact bilateral lower extremitiesdiagnostic data xrays performed today clinic include ap view pelvis frogleg lateral right hip acute findings fractures dislocations minimal degenerative changes noted joint however suggestion exostosis superior femoral neck could consistent femoroacetabular impingementimpression bilateral hip pain right worse left possibly suggesting femoroacetabular impingement based xrays clinical picture also consistent possible labral tearplan discussing possible diagnoses patient recommended get mri arthrograms bilateral hips evaluate anatomy especially concentrating labrum right hip get done soon possible meantime asked moderate activities follow soon mris performed

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.,PAST MEDICAL HISTORY: ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES: ,The patient has no known drug allergies.,SOCIAL HISTORY: ,The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:, X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:, After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed. ### Response: Consult - History and Phy., Orthopedic

HISTORY OF PRESENT ILLNESS: ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007. The patient presents with no complaints for cadaveric renal transplant. After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:, Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:, Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS: ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA: ,General endotracheal.,SPECIMEN: ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room, prepped and draped in sterile fashion. After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space. After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat. Camper's and Scarpa's were dissected with electrocautery. Hemostasis was achieved throughout the tissue plains with electrocautery. The external oblique aponeurosis was identified with musculature and was entered with electrocautery. Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia. Additionally, the rectus sheath was entered in a linear fashion. After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection. After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery. Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties. After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane. This was done without any complication and without entering the peritoneum grossly. The round ligament was identified and doubly ligated at this time with #0 silk ties as well. The dissection continued down now to layer of the alveolar tissue covering the right iliac artery. This alveolar tissue was cleared using blunt dissection as well as electrocautery. After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture. The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection. After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well. An additional perforating branch was noted at the inferior pole of the right iliac vein. This was tied with a #0 silk tie and secured. Hemostasis was achieved at this time and the tie had adequate control. The dissection continued down and identified all other vital structures in this area. Careful preservation of all vital structures was carried out throughout the dissection. At this time, Satinsky clamp was placed over the right iliac vein. This was then opened using a #11 blade, approximately 1 cm in length. The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked. The renal vein was then elevated and identified in this area. A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured. The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles. The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles. After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again. After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over. The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow. The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney. The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow. At this time, all Satinsky clamps were removed and all bulldog clamps were removed. The dissection then continued down to the layer of the bladder at which time the bladder was identified. Appropriate area on the dome the bladder was identified for entry. This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion. Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length. At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well. Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder. This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again. Good flow was noted from the ureter at the time of operation. Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself. At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again. This was inspected and noted for proper control. Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects. At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time. The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved. A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior. This was secured and knots were dumped. Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl. The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable. Dr. A was present and scrubbed through the entire procedure.

history present illness patient yearold african american female past medical history significant hypertension endstage renal disease hemodialysis secondary endstage renal disease last hemodialysis june patient presents complaints cadaveric renal transplant appropriate cross match workup hla typing recipient cadaveric kidneys patient deemed appropriate operative intervention transplantation kidneypreoperative diagnosis endstage renal diseasepostoperative diagnosis endstage renal diseaseprocedure cadaveric renal transplant right pelvisestimated blood loss mlfluids one liter normal saline one liter albuminanesthesia general endotrachealspecimen nonedrain nonecomplications nonethe patient tolerated procedure without complicationprocedure detail patient brought operating room prepped draped sterile fashion adequate anesthesia achieved curvilinear incision made right pelvic fossa approximately cm length extending cm medial asis suprapubic space taken blade electrocautery used take tissue layer subcutaneous fat campers scarpas dissected electrocautery hemostasis achieved throughout tissue plains electrocautery external oblique aponeurosis identified musculature entered electrocautery hemostats entered dissection continued electrocautery external internal obliques transversalis fascia additionally rectus sheath entered linear fashion planes entered using electrocautery retroperitoneum dissected free transversalis fascia using blunt dissection peritoneum peritoneal structures moved medially superiorly blunt dissection dissection continued bluntly throughout tissue planes removing alveolar tissue right iliac artery upon entering transversalis fascia epigastric vessels identified doubly ligated tied silk ties ligation epigastric vessels peritoneum bluntly dissected peritoneal structures bluntly dissected superior medial plane done without complication without entering peritoneum grossly round ligament identified doubly ligated time silk ties well dissection continued layer alveolar tissue covering right iliac artery alveolar tissue cleared using blunt dissection well electrocautery external iliac artery identified cleared circumferentially way around noted good flow good arterial texture right iliac vein identified cleared using electrocautery blunt dissection right iliac vein identified cleared alveolar tissue circumferentially cleared well additional perforating branch noted inferior pole right iliac vein tied silk tie secured hemostasis achieved time tie adequate control dissection continued identified vital structures area careful preservation vital structures carried throughout dissection time satinsky clamp placed right iliac vein opened using blade approximately cm length heparinized saline placed irrigated throughout inside vein kidney pulled abdominal field still covered protective socking superior pole marked renal vein elevated identified area doubleended prolene stitch used secure renal vein superiorly inferiorly appropriately secured prolene tied secured renal vein anastomosed right iliac vein circumferential manner running fashion secured superior inferior poles dissection continued iliac artery anastomosed renal artery time using similar method prolene securing superior inferior poles time prolene run around circumferential manner secured superior inferior poles done artery secured satinsky clamp removed bulldog placed flow opened arterial side opened venous side allow proper flow bulldog placed back renal vein allowed hyperperfusion kidney kidney pinked nicely good appearance appearance good blood flow time satinsky clamps removed bulldog clamps removed dissection continued layer bladder time bladder identified appropriate area dome bladder identified entry entered using electrocautery approximately cm length appropriately sizing incising ureter using metzenbaum scissors linear fashion done chromic catgut stitches placed secured laterally inferiorly dome bladder elevate area bladder bladder entered using electrocautery approximately cm length time renal stent placed ureter secured superiorly stent placed bladder secured well subsequently superior inferior pole stitches prolene used secure ureter bladder run mucosatomucosa circumferential manner secured superior inferior poles good flow noted ureter time operation additional vicryl stitches used overlay musculature seromuscular stitch dome bladder ureter time ethibond stitch used make additional seromuscular closure rolling bladder musculature dome anastomosis inspected noted proper control irrigation bladder revealed bladder appropriately filled flows defects time anastomoses inspected hemostasis achieved good closure anastomosis noted time kidney placed back new position right pelvic fossa area inspected hemostasis achieved prolene stitch used mass closure external internal transversalis fascias musculature running fashion superior inferior secured knots dumped subsequently area checked inspected hemostasis achieved electrocautery skin closed running monocryl patient tolerated procedure well without evidence complication transferred dunn icu noted stable dr present scrubbed entire procedure

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007. The patient presents with no complaints for cadaveric renal transplant. After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:, Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:, Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS: ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA: ,General endotracheal.,SPECIMEN: ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room, prepped and draped in sterile fashion. After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space. After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat. Camper's and Scarpa's were dissected with electrocautery. Hemostasis was achieved throughout the tissue plains with electrocautery. The external oblique aponeurosis was identified with musculature and was entered with electrocautery. Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia. Additionally, the rectus sheath was entered in a linear fashion. After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection. After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery. Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties. After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane. This was done without any complication and without entering the peritoneum grossly. The round ligament was identified and doubly ligated at this time with #0 silk ties as well. The dissection continued down now to layer of the alveolar tissue covering the right iliac artery. This alveolar tissue was cleared using blunt dissection as well as electrocautery. After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture. The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection. After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well. An additional perforating branch was noted at the inferior pole of the right iliac vein. This was tied with a #0 silk tie and secured. Hemostasis was achieved at this time and the tie had adequate control. The dissection continued down and identified all other vital structures in this area. Careful preservation of all vital structures was carried out throughout the dissection. At this time, Satinsky clamp was placed over the right iliac vein. This was then opened using a #11 blade, approximately 1 cm in length. The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked. The renal vein was then elevated and identified in this area. A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured. The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles. The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles. After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again. After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over. The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow. The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney. The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow. At this time, all Satinsky clamps were removed and all bulldog clamps were removed. The dissection then continued down to the layer of the bladder at which time the bladder was identified. Appropriate area on the dome the bladder was identified for entry. This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion. Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length. At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well. Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder. This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again. Good flow was noted from the ureter at the time of operation. Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself. At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again. This was inspected and noted for proper control. Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects. At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time. The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved. A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior. This was secured and knots were dumped. Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl. The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable. Dr. A was present and scrubbed through the entire procedure. ### Response: Nephrology, Surgery

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

history present illness patient yearold righthanded gentleman presents evaluation right arm pain states little less year ago developed pain right arm intermittent persisted since time describes experiences dull pain upper outer arm occurs daily basis also experiences achy sensation right hand radiating fingers numbness paresthesias hand armhe year history neck pain sought medical attention problem developed ear pain eventually led undergoing mri cervical spine showed degenerative changes referred dr x treatment neck pain receiving epidural injections care dr x since asked symptom receiving injections states neck pain recent onset arm pain also taken several medrol dose packs caused blood sugars increase taking multiple pain medications pain interfere significantly quality life although constant nagging painpast medical history diabetes since also asthma hypertension hypercholesterolemiacurrent medications takes actoplus albuterol androgel astelin diovan dolgic plus aspirin mg fish oil lipitor lorazepam multivitamins nasacort pulmicort ranitidine singulair viagra zetia zyrtec uroxatral also uses lidoderm patches multiple eye drops creamsallergies states dyazide zithromax amoxicillin cause feel warm itchyfamily history father died breast cancer also diabetes strong family history diabetes mother sister diabetes unaware family members neurological disorderssocial history lives alone works full time human resources state maryland previously alcoholic quit also quit smoking cigarettes years smoking history illicit drug use denies iv drug use denies hiv risk factors states last hiv test two years agoreview systems intermittent chest discomfort chronic tinnitus urinary dribbling otherwise complete review systems obtained negative except mentioned documented handwritten notes todays visitphysical examinationvital signs hr rr general appearance patient well appearing acute distresscardiovascular regular rhythm without murmurs gallops rubs carotid bruitschest lungs clear auscultation bilaterallyskin rashes lesionsneurological examinationmental status speech fluent without dysarthria aphasia patient alert oriented name place date attention concentration registration recall fund knowledge intactcranial nerves pupils equal round reactive light accommodation optic discs normal visual fields full extraocular movements intact without nystagmus facial sensation normal facial jaw palate tongue weakness hearing grossly intact shoulder shrug fullmotor normal muscle bulk tone atrophy fasciculations action percussion myotonia paramyotonia manual muscle testing reveals mrc grade strength proximal distal muscles upper lower extremitiessensory sensation intact light touch pinprick temperature vibratory sensation joint position sense romberg absentcoordination dysmetria ataxia fingernosefinger heeltoshin testingdeep tendon reflexes deep tendon reflexes biceps triceps brachioradialis patellas ankles plantar reflexes flexor finger flexors hoffmans sign jaw jerkgait stance casual gait normal heel toe tandem walking normalradiologic data mri cervical spine personally reviewed film showed narrowing foramen right cc degenerative changes without central stenosisimpression patient yearold gentleman oneyear history right arm pain also longstanding history neck pain neurological examination normal mri shows degenerative changes believe symptoms probably referable neck however think severe enough undergo surgery point time perhaps another course physical therapy may helpful probably would recommend anymore invasive procedure spinal stimulator pain really minimal could still try treat neuropathic pain medicationsrecommendations scheduled return emg nerve conduction studies determine whether evidence nerve damage although think likelihood low gave prescription neurontin discussed side effects medication discuss case tomorrow spine conference see recommendations

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

HISTORY OF PRESENT ILLNESS: ,The patient is a 78-year-old woman here because of recently discovered microscopic hematuria. History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation. The patient has no new joint pains; however, she does have a history of chronic degenerative joint disease. She does not use nonsteroidal agents. She has had no gross hematuria and she has had no hemoptysis.,REVIEW OF SYSTEMS: , No chest pain or shortness of breath, no problem with revision. The patient has had decreased hearing for many years. She has no abdominal pain or nausea or vomiting. She has no anemia. She has noticed no swelling. She has no history of seizures.,PAST MEDICAL HISTORY: , Significant for hypertension and hyperlipidemia. There is no history of heart attack or stroke. She has had bilateral simple mastectomies done 35 years ago. She has also had one-third of her lung removed for carcinoma (probably an adeno CA related to a pneumonia.) She also had hysterectomy in the past.,SOCIAL HISTORY: , She is a widow. She does not smoke.,MEDICATIONS:,1. Dyazide one a day.,2. Pravachol 80 mg a day in the evening.,3. Vitamin E once a day.,4. One baby aspirin per day.,FAMILY HISTORY:, Unremarkable.,PHYSICAL EXAMINATION:, She looks younger than her stated age of 78 years. She was hard of hearing, but could read my lips. Respirations were 16. She was afebrile. Pulse was about 90 and regular. Her gait was normal. Blood pressure is 140/70 in her left arm seated. HEENT: She had arcus cornealis. The pupils were equal. The sclerae were not icteric. The conjunctivae were pink. NECK: The thyroid is not palpated. No nodes were palpated in the neck. CHEST: Clear to auscultation. She had no sacral edema. CARDIAC: Regular, but she was tachycardic at the rate of about 90. She had no diastolic murmur. ABDOMEN: Soft, and nontender. I did not palpate the liver. EXTREMITIES: She had no appreciable edema. She had no digital clubbing. She had no cyanosis. She had changes of the degenerative joint disease in her fingers. She had good pedal pulses. She had no twitching or myoclonic jerks.,LABORATORY DATA: , The urine, I saw 1-2 red cells per high power fields. She had no protein. She did have many squamous cells. The patient has creatinine of 1 mg percent and no proteinuria. It seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.,PLAN: , To obtain a routine sonogram. I would also repeat a routine urinalysis to check for blood again. I have ordered a C3 and C4 and if the repeat urine shows red cells, I will recommend a cystoscopy with a retrograde pyelogram.

history present illness patient yearold woman recently discovered microscopic hematuria history present illness occurs setting recent check demonstrated red cells red cell casts routine evaluation patient new joint pains however history chronic degenerative joint disease use nonsteroidal agents gross hematuria hemoptysisreview systems chest pain shortness breath problem revision patient decreased hearing many years abdominal pain nausea vomiting anemia noticed swelling history seizurespast medical history significant hypertension hyperlipidemia history heart attack stroke bilateral simple mastectomies done years ago also onethird lung removed carcinoma probably adeno ca related pneumonia also hysterectomy pastsocial history widow smokemedications dyazide one day pravachol mg day evening vitamin e day one baby aspirin per dayfamily history unremarkablephysical examination looks younger stated age years hard hearing could read lips respirations afebrile pulse regular gait normal blood pressure left arm seated heent arcus cornealis pupils equal sclerae icteric conjunctivae pink neck thyroid palpated nodes palpated neck chest clear auscultation sacral edema cardiac regular tachycardic rate diastolic murmur abdomen soft nontender palpate liver extremities appreciable edema digital clubbing cyanosis changes degenerative joint disease fingers good pedal pulses twitching myoclonic jerkslaboratory data urine saw red cells per high power fields protein many squamous cells patient creatinine mg percent proteinuria seems unlikely glomerular disease however cannot explain red cells urineplan obtain routine sonogram would also repeat routine urinalysis check blood ordered c c repeat urine shows red cells recommend cystoscopy retrograde pyelogram

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,The patient is a 78-year-old woman here because of recently discovered microscopic hematuria. History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation. The patient has no new joint pains; however, she does have a history of chronic degenerative joint disease. She does not use nonsteroidal agents. She has had no gross hematuria and she has had no hemoptysis.,REVIEW OF SYSTEMS: , No chest pain or shortness of breath, no problem with revision. The patient has had decreased hearing for many years. She has no abdominal pain or nausea or vomiting. She has no anemia. She has noticed no swelling. She has no history of seizures.,PAST MEDICAL HISTORY: , Significant for hypertension and hyperlipidemia. There is no history of heart attack or stroke. She has had bilateral simple mastectomies done 35 years ago. She has also had one-third of her lung removed for carcinoma (probably an adeno CA related to a pneumonia.) She also had hysterectomy in the past.,SOCIAL HISTORY: , She is a widow. She does not smoke.,MEDICATIONS:,1. Dyazide one a day.,2. Pravachol 80 mg a day in the evening.,3. Vitamin E once a day.,4. One baby aspirin per day.,FAMILY HISTORY:, Unremarkable.,PHYSICAL EXAMINATION:, She looks younger than her stated age of 78 years. She was hard of hearing, but could read my lips. Respirations were 16. She was afebrile. Pulse was about 90 and regular. Her gait was normal. Blood pressure is 140/70 in her left arm seated. HEENT: She had arcus cornealis. The pupils were equal. The sclerae were not icteric. The conjunctivae were pink. NECK: The thyroid is not palpated. No nodes were palpated in the neck. CHEST: Clear to auscultation. She had no sacral edema. CARDIAC: Regular, but she was tachycardic at the rate of about 90. She had no diastolic murmur. ABDOMEN: Soft, and nontender. I did not palpate the liver. EXTREMITIES: She had no appreciable edema. She had no digital clubbing. She had no cyanosis. She had changes of the degenerative joint disease in her fingers. She had good pedal pulses. She had no twitching or myoclonic jerks.,LABORATORY DATA: , The urine, I saw 1-2 red cells per high power fields. She had no protein. She did have many squamous cells. The patient has creatinine of 1 mg percent and no proteinuria. It seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.,PLAN: , To obtain a routine sonogram. I would also repeat a routine urinalysis to check for blood again. I have ordered a C3 and C4 and if the repeat urine shows red cells, I will recommend a cystoscopy with a retrograde pyelogram. ### Response: Nephrology

HISTORY OF PRESENT ILLNESS: ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker. His mother is 88, living and well, status post lung cancer resection. Two brothers, living and well. One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:, The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:, Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. There are mild hemorrhoids in the anal canal. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative.,IMPRESSION:,1. Comprehensive annual health maintenance examination.,2. Dyslipidemia.,3. Tinnitus, left ear.,4. Hemorrhoids.,PLAN:, At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Followup fasting lipid profile and ALT in 6 months.

history present illness yearold white male seen comprehensive annual health maintenance examination although patient excellent overall health medical problems include chronic tinnitus left ear moderate hearing loss many years without recent change dyslipidemia well controlled niacin history hemorrhoids occasional external bleeding although problems last months also history concha bullosa left nostril followed ent associated slight septal deviation medical problems symptoms time remains excellent healthpast medical history otherwise noncontributory operation serious illness injury noted aboveallergies known allergiesfamily history father died mi age copd heavy smoker mother living well status post lung cancer resection two brothers living well one sister died age months pneumoniasocial history patient married wife living well jogs cross country track times week weight training twice weekly smoking significant alcohol intake physician allergyimmunologyreview systems otherwise noncontributory gastrointestinal cardiopulmonary genitourinary musculoskeletal symptomatology symptoms described abovephysical examinationgeneral appears alert oriented acute distress excellent cognitive function vital signs height feet inches weight blood pressure right arm left arm pulse rate regular respirations skin warm dry pallor cyanosis icterus heent tympanic membranes benign pharynx benign nasal mucosa intact pupils round regular equal reacting equally light accommodation eom intact fundi reveal flat discs clear margins normal vasculature hemorrhages exudates microaneurysms thyroid enlargement lymphadenopathy lungs clear percussion auscultation normal sinus rhythm premature beat murmur heart sounds good quality intensity carotids femorals dorsalis pedis posterior tibial pulsations brisk equal active bilaterally abdomen benign without guarding rigidity tenderness mass organomegaly neurologic grossly intact extremities normal gu genitalia normal inguinal hernias mild hemorrhoids anal canal prostate small normal mildly enlarged discrete margins symmetrical without significant palpable abnormality rectal mass stool hemoccult negativeimpression comprehensive annual health maintenance examination dyslipidemia tinnitus left ear hemorrhoidsplan time continue niacin mg morning mg noon mg evening aspirin mg daily multivitamins vitamin e units daily vitamin c mg daily consider adding lycopene selenium flaxseed regimen appropriate labs obtained today followup fasting lipid profile alt months

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker. His mother is 88, living and well, status post lung cancer resection. Two brothers, living and well. One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:, The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:, Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. There are mild hemorrhoids in the anal canal. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative.,IMPRESSION:,1. Comprehensive annual health maintenance examination.,2. Dyslipidemia.,3. Tinnitus, left ear.,4. Hemorrhoids.,PLAN:, At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Followup fasting lipid profile and ALT in 6 months. ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago. Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then. Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could. He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime. He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments. He would have a limited support system here in Colorado. He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July. I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained. The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION: ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand. There is no thought disorder and no hallucination. He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:, There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms. Activities of daily living (ADLs) appear intact. On formal testing, he is oriented to place. He can give a reasonable recitation of his medical history. He is oriented to the year, knows it is the 15th, but gave the month as June instead of May. He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits. He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:, Sodium of 135, BUN of 24, and glucose 119. GGT of 355, ALT of 97, LDH of 703, and alk phos of 144. FK506 is 28.8, which is elevated tacrolimus level. Hematocrit 29% and white count is 7000.,DIAGNOSES: ,AXIS I:, Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS: ,1. This patient appears to retain the ability to make decisions on his own behalf. I think he is mentally competent. Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness. If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2. The patient does complain of depressed mood, also of anxiety. We did discuss medications. He appeared somewhat sedated at the time of my interview. I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety. I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this.

history present illness yearold married man onset aplastic anemia december underwent bone marrow transplant end march developed severe graftversushost reaction psychiatric consultation requested patient noncompliant treatment leave unit return requested unclear whether secondary confusion willful behaviorthe patient gives significant history behavioral problems late adolescence onset illness states lot trouble law convicted assault also arrested small amount cannabis states served one year incarcerated abcd two years ago gives ongoing history substance abuse one year ago went drug rehabilitation program discharged states clean sober since prior going rehabilitation using intravenous heroin couple times week since age would period five years reports heavy use cannabis smoking pot five times day could would drink half fifth rum daily basis availablethe patient currently lexapro mg morning diazepam mg bedtime complained depressive anxiety symptoms appear proportion medical issues individual frustrations treatments would limited support system colorado married january states marriage going particularly well young sick hospitalized helped relationship new wife apparently expecting child july would recommend couples counseling part treatment herethe patient fairly drowsy interview full past developmental history obtained patients comment grew parents separated lived mother dropped school eleventh grade time living xyz area like schoolphysical examination general cooperative man speech soft difficult understand thought disorder hallucination denies suicidal express times feelings giving treatments primarily complaints feeling treated like child confined hospitalvital signs temperature pulse respirations blood pressure oxygen saturation weight poundspsychiatry thought disorder paranoia delusions psychotic symptoms activities daily living adls appear intact formal testing oriented place give reasonable recitation medical history oriented year knows th gave month june instead may memorize four items repeats three four five minutes gives fourth category places shortterm memory normal limits serial three subtractions accurately name objects appropriatelylaboratory data sodium bun glucose ggt alt ldh alk phos fk elevated tacrolimus level hematocrit white count diagnoses axis depressive disorder secondary underlying medical condition graftversushost reactionaxis ii personality disorder otherwise specified nosaxis iii history polysubstance abuse remissionrecommendations patient appears retain ability make decisions behalf think mentally competent unfortunately impulsive low frustration personality dynamics fit well demands requirements treatment chronic illness patient refuses treatment understands consequences would likely hastened mortality state want die patient complain depressed mood also anxiety discuss medications appeared somewhat sedated time interview would recommend try seroquel mg twice daily asneeded basis see diminishes anxiety dr x followup himplease feel free contact digital pager additional information neededmy overall recommendation would patient random urine drug screening use cell phone goes unit called back treatments scheduled hopefully agreeable complying

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago. Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then. Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could. He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime. He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments. He would have a limited support system here in Colorado. He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July. I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained. The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION: ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand. There is no thought disorder and no hallucination. He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:, There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms. Activities of daily living (ADLs) appear intact. On formal testing, he is oriented to place. He can give a reasonable recitation of his medical history. He is oriented to the year, knows it is the 15th, but gave the month as June instead of May. He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits. He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:, Sodium of 135, BUN of 24, and glucose 119. GGT of 355, ALT of 97, LDH of 703, and alk phos of 144. FK506 is 28.8, which is elevated tacrolimus level. Hematocrit 29% and white count is 7000.,DIAGNOSES: ,AXIS I:, Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS: ,1. This patient appears to retain the ability to make decisions on his own behalf. I think he is mentally competent. Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness. If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2. The patient does complain of depressed mood, also of anxiety. We did discuss medications. He appeared somewhat sedated at the time of my interview. I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety. I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this. ### Response: Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. At the time of my exam, he states that his left lower extremity pain has improved considerably. He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably. He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure. He has multiple chronic history of previous ischemia of his large bowel in the past.,PHYSICAL EXAM,VITAL SIGNS: Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,HEENT: Unremarkable.,LUNGS: Clear.,CARDIOVASCULAR: An irregular rhythm.,ABDOMEN: Soft.,EXTREMITIES: His upper extremities are well perfused. He has palpable radial and femoral pulses. He does not have any palpable pedal pulses in either right or left lower extremity. He does have reasonable capillary refill in both feet. He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm. Apparently, this was lot worst few hours ago. He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,IMPRESSION AND PLAN: , This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent. He currently has a viable extremity and viable foot, but certainly has significant making compromised flow. It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention. He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime. Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization. We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate. Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity. We will follow him along closely.

history present illness yearold man presented emergency room multiple complaints including pain hernia question blood stool nausea vomiting also left lower extremity pain time exam states left lower extremity pain improved considerably apparently significant paresthesias past feels paresthesias improved considerably history multiple medical problems including atrial fibrillation coumadin currently subtherapeutic multiple cvas past peripheral vascular disease congestive heart failure multiple chronic history previous ischemia large bowel pastphysical examvital signs currently temperature pulse blood pressure heent unremarkablelungs clearcardiovascular irregular rhythmabdomen softextremities upper extremities well perfused palpable radial femoral pulses palpable pedal pulses either right left lower extremity reasonable capillary refill feet one second capillary refill right hand left lower extremities left foot perhaps little cool relatively warm apparently lot worst hours ago describes significant pain pallor feels improved certainly clinically point appear significantimpression plan gentleman history multiple comorbidities detailed sounds clinically like acute exacerbation chronic peripheral vascular disease essentially related spasm versus small clot may lysed extent currently viable extremity viable foot certainly significant making compromised flow unclear whether chronic acute whether candidate type intervention certainly would benefit angiogram better define anatomy anticoagulation meantime given potential history recent lower gi bleeding evaluated gi see whether candidate heparinization order angiogram next hours followup results better define anatomy determine whether interventions appropriate point pain relatively rapid capillary refill relatively normal motor function suggesting viable extremity follow along closely

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. At the time of my exam, he states that his left lower extremity pain has improved considerably. He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably. He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure. He has multiple chronic history of previous ischemia of his large bowel in the past.,PHYSICAL EXAM,VITAL SIGNS: Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,HEENT: Unremarkable.,LUNGS: Clear.,CARDIOVASCULAR: An irregular rhythm.,ABDOMEN: Soft.,EXTREMITIES: His upper extremities are well perfused. He has palpable radial and femoral pulses. He does not have any palpable pedal pulses in either right or left lower extremity. He does have reasonable capillary refill in both feet. He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm. Apparently, this was lot worst few hours ago. He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,IMPRESSION AND PLAN: , This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent. He currently has a viable extremity and viable foot, but certainly has significant making compromised flow. It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention. He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime. Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization. We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate. Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity. We will follow him along closely. ### Response: Consult - History and Phy., Emergency Room Reports, General Medicine

HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improvement of her symptoms. The nursing home did not do a voiding diary. She is accompanied by her power of attorney. No dysuria, gross hematuria, fever or chills. No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION: ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. This has not improved on VESIcare as well as Enablex. Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure. The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today. Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided. They will see Dr. X with a prior voiding diary, which is again discussed. All questions answered.,PLAN:, As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney. In the meantime, Sanctura prescription is provided, and voiding diaries are provided. All questions answered.

history present illness yearold female history stroke presents today followup frequency urgency urge incontinence progressively worsening previously vesicare improvement continues take enablex mg noted improvement symptoms nursing home voiding diary accompanied power attorney dysuria gross hematuria fever chills bowel issues use several depends dayrecent urodynamics april office revealed significant detrusor instability involuntary urinary incontinence low bladder volumes cystoscopy unremarkableimpression persistent frequency urgency patient history neurogenic bladder history stroke improved vesicare well enablex options discussedwe discussed options pelvic floor rehabilitation interstim dr x well invasive procedure patient power attorney would like proceed meeting dr x discuss interstim briefly reviewed today brochure provided today prior discussion nursing home extensive voiding diary one week enablex reveals improvement patient started ventura twice daily prescription provided see dr x prior voiding diary discussed questions answeredplan patient scheduled meet dr x discuss option interstim accompanied power attorney meantime sanctura prescription provided voiding diaries provided questions answered

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,This is a 55-year-old female with a history of stroke, who presents today for followup of frequency and urgency with urge incontinence. This has been progressively worsening, and previously on VESIcare with no improvement. She continues to take Enablex 50 mg and has not noted any improvement of her symptoms. The nursing home did not do a voiding diary. She is accompanied by her power of attorney. No dysuria, gross hematuria, fever or chills. No bowel issues and does use several Depends a day.,Recent urodynamics in April 2008, here in the office, revealed significant detrusor instability with involuntary urinary incontinence and low bladder volumes, and cystoscopy was unremarkable.,IMPRESSION: ,Persistent frequency and urgency, in a patient with a history of neurogenic bladder and history of stroke. This has not improved on VESIcare as well as Enablex. Options are discussed.,We discussed other options of pelvic floor rehabilitation, InterStim by Dr. X, as well as more invasive procedure. The patient and the power of attorney would like him to proceed with meeting Dr. X to discuss InterStim, which was briefly reviewed here today and brochure for this is provided today. Prior to discussion, the nursing home will do an extensive voiding diary for one week, while she is on Enablex, and if this reveals no improvement, the patient will be started on Ventura twice daily and prescription is provided. They will see Dr. X with a prior voiding diary, which is again discussed. All questions answered.,PLAN:, As above, the patient will be scheduled to meet with Dr. X to discuss option of InterStim, and will be accompanied by her power of attorney. In the meantime, Sanctura prescription is provided, and voiding diaries are provided. All questions answered. ### Response: SOAP / Chart / Progress Notes, Urology

HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now. The patient apparently had a little bit of dry heaves, but no actual vomiting. She had just finished eating dinner. No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries. She has a pacemaker. She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS: Very difficult to get from the patient herself. She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her. She initially stated that everything was wrong, but could not specify any specific complaints. Denies chest pain, back pain, or abdominal pain. Denies any extremity symptoms or complaints.,SOCIAL HISTORY: The patient is a nonsmoker. She is accompanied here with daughter who brought her over here. They were visiting the patient when this episode occurred.,MEDICATIONS: Please see list.,ALLERGIES: NONE.,PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air. GENERAL: The patient is an elderly frail looking little lady lying on the gurney. She is awake, alert, and not really wanted to answer most of the questions I asked her. She does have a tremor with her mouth, which the daughter states has been there for "many years". HEENT: Eye exam is unremarkable. Oral mucosa is still moist and well hydrated. Posterior pharynx is clear. NECK: Supple. LUNGS: Actually clear with good breath sounds. There are no wheezes, no rales, or rhonchi. Good air movement. CARDIAC: Without murmur. ABDOMEN: Soft. I do not elicit any tenderness. There is no abdominal distention. Bowel sounds are present in all quadrants. SKIN: Skin is without rash or petechiae. There is no cyanosis. EXTREMITIES: No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE: I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly. After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better. Family states she seems more calm. They do not want to pursue any further workup at this time.,IMPRESSION: ACUTE EPISODE OF AGITATION.,PLAN: At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode. The patient herself has good vital signs. She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient. Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC. She is discharged in stable condition.

history present illness yearold female brought family apparently complaining felt might poisoned care facility daughter accompanied patient states think anything actually wrong became extremely agitated thinks biggest problem patient right patient apparently little bit dry heaves actual vomiting finished eating dinner one else facility illpast medical history remarkable previous abdominal surgeries pacemaker history recent collarbone fracturereview systems difficult get patient seems deny significant pain discomfort really seems particularly intent letting know bothering initially stated everything wrong could specify specific complaints denies chest pain back pain abdominal pain denies extremity symptoms complaintssocial history patient nonsmoker accompanied daughter brought visiting patient episode occurredmedications please see listallergies nonephysical examination vital signs patient afebrile actually normal vital signs including normal pulse oximetry room air general patient elderly frail looking little lady lying gurney awake alert really wanted answer questions asked tremor mouth daughter states many years heent eye exam unremarkable oral mucosa still moist well hydrated posterior pharynx clear neck supple lungs actually clear good breath sounds wheezes rales rhonchi good air movement cardiac without murmur abdomen soft elicit tenderness abdominal distention bowel sounds present quadrants skin skin without rash petechiae cyanosis extremities evidence trauma extremitiesemergency department course long discussion family would like patient receive something agitation given mg ativan intramuscularly half hour came back talk patient family patient states feels better family states seems calm want pursue workup timeimpression acute episode agitationplan time reviewed patients records particularly enlightening could triggered episode patient good vital signs seem specific acute process going seemed feel comfortable ativan given small quantity given patient family daughter specifically want pursue workup point point think reasonable follow abc discharged stable condition

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now. The patient apparently had a little bit of dry heaves, but no actual vomiting. She had just finished eating dinner. No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries. She has a pacemaker. She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS: Very difficult to get from the patient herself. She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her. She initially stated that everything was wrong, but could not specify any specific complaints. Denies chest pain, back pain, or abdominal pain. Denies any extremity symptoms or complaints.,SOCIAL HISTORY: The patient is a nonsmoker. She is accompanied here with daughter who brought her over here. They were visiting the patient when this episode occurred.,MEDICATIONS: Please see list.,ALLERGIES: NONE.,PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air. GENERAL: The patient is an elderly frail looking little lady lying on the gurney. She is awake, alert, and not really wanted to answer most of the questions I asked her. She does have a tremor with her mouth, which the daughter states has been there for "many years". HEENT: Eye exam is unremarkable. Oral mucosa is still moist and well hydrated. Posterior pharynx is clear. NECK: Supple. LUNGS: Actually clear with good breath sounds. There are no wheezes, no rales, or rhonchi. Good air movement. CARDIAC: Without murmur. ABDOMEN: Soft. I do not elicit any tenderness. There is no abdominal distention. Bowel sounds are present in all quadrants. SKIN: Skin is without rash or petechiae. There is no cyanosis. EXTREMITIES: No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE: I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly. After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better. Family states she seems more calm. They do not want to pursue any further workup at this time.,IMPRESSION: ACUTE EPISODE OF AGITATION.,PLAN: At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode. The patient herself has good vital signs. She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient. Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC. She is discharged in stable condition. ### Response: Consult - History and Phy., Emergency Room Reports

HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. The patient, additionally, had a questionable pseudocyst in the tail of the pancreas. The patient underwent ERCP on 04/04/2007 with placement of a stent. This revealed a strictured pancreatic duct, as well as strictured bile duct. A 10-french x 9 cm stent was placed with good drainage. The next morning, the patient felt quite a bit more comfortable. He additionally had a modest drop in his bilirubin and other liver tests. Of note, the patient has been having quite a bit of nausea during his admission. This responded to Zofran. It did not, initially, respond well to Phenergan, though after stent placement, he was significantly more comfortable and had less nausea, and in fact, had better response to the Phenergan itself. At the time of discharge, the patient's white count was 9.4, hemoglobin 10.8, hematocrit 32 with a MCV of 79, platelet count of 585,000. His sodium was 132, potassium 4.1, chloride 95, CO2 27, BUN of 8 with a creatinine of 0.3. His bilirubin was 17.1, alk phos 273, AST 104, ALT 136, total protein 7.8 and albumin of 3.8. He was tolerating a regular diet. The patient had been on oral hypoglycemics as an outpatient, but in hospital, he was simply managed with an insulin sliding scale. The patient will be transferred back to Pelican Bay, under the care of Dr. X at the infirmary. He will be further managed for his diabetes there. The patient will additionally undergo potential end of life meetings. I discussed the potentials of chemotherapy with patient. Certainly, there are modest benefits, which can be obtained with chemotherapy in metastatic pancreatic cancer, though at some cost with morbidity. The patient will consider this and will discuss this further with Dr. X. ,DISCHARGE MEDICATIONS:,1. Phenergan 25 mg q.6. p.r.n.,2. Duragesic patch 100 mcg q.3.d.,3. Benadryl 25-50 mg p.o. q.i.d. for pruritus.,4. Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary.,5. The patient had initially been on enalapril here. His hypertension will be managed by Dr. X as well. ,PLAN: , The patient should return for repeat ERCP if there are signs of stent occlusion such as fever, increased bilirubin, worsening pain. In the meantime, he will be kept on a regular diet and activity per Dr. X.

history present illness patient yearold man abdominal pain since october last year associated pound weight loss developed jaundice epigastric pain admitted hospital thinslice ct scan performed revealed x x cm pancreatic mass involved lymph nodes ring enhancing lesions consistent liver metastases patient additionally questionable pseudocyst tail pancreas patient underwent ercp placement stent revealed strictured pancreatic duct well strictured bile duct french x cm stent placed good drainage next morning patient felt quite bit comfortable additionally modest drop bilirubin liver tests note patient quite bit nausea admission responded zofran initially respond well phenergan though stent placement significantly comfortable less nausea fact better response phenergan time discharge patients white count hemoglobin hematocrit mcv platelet count sodium potassium chloride co bun creatinine bilirubin alk phos ast alt total protein albumin tolerating regular diet patient oral hypoglycemics outpatient hospital simply managed insulin sliding scale patient transferred back pelican bay care dr x infirmary managed diabetes patient additionally undergo potential end life meetings discussed potentials chemotherapy patient certainly modest benefits obtained chemotherapy metastatic pancreatic cancer though cost morbidity patient consider discuss dr x discharge medications phenergan mg q prn duragesic patch mcg qd benadryl mg po qid pruritus sliding scale discontinued time discharge reinstituted arrival pelican bay infirmary patient initially enalapril hypertension managed dr x well plan patient return repeat ercp signs stent occlusion fever increased bilirubin worsening pain meantime kept regular diet activity per dr x

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. The patient, additionally, had a questionable pseudocyst in the tail of the pancreas. The patient underwent ERCP on 04/04/2007 with placement of a stent. This revealed a strictured pancreatic duct, as well as strictured bile duct. A 10-french x 9 cm stent was placed with good drainage. The next morning, the patient felt quite a bit more comfortable. He additionally had a modest drop in his bilirubin and other liver tests. Of note, the patient has been having quite a bit of nausea during his admission. This responded to Zofran. It did not, initially, respond well to Phenergan, though after stent placement, he was significantly more comfortable and had less nausea, and in fact, had better response to the Phenergan itself. At the time of discharge, the patient's white count was 9.4, hemoglobin 10.8, hematocrit 32 with a MCV of 79, platelet count of 585,000. His sodium was 132, potassium 4.1, chloride 95, CO2 27, BUN of 8 with a creatinine of 0.3. His bilirubin was 17.1, alk phos 273, AST 104, ALT 136, total protein 7.8 and albumin of 3.8. He was tolerating a regular diet. The patient had been on oral hypoglycemics as an outpatient, but in hospital, he was simply managed with an insulin sliding scale. The patient will be transferred back to Pelican Bay, under the care of Dr. X at the infirmary. He will be further managed for his diabetes there. The patient will additionally undergo potential end of life meetings. I discussed the potentials of chemotherapy with patient. Certainly, there are modest benefits, which can be obtained with chemotherapy in metastatic pancreatic cancer, though at some cost with morbidity. The patient will consider this and will discuss this further with Dr. X. ,DISCHARGE MEDICATIONS:,1. Phenergan 25 mg q.6. p.r.n.,2. Duragesic patch 100 mcg q.3.d.,3. Benadryl 25-50 mg p.o. q.i.d. for pruritus.,4. Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary.,5. The patient had initially been on enalapril here. His hypertension will be managed by Dr. X as well. ,PLAN: , The patient should return for repeat ERCP if there are signs of stent occlusion such as fever, increased bilirubin, worsening pain. In the meantime, he will be kept on a regular diet and activity per Dr. X. ### Response: Discharge Summary, Gastroenterology

HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She was followed by another rheumatologist. She says she has been off and on, on prednisone and Arava. The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone. She says she had been on prednisone for the last 6 to 9 months. She is on 5 mg a day. She recently had a left BKA and there was a question of infection, so it had to be debrided. I was consulted to see if her prednisone is to be continued. The patient denies any joint pains at the present time. She says when this started she had significant joint pains and was unable to walk. She had pain in the hands and feet. Currently, she has no pain in any of her joints.,REVIEW OF SYSTEMS: , Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,PAST MEDICAL HISTORY: , Significant for hypertension, peripheral vascular disease, and left BKA.,FAMILY HISTORY: ,Noncontributory.,SOCIAL HISTORY: , Denies tobacco, alcohol or illicit drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: BP 130/70, heart rate 80, and respiratory rate 14.,HEENT: EOMI. PERRLA.,NECK: Supple. No JVD. No lymphadenopathy.,CHEST: Clear to auscultation.,HEART: S1 and S2. No S3, no murmurs.,ABDOMEN: Soft and nontender. No organomegaly.,EXTREMITIES: No edema.,NEUROLOGIC: Deferred.,ARTICULAR: She has swelling of bilateral wrists, but no significant tenderness.,LABORATORY DATA:, Labs in chart was reviewed.,ASSESSMENT AND PLAN:, A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone. She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that. As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow. If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone. I would defer that to Dr. X. If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone. I discussed this at length with the patient and she is in full agreement with the plan. I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there.

history present illness yearold female seeing first time history rheumatoid arthritis last years followed another rheumatologist says prednisone arava rheumatologist per patient would want longterm medicine would give prednisone switch arava switch back prednisone says prednisone last months mg day recently left bka question infection debrided consulted see prednisone continued patient denies joint pains present time says started significant joint pains unable walk pain hands feet currently pain jointsreview systems denies photosensitivity oral nasal ulcer seizure psychosis skin rashespast medical history significant hypertension peripheral vascular disease left bkafamily history noncontributorysocial history denies tobacco alcohol illicit drugsphysical examinationvital signs bp heart rate respiratory rate heent eomi perrlaneck supple jvd lymphadenopathychest clear auscultationheart murmursabdomen soft nontender organomegalyextremities edemaneurologic deferredarticular swelling bilateral wrists significant tendernesslaboratory data labs chart reviewedassessment plan yearold female history rheumatoid arthritis longstanding prednisone dmard recently surgery followed probable infection hold pain decreased prednisone mg day starting tomorrow go back nursing home tomorrow couple weeks symptoms stay would discontinue prednisone would defer dr x flares point prednisone may restarted dmard eventually could stay prednisone discussed length patient full agreement plan explained discharged wishes could follow clinic goes back victoria see rheumatologist

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , A 71-year-old female who I am seeing for the first time. She has a history of rheumatoid arthritis for the last 6 years. She was followed by another rheumatologist. She says she has been off and on, on prednisone and Arava. The rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to Arava and then switch her back to prednisone. She says she had been on prednisone for the last 6 to 9 months. She is on 5 mg a day. She recently had a left BKA and there was a question of infection, so it had to be debrided. I was consulted to see if her prednisone is to be continued. The patient denies any joint pains at the present time. She says when this started she had significant joint pains and was unable to walk. She had pain in the hands and feet. Currently, she has no pain in any of her joints.,REVIEW OF SYSTEMS: , Denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,PAST MEDICAL HISTORY: , Significant for hypertension, peripheral vascular disease, and left BKA.,FAMILY HISTORY: ,Noncontributory.,SOCIAL HISTORY: , Denies tobacco, alcohol or illicit drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: BP 130/70, heart rate 80, and respiratory rate 14.,HEENT: EOMI. PERRLA.,NECK: Supple. No JVD. No lymphadenopathy.,CHEST: Clear to auscultation.,HEART: S1 and S2. No S3, no murmurs.,ABDOMEN: Soft and nontender. No organomegaly.,EXTREMITIES: No edema.,NEUROLOGIC: Deferred.,ARTICULAR: She has swelling of bilateral wrists, but no significant tenderness.,LABORATORY DATA:, Labs in chart was reviewed.,ASSESSMENT AND PLAN:, A 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone. She is not on DMARD, but as she recently had a surgery followed by a probable infection, I will hold off on that. As she has no pain, I have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow. If in a couple of weeks her symptoms stay the same, then I would discontinue the prednisone. I would defer that to Dr. X. If she flares up at that point, prednisone may have to be restarted with a DMARD, so that eventually she could stay off the prednisone. I discussed this at length with the patient and she is in full agreement with the plan. I explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to Victoria, then see her rheumatologist over there. ### Response: Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , Goes back to yesterday, the patient went out for dinner with her boyfriend. The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night. She was found down on the floor this morning, soiled her bowel movements. Paramedics were called and the patient was brought to the emergency room. The patient was in the emergency room noted to be in respiratory failure, was intubated. The patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure. The patient was started on vasopressors. The patient was started on IV fluids as well as IV antibiotic. The CT of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation. A General Surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure. The patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis. The patient was also noted to have acute rhabdomyolysis on the workup in the emergency room.,PAST MEDICAL HISTORY: ,Significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer.,PAST SURGICAL HISTORY: ,Significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy.,SOCIAL HISTORY: , She lives with her boyfriend. The patient has a history of heavy tobacco and alcohol abuse for many years.,FAMILY HISTORY: , Not available at this current time.,REVIEW OF SYSTEMS: , As mentioned above.,PHYSICAL EXAMINATION:,GENERAL: She is intubated, obtunded, gangrenous ears with gangrenous fingertips.,VITAL SIGNS: Blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator.,HEENT: Examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light. No oropharyngeal lesions noted.,NECK: Supple. No JVD, distention or carotid bruit. No lymphadenopathy.,LUNGS: Bilateral crackles and bruits.,ABDOMEN: Distended, unable to evaluate if this is tender. No hepatosplenomegaly. Bowel sounds are very hyperactive.,LOWER EXTREMITIES: Show no edema. Distal pulses are decreased.,OVERALL NEUROLOGICAL: Examination cannot be assessed.,LABORATORY DATA: , The database was available at this point of time. WBC count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration. PT INR is prolonged at 1.7 and aPTT is prolonged at 60. Sodium was 143, BUN of 36, and creatinine of 2.5. The patient's blood gas shows pH of 7.05, pO2 of 99.6, and pCO2 of 99.6. Bicarb is 16.5.,ASSESSMENT AND EVALUATION:,1. Septicemia with septic shock.,2. Metabolic acidosis.,3. Respiratory failure.,4. Anuria.,5. Acute renal failure.,The patient has no blood pressure at this point in time. The patient is on IV fluids. The patient is on vasopressors due to ventilator support, bronchodilators as well as IV antibiotics. Her overall prognosis is extremely poor. This was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from Iowa. The patient will be maintained on these supports at this point in time, but prognosis is poor.

history present illness goes back yesterday patient went dinner boyfriend patient coming home family members episodes diarrhea unclear many times patient diarrhea last night found floor morning soiled bowel movements paramedics called patient brought emergency room patient emergency room noted respiratory failure intubated patient septic shock metabolic acidosis blood pressure rapid heart rate acute renal failure patient started vasopressors patient started iv fluids well iv antibiotic ct abdomen showed ileus versus bowel distention without actual bowel obstruction perforation general surgery consultation called think patient surgical candidate needed acute surgical procedure patient underwent ultrasound abdomen show evidence cholecystitis cholelithiasis patient also noted acute rhabdomyolysis workup emergency roompast medical history significant history osteoporosis hypertension tobacco dependency anxiety neurosis depression peripheral arterial disease peripheral neuropathy history uterine cancerpast surgical history significant hysterectomy bilateral femoropopliteal bypass surgeries well left eye cataract surgery appendicectomysocial history lives boyfriend patient history heavy tobacco alcohol abuse many yearsfamily history available current timereview systems mentioned abovephysical examinationgeneral intubated obtunded gangrenous ears gangrenous fingertipsvital signs blood pressure absent heart rate per minute patient ventilatorheent examination shows head atraumatic pupils dilated sluggishly reacting light oropharyngeal lesions notedneck supple jvd distention carotid bruit lymphadenopathylungs bilateral crackles bruitsabdomen distended unable evaluate tender hepatosplenomegaly bowel sounds hyperactivelower extremities show edema distal pulses decreasedoverall neurological examination cannot assessedlaboratory data database available point time wbc count elevated left shift hemoglobin hematocrit consistent severe dehydration pt inr prolonged aptt prolonged sodium bun creatinine patients blood gas shows ph po pco bicarb assessment evaluation septicemia septic shock metabolic acidosis respiratory failure anuria acute renal failurethe patient blood pressure point time patient iv fluids patient vasopressors due ventilator support bronchodilators well iv antibiotics overall prognosis extremely poor discussed patients niece bedside become indicated daughter arrives plane right iowa patient maintained supports point time prognosis poor

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , Goes back to yesterday, the patient went out for dinner with her boyfriend. The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night. She was found down on the floor this morning, soiled her bowel movements. Paramedics were called and the patient was brought to the emergency room. The patient was in the emergency room noted to be in respiratory failure, was intubated. The patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure. The patient was started on vasopressors. The patient was started on IV fluids as well as IV antibiotic. The CT of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation. A General Surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure. The patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis. The patient was also noted to have acute rhabdomyolysis on the workup in the emergency room.,PAST MEDICAL HISTORY: ,Significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer.,PAST SURGICAL HISTORY: ,Significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy.,SOCIAL HISTORY: , She lives with her boyfriend. The patient has a history of heavy tobacco and alcohol abuse for many years.,FAMILY HISTORY: , Not available at this current time.,REVIEW OF SYSTEMS: , As mentioned above.,PHYSICAL EXAMINATION:,GENERAL: She is intubated, obtunded, gangrenous ears with gangrenous fingertips.,VITAL SIGNS: Blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator.,HEENT: Examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light. No oropharyngeal lesions noted.,NECK: Supple. No JVD, distention or carotid bruit. No lymphadenopathy.,LUNGS: Bilateral crackles and bruits.,ABDOMEN: Distended, unable to evaluate if this is tender. No hepatosplenomegaly. Bowel sounds are very hyperactive.,LOWER EXTREMITIES: Show no edema. Distal pulses are decreased.,OVERALL NEUROLOGICAL: Examination cannot be assessed.,LABORATORY DATA: , The database was available at this point of time. WBC count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration. PT INR is prolonged at 1.7 and aPTT is prolonged at 60. Sodium was 143, BUN of 36, and creatinine of 2.5. The patient's blood gas shows pH of 7.05, pO2 of 99.6, and pCO2 of 99.6. Bicarb is 16.5.,ASSESSMENT AND EVALUATION:,1. Septicemia with septic shock.,2. Metabolic acidosis.,3. Respiratory failure.,4. Anuria.,5. Acute renal failure.,The patient has no blood pressure at this point in time. The patient is on IV fluids. The patient is on vasopressors due to ventilator support, bronchodilators as well as IV antibiotics. Her overall prognosis is extremely poor. This was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from Iowa. The patient will be maintained on these supports at this point in time, but prognosis is poor. ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day. This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52. Dr. X was again consulted from the bedside. We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful. In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care. Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS: T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL: The patient is much more alert appearing than my last examination of approximately 3 weeks ago. He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES: Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR: Reveals an irregularly irregular rhythm.,LUNGS: Have diminished breath sounds but are clear anteriorly.,ABDOMEN: Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES: Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL: The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday. Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000. INR 1.4. Transaminases are continuing to trend upwards of SGOT 546, SGPT 256. Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1. Hypotension. I would aggressively try and fluid replete the patient giving him another liter of fluids. If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2. Increased transaminases. Presumably this is from increased congestion. This is certainly concerning. We will continue to follow this. Ultrasound of the liver was apparently negative.,3. Fever and elevated white count. The patient does have a history of pneumonia and empyema. We will continue current antibiotics per infectious disease and continue to follow the patient's white count. He is not exceptionally toxic appearing at this time. Indeed, he does look improved from my last examination.,4. Ventilatory-dependent respiratory failure. The patient has received a tracheostomy since my last examination. Vent management per PMA.,5. Hypokalemia. This has resolved. Continue supplementation.,6. Hypernatremia. This is improving somewhat. I am hoping that with increased fluids this will continue to do so.,7. Diabetes mellitus. Fingerstick blood glucoses are reviewed and are at target. We will continue current management. This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis. Total critical care time spent today 37 minutes.

history present illness hospitalist followup required continuing issues atrial flutter rapid ventricular response resistant treatment diltiazem amiodarone followed dr x cardiology day afternoon seeing patient nursing informs rate finally controlled esmolol systolic blood pressures dropped map dr x consulted bedside agreed try fluid boluses consider neosynephrine pressure support successful addition last hours extensive discussions held family questions answered nursing staff concerning patients possible move tahoe pacific longterm acute care issues requiring following today elevated transaminases continuing fever pneumonia resolving adult respiratory distress syndrome ventilatorydependent respiratory failure hypokalemia nonstelevation mi hypernatremia chronic obstructive pulmonary disease bph atrial flutter inferior vena cava filter diabetesphysical examinationvital signs tmax blood pressure point running smid map heart rate general patient much alert appearing last examination approximately weeks ago denies pain appears intact mentation apparent distresseyes pupils round reactive light anicteric external ocular motions intactcardiovascular reveals irregularly irregular rhythmlungs diminished breath sounds clear anteriorlyabdomen somewhat distended guarding rebound obvious tenderness palpationextremities show trace edema clubbing cyanosisneurological patient moving extremities without focal neurological deficitslaboratory data sodium yesterday potassium chloride bicarb bun creatinine yesterday hemoglobin hematocrit wbc platelets inr transaminases continuing trend upwards sgot sgpt also noted scant amount concentrated appearing urine bagimpression overall impressions continues critically ill yearold multiple medical problems probably still showing signs volume depletion hypotension atrial flutter difficult control rateplan hypotension would aggressively try fluid replete patient giving another liter fluids work discussed dr x start neosynephrine also continue aggressive fluid repletion think indications diminished concentrated urine may still fluids still required even pressure support started increased transaminases presumably increased congestion certainly concerning continue follow ultrasound liver apparently negative fever elevated white count patient history pneumonia empyema continue current antibiotics per infectious disease continue follow patients white count exceptionally toxic appearing time indeed look improved last examination ventilatorydependent respiratory failure patient received tracheostomy since last examination vent management per pma hypokalemia resolved continue supplementation hypernatremia improving somewhat hoping increased fluids continue diabetes mellitus fingerstick blood glucoses reviewed target continue current management critically ill patient multiorgan dysfunction signs worsening renal hepatic cardiovascular function extremely guarded prognosis total critical care time spent today minutes

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day. This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52. Dr. X was again consulted from the bedside. We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful. In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care. Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS: T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL: The patient is much more alert appearing than my last examination of approximately 3 weeks ago. He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES: Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR: Reveals an irregularly irregular rhythm.,LUNGS: Have diminished breath sounds but are clear anteriorly.,ABDOMEN: Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES: Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL: The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday. Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000. INR 1.4. Transaminases are continuing to trend upwards of SGOT 546, SGPT 256. Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1. Hypotension. I would aggressively try and fluid replete the patient giving him another liter of fluids. If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2. Increased transaminases. Presumably this is from increased congestion. This is certainly concerning. We will continue to follow this. Ultrasound of the liver was apparently negative.,3. Fever and elevated white count. The patient does have a history of pneumonia and empyema. We will continue current antibiotics per infectious disease and continue to follow the patient's white count. He is not exceptionally toxic appearing at this time. Indeed, he does look improved from my last examination.,4. Ventilatory-dependent respiratory failure. The patient has received a tracheostomy since my last examination. Vent management per PMA.,5. Hypokalemia. This has resolved. Continue supplementation.,6. Hypernatremia. This is improving somewhat. I am hoping that with increased fluids this will continue to do so.,7. Diabetes mellitus. Fingerstick blood glucoses are reviewed and are at target. We will continue current management. This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis. Total critical care time spent today 37 minutes. ### Response: Cardiovascular / Pulmonary, SOAP / Chart / Progress Notes

HISTORY OF PRESENT ILLNESS: , I have seen ABC today. He is a very pleasant gentleman who is 42 years old, 344 pounds. He is 5'9". He has a BMI of 51. He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260. He is pursuing surgical attempts of weight loss to feel good, get healthy, and begin to exercise again. He wants to be able to exercise and play volleyball. Physically, he is sluggish. He gets tired quickly. He does not go out often. When he loses weight he always regains it and he gains back more than he lost. His biggest weight loss is 25 pounds and it was three months before he gained it back. He did six months of not drinking alcohol and not taking in many calories. He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin's Diet for one month two years ago.,PAST MEDICAL HISTORY: , He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, difficulty walking, high cholesterol, and high blood pressure. He has asthma and difficulty walking two blocks or going eight to ten steps. He has sleep apnea and snoring. He is a diabetic, on medication. He has joint pain, knee pain, back pain, foot and ankle pain, leg and foot swelling. He has hemorrhoids.,PAST SURGICAL HISTORY: , Includes orthopedic or knee surgery.,SOCIAL HISTORY: , He is currently single. He drinks alcohol ten to twelve drinks a week, but does not drink five days a week and then will binge drink. He smokes one and a half pack a day for 15 years, but he has recently stopped smoking for the past two weeks.,FAMILY HISTORY: , Obesity, heart disease, and diabetes. Family history is negative for hypertension and stroke.,CURRENT MEDICATIONS:, Include Diovan, Crestor, and Tricor.,MISCELLANEOUS/EATING HISTORY: ,He says a couple of friends of his have had heart attacks and have had died. He used to drink everyday, but stopped two years ago. He now only drinks on weekends. He is on his second week of Chantix, which is a medication to come off smoking completely. Eating, he eats bad food. He is single. He eats things like bacon, eggs, and cheese, cheeseburgers, fast food, eats four times a day, seven in the morning, at noon, 9 p.m., and 2 a.m. He currently weighs 344 pounds and 5'9". His ideal body weight is 160 pounds. He is 184 pounds overweight. If he lost 70% of his excess body weight that would be 129 pounds and that would get him down to 215.,REVIEW OF SYSTEMS: , Negative for head, neck, heart, lungs, GI, GU, orthopedic, or skin. He also is positive for gout. He denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, pulmonary embolism, or CVA. He denies venous insufficiency or thrombophlebitis. Denies shortness of breath, COPD, or emphysema. Denies thyroid problems, hip pain, osteoarthritis, rheumatoid arthritis, GERD, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. He denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION: ,He is alert and oriented x 3. Cranial nerves II-XII are intact. Neck is soft and supple. Lungs: He has positive wheezing bilaterally. Heart is regular rhythm and rate. His abdomen is soft. Extremities: He has 1+ pitting edema.,IMPRESSION/PLAN:, I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding, infection, deep venous thrombosis, pulmonary embolism, leakage from the gastrojejuno-anastomosis, jejunojejuno-anastomosis, and possible bowel obstruction among other potential complications. He understands. He wants to proceed with workup and evaluation for laparoscopic Roux-en-Y gastric bypass. He will need to get a letter of approval from Dr. XYZ. He will need to see a nutritionist and mental health worker. He will need an upper endoscopy by either Dr. XYZ. He will need to go to Dr. XYZ as he previously had a sleep study. We will need another sleep study. He will need H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobin, and fasting blood sugar. After this is performed, we will submit him for insurance approval.

history present illness seen abc today pleasant gentleman years old pounds bmi overweight ten years since age highest pounds lowest pursuing surgical attempts weight loss feel good get healthy begin exercise wants able exercise play volleyball physically sluggish gets tired quickly go often loses weight always regains gains back lost biggest weight loss pounds three months gained back six months drinking alcohol taking many calories multiple commercial weight loss programs including slim fast one month one year ago atkins diet one month two years agopast medical history difficulty climbing stairs difficulty airline seats tying shoes used public seating difficulty walking high cholesterol high blood pressure asthma difficulty walking two blocks going eight ten steps sleep apnea snoring diabetic medication joint pain knee pain back pain foot ankle pain leg foot swelling hemorrhoidspast surgical history includes orthopedic knee surgerysocial history currently single drinks alcohol ten twelve drinks week drink five days week binge drink smokes one half pack day years recently stopped smoking past two weeksfamily history obesity heart disease diabetes family history negative hypertension strokecurrent medications include diovan crestor tricormiscellaneouseating history says couple friends heart attacks died used drink everyday stopped two years ago drinks weekends second week chantix medication come smoking completely eating eats bad food single eats things like bacon eggs cheese cheeseburgers fast food eats four times day seven morning noon pm currently weighs pounds ideal body weight pounds pounds overweight lost excess body weight would pounds would get review systems negative head neck heart lungs gi gu orthopedic skin also positive gout denies chest pain heart attack coronary artery disease congestive heart failure arrhythmia atrial fibrillation pacemaker pulmonary embolism cva denies venous insufficiency thrombophlebitis denies shortness breath copd emphysema denies thyroid problems hip pain osteoarthritis rheumatoid arthritis gerd hiatal hernia peptic ulcer disease gallstones infected gallbladder pancreatitis fatty liver hepatitis rectal bleeding polyps incontinence stool urinary stress incontinence cancer denies cellulitis pseudotumor cerebri meningitis encephalitisphysical examination alert oriented x cranial nerves iixii intact neck soft supple lungs positive wheezing bilaterally heart regular rhythm rate abdomen soft extremities pitting edemaimpressionplan explained risks potential complications laparoscopic gastric bypass detail include bleeding infection deep venous thrombosis pulmonary embolism leakage gastrojejunoanastomosis jejunojejunoanastomosis possible bowel obstruction among potential complications understands wants proceed workup evaluation laparoscopic rouxeny gastric bypass need get letter approval dr xyz need see nutritionist mental health worker need upper endoscopy either dr xyz need go dr xyz previously sleep study need another sleep study need h pylori testing thyroid function tests lfts glycosylated hemoglobin fasting blood sugar performed submit insurance approval

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , I have seen ABC today. He is a very pleasant gentleman who is 42 years old, 344 pounds. He is 5'9". He has a BMI of 51. He has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260. He is pursuing surgical attempts of weight loss to feel good, get healthy, and begin to exercise again. He wants to be able to exercise and play volleyball. Physically, he is sluggish. He gets tired quickly. He does not go out often. When he loses weight he always regains it and he gains back more than he lost. His biggest weight loss is 25 pounds and it was three months before he gained it back. He did six months of not drinking alcohol and not taking in many calories. He has been on multiple commercial weight loss programs including Slim Fast for one month one year ago and Atkin's Diet for one month two years ago.,PAST MEDICAL HISTORY: , He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, difficulty walking, high cholesterol, and high blood pressure. He has asthma and difficulty walking two blocks or going eight to ten steps. He has sleep apnea and snoring. He is a diabetic, on medication. He has joint pain, knee pain, back pain, foot and ankle pain, leg and foot swelling. He has hemorrhoids.,PAST SURGICAL HISTORY: , Includes orthopedic or knee surgery.,SOCIAL HISTORY: , He is currently single. He drinks alcohol ten to twelve drinks a week, but does not drink five days a week and then will binge drink. He smokes one and a half pack a day for 15 years, but he has recently stopped smoking for the past two weeks.,FAMILY HISTORY: , Obesity, heart disease, and diabetes. Family history is negative for hypertension and stroke.,CURRENT MEDICATIONS:, Include Diovan, Crestor, and Tricor.,MISCELLANEOUS/EATING HISTORY: ,He says a couple of friends of his have had heart attacks and have had died. He used to drink everyday, but stopped two years ago. He now only drinks on weekends. He is on his second week of Chantix, which is a medication to come off smoking completely. Eating, he eats bad food. He is single. He eats things like bacon, eggs, and cheese, cheeseburgers, fast food, eats four times a day, seven in the morning, at noon, 9 p.m., and 2 a.m. He currently weighs 344 pounds and 5'9". His ideal body weight is 160 pounds. He is 184 pounds overweight. If he lost 70% of his excess body weight that would be 129 pounds and that would get him down to 215.,REVIEW OF SYSTEMS: , Negative for head, neck, heart, lungs, GI, GU, orthopedic, or skin. He also is positive for gout. He denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, pulmonary embolism, or CVA. He denies venous insufficiency or thrombophlebitis. Denies shortness of breath, COPD, or emphysema. Denies thyroid problems, hip pain, osteoarthritis, rheumatoid arthritis, GERD, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. He denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION: ,He is alert and oriented x 3. Cranial nerves II-XII are intact. Neck is soft and supple. Lungs: He has positive wheezing bilaterally. Heart is regular rhythm and rate. His abdomen is soft. Extremities: He has 1+ pitting edema.,IMPRESSION/PLAN:, I have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding, infection, deep venous thrombosis, pulmonary embolism, leakage from the gastrojejuno-anastomosis, jejunojejuno-anastomosis, and possible bowel obstruction among other potential complications. He understands. He wants to proceed with workup and evaluation for laparoscopic Roux-en-Y gastric bypass. He will need to get a letter of approval from Dr. XYZ. He will need to see a nutritionist and mental health worker. He will need an upper endoscopy by either Dr. XYZ. He will need to go to Dr. XYZ as he previously had a sleep study. We will need another sleep study. He will need H. pylori testing, thyroid function tests, LFTs, glycosylated hemoglobin, and fasting blood sugar. After this is performed, we will submit him for insurance approval. ### Response: Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery. She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell. She suffered a right hip fracture and is being considered for right hip replacement. The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel. She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change. She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve. She also has had some presumed atrial arrhythmias that have not been sustained. She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY: ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia. Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:, As an outpatient:,1. Lanoxin 0.125 mg, 1/2 tablet once a day.,2. Tramadol 50 mg p.o. q.i.d. as needed.,3. Verapamil 240 mg once a day.,4. Bumex 2 mg once a day.,5. ProAir HFA.,6. Atrovent nebs b.i.d.,7. Pulmicort nebs b.i.d.,8. Nasacort 55 mcg, 2 sprays daily.,9. Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10. Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11. Aldactone 25 mg p.o. daily.,12. Theo-24 200 mg p.o., 2 in the morning.,13. Zocor 40 mg once a day.,14. Vitamin D 400 units twice daily.,15. Levoxyl 125 mcg once a day.,16. Trazodone 50 mg p.o. q.h.s. p.r.n.,17. Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1. LEVAQUIN.,2. AZITHROMYCIN.,3. ADHESIVE TAPE.,4. BETA BLOCKERS. When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY: ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY: ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery. She does not drink alcohol nor use illicit drugs. She lives alone and is widowed. She is a retired custodian at University. Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS: ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%. On general exam, she is an elderly, chronically ill appearing woman in no acute distress. She is able to lie flat, she does have pain if she moves. HEENT shows the cranium is normocephalic, atraumatic. She has dry mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin is warm and she appears pale. Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately. Lungs are clear to auscultation anteriorly, no wheezes. Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region. No rub nor gallop. PMI is nondisplaced, unable to appreciate RV heave. Abdomen soft, mildly distended, appears benign. Extremities with trivial peripheral edema. Pulses grossly intact. She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA: ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04. Theophylline level 16.6 on January 23, 2009. TSH 0.86 on March 10, 2009. INR 1.06. White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes. When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen. This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered. I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today. There are no clear absolute cardiac contraindications that I can see. Of note at the time of this dictation a chest x-ray report is pending. With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint. We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences. The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1. The patient is going to decide on surgery. If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2. Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3. Continue digoxin and verapamil. Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.

history present illness kindly asked see ms abc dr x cardiology consultation regarding preoperative evaluation right hip surgery patient history coronary artery disease status post bypass surgery tripped oxygen last pm states fell suffered right hip fracture considered right hip replacement patient denies recent angina noted prominent shortness breathpast cardiac history significant coronary artery disease status post bypass surgery states believe single vessel stress test done office september shows evidence small apical infarct area ischemia compared study december significant change transthoracic echocardiogram done office august showed normal left ventricular size systolic function dilated right ventricle septal flattening left ventricle consistent right ventricular pressure overload left atrial enlargement severe tricuspid regurgitation estimated pa systolic pressure mmhg consistent severe pulmonary hypertension structurally normal aortic mitral valve also presumed atrial arrhythmias sustained follows dr partner cardiology associatespast medical history medical history includes severe copd oxygen dependent severe pulmonary hypertension diabetes abdominal aortic aneurysm hypertension dyslipidemia last ultrasound abdominal aorta done june states fusiform infrarenal shaped aneurysm distal abdominal aorta measuring cm unchanged prior study june medications outpatient lanoxin mg tablet day tramadol mg po qid needed verapamil mg day bumex mg day proair hfa atrovent nebs bid pulmicort nebs bid nasacort mcg sprays daily quinine sulfate mg po qhs prn meclizine mg po tid prn aldactone mg po daily theo mg po morning zocor mg day vitamin units twice daily levoxyl mcg day trazodone mg po qhs prn janumet tablet po bidallergies medications listed levaquin azithromycin adhesive tape beta blockers talked patient beta blocker states made short breath pastshe denies shrimp seafood dye allergyfamily history significant heart problems states mother fathersocial history used smoke cigarettes smoked age quit time bypass surgery drink alcohol use illicit drugs lives alone widowed retired custodian university note accompanied verbal consent daughter grandson bedsidereview systems unable obtain patient somnolent pain medication alert able answer direct questionsphysical exam height weight pounds temperature degrees ranging blood pressure pulse respiratory rate saturation general exam elderly chronically ill appearing woman acute distress able lie flat pain moves heent shows cranium normocephalic atraumatic dry mucosal membranes neck veins distended carotid bruits visible skin warm appears pale affect appropriate somnolent pain medications arouses easily answers direct questions appropriately lungs clear auscultation anteriorly wheezes cardiac exam regular rate soft holosystolic murmur heard tricuspid region rub gallop pmi nondisplaced unable appreciate rv heave abdomen soft mildly distended appears benign extremities trivial peripheral edema pulses grossly intact quite bit pain right hip fracturediagnosticlaboratory data sodium potassium chloride bicarbonate bun creatinine glucose troponin followed theophylline level january tsh march inr white blood cell count hematocrit platelet count ekg done july shows sinus rhythm showed pr interval milliseconds nonspecific wave changes compared ekg done july previously frequent pvcs seen ecg appears similar ones done previously office including june although wave changes bit prominent nonspecific findingimpression yearold woman severe requiring chronic obstructive pulmonary disease evidence right heart overload well known coronary artery disease status post singlevalve bypass suffering right hip fracture right hip replacement considered long discussion patient well daughter grandson bedside today clear absolute cardiac contraindications see note time dictation chest xray report pending said however extremely high risk pulmonary cardiac standpoint also however review untreated hip fractures high morbidity mortality incidences patient deciding surgery clearly aware high risk proposed surgery well pursue surgeryplanrecommendations patient going decide surgery right hip surgery would recommend overnight observation intensive care unit optimize pulmonary function pursue aggressive dvt prophylaxis continue digoxin verapamil patient describes clear intolerance beta blockers history

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery. She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell. She suffered a right hip fracture and is being considered for right hip replacement. The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel. She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change. She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve. She also has had some presumed atrial arrhythmias that have not been sustained. She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY: ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia. Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:, As an outpatient:,1. Lanoxin 0.125 mg, 1/2 tablet once a day.,2. Tramadol 50 mg p.o. q.i.d. as needed.,3. Verapamil 240 mg once a day.,4. Bumex 2 mg once a day.,5. ProAir HFA.,6. Atrovent nebs b.i.d.,7. Pulmicort nebs b.i.d.,8. Nasacort 55 mcg, 2 sprays daily.,9. Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10. Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11. Aldactone 25 mg p.o. daily.,12. Theo-24 200 mg p.o., 2 in the morning.,13. Zocor 40 mg once a day.,14. Vitamin D 400 units twice daily.,15. Levoxyl 125 mcg once a day.,16. Trazodone 50 mg p.o. q.h.s. p.r.n.,17. Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1. LEVAQUIN.,2. AZITHROMYCIN.,3. ADHESIVE TAPE.,4. BETA BLOCKERS. When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY: ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY: ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery. She does not drink alcohol nor use illicit drugs. She lives alone and is widowed. She is a retired custodian at University. Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS: ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%. On general exam, she is an elderly, chronically ill appearing woman in no acute distress. She is able to lie flat, she does have pain if she moves. HEENT shows the cranium is normocephalic, atraumatic. She has dry mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin is warm and she appears pale. Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately. Lungs are clear to auscultation anteriorly, no wheezes. Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region. No rub nor gallop. PMI is nondisplaced, unable to appreciate RV heave. Abdomen soft, mildly distended, appears benign. Extremities with trivial peripheral edema. Pulses grossly intact. She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA: ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04. Theophylline level 16.6 on January 23, 2009. TSH 0.86 on March 10, 2009. INR 1.06. White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes. When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen. This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered. I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today. There are no clear absolute cardiac contraindications that I can see. Of note at the time of this dictation a chest x-ray report is pending. With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint. We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences. The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1. The patient is going to decide on surgery. If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2. Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3. Continue digoxin and verapamil. Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology. Please see also my cardiovascular consultation dictated separately. But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent. I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear. The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction. The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself. She received 20 cc of viscous lidocaine for topical oral anesthetic effect. She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect. The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition. This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout. She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function. LVEF of 60%. Mild left atrial enlargement. Normal right atrial size. Normal right ventricular size and systolic function. No left ventricular wall motion abnormalities identified. The four pulmonary veins are identified. The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage. No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves. The mitral valve is seen. There is mild mitral regurgitation with two jets. No mitral stenosis. Four pulmonary veins were identified without reversible pulmonary venous flow. There are three cusps of the aortic valve seen. No aortic stenosis. There is trace aortic insufficiency. There is trace pulmonic insufficiency. The pulmonary artery is seen and is within normal limits. There is trace to mild tricuspid regurgitation. Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study. E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds. The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm. The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits. The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale. No pericardial effusion. There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1. Normal left ventricular size and systolic function. Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2. Mild left atrial enlargement.,3. Intracardiac thrombus identified at the base of the left atrial appendage.,4. Mild mitral regurgitation with two jets.,5. Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.

history present illness kindly asked see patient transesophageal echocardiogram performance dr neurology please see also cardiovascular consultation dictated separately essentially pleasant yearold woman admitted hospital large right mca cva causing leftsided neurological deficit incidentally found atrial fibrillation telemetry recommended transesophageal echocardiogram cardioembolic source cns insulti discussed procedure detail patient well daughter present patients bedside patients verbal consent performed riskbenefitalternative analysis benefits definitive exclusion intracardiac thrombus well assessment intracardiac shunts alternatives transthoracic echo imaging already inherent false negativity indication well empiric medical management patient interested risks including limited patient aware allinclusive list oversedation conscious sedation risk aspiration pneumonia regurgitation stomach contents risk oropharyngeal esophageal oral tracheal pulmonary andor gastric perforation hemorrhage tear patient expressed understanding riskbenefitalternative analysis opportunity ask questions invited daughter answered selfstated satisfaction patient stated clear competent coherent fashion wished go forward transesophageal echocardiogramprocedure appropriate timeout procedure performed per medical center protocol direct supervision appropriate identification patient position physician procedure documentation safety issues identified staff received cc viscous lidocaine topical oral anesthetic effect received total mg versed micrograms fentanyl utilizing titrated conscious sedation continuous hemodynamic oximetric monitoring reasonable effect multiplane probe passed using digital guidance several passes oral bite block put place protection oral dentition placed posterior oropharynx advanced esophagus advanced stomach rotated withdrawn removed adequate imaging obtained throughout recovered per medical center conscious sedation protocol apparent complications procedurefindings normal left ventricular size systolic function lvef mild left atrial enlargement normal right atrial size normal right ventricular size systolic function left ventricular wall motion abnormalities identified four pulmonary veins identified left atrial appendage interrogated including doppler color flow good toandfro motion seen echo smoke seen fact intracardiac thrombus identified circumscribed cm circumference base left atrial appendage intracardiac vegetations endocarditis seen intracardiac valves mitral valve seen mild mitral regurgitation two jets mitral stenosis four pulmonary veins identified without reversible pulmonary venous flow three cusps aortic valve seen aortic stenosis trace aortic insufficiency trace pulmonic insufficiency pulmonary artery seen within normal limits trace mild tricuspid regurgitation unable estimate pa systolic pressure accurately however recent transthoracic echocardiogram would direct reader january rvsp calculated mmhg study e wave velocity average msec deceleration time milliseconds proximal aorta within normal limits annulus cm sinuses valsalva cm ascending aorta cm intraatrial septum identified svc ivc within normal limits intraatrial septum interrogated color flow well agitated dw evidence intracardiac shunting including atrial septal defect patent foramen ovale pericardial effusion mild nonmobile descending aortic atherosclerosis seenimpression normal left ventricular size systolic function left ventricular ejection fraction visually estimated without regional wall motion abnormalities mild left atrial enlargement intracardiac thrombus identified base left atrial appendage mild mitral regurgitation two jets mild nonmobile descending aortic atherosclerosiscompared transthoracic echocardiogram done previously identification intracardiac thrombus findings appear quite similarthese results discussed dr inpatient internal medicine service well patient recovering conscious sedation daughter patients verbal consent

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology. Please see also my cardiovascular consultation dictated separately. But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent. I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear. The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction. The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself. She received 20 cc of viscous lidocaine for topical oral anesthetic effect. She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect. The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition. This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout. She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function. LVEF of 60%. Mild left atrial enlargement. Normal right atrial size. Normal right ventricular size and systolic function. No left ventricular wall motion abnormalities identified. The four pulmonary veins are identified. The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage. No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves. The mitral valve is seen. There is mild mitral regurgitation with two jets. No mitral stenosis. Four pulmonary veins were identified without reversible pulmonary venous flow. There are three cusps of the aortic valve seen. No aortic stenosis. There is trace aortic insufficiency. There is trace pulmonic insufficiency. The pulmonary artery is seen and is within normal limits. There is trace to mild tricuspid regurgitation. Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study. E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds. The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm. The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits. The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale. No pericardial effusion. There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1. Normal left ventricular size and systolic function. Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2. Mild left atrial enlargement.,3. Intracardiac thrombus identified at the base of the left atrial appendage.,4. Mild mitral regurgitation with two jets.,5. Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent. ### Response: Cardiovascular / Pulmonary, Radiology

HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities. He is also an ex-smoker. He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. ,PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us. His pulse is 78, temperature is 97.5, blood pressure is 132/74. Lungs are clear. He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size. Abdomen is soft, nontender. No incisions. No umbilical hernia, no groin hernia, has a large abdominal pannus. No hepatosplenomegaly. Lower extremities; no pedal edema. No calf tenderness. Deep tendon reflexes are normal. Lungs are clear. S1, S2 is heard. Regular rate and rhythm. ,DISCUSSION:, I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines. I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,All these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient. The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities. Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk. He will be seen by cardiologist, pulmonologist. He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities. He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox. He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so. All these were discussed with the patient. The patient understands. He wants to go to surgery. All questions were answered. I will see him in few weeks before the planned date of surgery.

history present illness short patient yearold gentleman longstanding morbid obesity resistant nonsurgical methods weight loss bmi comorbidities hypertension atrial fibrillation hyperlipidemia possible sleep apnea also osteoarthritis lower extremities also exsmoker currently smoking planning quit least six eight days multiple reasons including decreasing dvt pe rates marginal ulcer problems surgery discussed later physical examination physical examination today weighs pounds gained pounds since last visit us pulse temperature blood pressure lungs clear pleasant gentleman stigmata supermorbid obesity expected size abdomen soft nontender incisions umbilical hernia groin hernia large abdominal pannus hepatosplenomegaly lower extremities pedal edema calf tenderness deep tendon reflexes normal lungs clear heard regular rate rhythm discussion long talk patient laparoscopic gastric bypass possible open including risks benefits alternatives need longterm followup need adhere dietary exercise guidelines also explained complications including rare cases death secondary dvt pe leak peritonitis sepsis shock multisystem organ failure need reoperations need endoscopy bleeding leak operations could diagnostic laparoscopy exploratory laparotomy drainage procedure gastrostomy jejunostomy feeding bleeding requiring blood transfusion myocardial infarction pneumonia atelectasis respiratory failure requiring mechanical ventilation rarely tracheostomy rare cases renal failure requiring dialysis etc discussed going high risk patient secondary supermorbid obese condition also explained specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation marginal ulcer secondary smoking antiinflammatory drug intake progress perforation bleeding small bowel obstruction secondary internal hernia adhesions signs symptoms described patient could alert us earlier intervention symptomatic gallstone formation rapid weight loss avoid taking ursodiol prescribed postoperative period longterm complication gastric bypass including hair loss excess skin multivitamin mineral deficiencies proteincalorie malnutrition weight regain weight plateauing psychosocial marital issues addiction transfer etc discussed patient patient higher risk usual set patients secondary supermorbid obesity bmi nearing also major cardiopulmonary metabolic comorbidities smoking course help increase risk cardiopulmonary complications increased risk cardiac risk seen cardiologist pulmonologist also undergo long medifast dieting guidance lowcalorie diet decrease size liver also optimize cardiopulmonary metabolic comorbidities also see psychologist nutritionist exercise physiologist preparation surgery multidisciplinary approach short longterm success especially view restricted mobility supermorbid obesity status possibility pulmonary hypertension secondary sleep apnea advised retrievable ivc filter also go home lovenox also needs start exercising increase flexibility muscle tone surgery also start getting habit discussed patient patient understands wants go surgery questions answered see weeks planned date surgery

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities. He is also an ex-smoker. He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. ,PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us. His pulse is 78, temperature is 97.5, blood pressure is 132/74. Lungs are clear. He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size. Abdomen is soft, nontender. No incisions. No umbilical hernia, no groin hernia, has a large abdominal pannus. No hepatosplenomegaly. Lower extremities; no pedal edema. No calf tenderness. Deep tendon reflexes are normal. Lungs are clear. S1, S2 is heard. Regular rate and rhythm. ,DISCUSSION:, I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines. I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,All these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient. The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities. Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk. He will be seen by cardiologist, pulmonologist. He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities. He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox. He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so. All these were discussed with the patient. The patient understands. He wants to go to surgery. All questions were answered. I will see him in few weeks before the planned date of surgery. ### Response: Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged. He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here. Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide. He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia. Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1. Atenolol 25 mg once a day.,2. Altace 2.5 mg once a day.,3. Zocor 20 mg once a day.,4. Flecainide 200 in the morning and 100 in the evening.,5. Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE. HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well. The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine. No use of illicit drugs. He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife. He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish. He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi. There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18. On general exam, he is a pleasant overweight gentleman, in no acute distress. HEENT: Shows cranium is normocephalic and atraumatic. He has moist mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin warm and perfused. Affect appropriate. He is quite oriented and pleasant. No significant kyphoscoliosis on recumbent back exam. Lungs are clear to auscultation anteriorly. No wheezes. No egophony. Cardiac Exam: S1, S2. Regular rate, controlled. No significant murmurs, rubs or gallops. PMI is nondisplaced. Abdomen is soft, nondistended, appears benign. Extremities without significant edema. Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:, Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so. I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of. After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null. The patient expressed understanding of this risk, benefit, and alternative analysis. I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE: ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions. The patient did actively participate in this time-out procedure. After the universal protocol was done, he then received the cardioversion attempt with 50 joules using "lollipop posterior patch" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy. There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22. We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed. I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself. Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.

history present illness mr yearold gentleman history atrial fibrillation past recently atrial flutter estimates six cardioversions since estimates life beginning atrial fibrillation first emerged since pm noted recurrence atrial fibrillation called office morning despite flecainide atenolol maintained coumadinthe patient noted lightheadedness well chest discomfort shortness breath atrial flutter recurred see lead ekg otherwise chest painpast medical history significant atrial fibrillationatrial flutter atrial fibrillation persistently recently atrial flutter despite use antiarrhythmics including flecainide completed stress test office within past several weeks normal without evidence ischemia medical history significant hyperlipidemiamedicationsas outpatient atenolol mg day altace mg day zocor mg day flecainide morning evening coumadin directed officeallergies medications none denies shrimp sea food dye allergyfamily history nephew sisters son passed away age reportedly mi reported hypertrophic cardiomyopathy well patient previously met electrophysiologist dr x general hospital sounds like negative ep studysocial history patient smoke cigarettes abuse alcohol drink caffeine use illicit drugs married years actually accompanied throughout todays cardiology consultation wife participating regular exercises states since starting flecainide gotten sluggish employed attorney states overall mental stress better noted recent mental stress past weekend taking daughter back collegereview systems denies history stroke cancer vomiting blood coughing blood bright red blood per rectum bleeding stomach ulcers renal calculi questions especially wife told may obstructive sleep apnea formal sleep studyphysical exam blood pressure pulse respiratory rate general exam pleasant overweight gentleman acute distress heent shows cranium normocephalic atraumatic moist mucosal membranes neck veins distended carotid bruits visible skin warm perfused affect appropriate quite oriented pleasant significant kyphoscoliosis recumbent back exam lungs clear auscultation anteriorly wheezes egophony cardiac exam regular rate controlled significant murmurs rubs gallops pmi nondisplaced abdomen soft nondistended appears benign extremities without significant edema pulses grossly intactdiagnostic studieslab data initial ecg shows atrial flutterimpression mr yearold gentleman history paroxysmal atrial fibrillation past recently breakthrough atrial flutter despite flecainide performed transesophageal echocardiogramguided cardioversion late another recurrence within past hours reviewed detail regarding risks benefits alternatives proceeding cardioversion patient favor depth explanation procedure would definitive resumption normal sinus rhythm using electrocardioversion less longterm side effects past acute procedure alternatives continued atrial flutter potential electrophysiologic consultation ablation andor heart rate control anticoagulation patient interested primarily recommending next step risks including limited patient aware done presence wife allinclusive list risks include limited oversedation conscious sedation risk aspiration pneumonia regurgitation stomach contents would less likely confirm patient npo greater hours risk induction arrhythmias including tachyarrhythmias requiring management including cardioversion risk bradyarrhythmias past cardioverter joules second pause especially antiarrhythmic therapy statistically less significant risk cva although cannot really make null patient expressed understanding risk benefit alternative analysis invited questions wife questions answered selfstated satisfaction planned go forward procedureprocedure note patient received total mg versed micrograms fentanyl utilizing titratedown sedation good effect appropriate timeout procedure done per medical center universal protocol appropriate identification patient position procedure documentation procedure indication questions patient actively participate timeout procedure universal protocol done received cardioversion attempt joules using lollipop posterior patch handsdriven paddle side joules synchronized biphasic energy successful resumption normal sinus rhythm fact time significant pause compared done previously late sinus rhythm confirmed lead ekgimpression cardioversion shows successful resumption normal sinus rhythm atrial flutter patient maintained coumadin inr going watch discharge medical center area current flecainide mg morning mg evening atenolol mg day coumadin _____ currently diagnosed previously discussed patient agreeable meeting electrophysiologist dr x electrophysiology unit general hospital planning place call dr x ischemia recent stress test suppose future may reasonable get obstructive sleep apnea evaluation may one issue promulgating symptomsi previously discussed case dr patients general cardiologist well updated wife patients bedside regarding findings

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged. He, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on Coumadin.,The patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead EKG here. Otherwise, no chest pain.,PAST MEDICAL HISTORY: , Significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide. He completed a stress test in my office within the past several weeks that was normal without evidence of ischemia. Other medical history is significant for hyperlipidemia.,MEDICATIONS:,As outpatient,,1. Atenolol 25 mg once a day.,2. Altace 2.5 mg once a day.,3. Zocor 20 mg once a day.,4. Flecainide 200 in the morning and 100 in the evening.,5. Coumadin as directed by our office.,ALLERGIES: , TO MEDICATIONS ARE NONE. HE DENIES SHRIMP, SEA FOOD OR DYE ALLERGY.,FAMILY HISTORY: , He has a nephew who was his sister's son who passed away at age 22 reportedly from an MI, but was reported to have hypertrophic cardiomyopathy as well. The patient has previously met with the electrophysiologist, Dr. X, at General Hospital and it sounds like he had a negative EP study.,SOCIAL HISTORY: , The patient does not smoke cigarettes, abuse alcohol nor drink any caffeine. No use of illicit drugs. He has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife. He is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish. He is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,REVIEW OF SYSTEMS: , He denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi. There are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,PHYSICAL EXAM: , Blood pressure 156/93, pulse is 100, respiratory rate 18. On general exam, he is a pleasant overweight gentleman, in no acute distress. HEENT: Shows cranium is normocephalic and atraumatic. He has moist mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin warm and perfused. Affect appropriate. He is quite oriented and pleasant. No significant kyphoscoliosis on recumbent back exam. Lungs are clear to auscultation anteriorly. No wheezes. No egophony. Cardiac Exam: S1, S2. Regular rate, controlled. No significant murmurs, rubs or gallops. PMI is nondisplaced. Abdomen is soft, nondistended, appears benign. Extremities without significant edema. Pulses grossly intact.,DIAGNOSTIC STUDIES/LAB DATA:, Initial ECG shows atrial flutter.,IMPRESSION: , Mr. A is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so. I have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of. After in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was I primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as I did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of CVA, although we cannot really make that null. The patient expressed understanding of this risk, benefit, and alternative analysis. I invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,PROCEDURE NOTE: ,The patient received a total of 7 mg of Versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the Medical Center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions. The patient did actively participate in this time-out procedure. After the universal protocol was done, he then received the cardioversion attempt with 50 joules using "lollipop posterior patch" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy. There was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead EKG.,IMPRESSION: , Cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on Coumadin and his INR is 3.22. We are going to watch him and discharge him from the Medical Center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, Coumadin _____ as currently being diagnosed. I had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, Dr. X, at Electrophysiology Unit at General Hospital and I will be planning to place a call for Dr. X myself. Again, he has no ischemia on this most recent stress test and I suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,I had previously discussed the case with Dr. Y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy., Surgery

HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded. The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1. Aspirin 325 mg once a day.,2. Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. Nexium 40 mg once a day.,4. Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. I see that his LDL was 136 on May 3, 2002.,5. Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.

history present illness mr abc yearold gentleman markedly abnormal stress test earlier today office severe chest pain minutes exercise standard bruce horizontal st depressions moderate apical ischemia stress imaging required sublingual nitroglycerin total please see also admission history physical full detailsthe patient underwent cardiac catheterization today showed mildtomoderate left main distal disease moderate proximal lad severe midlad lesion midleft circumflex lesion normal lv function mild luminal irregularities right coronary artery moderate stenosis seen mid distal right pdai discussed results patient relating rest anginal symptoms well nocturnal anginal symptoms especially given severity mid left anterior descending lesion markedly abnormal stress test felt best suited transfer pci discussed case dr x medical center kindly accepted patient transfercondition transfer stable guarded patient painfree timemedications transfer aspirin mg day metoprolol mg day hold relative bradycardia apparently history nexium mg day zocor mg day fasting lipid profile pending time dictation see ldl may plavix mg po x giving tonightother medical history inclusive obstructive sleep apnea unable tolerate positive pressure ventilation gerd arthritisdisposition patient wife requested agreeable transfer medical center enclosing cd rom images

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded. The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1. Aspirin 325 mg once a day.,2. Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. Nexium 40 mg once a day.,4. Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. I see that his LDL was 136 on May 3, 2002.,5. Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting or diarrhea. She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:, The patient does note some pressure in her sinuses. She denies any skin rash.,SOCIAL HISTORY:, Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits. Room air oximetry is 100%.,GENERAL: Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT: Head is normocephalic, atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. Both TMs are easily visualized and are clear with good light reflex and no erythema. Sinuses do show some mild tenderness to percussion.,NECK: No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,SKIN: No rash.,ASSESSMENT:, Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:, I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort. I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses. If she is unimproved in five days, follow up with her PCP for re-exam.

history present illness patient yearold white female presents mother complaining fourday history cold symptoms consisting nasal congestion left ear pain dry cough fever high since first day denies vomiting diarrhea try tylenol cough cold followed tylenol cough cold severe think helpedfamily history patients younger sister recently respiratory infection complicated pneumonia otitis mediareview systems patient note pressure sinuses denies skin rashsocial history patient lives mother hernursing notes reviewed agreephysical examinationvital signs temp pulse elevated vital signs within normal limits room air oximetry general patient healthyappearing white female adolescent sitting stretcher appears mildly illheent head normocephalic atraumatic pharynx shows erythema tonsillar edema exudate tms easily visualized clear good light reflex erythema sinuses show mild tenderness percussionneck meningismus enlarged anteriorposterior cervical lymph nodesheart regular rate rhythm without murmurs rubs gallopslungs clear without rales rhonchi wheezesskin rashassessment viral upper respiratory infection uri sinus eustachian congestionplan educate patient problem urged switch advil cold sinus next three five days better control sinus eustachian discomfort urge use afrin nasal spray next three five days decongest sinuses unimproved five days follow pcp reexam

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting or diarrhea. She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:, The patient does note some pressure in her sinuses. She denies any skin rash.,SOCIAL HISTORY:, Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits. Room air oximetry is 100%.,GENERAL: Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT: Head is normocephalic, atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. Both TMs are easily visualized and are clear with good light reflex and no erythema. Sinuses do show some mild tenderness to percussion.,NECK: No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,SKIN: No rash.,ASSESSMENT:, Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:, I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort. I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses. If she is unimproved in five days, follow up with her PCP for re-exam. ### Response: Consult - History and Phy., ENT - Otolaryngology, Pediatrics - Neonatal

HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine." She states after vomiting, she felt "fine through the night," but woke with more nausea and vomiting and diaphoresis. She states she has vomited approximately 20 times today and has also had some slight diarrhea. She denies any sore throat or cough. She states no one else at home has been ill. She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough. She notes no blood in her vomitus or stool. The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 37.6. Other vital signs are all within normal limits.,GENERAL: Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT: Head is normocephalic and atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. NECK: No enlarged anterior or posterior cervical lymph nodes. There is no meningismus.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,ABDOMEN: Active bowel sounds. Soft without any focal tenderness on palpation. There are no masses, guarding, or rebound noted.,SKIN: No rash.,EXTREMITIES: No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential. Hematocrit is 33.8, but the indices are normochromic and normocytic. BMP is remarkable for a random glucose of 147. All other values are unremarkable. LFTs are normal. Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea. She was given two capsules of Imodium with some apple juice, which she was able to keep down. The patient did feel well enough to be discharged home.,ASSESSMENT:, Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea. She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet. Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours. If she is unimproved in the next two days, she was urged to follow up with her PCP back home.

history present illness patient yearold white female visiting husband complaining onset nausea vomiting approximately pm last night states drank lots red wine states vomiting felt fine night woke nausea vomiting diaphoresis states vomited approximately times today also slight diarrhea denies sore throat cough states one else home ill taken anything symptomsmedications currently patient fluoxetine depression zyrtec environmental allergiesallergies known drug allergiessocial history patient married nonsmoker lives husband herreview systemspatient denies fever cough notes blood vomitus stool remainder review systems discussed negativenursing notes reviewed agreephysical examinationvital signs temp vital signs within normal limitsgeneral patient healthyappearing middleaged white female lying stretcher appears mildly illheent head normocephalic atraumatic pharynx shows erythema tonsillar edema exudate neck enlarged anterior posterior cervical lymph nodes meningismusheart regular rate rhythm without murmurs rubs gallopslungs clear without rales rhonchi wheezesabdomen active bowel sounds soft without focal tenderness palpation masses guarding rebound notedskin rashextremities cyanosis clubbing edemalaboratory data cbc shows white count elevation neutrophil count differential hematocrit indices normochromic normocytic bmp remarkable random glucose values unremarkable lfts normal serum alcohol less treatment patient given l normal saline wide open well compazine mg iv x doses resolution nausea given two capsules imodium apple juice able keep patient feel well enough discharged homeassessment viral gastroenteritisplan rx compazine mg tabs dispense five sig one po qh prn recurrent nausea urged use liquids nausea gone hours slow advancement diet imodium diarrhea dairy products diarrhea gone least hours unimproved next two days urged follow pcp back home

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine." She states after vomiting, she felt "fine through the night," but woke with more nausea and vomiting and diaphoresis. She states she has vomited approximately 20 times today and has also had some slight diarrhea. She denies any sore throat or cough. She states no one else at home has been ill. She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough. She notes no blood in her vomitus or stool. The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 37.6. Other vital signs are all within normal limits.,GENERAL: Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT: Head is normocephalic and atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. NECK: No enlarged anterior or posterior cervical lymph nodes. There is no meningismus.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,ABDOMEN: Active bowel sounds. Soft without any focal tenderness on palpation. There are no masses, guarding, or rebound noted.,SKIN: No rash.,EXTREMITIES: No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential. Hematocrit is 33.8, but the indices are normochromic and normocytic. BMP is remarkable for a random glucose of 147. All other values are unremarkable. LFTs are normal. Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea. She was given two capsules of Imodium with some apple juice, which she was able to keep down. The patient did feel well enough to be discharged home.,ASSESSMENT:, Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea. She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet. Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours. If she is unimproved in the next two days, she was urged to follow up with her PCP back home. ### Response: Consult - History and Phy., Gastroenterology

HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTORY: , Mother is age 78 with history of mesothelioma. Father is alive, but unknown medical history as they have been estranged. She has a 51-year-old sister with history of multiple colon polyps. She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history. To the best of her knowledge, there are no family members with stomach cancer or colon cancer.,SOCIAL HISTORY: , She was born in Houston, Texas and moved to Florida about 3 years ago. She is divorced. She has worked as a travel agent. She has 2 sons ages 24 and 26, both of whom are alive and well. She smokes a half a pack of cigarettes per day for more than 35 years. She does not consume alcohol.,REVIEW OF SYSTEMS: , As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated. Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus.,PHYSICAL EXAMINATION: ,Weight 152 pounds. Height is 5 feet 3 inches. Blood pressure 136/80. Pulse 68. In general: She is a well-developed and well-nourished female who ambulates with the assistance of a cane. Neurologically nonfocal. Awake, alert, and oriented x 3. HEENT: Head normocephalic, atraumatic. Sclerae anicteric. Conjunctivae are pink. Mouth is moist without any obvious oral lesions. Neck is supple. There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable. Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm without obvious gallops or murmurs. Abdomen is soft, nontender with good bowel sounds. No organomegaly or masses are appreciable. Extremities are without clubbing, cyanosis, and/or edema. Skin is warm and dry. Rectal was deferred and will be done at the time of the colonoscopy.,IMPRESSION:,1. A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.,2. Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year. Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer.,3. Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation. She is on multiple medications including narcotics and may have developed narcotic bowel syndrome.,4. A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids. She may likely have underlying gastroesophageal reflux disease.,5. A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds. She may also have some GI dysmotility including gastroparesis.,6. Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine. If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia. Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy.,7. A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology. She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases. She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C.,PLAN:,1. We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases. She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like.,2. Discussed reflux precautions and gave literature for further review.,3. Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids. Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor.,4. Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above.,5. Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination.,

history present illness see chart attachedmedications tramadol mg every hours prn hydrocodone mg mg every hours prn zolpidem mg bedtime triamterene mg atenolol mg vitamin tricor mg simvastatin mg ibuprofen mg tid lyrica mgfamily history mother age history mesothelioma father alive unknown medical history estranged yearold sister history multiple colon polyps brothers schizophrenia knows little medical history best knowledge family members stomach cancer colon cancersocial history born houston texas moved florida years ago divorced worked travel agent sons ages alive well smokes half pack cigarettes per day years consume alcoholreview systems per form filled office today positive hypertension weakness arms legs arthritis pneumonia ankle swelling getting full quickly eating loss appetite weight loss stated fluctuating pounds trouble swallowing heartburn indigestion belching nausea diarrhea constipation change bowel habits change consistency rectal bleeding hemorrhoids abdominal discomfort cramping associated constipation hepatitis infectious hepatitis past smoking alcohol previously stated otherwise review systems negative strokes paralysis gout cataracts glaucoma respiratory difficulties tuberculosis chest pain heart disease kidney stones hematuria rheumatic fever scarlet fever cancer diabetes thyroid disease seizure disorder blood transfusions anemia jaundice pruritusphysical examination weight pounds height feet inches blood pressure pulse general welldeveloped wellnourished female ambulates assistance cane neurologically nonfocal awake alert oriented x heent head normocephalic atraumatic sclerae anicteric conjunctivae pink mouth moist without obvious oral lesions neck supple submandibular submaxillary axillary supraclavicular epitrochlear adenopathy appreciable lungs clear auscultation bilaterally heart regular rate rhythm without obvious gallops murmurs abdomen soft nontender good bowel sounds organomegaly masses appreciable extremities without clubbing cyanosis andor edema skin warm dry rectal deferred done time colonoscopyimpression yearold female whose yearold sister history multiple colon polyps may slightly increase risk colon cancer future reports recurrent bright red blood per rectum mostly toilet paper past year bleeding likely consistent internal hemorrhoids however needs evaluation colon polyps colon cancer alternations constipation diarrhea past several years lower abdominal cramping discomfort particularly associated constipation multiple medications including narcotics may developed narcotic bowel syndrome long history pyrosis dyspepsia nausea belching many years relieved antacids may likely underlying gastroesophageal reflux disease year history early satiety fluctuations weight pounds may also gi dysmotility including gastroparesis report dysphagia solids past several years history bone spur cervical spine bone spur pressing anteriorly could certainly cause recurrent symptoms dysphagia differential also includes peptic stricture schatzkis ring even remotely possibility esophageal malignancy history infectious hepatitis past recent mild elevations ast alt levels without clear etiology may reaction multiple medications including statin drugs cause mild elevations transaminases may underlying fatty liver disease differential could include form viral hepatitis hepatitis b even cplan asked follow primary care physician regard recent elevation transaminases likely lab tests repeated future remain persistently elevated happy see future evaluation primary care physician would like discussed reflux precautions gave literature review schedule upper endoscopy possible esophageal dilatation well colonoscopy possible infrared coagulation suspected internal hemorrhoids procedures explained detail including risks complications adverse reaction medication well respiratory embarrassment infection bleeding perforation possibility missing small polyp tumor alternatives including upper gi series flexible sigmoidoscopy barium enema ct colonography discussed however patient agrees proceed plan outlined due sisters history colon polyps likely advised repeat colonoscopy years perhaps sooner pending results baseline examination

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTORY: , Mother is age 78 with history of mesothelioma. Father is alive, but unknown medical history as they have been estranged. She has a 51-year-old sister with history of multiple colon polyps. She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history. To the best of her knowledge, there are no family members with stomach cancer or colon cancer.,SOCIAL HISTORY: , She was born in Houston, Texas and moved to Florida about 3 years ago. She is divorced. She has worked as a travel agent. She has 2 sons ages 24 and 26, both of whom are alive and well. She smokes a half a pack of cigarettes per day for more than 35 years. She does not consume alcohol.,REVIEW OF SYSTEMS: , As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated. Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus.,PHYSICAL EXAMINATION: ,Weight 152 pounds. Height is 5 feet 3 inches. Blood pressure 136/80. Pulse 68. In general: She is a well-developed and well-nourished female who ambulates with the assistance of a cane. Neurologically nonfocal. Awake, alert, and oriented x 3. HEENT: Head normocephalic, atraumatic. Sclerae anicteric. Conjunctivae are pink. Mouth is moist without any obvious oral lesions. Neck is supple. There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable. Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm without obvious gallops or murmurs. Abdomen is soft, nontender with good bowel sounds. No organomegaly or masses are appreciable. Extremities are without clubbing, cyanosis, and/or edema. Skin is warm and dry. Rectal was deferred and will be done at the time of the colonoscopy.,IMPRESSION:,1. A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.,2. Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year. Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer.,3. Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation. She is on multiple medications including narcotics and may have developed narcotic bowel syndrome.,4. A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids. She may likely have underlying gastroesophageal reflux disease.,5. A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds. She may also have some GI dysmotility including gastroparesis.,6. Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine. If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia. Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy.,7. A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology. She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases. She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C.,PLAN:,1. We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases. She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like.,2. Discussed reflux precautions and gave literature for further review.,3. Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids. Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor.,4. Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above.,5. Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination., ### Response: Consult - History and Phy., Gastroenterology

HISTORY OF PRESENT ILLNESS: , She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,PAST MEDICAL HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , No alcohol, drugs, or tobacco.,PAST OBSTETRICAL HISTORY: ,This is her first pregnancy.,PAST GYNECOLOGICAL HISTORY: , Not pertinent.,While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2. Her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria. H and H stable at 14.1 and 48.7. She was then admitted after giving some Phenergan and Zofran IV. As started on IV, given hydration as well as given a dose of Rocephin to treat bladder infection. She was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving Maalox, tolerated fluids as well as p.o. food. Followup chemistry was obtained for AST, ALT and we will plan for discharge if lab variables resolve.,ASSESSMENT AND PLAN:,1. This is a 28-year-old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup.,2. Slightly elevated ALT, questionable, likely due to the nausea and vomiting. We will recheck for followup.

history present illness yearold g approximately plus weeks presented intractable nausea vomiting bloodtinged vomit starting approximately worse past couple days patients fourth trip emergency room second trip admissionpast medical history nonsignificantpast surgical history nonesocial history alcohol drugs tobaccopast obstetrical history first pregnancypast gynecological history pertinentwhile emergency room patient found slight low sodium potassium slightly elevated alt ast total bilirubin urine ketones protein esterase rbc numerous count moderate amount bacteria h h stable admitted giving phenergan zofran iv started iv given hydration well given dose rocephin treat bladder infection admitted overnight nausea vomiting resolved one episode vomiting receiving maalox tolerated fluids well po food followup chemistry obtained ast alt plan discharge lab variables resolveassessment plan yearold g approximately weeks gestation one hyperemesis gravidarum admit iv hydration followup slightly elevated alt questionable likely due nausea vomiting recheck followup

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission.,PAST MEDICAL HISTORY: , Nonsignificant.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , No alcohol, drugs, or tobacco.,PAST OBSTETRICAL HISTORY: ,This is her first pregnancy.,PAST GYNECOLOGICAL HISTORY: , Not pertinent.,While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2. Her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria. H and H stable at 14.1 and 48.7. She was then admitted after giving some Phenergan and Zofran IV. As started on IV, given hydration as well as given a dose of Rocephin to treat bladder infection. She was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving Maalox, tolerated fluids as well as p.o. food. Followup chemistry was obtained for AST, ALT and we will plan for discharge if lab variables resolve.,ASSESSMENT AND PLAN:,1. This is a 28-year-old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup.,2. Slightly elevated ALT, questionable, likely due to the nausea and vomiting. We will recheck for followup. ### Response: Emergency Room Reports, General Medicine

HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital. He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,POSTOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,PROCEDURE: , Closed reduction of mandible fractures with Erich arch bars and elastic fixation.,ANESTHESIA:, General nasotracheal.,COMPLICATIONS:, None.,CONDITION:, Stable to PACU.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars. Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires. After the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable. The throat pack was then removed. An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out.,The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the PACU in stable condition.

history present illness patient yearold male sustained mandible fracture seen emergency department hospital seen office today scheduled surgery today closed reduction mandible fracturespreoperative diagnoses left angle right body mandible fracturespostoperative diagnoses left angle right body mandible fracturesprocedure closed reduction mandible fractures erich arch bars elastic fixationanesthesia general nasotrachealcomplications nonecondition stable pacudescription procedure patient brought operating room placed table supine position demonstration adequate plane general anesthesia via nasotracheal route patient prepped draped usual fashion placement arch bars gauze throat pack placed upper lower arch bars placed maxillary mandibular dentition gauge circumdental wires placement arch bars occlusion checked found satisfactory stable throat pack removed ng tube passed approximately cc stomach contents suctioned outthe elastic fixation placed arch bars holding patient maxillomandibular fixation point procedure terminated patient awakened extubated taken pacu stable condition

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital. He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,POSTOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,PROCEDURE: , Closed reduction of mandible fractures with Erich arch bars and elastic fixation.,ANESTHESIA:, General nasotracheal.,COMPLICATIONS:, None.,CONDITION:, Stable to PACU.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars. Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires. After the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable. The throat pack was then removed. An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out.,The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the PACU in stable condition. ### Response: Surgery

HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection. The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall. The patient gave birth in August 2008 and since the childbirth, has experienced low back pain. The patient also states that she fell four to five days ago, while mopping her floor. The patient stated that she landed on her tailbone and symptoms have increased since that fall. The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an appendectomy. The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1. Vicodin 500 mg two times a day.,2. Risperdal.,3. Zoloft.,4. Stool softeners.,5. Prenatal pills.,DIAGNOSTIC IMAGERY: ,The patient states she has not had an MRI performed on her lumbar spine. The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time. Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE: ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE: 26 years old. HEIGHT: 5 feet 2 inches. WEIGHT: The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION: ,The patient complained of bilateral SI joint point tenderness. The patient also complained of left greater trochanter hip point tenderness. The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH: ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5. With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance. It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL: ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes. However, they subside when she stands. The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes. Upon standing, the patient stated that the numbness and tingling subsides almost immediately. The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities. The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT: ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT: ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain. The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued. At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1. The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2. The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3. The patient will report 25% improvement in her functional and ADL activities.,4. Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1. The patient will be independent with home exercise program.,2. Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3. The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4. The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5. The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1. Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.

history present illness patient yearold female referred physical therapy low back pain patient history traumatic injury low back patient stated initial injury occurred eight years ago fell abc store patient stated received physical therapy one two visits received modality treatment specifically electrical stimulation heat pack per patient recollection patient stated continuous lowback pain varying degrees past eight years since fall patient gave birth august since childbirth experienced low back pain patient also states fell four five days ago mopping floor patient stated landed tailbone symptoms increased since fall patient stated initial physician examination dr x followup appointment past medical history patient denies high blood pressure diabetes heart disease lung disease thyroid kidney bladder dysfunctions patient stated quit smoking prior past childbirth currently pregnant patient csection also appendectomy patient involved motor vehicle accident four five years ago time patient require physical therapy report complaints increased back pain following accidentmedications patient currently states taking vicodin mg two times day risperdal zoloft stool softeners prenatal pillsdiagnostic imagery patient states mri performed lumbar spine patient also states dr x took xrays two weeks ago fractures found time per physician note dated dr x dictated xray showed anterior grade spondylolisthesis l requested physical therapy evaluate treatsubjective patient states pain constant nature baseline pain increasing night cold weather patient states pain dramatically less weather warmer patient also states pain worsens day progresses also hard time getting bed morning patient states sleep night well sleeps less one hour timeaggravating factors include sitting periods greater minutes lying supine back easing factors include side lying position attempts sleepobjective age years old height feet inches weight patient obese yearold femaleactive range motion lumbar spine flexion lateral flexion rotation within functional limits without complaints pain soreness performing evaluationpalpation patient complained bilateral si joint point tenderness patient also complained left greater trochanter hip point tenderness patient also complained bilateral paraspinal tenderness cervical spine lumbar spinestrength right lower extremityknee extension hip flexion knee flexion internal external hip rotation manual muscle testing knee flexion hip internal external rotation patient reports increase right si joint pain left lower extremityhip flexion knee extension knee flexion hip internal external rotation slight increase pain level manual muscle testing resistance must noted pt apply much resistance manual muscle testing secondary pain elicited right lower extremityneurological patient subjectively complains numbness tingling bilateral extremities sits longer minutes however subside stands patient complain numbness tingling evaluation patient seated period minutes upon standing patient stated numbness tingling subsides almost immediately patient stated dr x told believes past childbirth epidural administered possibility sensory nerve may also affected epidural less causing numbness tingling bilateral lower extremities patient demonstrate sensation deficits gentle pressure lumbar spine manual muscle testinggait patient ambulated examination room carrying baby car seatassessment patient yearold overweight female referred physical therapy low back pain patient presents lower extremity weakness may contributing lumbosacral pain poor lumbar stabilization dynamic adls transfers gait activity fatigued time patient may benefit skilled physical therapy address decreased strength core stability order improve adl transfer mobility skillsprognosis patients prognosis physical therapy good dictated goalsshortterm goals achieved two weeks patient able sit greater minutes without complaints paraesthesia pain bilateral lower extremities bilateral si joints patient increase bilateral hip internal external rotation si joint pain less equal patient report improvement functional adl activities pain less performing __________ pt sessionlongterm goals accomplished one month patient independent home exercise program bilateral hamstring bilateral hip internal external rotation strength si joint pain less equal performing manual muscle test patient report improvement greater functional transfers general adl activity patient able sit greater equal minutes without complaint lumbosacral pain patient able sleep greater hours without paintreatment plan therapeutic exercises increase lower extremity strength assist lumbar sacral stability

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection. The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall. The patient gave birth in August 2008 and since the childbirth, has experienced low back pain. The patient also states that she fell four to five days ago, while mopping her floor. The patient stated that she landed on her tailbone and symptoms have increased since that fall. The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an appendectomy. The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1. Vicodin 500 mg two times a day.,2. Risperdal.,3. Zoloft.,4. Stool softeners.,5. Prenatal pills.,DIAGNOSTIC IMAGERY: ,The patient states she has not had an MRI performed on her lumbar spine. The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time. Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE: ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE: 26 years old. HEIGHT: 5 feet 2 inches. WEIGHT: The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION: ,The patient complained of bilateral SI joint point tenderness. The patient also complained of left greater trochanter hip point tenderness. The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH: ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5. With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance. It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL: ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes. However, they subside when she stands. The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes. Upon standing, the patient stated that the numbness and tingling subsides almost immediately. The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities. The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT: ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT: ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain. The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued. At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1. The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2. The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3. The patient will report 25% improvement in her functional and ADL activities.,4. Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1. The patient will be independent with home exercise program.,2. Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3. The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4. The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5. The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1. Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability. ### Response: Orthopedic

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

history present illness patient yearold lady admitted chief complaints chest pain leftsided severe chest tightness emotional argument boyfriend patient long history psychological disorders per patient also history supraventricular tachycardia coronary artery disease patient workup done abc medical center patient evaluated emergency room initial cardiac workup negative patient admitted telemetry unit evaluation emergency room patient also noted strongly positive drug screen including methadone morphine patients ekg emergency room normal patient relief chest pain got nitroglycerinpast medical history mentioned significant history seizure disorder migraine headaches coronary artery disease chf apparently coronary stenting done mitral valve prolapse supraventricular tachycardia pacemaker placement colon cancer breast cancer none details availablepast surgical history significant history lumpectomy left breast breast augmentation surgery cholecystectomy cardiac ablation x left knee surgery well removal half pancreascurrent medications home included dilantin mg daily klonopin mg times day elavil mg night nitroglycerin sublingual prn thorazine mg times day neurontin mg times day phenergan mg toleratedob history last menstrual period patient admitting recent abortion done sure whether abortion completed followup obgynfamily history noncontributorysocial history lives boyfriend patient history tobacco abuse well multiple illicit drug abusereview systems mentioned abovephysical examinationgeneral alert awake orientedvital signs blood pressure heart rate per minute respiratory rate heent shows head atraumatic pupils round reactive light extraocular muscles intact oropharyngeal lesions notedneck supple jv distention carotid bruits lymphadenopathylungs clear auscultation bilaterallycardiac reveals regular rate rhythmabdomen soft nontender nondistended bowel sounds normally presentlower extremities shows edema distal pulses neurological grossly nonfocallaboratory data database available point time wbc count normal hemoglobin hematocrit normal sodium potassium chloride glucose bicarbonate bun creatinine liver function tests normal patients sets cardiac enzymes including troponini cpkmb myoglobulin normal ekg normal sinus rhythm without acute stt wave changes mentioned patients toxicology screen positive morphine methadone marijuana patient also head ct done emergency room fairly unremarkable patients betahcg level marginally elevated assessment evaluation chest pains appear completely noncardiac patient seem psychosomatic component chest pain evidence acute coronary syndrome unstable angina point time possible early pregnancy patients case discussed obgyn oncall phone medications held secondary potential danger patient follow outpatient basis primary obgyn well pcp workup pregnancy well continuation pregnancy prenatal visits migraine headaches patient using routine medications headaches seem control outpatient diagnosis patient follow pcp control migraine headacheoverall prognosis soon predictthe plan discharge patient home secondary evidence acute coronary syndrome

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

HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time. On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. She is not able to walk by herself, and needs assistance to stand. She was discharged from hospital after the Cesarean section on the 3rd of November. Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. She was then seen at ABC Hospital on November 05, 2008. She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December. At the present time, she also complains of a pressure in both her legs and in her thighs. She complains that her right foot hurts and that she has some hyperesthesia there. She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above. She has seasonal allergies.,CURRENT MEDICATIONS:, Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: P 74, BP 144/75, and a pain score of 0.,GENERAL: Her general physical examination was unremarkable.,CARDIOVASCULAR: Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY: Unremarkable, both lung bases were clear, and respiration was normal.,GI: Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE: The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. Executive function was normal.,CRANIAL NERVES: The cranial nerve examination II through XII was unremarkable. Both disks were normal, with normal retina. Pupils were equal and reactive to light. Eye movements were full. Facial sensation and strength was normal. Bulbar function was normal. The trapezius had normal strength.,MOTOR: Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. Muscle strength was 5/5 in all muscle groups in the upper extremities. In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES: Reflexes in the upper extremities were 2+ bilaterally. In the lower extremities, they were 0 bilaterally at the knee and ankles. The abdominal reflexes were present above the umbilicus and absent below the umbilicus. The plantar responses were mute. The jaw reflex was normal.,SENSATION: Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly. There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side. In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. There was no evidence of allodynia or hyperesthesia. Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION: Coordination for rapid alternating movements and finger-to-nose testing was normal. Coordination could not be tested in the lower extremities.,GAIT: The patient was unable to stand and therefore we were unable to test gait or Romberg's. There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6. The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast. This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable. The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers. The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities. We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008. The complete study included the cervical, thoracic, and lumbar spine. There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November. It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section. It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. She was severely weak in both lower extremities, slightly worse on the right than the left. There has been some interval improvement in her strength since the beginning of November 2008. Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy. The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. There had been no response to IV methylprednisolone given to her at ABC. The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself. The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. At the present time, she is able to stand with aid but is unable to walk. There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1. The diagnostic issues were discussed with the patient at length. She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2. She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility. I am not prescribing these because at the present time she does not need them.,3. We discussed increasing the dose of gabapentin. The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. She may need other neuropathic pain medications as needed. She will determine whether her current symptoms are significant enough to require this increase in dosage.,4. The patient will follow up with Dr. Y and his team at ABC Hospital. She will also continue with physical therapy within the ABC system.

history present illness patient yearold woman reports th october rupture membranes nine months pregnancy admitted hospital given epidural anesthetic records hospital admission apparently epidural administered approximately hours sitting epiduralshe notice difference lower extremities time epidural however reports extremely sleepy may aware change strength sensation lower extremities time delivered st october cesarean section failed progress pyrexiashe also foley catheter placed time st november began mobilize time first noticed could walk aware could move legs within days aware could move toes left foot could move right foot since time gradual improvement strength point limited movement left leg severely restricted movement right leg able walk needs assistance stand discharged hospital cesarean section rd november unfortunately records know discussion anesthesiologist patient time discharge seen abc hospital november mri scan spine showed evidence abnormality specifically cord changes evidence hematoma also emg study time dr x abnormal diagnostic repeated december present time also complains pressure legs thighs complains right foot hurts hyperesthesia taking gabapentin try reduce discomfort although low dose effect minimal symptoms arms bowel bladder function normal bulbar function normal problem vision swallowing respiratory functionpast medical history unremarkable except noted seasonal allergiescurrent medications gabapentin mg bid centrum day another multivitaminallergies medication allergies seasonal allergiesfamily history family history diabetes hypertension family history neuropathy neurological disease one child son born october social history patient civil engineer currently works home working approximately half time limitations imposed disability need attend frequent physical therapy also needs looking baby smoke drink never done eithergeneral physical examinationvital signs p bp pain score general general physical examination unremarkablecardiovascular normal first second heart sound regular pulse normal volumerespiratory unremarkable lung bases clear respiration normalgi unremarkable organomegaly normal bowel soundsneurological exammse patients orientation normal fund knowledge normal memory normal speech normal calculation normal immediate longterm recall normal executive function normalcranial nerves cranial nerve examination ii xii unremarkable disks normal normal retina pupils equal reactive light eye movements full facial sensation strength normal bulbar function normal trapezius normal strengthmotor muscle tone showed slight increase tone lower extremities normal tone upper extremities muscle strength muscle groups upper extremities lower extremities hip flexors bilaterally hip extensors bilaterally knee extension right left knee flexion right left foot dorsiflexion right left foot plantar flexion right left toe extension right left toe flexion right leftreflexes reflexes upper extremities bilaterally lower extremities bilaterally knee ankles abdominal reflexes present umbilicus absent umbilicus plantar responses mute jaw reflex normalsensation vibration moderately decreased right great toe mildly decreased left great toe sensory level light touch approximately posteriorly approximately anteriorly range sensation clearly decrease sensation level complete loss sensation pain sensory level even less clear appeared right side lower extremities slight decrease pin light touch right great toe compared left evidence allodynia hyperesthesia joint position sense mildly reduced right toe normal leftcoordination coordination rapid alternating movements fingertonose testing normal coordination could tested lower extremitiesgait patient unable stand therefore unable test gait rombergs evidence focal back tendernessreview outside records reviewed records abc hospital including letter dr emg report dated dr x emg report shows evidence lumbosacral polyradiculopathy approximately lower extremity sensory responses essentially normal however decrease amplitude motor responses minimal changes latency mri lumbar spine report without contrast showed minimal concentric disc bulge without disc herniation otherwise unremarkable patient brought disc recent mri study however unable open computers verbal report study unremarkable except gadolinium enhancement lumbar nerve roots doppler lower extremities showed evidence deep venous thrombosis either lower extremity chest xray showed scoliosis lumbar spine curve left evidence abnormalities ct pelvis study performed november showed nonspecific fluid subcutaneous fat back posterior l l levels however pelvic masses abnormalities able obtain update report mri lumbar spine without contrast dated complete study included cervical thoracic lumbar spine diffuse enhancement nerve roots cauda equina increased enhancement since prior exam november also reported patient given intravenous methylprednisolone effect strength lower extremitiesimpression patient condition temporarily related epidural injection given end october prior cesarean section appears became aware weakness within two days administration epidural tired epidural may missed change neurological function severely weak lower extremities slightly worse right left interval improvement strength since beginning november emg study end december consistent lumbosacral polyradiculopathy mri findings gadolinium enhancement lumbar nerve roots would consistent inflammatory radiculitis likely related epidural anesthesia administration epidural response iv methylprednisolone given abc issue lumbar puncture look evidence inflammatory cells elevated protein discussed abc patient wish consider lumbar puncture concerns might worsen condition present time able stand aid unable walk evidence previous emg demyelinating neuropathyrecommendations diagnostic issues discussed patient length informed still early course problem expect show improvement function next one two years although unclear much function regain strongly recommended continue vigorous physical therapy continue plan mobilize much possible goal trying get ambulatory able walk need bilateral afos ankles improve overall mobility prescribing present time need discussed increasing dose gabapentin paresthesias may indicate actually regaining sensory function although concern recovery continues may left significant neuropathic pain case advised increase gabapentin dose mg bid gradually mg four times day mg mg four times day may need neuropathic pain medications needed determine whether current symptoms significant enough require increase dosage patient follow dr team abc hospital also continue physical therapy within abc system

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time. On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. She is not able to walk by herself, and needs assistance to stand. She was discharged from hospital after the Cesarean section on the 3rd of November. Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. She was then seen at ABC Hospital on November 05, 2008. She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December. At the present time, she also complains of a pressure in both her legs and in her thighs. She complains that her right foot hurts and that she has some hyperesthesia there. She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above. She has seasonal allergies.,CURRENT MEDICATIONS:, Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: P 74, BP 144/75, and a pain score of 0.,GENERAL: Her general physical examination was unremarkable.,CARDIOVASCULAR: Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY: Unremarkable, both lung bases were clear, and respiration was normal.,GI: Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE: The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. Executive function was normal.,CRANIAL NERVES: The cranial nerve examination II through XII was unremarkable. Both disks were normal, with normal retina. Pupils were equal and reactive to light. Eye movements were full. Facial sensation and strength was normal. Bulbar function was normal. The trapezius had normal strength.,MOTOR: Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. Muscle strength was 5/5 in all muscle groups in the upper extremities. In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES: Reflexes in the upper extremities were 2+ bilaterally. In the lower extremities, they were 0 bilaterally at the knee and ankles. The abdominal reflexes were present above the umbilicus and absent below the umbilicus. The plantar responses were mute. The jaw reflex was normal.,SENSATION: Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly. There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side. In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. There was no evidence of allodynia or hyperesthesia. Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION: Coordination for rapid alternating movements and finger-to-nose testing was normal. Coordination could not be tested in the lower extremities.,GAIT: The patient was unable to stand and therefore we were unable to test gait or Romberg's. There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6. The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast. This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable. The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers. The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities. We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008. The complete study included the cervical, thoracic, and lumbar spine. There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November. It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section. It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. She was severely weak in both lower extremities, slightly worse on the right than the left. There has been some interval improvement in her strength since the beginning of November 2008. Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy. The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. There had been no response to IV methylprednisolone given to her at ABC. The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself. The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. At the present time, she is able to stand with aid but is unable to walk. There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1. The diagnostic issues were discussed with the patient at length. She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2. She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility. I am not prescribing these because at the present time she does not need them.,3. We discussed increasing the dose of gabapentin. The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. She may need other neuropathic pain medications as needed. She will determine whether her current symptoms are significant enough to require this increase in dosage.,4. The patient will follow up with Dr. Y and his team at ABC Hospital. She will also continue with physical therapy within the ABC system. ### Response: Consult - History and Phy., Neurology

HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. Neurology consult was called to evaluate the patient in view of the current symptomatology. The headaches were refractory to the treatment. The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY: ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY: ,No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:, Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT: Head, normocephalic, atraumatic. Neck supple. Throat clear. No discharge from the ears or nose. No discoloration of conjunctivae and sclerae. No bruits auscultated over temple, orbits, or the neck.,LUNGS: Clear to auscultation.,CARDIOVASCULAR: Normal heart sounds.,ABDOMEN: Benign.,EXTREMITIES: No edema, clubbing or cyanosis.,SKIN: No rash. No neurocutaneous disorder.,MENTAL STATUS: The patient is awake, alert and oriented to place and person. Speech is fluent. No language deficits. Mood normal. Affect is clear. Memory and insight is normal. No abnormality with thought processing and thought content. Cranial nerve examination intact II through XII. Motor examination: Normal bulk, tone and power. Deep tendon reflexes symmetrical. Downgoing toes. No sign of any myelopathy. Cortical sensation intact. Peripheral sensation grossly intact. Vibratory sense not tested. Gait not tested. Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines. Complicated migraines by clinical criteria. Rule out sinusitis. Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today. Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially. The patient already had MRI of the brain and the cervical spine. MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache. Plan and followup discussed with the patient in detail.

history present illness patient yearold female past medical history migraine headaches brought er uncontrolled headaches er patient ct scan done reported negative lumbar puncture normal pressure cell count admitted followup neurology consult called evaluate patient view current symptomatology headaches refractory treatment patient topamax maxalt past work according patient got confusedpast medical history history migrainepast surgical history significant partial oophorectomy appendectomy abdominoplastysocial history history smoking alcohol drug abuse patient registered nurse professionmedications currently taking medicationallergies known allergiesfamily history nothing significantreview systems patient considered ask systemic review including neurology psychiatry sleep ent ophthalmology pulmonary cardiology gastroenterology genitourinary hematology rheumatology dermatology allergy immunology endocrinology toxicology oncology found positive symptoms mentioned history presenting illnessphysical examinationvital signs blood pressure heart rate respiratory rate temperature normal pulse oximetry room air time initial evaluationheent head normocephalic atraumatic neck supple throat clear discharge ears nose discoloration conjunctivae sclerae bruits auscultated temple orbits necklungs clear auscultationcardiovascular normal heart soundsabdomen benignextremities edema clubbing cyanosisskin rash neurocutaneous disordermental status patient awake alert oriented place person speech fluent language deficits mood normal affect clear memory insight normal abnormality thought processing thought content cranial nerve examination intact ii xii motor examination normal bulk tone power deep tendon reflexes symmetrical downgoing toes sign myelopathy cortical sensation intact peripheral sensation grossly intact vibratory sense tested gait tested coordination normal dysmetriaimpression intractable headaches description migraines complicated migraines clinical criteria rule sinusitis rule vasculitis including temporal arthritis lupus polyarthritis moyamoya disease takayasu kawasaki diseaseplan recommendations patient given trial prednisone plan taper days already received mg today depakote part migraine prophylaxis fioricet prn basisthe patient get vasculitis workup ordered primary care physician initially patient already mri brain cervical spine mri brain reported negative cervical spine shown signs disk protrusion c c level explain temporal headache plan followup discussed patient detail

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. Neurology consult was called to evaluate the patient in view of the current symptomatology. The headaches were refractory to the treatment. The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY: ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY: ,No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:, Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT: Head, normocephalic, atraumatic. Neck supple. Throat clear. No discharge from the ears or nose. No discoloration of conjunctivae and sclerae. No bruits auscultated over temple, orbits, or the neck.,LUNGS: Clear to auscultation.,CARDIOVASCULAR: Normal heart sounds.,ABDOMEN: Benign.,EXTREMITIES: No edema, clubbing or cyanosis.,SKIN: No rash. No neurocutaneous disorder.,MENTAL STATUS: The patient is awake, alert and oriented to place and person. Speech is fluent. No language deficits. Mood normal. Affect is clear. Memory and insight is normal. No abnormality with thought processing and thought content. Cranial nerve examination intact II through XII. Motor examination: Normal bulk, tone and power. Deep tendon reflexes symmetrical. Downgoing toes. No sign of any myelopathy. Cortical sensation intact. Peripheral sensation grossly intact. Vibratory sense not tested. Gait not tested. Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines. Complicated migraines by clinical criteria. Rule out sinusitis. Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today. Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially. The patient already had MRI of the brain and the cervical spine. MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache. Plan and followup discussed with the patient in detail. ### Response: Consult - History and Phy., Neurology

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me. He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation. There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission. He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation. The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1. Type I diabetes mellitus.,2. Hyperlipidemia.,3. Hypertension.,4. Morbid obesity.,5. Sleep apnea syndrome.,6. Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General: Unremarkable.,Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal: Unremarkable.,Genitourinary: See above.,Musculoskeletal: Unremarkable.,Neurologic: Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease. His mother has congestive heart failure.,SOCIAL HISTORY: ,The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1. Clonidine 0.3 mg b.i.d.,2. Atenolol 50 mg daily.,3. Simvastatin 80 mg daily.,4. Furosemide 40 mg daily.,5. Metformin 1000 mg b.i.d.,6. Hydralazine 25 mg t.i.d.,7. Diovan 320 mg daily.,8. Lisinopril 40 mg daily.,9. Amlodipine 10 mg daily.,10. Lantus insulin 50 units q.p.m.,11. KCl 20 mEq daily.,12. NovoLog sliding scale insulin coverage.,13. Warfarin 7.5 mg daily.,14. Levothyroxine 0.2 mg daily.,15. Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General: A well-appearing, obese black male.,Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.,HEENT: Grossly normal.,Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.,Chest: Midline sternotomy scar.,Lungs: Clear.,Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.,Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.

history present illness patient yearold africanamerican male previously well known previous history aortic valve disease status post aortic valve replacement chronic anticoagulation previous history paroxysmal atrial fibrillation congestive heart failure stable prior admission previous history transient ischemic attack residual neurologic deficitsthe patient undergone surgery dr x attempted nephrolithotomy patient experienced significant postoperative bleeding necessary discontinue anticoagulation patient presently seen request dr x management anticoagulation heart diseasepast medical surgical history type diabetes mellitus hyperlipidemia hypertension morbid obesity sleep apnea syndrome status post thyroidectomy thyroid carcinomareview systemsgeneral unremarkablecardiopulmonary chest pain shortness breath palpitations dizzinessgastrointestinal unremarkablegenitourinary see abovemusculoskeletal unremarkableneurologic unremarkablefamily history family members coronary artery disease mother congestive heart failuresocial history patient married lives wife employed barber use alcohol tobacco illicit drugsmedications prior admission clonidine mg bid atenolol mg daily simvastatin mg daily furosemide mg daily metformin mg bid hydralazine mg tid diovan mg daily lisinopril mg daily amlodipine mg daily lantus insulin units qpm kcl meq daily novolog sliding scale insulin coverage warfarin mg daily levothyroxine mg daily folic acid mg dailyallergies nonephysical examinationgeneral wellappearing obese black malevital signs bp hr respirations afebrileheent grossly normalneck normal thyroid normal carotid normal upstroke bruitschest midline sternotomy scarlungs clearheart pmi fifth intercostal space mid clavicular line normal prosthetic murmur rub gallop clickabdomen soft nontender palpable mass hepatosplenomegaly

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me. He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation. There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission. He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation. The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1. Type I diabetes mellitus.,2. Hyperlipidemia.,3. Hypertension.,4. Morbid obesity.,5. Sleep apnea syndrome.,6. Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General: Unremarkable.,Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal: Unremarkable.,Genitourinary: See above.,Musculoskeletal: Unremarkable.,Neurologic: Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease. His mother has congestive heart failure.,SOCIAL HISTORY: ,The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1. Clonidine 0.3 mg b.i.d.,2. Atenolol 50 mg daily.,3. Simvastatin 80 mg daily.,4. Furosemide 40 mg daily.,5. Metformin 1000 mg b.i.d.,6. Hydralazine 25 mg t.i.d.,7. Diovan 320 mg daily.,8. Lisinopril 40 mg daily.,9. Amlodipine 10 mg daily.,10. Lantus insulin 50 units q.p.m.,11. KCl 20 mEq daily.,12. NovoLog sliding scale insulin coverage.,13. Warfarin 7.5 mg daily.,14. Levothyroxine 0.2 mg daily.,15. Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General: A well-appearing, obese black male.,Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.,HEENT: Grossly normal.,Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.,Chest: Midline sternotomy scar.,Lungs: Clear.,Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.,Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy.

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

history present illness patient yearold white male history hiv disease last cd count viral load less recently hospitalized left gluteal abscess underwent id newly diagnosed diabetes mellitus also history hypertension hypertriglyceridemia increased urination thirst seen hospital endocrinology staff treated insulin hospitalized getting treatment perirectal abscess endocrine team apparently felt insulin might best patient financial issues elected place glucophage glyburide patient reports taking medication general feeling better says gluteal abscess improving following surgery todaycurrent medications gabapentin mg night metformin mg twice day glipizide mg day flagyl mg four times day flexeril mg twice day paroxetine mg day atripla one night clonazepam mg twice day blood pressure medicine name unknownreview systems otherwise negative review systemsphysical examinationvital signs temperature blood pressure pulse respirations weight kg pounds heent unremarkable except submandibular lymph nodes fundi benign neck supple lungs clear auscultation percussion cardiac reveals regular rate rhythm without murmur rub gallop abdomen soft nontender without organomegaly mass extremities show cyanosis clubbing edema gu examination perineum revealed open left gluteal wound appears clear secretionsimpression human immunodeficiency virus disease stable control atripla resolving left gluteal abscess completing flagyl diabetes mellitus currently oral therapy hypertension depression chronic musculoskeletal pain unclear etiologyplan patient continue current medications laboratory studies done weeks see weeks thereafter encouraged keep appointment psychologist

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

HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05. He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10. He still localizes it to a band between L4 and the sacrum. He initially had some right leg pain but states that this is minimal and intermittent at the present time. His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994. The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1. There was no neural impingement. He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:, Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak. He denies any recent illness. He has no constitutional complaints such as fevers, chills or sweats. HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms. He has no dysphagia. Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope. Pulmonary: He denies any dyspnea or respiratory difficulties. GI: The patient has no abdominal pain, nausea or vomiting. GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria. Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities. Musculoskeletal: Denies any recent falls or near-falls. He denies any abnormalities of endocrine, immunologic, hematologic, organ systems. , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:, None., ,SOCIOECONOMIC STATUS:, Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs: Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2. He is sitting upright, alert and oriented and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. , ,On examination of the lumbar spine, he is minimally tender to palpation. There is no overt muscular spasm. His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension. Straight leg raises do not elicit any leg complaints on today's visit. Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain. The leg pain is no longer present. His pain level has improved., ,PLAN: ,1. The patient will take another Medrol Dosepak.,2. He can continue with physical therapy.,3. He also continues with the same lifting restrictions.,4. Follow up is within one week.

history present illness patient yearold man seen complaints low back right thigh pain attributes incident injured paperwork authenticating claim open claim recently working taco bell recurrence back pain seen clinic rated pain approximately severity took medrol dosepak states pain level decreased approximately still localizes band l sacrum initially right leg pain states minimal intermittent present time back history significant two laminectomies discectomy performed area concern patients mri dated showed multilevel degenerative changes facet involvement ls neural impingement also mr myelogram showed severe stenosis however qualified may artifact rather genuine finding review systems focal lower paralumbar pain affecting right left sides well intermittent right leg pain appears improved significantly medrol dosepak denies recent illness constitutional complaints fevers chills sweats heent patient denies cephalgia ocular nasopharyngeal symptoms dysphagia cardiovascular denies palpitations chest pain syncope nearsyncope pulmonary denies dyspnea respiratory difficulties gi patient abdominal pain nausea vomiting gu patient denies urinary frequency dysuria gross hematuria dermatologic patient notes new onset rash dermatological abnormalities musculoskeletal denies recent falls nearfalls denies abnormalities endocrine immunologic hematologic organ systems medications atenolol zestril vicodin allergies none socioeconomic status lifting limitations pounds limited stooping bending twisting physical examination vital signs blood pressure respiration pulse temperature sitting upright alert oriented acute distress skin warm dry gross neurologic examination normal ent examination reveals normal oropharynx nasopharynx tympanic membranes neck full range motion adenopathy thyromegaly cardiovascular regular rate rhythm lungs clear examination lumbar spine minimally tender palpation overt muscular spasm range motion estimated degrees flexion degrees extension straight leg raises elicit leg complaints todays visit lower extremity reflexes symmetric diagnosis low back pain history right leg pain leg pain longer present pain level improved plan patient take another medrol dosepak continue physical therapy also continues lifting restrictions follow within one week

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05. He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10. He still localizes it to a band between L4 and the sacrum. He initially had some right leg pain but states that this is minimal and intermittent at the present time. His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994. The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1. There was no neural impingement. He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:, Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak. He denies any recent illness. He has no constitutional complaints such as fevers, chills or sweats. HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms. He has no dysphagia. Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope. Pulmonary: He denies any dyspnea or respiratory difficulties. GI: The patient has no abdominal pain, nausea or vomiting. GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria. Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities. Musculoskeletal: Denies any recent falls or near-falls. He denies any abnormalities of endocrine, immunologic, hematologic, organ systems. , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:, None., ,SOCIOECONOMIC STATUS:, Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs: Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2. He is sitting upright, alert and oriented and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. , ,On examination of the lumbar spine, he is minimally tender to palpation. There is no overt muscular spasm. His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension. Straight leg raises do not elicit any leg complaints on today's visit. Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain. The leg pain is no longer present. His pain level has improved., ,PLAN: ,1. The patient will take another Medrol Dosepak.,2. He can continue with physical therapy.,3. He also continues with the same lifting restrictions.,4. Follow up is within one week. ### Response: Orthopedic, SOAP / Chart / Progress Notes

HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp: Patient denies asthma, lung infections and lung lesions.,GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology: Patient denies allergic reactions, rashes and skin lesions.,MEDS:, Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:, No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:, No significant family history.,REVIEW OF SYSTEMS:, Non-contributory.,Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.,Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and conto.,Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.,Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.,Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.,Extremities: There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled. Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC. ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.

history present illness patient yearold male complaining abdominal pain patient also longstanding history diabetes treated micronase dailypast medical history significant past medical history noted todayphysical examinationheent patient denies ear abnormalities nose abnormalities throat abnormalitiescardio patient history elevated cholesterol ashd hypertension pvdresp patient denies asthma lung infections lung lesionsgi patient denies colon abnormalities gall bladder problems liver abnormalities peptic ulcer diseasegu patient history urinary tract disorder bladder disorder kidney disorderendocrine patient history diabetes hormonal irregularities thyroid abnormalitiesdermatology patient denies allergic reactions rashes skin lesionsmeds micronase mg tab po qam bactrim tab po bid social history known history drug alcohol abuse work diet exercise patterns within normal limitsfamily history significant family historyreview systems noncontributoryvital signs height weight lbs upright bp mmhg pulse bpm resp pm patient afebrileneck neck supple jugular venous distension thyroid nontender normal size contolungs lung expansion excursions symmetric lungs clear auscultation percussioncardio regular rhythm si normal abnormal heart sounds detected blood pressure equal bilaterallyabdomen normal bowel sounds present abdomen soft abdomen nontender without organomegaly cva tenderness hernias notedextremities clubbing cyanosis edemaassessment diabetes type ii uncontrolled acute cystitisplan endocrinology consult complete cbc rx micronase mg tab po qam bactrim tab po bid

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp: Patient denies asthma, lung infections and lung lesions.,GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology: Patient denies allergic reactions, rashes and skin lesions.,MEDS:, Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:, No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:, No significant family history.,REVIEW OF SYSTEMS:, Non-contributory.,Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.,Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and conto.,Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.,Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.,Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.,Extremities: There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled. Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC. ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30. ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76

history present illness patient yearold righthanded gentleman presents clinic evaluation diplopia states usual state health awoke one morning january double vision states closed eye double vision dissipated double vision entirely dissipated within one hour able drive however next day woke double vision next week double vision worsened intensity frequency second week severe states called sinai hospital spoke physician recommended come evaluation seen primary care physician sent ophthalmologic evaluation seen referred emergency department urgent mri evaluate possible aneurysm patient states normal mri discharged homefor next month double vision improved although currently still experiences constant diplopia whereas past would see two objects far apart horizontal plane much closer together still drive also working due double vision temporal fluctuation double vision recently past month developed right supraorbital pain actually feels like pain right lid denies dysphagia dysarthria weakness numbness tingling neurological symptomsthere neurology consultation computer system dr x saw patient february emergency department underwent mri showed questionable mm aneurysm medial left supraclinoid internal carotid artery abnormalities right side mrv negative mri brain without contrast also negative also mri orbit without contrast normal impression patient follow possible evaluation myasthenia gravis disorderat time examination documented right lid ptosis left gaze diplopia pupils equal round reactive light neurological examination otherwise entirely normal according dr xs note ophthalmologist saw thought ptosis right eye well abnormal pupil also right medial rectus well possibly extraocular abnormalities official ophthalmologic consultation available todaypast medical history patient denies previous past medical history currently primary care physician uninsuredmedications take medicationsallergies known drug allergiessocial history patient lives wife software developer work several months smokes less pack cigarettes daily denies alcohol illicit drug usefamily history mother died stroke father colon cancer unaware family members neurological disordersreview systems complete review systems obtained negative except mentioned documented handwritten notes todays visitphysical examinationvital signs bp

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76 ### Response: Consult - History and Phy., Neurology, Ophthalmology

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. The patient at that time stated that he had established diagnosis of liver cirrhosis. Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody. Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion. He spent 3 days in the hospital. He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient. From the patient's report he was diagnosed with some kind of viral infection. At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS: Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions.,NECK: Supple. No lymphadenopathy. No thyromegaly.,LUNGS: Clear to auscultation and percussion bilateral.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.,ABDOMEN: Not tender, not distended. Splenomegaly about 4 cm under the costal margin. No hepatomegaly. Bowel sounds present.,MUSCULOSKELETAL: No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC: Nonfocal. No asterixis. No costovertebral tenderness.,PSYCHE: The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63. His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53. We do not have any other results back. No hepatitis panels. No alpha-fetoprotein level. The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:, The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1. Epigastric pain. The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time. In the office twice the patient did not have any abdominal pain on physical exam. His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously. He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2. End-stage liver disease. Of course, we need to find out the cause of the liver cirrhosis. We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before. We do not have any information of any type of investigation in the past. Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X. The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result. It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level. We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver. We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B. Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C. The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also. We will need to look for nuclear antibody if it is not done before. PSC is extremely unlikely but possible. Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not. Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem. On his end-stage liver disease we already know that he had low platelet count splenomegaly. We know that his bilirubin is elevated and albumin is very low. I suspect that at the time of admission to the hospital the patient presented with encephalopathy. We do not know if INR was checked to look for coagulopathy. The patient had an EGD in 2005 as well as colonoscopy in Silver City. We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily. The patient tolerated it well; no diarrhea at this point in time. I also recommended for him to contact his primary care physician for increased dose of opiates for him. As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal. The patient got a prescription for 10 mg pills. He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58. The patient was educated how to use Inderal and he was explained why we decided to use this medication. The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues. The patient was provided information that his protein intake is supposed to be about 25 g per day. He was advised not to over-eat protein and advised not to starve. He also was advised to stay away from alcohol. His next visit is in 2 weeks with all results available.

history present illness patient yearold hispanic male seen initially office february epigastric right upper quadrant abdominal pain nausea dizziness bloating patient time stated established diagnosis liver cirrhosis since last visit patient asked sign lease information form sent request information doctor patient saw dr x las cruces primary care physician silver city unfortunately get information anybody also patient admission gila medical center epigastric pain diarrhea confusion spent days hospital followed dr x unfortunately also information wrong patient patients report diagnosed kind viral infection time admission lot epigastric pain nausea vomiting fever chillsphysical examinationvital signs weight height feet inch blood pressure heart rate saturation pain localization pain epigastric areaheent perrla eom intact oropharynx clear lesionsneck supple lymphadenopathy thyromegalylungs clear auscultation percussion bilateralcardiovascular regular rate rhythm murmurs rubs gallopsabdomen tender distended splenomegaly cm costal margin hepatomegaly bowel sounds presentmusculoskeletal cyanosis clubbing pitting edemaneurologic nonfocal asterixis costovertebral tendernesspsyche patient oriented x alert cooperativelaboratory data able collect lab results medical center got cmp hospital showed glucose level bun creatinine sodium potassium chloride co calcium total protein albumin total bilirubin ast alt alkaline phosphatase ammonia level results back hepatitis panels alphafetoprotein level patient told today also got ultrasound abdomen result impressive result despite calling medical records hospital release informationassessment plan patient yearold established diagnosis liver cirrhosis unknown cause epigastric pain patient chronic pain syndrome multiple back surgeries taken opiate prolonged period time office twice patient abdominal pain physical exam pain sound like obstruction common bile duct episodes abdominal pain almost continuously probably requires increased level pain control increased dose opiates addressed primary care physician endstage liver disease course need find cause liver cirrhosis hepatitis panel yet information liver biopsy performed information type investigation past patient seen gastroenterologist already las cruces dr x patient advised contact dr x convince send available information already send release information form signed patient without result reasonable repeat unnecessary tests point timewe waiting hepatitis panel alphafetoprotein level also need get information ultrasound done gila medical center obviously tumor found exam liver figure hepatitis status another reason needs vaccination hepatitis b know exactly cause patients endstage liver disease differential diagnosis probably hepatitis c patient denied excessive alcohol intake could preclude alcoholrelated liver cirrhosis also need look nuclear antibody done psc extremely unlikely possible wilson disease also possible diagnosis first figure tests done patient alphaantitrypsin deficiency extremely unlikely patient lung problem endstage liver disease already know low platelet count splenomegaly know bilirubin elevated albumin low suspect time admission hospital patient presented encephalopathy know inr checked look coagulopathy patient egd well colonoscopy silver city result evaluate patient varices needs intervention thatat point time recommended patient continue take lactulose ml times daily patient tolerated well diarrhea point time also recommended contact primary care physician increased dose opiates primary prophylaxis gi bleeding patient endstage liver disease try use inderal patient got prescription mg pills take mg twice daily gradually increase dose heart rate drop probably patient educated use inderal explained decided use medication patient hold medication orthostatic bradycardicagain patient wife advised contact offices seen get information tests already done next visit weeks still information need repeat tests mentioned abovewe also discussed nutrition issues patient provided information protein intake supposed g per day advised overeat protein advised starve also advised stay away alcohol next visit weeks results available

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. The patient at that time stated that he had established diagnosis of liver cirrhosis. Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody. Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion. He spent 3 days in the hospital. He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient. From the patient's report he was diagnosed with some kind of viral infection. At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS: Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions.,NECK: Supple. No lymphadenopathy. No thyromegaly.,LUNGS: Clear to auscultation and percussion bilateral.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.,ABDOMEN: Not tender, not distended. Splenomegaly about 4 cm under the costal margin. No hepatomegaly. Bowel sounds present.,MUSCULOSKELETAL: No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC: Nonfocal. No asterixis. No costovertebral tenderness.,PSYCHE: The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63. His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53. We do not have any other results back. No hepatitis panels. No alpha-fetoprotein level. The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:, The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1. Epigastric pain. The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time. In the office twice the patient did not have any abdominal pain on physical exam. His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously. He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2. End-stage liver disease. Of course, we need to find out the cause of the liver cirrhosis. We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before. We do not have any information of any type of investigation in the past. Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X. The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result. It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level. We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver. We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B. Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C. The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also. We will need to look for nuclear antibody if it is not done before. PSC is extremely unlikely but possible. Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not. Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem. On his end-stage liver disease we already know that he had low platelet count splenomegaly. We know that his bilirubin is elevated and albumin is very low. I suspect that at the time of admission to the hospital the patient presented with encephalopathy. We do not know if INR was checked to look for coagulopathy. The patient had an EGD in 2005 as well as colonoscopy in Silver City. We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily. The patient tolerated it well; no diarrhea at this point in time. I also recommended for him to contact his primary care physician for increased dose of opiates for him. As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal. The patient got a prescription for 10 mg pills. He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58. The patient was educated how to use Inderal and he was explained why we decided to use this medication. The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues. The patient was provided information that his protein intake is supposed to be about 25 g per day. He was advised not to over-eat protein and advised not to starve. He also was advised to stay away from alcohol. His next visit is in 2 weeks with all results available. ### Response: Gastroenterology, SOAP / Chart / Progress Notes

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

history present illness patient yearold gentleman presents evaluation right leg weakness difficulty recollecting exact details chronology problem best recollection thinks six months ago developed weakness right leg describes reaching get something cabinet noticed unable stand right toe since time difficulty pushing walks mild tingling numbness toes chronic problem nothing new since developed weakness chronic mild back pain persistent many years changed experienced cramps calves past year dissipated two months ago think left leg weak bowel bladder incontinence radicular pain think problem progressive meaning weakness perceives right leg different six months agohe first sought medical attention problem october saw couple months later undergone emg nerve conduction studies unfortunately cannot undergo mri spine ear implant ct scan shows degenerative changes nothing obviously abnormalin addition patient hyperckemia tells elevated ck prior starting taking stat medications although entirely clear thinks taking lipitor months thought ck prior starting started increased came stopped recent bump since lipitor stopped ck apparently returned laboratory data support statements patient seems speed recently started taking zetia proximal weakness denies myalgias past medical history coronary artery disease received five stents hypertension hypercholesterolemia states diagnosed diabetes based results abnormal oral glucose tolerance test believes glucose shot testing take medications blood glucoses generally normal checks plastic surgery face orbital injury also ear graft developed ear infection honeymoon current medications takes amlodipine diovan zetia hydrochlorothiazide lovaza fish oil niaspan aspirin chantix allergies known drug allergies social history lives wife works shepherd pratt network engineering smokes pack cigarettes day working quitting drinks four alcoholic beverages per night prior drank significantly denies illicit drug use athletic growing family history mother died complications heart disease father died heart disease two living brothers one speak much know medical history apparently healthy one healthy child maternal uncles apparently polio asked tell details states one wear crutches due severe leg deformans leg deformities one leg fairly certain polio unaware family members neurological conditionsreview systems occasional tinnitus difficulty sleeping otherwise complete review systems obtained negative except mentioned documented handwritten notes todays visitphysical examination vital signs

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

HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:, See Patient History sheet, which was reviewed with the patient and is signed in the chart. Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds. She has palpable pulses. Neurologic sensation is intact. Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy. There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement. She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right. Gait analysis: The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:, X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy. Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle. No evidence of arthrosis in the joint is noted. Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1. Recurrent bunion deformity, right forefoot.,2. Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal. Anticipated length of healing was noted for the patient as were potential risks and complications. The patient ultimately would probably require surgery on her left foot at a later date as well.,2. The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3. All questions were answered.

history present illness patient yearold female seen today evaluation pain symptoms related recurrent bunion deformity bilateral feet right greater left patient states increasing symptoms pain discomfort associated recurrence bunion deformity right foot pain localized second toe mtp joint right foot well patient prior surgery performed approximately years ago states since time original surgery deformity slowly recurred noticed progressive deformity lesser toes second third toes left foot involving second toe right foot patient employed feet hospital employee states wear functional orthotic provide relief forefoot pain although completepast medical history family history social history review systems see patient history sheet reviewed patient signed chart past medical history patient past surgical history current medications drugrelated allergies social history updated reviewed enclosed chartphysical examination physical exam reveals pleasant yearold female feet inches pounds palpable pulses neurologic sensation intact examination extremities shows patient wellhealed surgical sites arthroplasty second digits bilaterally prior bunionectomy recurrence bunion deformity noted great toes although patient notes reasonably good range movement particular pain second mtp joint right foot demonstrates mild clawtoe deformity second third toes left foot lesser degree second toe right gait analysis patient stands walks rather severe pes planus generalized hypermobility noted feetxray interpretation xrays taken today three views right foot shows presence internal kwire wire prior bunionectomy biomechanical analysis shows degree intermetatarsal angle approximately degree hallux abducto valgus angle evidence arthrosis joint noted significant shift fibular sesamoid presentassessment recurrent bunion deformity right forefoot pes planovalgus deformity bilateral feetplantreatment today review remaining treatment options patient including feasibility conservative versus surgical treatment patient would require open wedge osteotomy reduce intermetatarsal angle lateral release decompression osteotomy second metatarsal anticipated length healing noted patient potential risks complications patient ultimately would probably require surgery left foot later date well patient explore ability get work abovementioned period time touch regards regarding scheduling later date questions answered

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:, See Patient History sheet, which was reviewed with the patient and is signed in the chart. Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds. She has palpable pulses. Neurologic sensation is intact. Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy. There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement. She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right. Gait analysis: The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:, X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy. Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle. No evidence of arthrosis in the joint is noted. Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1. Recurrent bunion deformity, right forefoot.,2. Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal. Anticipated length of healing was noted for the patient as were potential risks and complications. The patient ultimately would probably require surgery on her left foot at a later date as well.,2. The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3. All questions were answered. ### Response: Consult - History and Phy., Orthopedic

HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis. Biopsies were done. The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender. Lungs clear. Blood pressure 129/69 on admission. At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3. Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema. This was done and did not really show what the cecum on the barium enema. There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon. She did have some enemas. She had persistent nausea, headache, neck pain throughout this hospitalization. Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS: ,Migraine headache.,COMPLICATIONS: ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications. Diet and activity as tolerated.

history present illness patient yearold female patient past months almost daily diarrhea nausea inability eat egd colonoscopy dr abc days prior admission colonoscopy reveal diverticulosis egd showed retained bile possible gastritis biopsies done patient presented emergency room worsening abdominal pain well swelling right lower legpast medical history extensive well documented prior chartsphysical examination abdomen diffusely tender lungs clear blood pressure admission time admission trace bilateral lower edemalaboratory studies white count hemoglobin hematocrit potassium hospital course dr abc apparently could advance scope cecum therefore warranted barium enema done really show cecum barium enema retained stool area patient somewhat prolonged hospital course remaining barium colon enemas persistent nausea headache neck pain throughout hospitalization finally improve enough point could discharged homedischarge diagnosis nausea abdominal pain uncertain etiologysecondary diagnosis migraine headachecomplications nonedischarge condition guardeddischarge plan follow office days resume preadmission medications diet activity tolerated

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis. Biopsies were done. The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender. Lungs clear. Blood pressure 129/69 on admission. At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3. Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema. This was done and did not really show what the cecum on the barium enema. There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon. She did have some enemas. She had persistent nausea, headache, neck pain throughout this hospitalization. Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS: ,Migraine headache.,COMPLICATIONS: ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications. Diet and activity as tolerated. ### Response: Discharge Summary, General Medicine

HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP: 122/86. Temp: 96.8. HR: 79. RR: 26. RAS: 100%.,HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. EOMs intact.,NECK: Supple without masses or lymphadenopathy.,LUNGS: Clear to auscultation bilaterally,CARDIAC: Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES: No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT.

history present illness patient yearold female treated cyberknife therapy right upper lobe stage ia nonsmall cell lung cancer cyberknife treatment completed one month ago seen first postcyberknife treatment visitsince undergoing cyberknife treatment lowlevel nausea without vomiting continues pain deep inspiration resolving dysphagia heartburn cough hemoptysis rash palpable rib painmedications dilantin mg four times day phenobarbital mg three times per day levothyroxine mg po q day tylenol codeine bid prednisone mg prn citalopram mg po q day spiriva q day combivent inhaler prn omeprazole mg po q day lidoderm patch every hours naprosyn mg po bid oxaprozin mg po bid megace mg po bid asacol prnphysical examination bp temp hr rr ras heent normocephalic pupils equal reactive light accommodation eoms intactneck supple without masses lymphadenopathylungs clear auscultation bilaterallycardiac regular rate rhythm without rubs murmurs gallopsextremities cyanosis clubbing edemaassessment patient done well cyberknife treatment stage ia nonsmall cell lung cancer right upper lobe one month agoplan return clinic three months pet ct

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP: 122/86. Temp: 96.8. HR: 79. RR: 26. RAS: 100%.,HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. EOMs intact.,NECK: Supple without masses or lymphadenopathy.,LUNGS: Clear to auscultation bilaterally,CARDIAC: Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES: No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT. ### Response: Cardiovascular / Pulmonary, SOAP / Chart / Progress Notes

HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to "pop into place." He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 130/70

history present illness patient yearold righthanded gentleman presents evaluation feet hand cramps states past six months experienced cramps feet hands describes foot cramps much notable hand ones reports develops muscle contractions toes feet occur exclusively night may occur three times per week develops cramps stands relieve discomfort notices toes extended position steps ground seem pop place develops calf pain experiences cramp sometimes awaken sleephe also developed cramps hands although less severe less frequent legs occur night completely random notices thumb assumes flexed position sometimes needs pry open relieve cramphe never symptoms like past started taking bactrim nine months ago taken past briefly never taken long cannot think possible contributing factors symptomshe history hiv years taking antiretroviral medications stopped six seven years ago reports unable tolerate medications due severe stomach upset cd count states never developed aids considering resuming antiretroviral treatmentpast medical history diabetes well controlled also hepatitis c hivcurrent medications takes insulin bactrimallergies known drug allergiessocial history lives alone recently lost partner happened six months ago denies alcohol tobacco illicit drug use retired active walks four miles every daysfamily history father mother diabetesreview systems complete review systems obtained negative except mentioned documented handwritten notes todays visitphysical examinationvital signs blood pressure

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to "pop into place." He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 130/70 ### Response: Consult - History and Phy., Neurology

HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left. He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant. Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease. Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting. History of high blood pressure, as well. He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:, Penicillin.,SOCIAL HISTORY:, He is not a smoker. He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT: Examination unremarkable.,Breasts: Examination deferred.,Chest: Clear to auscultation.,Cardiac: Regular rate and rhythm.,Abdomen: Soft and nontender. He has no hernias.,Genitourinary: There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities: Examination unremarkable.,Neurologic: Examination nonfocal.,IMPRESSION:,1. Adenocarcinoma of the prostate.,2. Erectile dysfunction.,PLAN: ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. The risks, benefits, and alternatives of this have been discussed. He understands and asks that I proceed ahead. We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.

history present illness patient year old male gleason score adenocarcinoma prostate involving left right lobes psa prostate gland size grams initially found rectal examination nodule right side prostate showing enlargement relative left undergone evaluation bone scan showed right parietal lesion uptake seen dr xxx ultimately underwent open biopsy malignant prior also prostascint scan negative metastatic disease admitted undergo radical prostatectomy risks benefits alternatives discussed including bleeding blood transfusionpast medical history coronary stenting history high blood pressure well erectile dysfunction treated viagramedications lisinopril aspirin zocor prilosecallergies penicillinsocial history smoker drink six beers dayreview systems remarkable high blood pressure drug allergies otherwise unremarkable except obstructive urinary symptoms aua score physical examinationheent examination unremarkablebreasts examination deferredchest clear auscultationcardiac regular rate rhythmabdomen soft nontender herniasgenitourinary normalappearing phallus prominence right side prostateextremities examination unremarkableneurologic examination nonfocalimpression adenocarcinoma prostate erectile dysfunctionplan patient undergo bilateral pelvic lymphadenectomy radical retropubic prostatectomy risks benefits alternatives discussed understands asks proceed ahead also discussed bleeding blood transfusions risks benefits alternatives thereof

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left. He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant. Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease. Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting. History of high blood pressure, as well. He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:, Penicillin.,SOCIAL HISTORY:, He is not a smoker. He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT: Examination unremarkable.,Breasts: Examination deferred.,Chest: Clear to auscultation.,Cardiac: Regular rate and rhythm.,Abdomen: Soft and nontender. He has no hernias.,Genitourinary: There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities: Examination unremarkable.,Neurologic: Examination nonfocal.,IMPRESSION:,1. Adenocarcinoma of the prostate.,2. Erectile dysfunction.,PLAN: ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. The risks, benefits, and alternatives of this have been discussed. He understands and asks that I proceed ahead. We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof. ### Response: Consult - History and Phy., Urology

HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms. I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems. He first mentioned that he has neck pain. He states that he has had this for at least 15 years. It is worse with movement. It has progressed very slowly over the course of 15 years. It is localized to the base of his neck and is sharp in quality. He also endorses a history of gait instability. This has been present for a few years and has been slightly progressively worsening. He describes that he feels unsteady on his feet and "walks like a duck." He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet. When I asked him to describe this in more detail, the numbness is actually restricted to his toes. Left is slightly more affected than the right. He denies any tingling or paresthesias. He also described that he is slowly losing control of his hands. He thinks that he is dropping objects due to weakness or incoordination in his hands. This has also been occurring for the past one to two years. He has noticed that buttoning his clothes is more difficult for him. He also does not have any numbness or tingling in the hands. He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome. He did not even mention this on the initial part of my history taking. When I asked him to describe this further, he states that he experiences a general exhaustion. He basically lays in bed all day everyday. I asked him if he was depressed, he states that he is treated for depression. He is unsure if this is optimally treated. As I just mentioned, he stays in bed almost all day long and does not engage in any social activities. He does not think that he is necessarily sad. His appetite is good. He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past. I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago. He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago. He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes. He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation. He also saw Dr. Z for neurosurgical consultation a couple of weeks ago. He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years. He also has had hypercholesterolemia. He has had Crohn's disease for 25 or 30 years. He has had a colostomy for four years. He has arthritis, which is reportedly related to the Crohn's disease. He has hypertension and coronary artery disease and is status post stent placement. He has depression. He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:, He previously worked with pipeline work, but has been on disability for five years. He is unsure which symptoms led him to go on disability. He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago. He denies alcohol or illicit drug use. He lives with his wife. He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49. His mother died in her 70s from complications of congestive heart failure. He has one sister who died during a cardiac surgery two years ago. He has another sister with diabetes. He has one daughter with hypercholesterolemia. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion. He states that he was evaluated by a pulmonologist and had a normal evaluation. He has occasional night sweats. His hearing is poor. He occasionally develops bloody stools, which he attributes to his Crohn's disease. He also was diagnosed with sleep apnea. He does not wear his CPAP machine on a regular basis. He has a history of anemia. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance: He is well appearing in no acute distress. He has somewhat of a flat affect.,Cardiovascular: He has a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.,Chest: The lungs are clear to auscultation bilaterally.,Skin: There are no rashes or lesions.,Musculoskeletal: He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status: His speech is fluent without dysarthria or aphasia. He is alert and oriented to name, place, and date. Attention, concentration, and fund of knowledge are intact. He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Visual fields are full. Optic discs are normal. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.,Motor: He has normal muscle bulk and tone. There is no atrophy. He has few fasciculations in his calf muscles bilaterally. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities. There is no action or percussion myotonia or paramyotonia.,Sensory: He has absent vibratory sensation at the left toe. This is diminished at the right toe. Joint position sense is intact. There is diminished sensation to light touch and temperature at the feet to the knees bilaterally. Pinprick is intact. Romberg is absent. There is no spinal sensory level.,Coordination: This is intact by finger-nose-finger or heel-to-shin testing. He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes: They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles. Plantar reflexes are flexor. There is no ankle clonus, finger flexors, or Hoffman's signs. He has crossed adductors bilaterally.,Gait and Stance: He has a slightly wide-based gait. He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk. He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08: Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal. Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast: Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08: Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves. He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial. He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy. He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea. Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1. I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2. I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3. I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4. I believe that he needs to undergo psychotherapy for his depression. It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist. The patient is very open about proceeding with this suggestion.,5. He does need to have his sleep apnea better controlled. He states that he is not compliant because the face mask that he uses does not fit him well. This should also be addressed.

history present illness patient yearold lefthanded gentleman presents evaluation multiple neurological symptoms asked discuss symptom individually hard time describing nature problems first mentioned neck pain states least years worse movement progressed slowly course years localized base neck sharp quality also endorses history gait instability present years slightly progressively worsening describes feels unsteady feet walks like duck fallen three four times past year halfhe also describes numbness feet asked describe detail numbness actually restricted toes left slightly affected right denies tingling paresthesias also described slowly losing control hands thinks dropping objects due weakness incoordination hands also occurring past one two years noticed buttoning clothes difficult also numbness tingling hands history chronic low back painat end visit asked symptom bothersome actually stated fatigue troublesome even mention initial part history taking asked describe states experiences general exhaustion basically lays bed day everyday asked depressed states treated depression unsure optimally treated mentioned stays bed almost day long engage social activities think necessarily sad appetite good never undergone psychotherapy depressionwhen took history noticed slow responding questions also lot difficulty recalling details history well names physicians seen past asked ever evaluated cognitive difficulties states undergo testing johns hopkins couple years ago states results normal specifically dementiawhen asked first evaluated current symptoms states saw dr x several years ago believes told neuropathy unclear due diabetes told recently evaluated dr referred evaluation also saw dr z neurosurgical consultation couple weeks ago reports think surgical indication neck back point timepast medical history diabetes five years also hypercholesterolemia crohns disease years colostomy four years arthritis reportedly related crohns disease hypertension coronary artery disease status post stent placement depression kidney stone removed years agocurrent medications takes actos ambien baby aspirin coreg entocort folic acid flomax iron lexapro mg qhs lipitor pentasa plavix protonix toprol celebrex zetiaallergies states imuran caused develop tachycardiasocial history previously worked pipeline work disability five years unsure symptoms led go disability previously smoked two packs cigarettes daily years quit years ago denies alcohol illicit drug use lives wife really hobbiesfamily history father died cerebral hemorrhage age mother died complications congestive heart failure one sister died cardiac surgery two years ago another sister diabetes one daughter hypercholesterolemia unaware family members neurological disordersreview systems dyspnea exertion states evaluated pulmonologist normal evaluation occasional night sweats hearing poor occasionally develops bloody stools attributes crohns disease also diagnosed sleep apnea wear cpap machine regular basis history anemia otherwise complete review systems obtained negative except mentioned documented handwritten notes todays visitphysical examinationvital signs blood pressure hr rr wt pounds pain general appearance well appearing acute distress somewhat flat affectcardiovascular regular rhythm without murmurs gallops rubs carotid bruitschest lungs clear auscultation bilaterallyskin rashes lesionsmusculoskeletal joint deformities scoliosisneurological examinationmental status speech fluent without dysarthria aphasia alert oriented name place date attention concentration fund knowledge intact object registration recall minutescranial nerves pupils equal round reactive light accommodation visual fields full optic discs normal extraocular movements intact without nystagmus facial sensation normal facial jaw palate tongue weakness hearing grossly intact shoulder shrug fullmotor normal muscle bulk tone atrophy fasciculations calf muscles bilaterally manual muscle testing reveals mrc grade strength proximal distal muscles upper lower extremities action percussion myotonia paramyotoniasensory absent vibratory sensation left toe diminished right toe joint position sense intact diminished sensation light touch temperature feet knees bilaterally pinprick intact romberg absent spinal sensory levelcoordination intact fingernosefinger heeltoshin testing slight tremor head outstretched armsdeep tendon reflexes biceps triceps brachioradialis patellas ankles plantar reflexes flexor ankle clonus finger flexors hoffmans signs crossed adductors bilaterallygait stance slightly widebased gait difficulty toe walking able walk heels tandem walk difficulty toe raises leftradiologic data mri cervical spine chronic spondylosis cc causing severe bilateral neuroforamining borderlinetomold cord compression normal cord signal spondylosis cc causing mild bilateral neuroforamining left paracentral disc herniation causing borderline cord compressionthoracic mri spine without contrast minor degenerative changes without stenosisi mri lumbar spine available reviewlaboratory data vitamin b vitamin b esr ast alt vitamin b cpk tsh magnesium rpr nonreactive crp lyme antibody negative spep abnormal serum protein electrophoresis paraprotein manifestation hemoglobin ac aldolase homocystine assessment patient yearold gentleman multiple neurologic nonneurologic symptoms including numbness gait instability decreased dexterity arms general fatigue neurological examination notable sensory loss lengthdependent fashion feet legs scant fasciculations calves fairly normal mild increased reflexes including notably presence normal ankle jerksi think etiology symptoms multifactorial probably mild peripheral neuropathy sparing ankle jerks suggested either neuropathy mild superimposed myelopathic process cervical lumbosacral myelopathy really concerned fatigue think possible due suboptimally treated depression suboptimally treated sleep apnea whether another underlying muscular disorder primary myopathy remains seenrecommendations scheduled repeat emg nerve conduction studies evaluate evidence neuropathy myopathy review films spine conference tomorrow although confident dr zs opinion surgical indication gave prescription physical therapy help gait imbalance training well treatment neck pain believe needs undergo psychotherapy depression may also worthwhile adjust medications defer primary care physician managing referring therapist patient open proceeding suggestion need sleep apnea better controlled states compliant face mask uses fit well also addressed

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms. I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems. He first mentioned that he has neck pain. He states that he has had this for at least 15 years. It is worse with movement. It has progressed very slowly over the course of 15 years. It is localized to the base of his neck and is sharp in quality. He also endorses a history of gait instability. This has been present for a few years and has been slightly progressively worsening. He describes that he feels unsteady on his feet and "walks like a duck." He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet. When I asked him to describe this in more detail, the numbness is actually restricted to his toes. Left is slightly more affected than the right. He denies any tingling or paresthesias. He also described that he is slowly losing control of his hands. He thinks that he is dropping objects due to weakness or incoordination in his hands. This has also been occurring for the past one to two years. He has noticed that buttoning his clothes is more difficult for him. He also does not have any numbness or tingling in the hands. He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome. He did not even mention this on the initial part of my history taking. When I asked him to describe this further, he states that he experiences a general exhaustion. He basically lays in bed all day everyday. I asked him if he was depressed, he states that he is treated for depression. He is unsure if this is optimally treated. As I just mentioned, he stays in bed almost all day long and does not engage in any social activities. He does not think that he is necessarily sad. His appetite is good. He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past. I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago. He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago. He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes. He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation. He also saw Dr. Z for neurosurgical consultation a couple of weeks ago. He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years. He also has had hypercholesterolemia. He has had Crohn's disease for 25 or 30 years. He has had a colostomy for four years. He has arthritis, which is reportedly related to the Crohn's disease. He has hypertension and coronary artery disease and is status post stent placement. He has depression. He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:, He previously worked with pipeline work, but has been on disability for five years. He is unsure which symptoms led him to go on disability. He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago. He denies alcohol or illicit drug use. He lives with his wife. He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49. His mother died in her 70s from complications of congestive heart failure. He has one sister who died during a cardiac surgery two years ago. He has another sister with diabetes. He has one daughter with hypercholesterolemia. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion. He states that he was evaluated by a pulmonologist and had a normal evaluation. He has occasional night sweats. His hearing is poor. He occasionally develops bloody stools, which he attributes to his Crohn's disease. He also was diagnosed with sleep apnea. He does not wear his CPAP machine on a regular basis. He has a history of anemia. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance: He is well appearing in no acute distress. He has somewhat of a flat affect.,Cardiovascular: He has a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.,Chest: The lungs are clear to auscultation bilaterally.,Skin: There are no rashes or lesions.,Musculoskeletal: He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status: His speech is fluent without dysarthria or aphasia. He is alert and oriented to name, place, and date. Attention, concentration, and fund of knowledge are intact. He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Visual fields are full. Optic discs are normal. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.,Motor: He has normal muscle bulk and tone. There is no atrophy. He has few fasciculations in his calf muscles bilaterally. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities. There is no action or percussion myotonia or paramyotonia.,Sensory: He has absent vibratory sensation at the left toe. This is diminished at the right toe. Joint position sense is intact. There is diminished sensation to light touch and temperature at the feet to the knees bilaterally. Pinprick is intact. Romberg is absent. There is no spinal sensory level.,Coordination: This is intact by finger-nose-finger or heel-to-shin testing. He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes: They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles. Plantar reflexes are flexor. There is no ankle clonus, finger flexors, or Hoffman's signs. He has crossed adductors bilaterally.,Gait and Stance: He has a slightly wide-based gait. He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk. He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08: Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal. Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast: Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08: Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves. He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial. He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy. He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea. Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1. I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2. I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3. I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4. I believe that he needs to undergo psychotherapy for his depression. It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist. The patient is very open about proceeding with this suggestion.,5. He does need to have his sleep apnea better controlled. He states that he is not compliant because the face mask that he uses does not fit him well. This should also be addressed. ### Response: Consult - History and Phy., Neurology

HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. This most likely is secondary to tertiary contractions with some delayed emptying. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months. She has had a previous DVT in 1975 and 1985. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP: 117/78. RR: 18. P: 93.,WT: 186 lbs. RAS: 100%.,HEENT: Mucous membranes are moist. No cervical or supraclavicular lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIAC: Regular rate and rhythm without murmurs.,EXTREMITIES: No cyanosis, clubbing or edema.,NEURO: Alert and oriented x3. Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN: ,She is to return to clinic in six months with a chest CT. She was given a prescription for an ultrasound of the left lower extremity to rule out DVT. She will be called with the results. She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.

history present illness patient yearold female underwent left upper lobectomy stage ia nonsmall cell lung cancer returns routine surveillance visitshe undergone since last visit abdominopelvic ct shows enlarging simple cyst left kidney underwent barium swallow demonstrates small sliding hiatal hernia minimal reflux minimal delayed emptying secondary tertiary contractions pa lateral chest xray also reviewed demonstrates lesions infiltrates review systems patient continues periodic odynophagia mid thoracic dysphagia likely secondary tertiary contractions delayed emptying also increased size left calf without tenderness resolved past several months previous dvt denies weight loss anorexia fevers chills headaches new aches pains cough hemoptysis shortness breath rest dyspnea exertionmedications aspirin mg po qd spiriva mcg qd albuterol prnphysical examination bp rr p wt lbs ras heent mucous membranes moist cervical supraclavicular lymphadenopathylungs clear auscultation bilaterallycardiac regular rate rhythm without murmursextremities cyanosis clubbing edemaneuro alert oriented x cranial nerves ii xii intactassessment patient evidence disease status post left upper lobectomy stage ia nonsmall cell lung cancer months agoplan return clinic six months chest ct given prescription ultrasound left lower extremity rule dvt called results given prescription nifedipine mg po tid prn esophageal spasm

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. This most likely is secondary to tertiary contractions with some delayed emptying. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months. She has had a previous DVT in 1975 and 1985. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP: 117/78. RR: 18. P: 93.,WT: 186 lbs. RAS: 100%.,HEENT: Mucous membranes are moist. No cervical or supraclavicular lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIAC: Regular rate and rhythm without murmurs.,EXTREMITIES: No cyanosis, clubbing or edema.,NEURO: Alert and oriented x3. Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN: ,She is to return to clinic in six months with a chest CT. She was given a prescription for an ultrasound of the left lower extremity to rule out DVT. She will be called with the results. She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm. ### Response: Cardiovascular / Pulmonary, SOAP / Chart / Progress Notes

HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call 911, which she did. While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain. By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months. She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia. I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker. However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room. On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80% mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area. The decision was made to transfer her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel. She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08. She had some left arm discomfort on 08/18/08, but this was mild. Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin. This is her usual angina. She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1. Detrol LA 2 mg once a day.,2. Prilosec for GERD 20 mg once a day.,3. Glucosamine 500/400 mg once a day for arthritis.,4. Multivitamin p.o. daily.,5. Nitroglycerin sublingual as available to her.,6. Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7. Aspirin 325 mg once a day.,8. Plavix 75 mg once a day.,9. Diovan 160 mg once a day.,10. Claritin 10 mg once a day for allergic rhinitis.,11. Norvasc 5 mg once a day.,12. Lipitor 5 mg once a day.,13. Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE. SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY: ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs. She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:, She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. She has moist mucosal membranes.,NECK: Veins are not distended. There are no carotid bruits.,LUNGS: Clear to auscultation and percussion without wheezes.,HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced.,ABDOMEN: Soft and nondistended. Bowel sounds present.,EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. BUN 16 and creatinine 0.9. Glucose 110. Magnesium 2.5. ALT 107 and AST 65 and these were normal on 08/15/08. INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. Aspirin, Plavix, valsartan, Lipitor, and Norvasc. I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes. All this was discussed in detail with the patient and her daughter who expressed understanding and agreement. The patient desires full resuscitation status.

history present illness patient yearold woman following angina case today called recurrent left arm pain stent three days ago persisted two sublingual nitroglycerin spoke advised call waiting attended physician neighbor advised take third nitroglycerin apparently relieved pain time presented currently painfree feeling wellpast cardiac history patient arm pain several months underwent exercise stress echocardiogram within last several months equivocal nuclear stress test showed inferobasilar ischemia originally advised heart catheterization wanted medical therapy put betablocker however arm pain symptoms accelerated jaw pain presented emergency room ended cardiac catheterization showed normal left main mid lad lesion circumflex normal rca totally occluded mid portion collaterals left right well right right area decision made transfer may collateral insufficiency lad stenosis rca vessel underwent drugeluting stents believe three four total placed discharged left arm discomfort mild yesterday felt fatigued arm pain today arm pain walking resolved completely three sublingual nitroglycerin usual angina admitted unstable angina post stentpast medical history longstanding hypertension cad hyperlipidemia overactive bladdermedications detrol la mg day prilosec gerd mg day glucosamine mg day arthritis multivitamin po daily nitroglycerin sublingual available toprolxl mg day started although bradycardic seems tolerating aspirin mg day plavix mg day diovan mg day claritin mg day allergic rhinitis norvasc mg day lipitor mg day evista mg dayallergies allergies medications none denies shrimp sea food allergyfamily history father died mi brother first mi bypass surgery social history smoke cigarettes abuse alcohol use illicit drugs divorced lives alone retired laboratory technician cornell diagnostic laboratoryreview systems denies history stroke cancer vomiting blood coughing blood bright red blood per rectum bleeding stomach ulcers renal calculi cholelithiasis asthma emphysema pneumonia tuberculosis home oxygen use sleep apnea although told past snores question apnea morning headaches fatigue psychiatric diagnosis psoriasis lupus remainder review systems negative x systems except described abovephysical examinationgeneral pleasant elderly woman currently acute distressvital signs height feet inches weight pounds temperature degrees fahrenheit blood pressure pulse respiratory rate saturation heent cranium normocephalic atraumatic moist mucosal membranesneck veins distended carotid bruitslungs clear auscultation percussion without wheezesheart regular rate significant murmurs rubs gallops pmi nondisplacedabdomen soft nondistended bowel sounds presentextremities without significant clubbing cyanosis edema pulses grossly intact bilateral groins inspected status post right femoral artery used access diagnostic cardiac catheterization left femoral artery used pci evidence hematoma bruit intact distal pulseslaboratory data ekg reviewed shows sinus bradycardia rate beats per minute acute diseasesodium potassium chloride bicarbonate bun creatinine glucose magnesium alt ast normal inr ptt white blood cell count hematocrit platelet count impression plan patient yearold woman exertional angina characterized arm pain underwent recent left anterior descending percutaneous coronary intervention recurrence arm pain post stenting left anterior descending artery may continuing collateral insufficiency right coronary artery case given unstable presentation requiring three sublingual nitroglycerin even pain free going admit hospital currently evidence requiring acute reperfusion therapy continue betablocker cannot increase dose bradycardic already aspirin plavix valsartan lipitor norvasc going add imdur watch headaches apparently nitro paste rule mi although little suspicion suppose possible noncardiac arm pain seems less likely nitrate responsive seems exertionally related possibility may end needing put pacemaker maximize betablocker use antianginal effect concern persistent right coronary artery ischemia helped left anterior descending percutaneous coronary intervention severely stenotic normal lv function continue glucosamine arthritis claritin allergies detrol la urinary incontinencetotal patient care time emergency department minutes discussed detail patient daughter expressed understanding agreement patient desires full resuscitation status

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call 911, which she did. While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain. By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months. She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia. I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker. However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room. On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80% mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area. The decision was made to transfer her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel. She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08. She had some left arm discomfort on 08/18/08, but this was mild. Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin. This is her usual angina. She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1. Detrol LA 2 mg once a day.,2. Prilosec for GERD 20 mg once a day.,3. Glucosamine 500/400 mg once a day for arthritis.,4. Multivitamin p.o. daily.,5. Nitroglycerin sublingual as available to her.,6. Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7. Aspirin 325 mg once a day.,8. Plavix 75 mg once a day.,9. Diovan 160 mg once a day.,10. Claritin 10 mg once a day for allergic rhinitis.,11. Norvasc 5 mg once a day.,12. Lipitor 5 mg once a day.,13. Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE. SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY: ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs. She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:, She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. She has moist mucosal membranes.,NECK: Veins are not distended. There are no carotid bruits.,LUNGS: Clear to auscultation and percussion without wheezes.,HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced.,ABDOMEN: Soft and nondistended. Bowel sounds present.,EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. BUN 16 and creatinine 0.9. Glucose 110. Magnesium 2.5. ALT 107 and AST 65 and these were normal on 08/15/08. INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. Aspirin, Plavix, valsartan, Lipitor, and Norvasc. I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes. All this was discussed in detail with the patient and her daughter who expressed understanding and agreement. The patient desires full resuscitation status. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy., Emergency Room Reports

HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. The patient and her husband live in ABC but they have family in XYZ. She came to our office today as she is in the area visiting her family. She complains of having shortness of breath for the past month that has been increasingly getting worse. She developed a frequent nonproductive cough about 2 weeks ago. She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath. She has also gained about 15 pounds in the past few months and has significant peripheral edema. In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY: ,The patient is married. Lives with her husband. They are retired from ABC.,MEDICATIONS:,1. Plavix 75 mg p.o. daily.,2. Aspirin 81 mg p.o. daily.,3. Isosorbide mononitrate 60 mg p.o. daily.,4. Colace 100 mg p.o. b.i.d.,5. Atenolol 50 mg p.o. daily.,6. Lantus insulin 15 units subcutaneously every evening.,7. Protonix 40 mg p.o. daily.,8. Furosemide 40 mg p.o. daily.,9. Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Positive for generalized fatigue and malaise.,HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing.,ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms.,NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC: Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact.,CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs.,EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish.,RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded.,ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated.,GENITOURINARY: Deferred.,MUSCULOSKELETAL: Adequate range of motion along with extremities.,SKIN: Warm and dry. No lesions or ulcerations are noted.,NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits.,PSYCHIATRIC: Normal affect.,IMPRESSION,1. Coronary artery disease.

history present illness patient yearold woman history coronary artery disease coronary artery bypass grafting x percutaneous coronary intervention stenting x also significant history chronic renal insufficiency severe copd patient husband live abc family xyz came office today area visiting family complains shortness breath past month increasingly getting worse developed frequent nonproductive cough weeks ago also episodes paroxysmal nocturnal dyspnea awaking middle night panicking dyspnea shortness breath also gained pounds past months significant peripheral edema office obviously dyspnea speaking word sentencespast medical history coronary artery disease anemia secondary chronic renal insufficiency stage iv chronic kidney disease diabetic nephropathy hypertension hyperlipidemia copd insulindependent diabetes mild mitral valve regurgitation severe tricuspid valve regurgitation sick sinus syndrome gastritis heparininduced thrombocytopeniapast surgical history status post pacemaker implantation status post cabg x status post cabg x status post pca stenting x left anterior descending artery cholecystectomy back surgery bladder surgery colonic polypectomiessocial history patient married lives husband retired abcmedications plavix mg po daily aspirin mg po daily isosorbide mononitrate mg po daily colace mg po bid atenolol mg po daily lantus insulin units subcutaneously every evening protonix mg po daily furosemide mg po daily norvasc mg po dailyallergies allergic heparin agents cause heparininduced thrombocytopeniareview systemsconstitutional positive generalized fatigue malaisehead neck negative diplopia blurred vision visual disturbances hearing loss tinnitus epistaxis vertigo sinusitis gum oral lesionscardiovascular positive epigastric discomfort x weeks negative palpitations syncope nearsyncopal episodes chest pressure chest painrespiratory positive dyspnea rest paroxysmal nocturnal dyspnea orthopnea frequent nonproductive cough negative wheezingabdomen negative abdominal pain bloating nausea vomiting constipation melena hematemesisgenitourinary negative dysuria polyuria hematuria incontinencemusculoskeletal negative recent trauma stiffness deformities muscular weakness atrophyskin negative rashes petechiae hair nail changes positive easy bruising forearmsneurologic negative paralysis paresthesias dysphagia dysarthriapsychiatric negative depression anxiety mood swingsall systems reviewed negativephysical examinationvital signs blood pressure office heart rate respiratory rate saturations room air height inches weighs pounds bmi constitutional yearold woman significant distress shortness breath dyspnea restheent eyes pupils reactive sclera nonicteric ears nose mouth throatneck supple lymphadenopathy thyromegaly swallow intactcardiovascular positive jvd degrees heart tones distant murmursextremities edema feet ankles bilaterally extends knees femoral pulses weakly palpable posterior tibial pulses palpable capillary refill somewhat sluggishrespiratory breath sounds clear bilateral basilar diminishment rales wheezing speaking word sentences diaphragmatic excursions limited ap diameter expandedabdomen soft nontender active bowel sounds x quadrants hepatosplenomegaly masses appreciatedgenitourinary deferredmusculoskeletal adequate range motion along extremitiesskin warm dry lesions ulcerations notedneurologic alert oriented x head normocephalic atraumatic focal motor sensory deficitspsychiatric normal affectimpression coronary artery disease

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. The patient and her husband live in ABC but they have family in XYZ. She came to our office today as she is in the area visiting her family. She complains of having shortness of breath for the past month that has been increasingly getting worse. She developed a frequent nonproductive cough about 2 weeks ago. She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath. She has also gained about 15 pounds in the past few months and has significant peripheral edema. In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY: ,The patient is married. Lives with her husband. They are retired from ABC.,MEDICATIONS:,1. Plavix 75 mg p.o. daily.,2. Aspirin 81 mg p.o. daily.,3. Isosorbide mononitrate 60 mg p.o. daily.,4. Colace 100 mg p.o. b.i.d.,5. Atenolol 50 mg p.o. daily.,6. Lantus insulin 15 units subcutaneously every evening.,7. Protonix 40 mg p.o. daily.,8. Furosemide 40 mg p.o. daily.,9. Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Positive for generalized fatigue and malaise.,HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing.,ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms.,NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC: Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact.,CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs.,EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish.,RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded.,ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated.,GENITOURINARY: Deferred.,MUSCULOSKELETAL: Adequate range of motion along with extremities.,SKIN: Warm and dry. No lesions or ulcerations are noted.,NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits.,PSYCHIATRIC: Normal affect.,IMPRESSION,1. Coronary artery disease. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable pattern. She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. While working on a computer, she had a spell. Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse. She does have a couple of sodas and at least one to two coffees daily. She is a nonsmoker. She is a mother of two. There is no family history of congenital heart disease. She has had no history of thoracic trauma. No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia. Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals. No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable. No evidence of myocardial injury. Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period. Outpatient workup would be appropriate. Event recorder should be obtained and the patient can be seen again in the office upon completion of that study. Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation. We will be happy to follow her both during this hospitalization and following discharge. Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5. CT scan showed no evidence of pulmonary embolus. Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,

history present illness patient charming delightful yearold woman admitted palpitations presyncopethe patient active previously healthy young woman nine years occasional palpitations symptoms occur three four times per year follow identifiable pattern put thought effort trying identify precipitating factors circumstances unable symptoms last hour feels heart going rapidly never measured heart rate last two episodes recent yesterday associated feeling darkness descending shade pulled front vision neither occasion lose consciousnessyesterday modestly active morning taking walk dogs performing normal routines working computer spell palpitations persisted short time thereafter outlined hospitals admission note prompting seek evaluation hospital sinus rhythm arrival asymptomatic sinceno history exogenous substance abuse alcohol abuse caffeine abuse couple sodas least one two coffees daily nonsmoker mother two family history congenital heart disease history thoracic trauma symptoms suggest thyroid diseaseno known history diabetes hypertension dyslipidemia family history negative ischemic heart diseaseremote history significant acl repair complicated contact urticaria neoprene castno regular medications prior admissionthe allergy neoprene reaction outlined abovephysical examination vital signs charted pupils reactive sclerae nonicteric mucous membranes moist neck veins distended bruits lungs clear cardiac exam regular without murmurs gallops rubs abdomen soft without guarding rebound masses bruits extremities well perfused edema strong symmetrical distal pulsesa lead ekg shows sinus rhythm normal axis intervals evidence preexcitationlaboratory studies unremarkable evidence myocardial injury thyroid function pendingtwodimensional echocardiogram shows evidence clinically significant structural functional heart diseaseimpressionplan episodic palpitations nineyear period outpatient workup would appropriate event recorder obtained patient seen office upon completion study suppressive medication betablocker cardizem discussed patient symptomatic improvement though would unlikely curative therapy patient expresses preference avoid medical therapy possiblethank consultation happy follow hospitalization following discharge caffeine avoidance discussed welladdendum initial evaluation ddimer mildly elevated ct scan showed evidence pulmonary embolus lower extremity venous ultrasound pending however absence embolization pulmonary vasculature would unlikely cause palpitations addition progression nineyear period symptomatic suggests unlikely cause

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable pattern. She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. While working on a computer, she had a spell. Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse. She does have a couple of sodas and at least one to two coffees daily. She is a nonsmoker. She is a mother of two. There is no family history of congenital heart disease. She has had no history of thoracic trauma. No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia. Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals. No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable. No evidence of myocardial injury. Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period. Outpatient workup would be appropriate. Event recorder should be obtained and the patient can be seen again in the office upon completion of that study. Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation. We will be happy to follow her both during this hospitalization and following discharge. Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5. CT scan showed no evidence of pulmonary embolus. Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause., ### Response: Cardiovascular / Pulmonary, Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time, she complains of pain and instability in the knee. The patient's past medical history is significant for having had an ACL injury to the knee in 2008. She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008. The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:, She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008. She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY: ,The patient is single. She is a full-time student at University. Uses no tobacco, alcohol, or illicit drugs. She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS: ,Significant for recent weight gain, occasional skin rashes. The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL: The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES: She ambulates with some difficulty with a marked limp on the right side. Inspection of the knee reveals a significant effusion in the knee. She has difficulty with passive range of motion of the knee secondary to pain. She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR: She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft. In the meantime, she will continue to use ice as needed. Moderate her activities and use crutches. She will follow up as soon as the MRI is performed.

history present illness patient yearold girl brought father today evaluation right knee injury states approximately days ago playing tennis noncontact injury injured right knee immediate pain swelling time complains pain instability knee patients past medical history significant acl injury knee underwent anterior cruciate ligament reconstruction dr x time subsequently year developed laxity graft due part noncompliance subsequently sought attention dr performed revision acl reconstruction end patient states rehabbed knee well fine good stability knee recent injurypast medical history claims chronic illnessespast surgical history anterior cruciate ligament reconstruction subsequently revision acl reconstruction also arm surgery years oldmedications takes medications regular basisallergies allergic keflex skin sensitivity steristripssocial history patient single fulltime student university uses tobacco alcohol illicit drugs exercises weekly mainly tennis swellingreview systems significant recent weight gain occasional skin rashes remainder systems negativephysical examinationgeneral patient foot inches tall weighs poundsextremities ambulates difficulty marked limp right side inspection knee reveals significant effusion knee difficulty passive range motion knee secondary pain tenderness palpation medial joint line positive lachmans examneurovascular neurovascularly intactimpression right knee injury suggestive recurrent anterior cruciate ligament tear possible internal derangementplan patient referred mri right knee evaluate integrity revision acl graft meantime continue use ice needed moderate activities use crutches follow soon mri performed

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time, she complains of pain and instability in the knee. The patient's past medical history is significant for having had an ACL injury to the knee in 2008. She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008. The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:, She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008. She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY: ,The patient is single. She is a full-time student at University. Uses no tobacco, alcohol, or illicit drugs. She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS: ,Significant for recent weight gain, occasional skin rashes. The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL: The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES: She ambulates with some difficulty with a marked limp on the right side. Inspection of the knee reveals a significant effusion in the knee. She has difficulty with passive range of motion of the knee secondary to pain. She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR: She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft. In the meantime, she will continue to use ice as needed. Moderate her activities and use crutches. She will follow up as soon as the MRI is performed. ### Response: Consult - History and Phy., Orthopedic

HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1. Multivitamin p.o. daily.,2. Aspirin 325 mg once a day.,3. Lisinopril 40 mg once a day.,4. Felodipine 10 mg once a day.,5. Klor-Con 20 mEq p.o. b.i.d.,6. Omeprazole 20 mg p.o. daily presumably for GERD.,7. MiraLax 17 g p.o. daily.,8. Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:, She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM: ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION: ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.

history present illness patient yearold woman history hypertension severe tricuspid regurgitation mild pulmonary hypertension mild aortic stenosis previously moderate mitral regurgitation although seen recently asked perform cardiology consultation concern atrial fibrillation fall basically patient states yesterday fell certain circumstances driveway left side hit rock came emergency room found rapid atrial tachyarrhythmia put cardizem reportedly heart rate stopped review ekgs time shows appears multifocal atrial tachycardia followup ekg showing wandering atrial pacemaker ecg morning showing normal sinus rhythm frequent apcs potassium time recall palpitations pain fall states since prior denies chest pain shortness breath prior since fall states clearly walk would able climb flights stairs without problemspast cardiac history followed dr x office history severe tricuspid regurgitation mild elevation pa pressure preserved left right ventricular systolic function aortic sclerosis apparent mild aortic stenosis biatrial enlargement previously persantine myoview nuclear reststress test scan completed abcd medical center negative significant mitral valve regurgitation past moderate recent echocardiogram felt significant history hypertension ekgs office show normal sinus rhythm frequent apcs versus wandering atrial pacemaker history significant hypertension past dizzy spells denies clearly true syncope bradycardia past betablocker therapymedications admission multivitamin po daily aspirin mg day lisinopril mg day felodipine mg day klorcon meq po bid omeprazole mg po daily presumably gerd miralax g po daily lasix mg po dailyallergies penicillin listed toprol caused shortness breath office chart believe significant bradycardia pastfamily history states brother died mi suddenly ssocial history smoke cigarettes abuse alcohol use illicit drugs retired morse chain delivering newspapers widowed lives alone family members live either property adjacent itreview systems denies history stroke cancer vomiting blood coughing blood bright red blood per rectum bleeding stomach ulcers recall renal calculi cholelithiasis denies asthma emphysema pneumonia tuberculosis sleep apnea home oxygen use note occasional peripheral edema aware prior history mi denies diabetes history gerd notes feeling depressed times living alone denies rheumatologic conditions including psoriasis lupus remainder review systems negative times except described abovephysical exam height feet inches weight pounds temperature degrees fahrenheit blood pressure ranged pulses recorded currently ranges pulse respiratory rate saturation general exam pleasant elderly woman hard hearing alert interactive heent shows cranium normocephalic atraumatic moist mucosal membranes neck veins distended carotid bruits lungs clear auscultation anteriorly without wheezes relatively immobile left hip fracture cardiac exam regular rate frequent ectopic beats systolic ejection murmur preserved aortic component second heart sound also soft holosystolic murmur heard rub gallop pmi nondisplaced abdomen soft nondistended bowel sounds present extremities without significant clubbing cyanosis trivial peripheral edema pulses appear grossly intact affect appropriate visible skin warm perfused able move left hip fracture easily beddiagnostic studieslab data pertinent labs include chest xray radiology report pending shows calcified aortic knob clear pulmonary vascular congestion sodium potassium admission chloride bicarbonate bun creatinine glucose magnesium troponin followed inr white blood cell count hematocrit platelet count ekgs reviewed initial ekg done shows mat heart rate beats per minute ischemic changes followup ekg done shows wandering atrial pacemaker lateral twave changes significantly changed prior followup ekg done morning shows normal sinus rhythm frequent apcsimpression yearold female history hypertension severe tricuspid regurgitation mild pulmonary hypertension mild aortic stenosis admitted fall left hip fracture require surgery telemetry reviewed shows predominantly normal sinus rhythm frequent apcs _____ earlier yesterday evening showed burst multifocal atrial tachycardia suspect exacerbated prior hypokalemia corrected atrial fibrillation documented feel troponins significant given stress fall prior multifocal atrial tachycardia increased rate especially absence chest pain shortness breath actually describes feeling good exercise capacity prior fall given favorable risk benefit ratio needed left hip surgery feel may proceed needed left hip surgery cardiac standpoint continued verapamil started help control multifocal atrial tachycardia would watch heart rate continued optimization electrolytes patient cannot take betablockers previously toprol reportedly caused shortness breath although report caused bradycardia would watch heart rate verapamil patient aware cardiac risks certainly moderate wishes proceed needed surgery feel cardiac evaluation needed time patient may followup dr x discharge regarding mild thrombocytopenia would defer hospitalist continue proton pump inhibitors history gastroesophageal reflux disease management left hip fracture per orthopedist

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1. Multivitamin p.o. daily.,2. Aspirin 325 mg once a day.,3. Lisinopril 40 mg once a day.,4. Felodipine 10 mg once a day.,5. Klor-Con 20 mEq p.o. b.i.d.,6. Omeprazole 20 mg p.o. daily presumably for GERD.,7. MiraLax 17 g p.o. daily.,8. Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:, She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM: ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION: ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy., Emergency Room Reports, General Medicine

HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker. Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle. He also has a fairly advanced degree of Alzheimer's dementia and is living in an assisted care facility. The patient is unable to make his own health care decision and his daughter ABC has medical power of attorney. The patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her. For this reason the Casa Grande Regional Medical Center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated. Furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,PAST MEDICAL HISTORY:,1. Sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2. Dementia of Alzheimer's disease.,3. Gastroesophageal reflux disease.,4. Multiple pacemaker implantation and exchanges.,FAMILY HISTORY: , Unobtainable.,SOCIAL HISTORY: , The patient resides full time at ABC supervised living facility. He is nonsmoker, nondrinker. He uses wheelchair and moves himself about with his feet. He is independent of activities of daily living and dependent on independent activities of daily living.,ALLERGIES TO MEDICATIONS: , No known drug allergies.,MEDICATIONS: ,Omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,REVIEW OF SYSTEMS: , A 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes. Negative for recent falls. Positive for significant memory loss. All other review of systems is negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,VITAL SIGNS: Blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,HEENT: Head atraumatic and normocephalic. Eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy, thyromegaly, or thyroid masses appreciated.,CARDIOVASCULAR: No JVD or no jugular venous distention. No carotid bruits bilaterally. Pacemaker pocket right upper thorax with healed surgical incisions. S1 and S2 are normal. No S3 or S4. There are no murmurs. No heaves or thrills, gout, or gallops. Trace edema at dorsum of his feet and ankles. Femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,RESPIRATORY: Breath sounds are clear but diminished throughout AP diameters expanded. The patient speaks in full sentences. No wheezing, no accessory muscles used for breathing.,GASTROINTESTINAL: Abdomen is soft and nontender. Bowel sounds are active in all 4 quadrants. No palpable pulses. No abdominal bruit is appreciated. No hepatosplenomegaly.,GENITOURINARY: Nonfocal.,MUSCULOSKELETAL: Muscle strength in lower extremities is 4/5 bilaterally. Upper extremities are 5/5 bilaterally with adequate range of motion.,SKIN: Warm and dry. No obvious rashes, lesions, or ulcerations. ,NEUROLOGIC: Alert, not oriented to place and date. His speech is clear. There are no focal motor or sensory deficits.,PSYCHIATRIC: Talkative, pleasant affect with limited impulse control, severe short-term memory loss.,LABORATORY DATA:, Blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000. BUN 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,DIAGNOSTIC DATA:, St. Jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and VVIR mode, implant date 08/2000, 100% paced in right ventricle, battery status is ERI. A 12-lead ECG 12/15/08 shows 100% paced rhythm with rate of 80. No Q waves at the baseline of atrial fibrillation. Last measured ejection fraction 40% 12/08 with no significant decompensation.,IMPRESSION/PLAN:,1. Sick sinus syndrome.,2. Atrial fibrillation.,3. Pacemaker dependent.,4. Mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5. Pacemaker battery end of life requiring exchange.,6. Dementia of Alzheimer's disease with short and long term memory dysfunction. The dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care. Dementia also renders the patient incapable informed consent, schedule the patient for pacemaker. I explain the patient and reimplantation with any device in the surgical suite. He will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7. Admit the patient after surgery for postoperative care and monitoring.

history present illness patient yearold gentleman history sick sinus syndrome st jude permanent pacemaker pacemaker battery reached end life patient dependent pacemaker pacing right ventricle also fairly advanced degree alzheimers dementia living assisted care facility patient unable make health care decision daughter abc medical power attorney patients dementia resulted patients sufficient chronic anger daughter refuses speak refuses room reason casa grande regional medical center would obtain surgical anesthesia consent patients daughter fashion keeps patient daughter separated furthermore important note degree dementia disabled patient adequately self monitor status following surgery significant changes seek appropriate medical care hence admitted pacemaker exchangepast medical history sick sinus syndrome pacemaker dependence right ventricular pacing dementia alzheimers disease gastroesophageal reflux disease multiple pacemaker implantation exchangesfamily history unobtainablesocial history patient resides full time abc supervised living facility nonsmoker nondrinker uses wheelchair moves feet independent activities daily living dependent independent activities daily livingallergies medications known drug allergiesmedications omeprazole mg po daily furosemide mg po daily citalopram mg po daily loratadine mg po prnreview systems systems review negative chest pain pressure shortness breath paroxysmal nocturnal dyspnea orthopnea syncope nearsyncopal episodes negative recent falls positive significant memory loss review systems negativephysical examinationgeneral patient yearold gentleman acute distress sitting wheelchairvital signs blood pressure pulse regular respirations weight pounds oxygen saturation room airheent head atraumatic normocephalic eyes pupils equal reactive light accommodate bilaterally free focal lesions ears nose mouth throatneck supple lymphadenopathy thyromegaly thyroid masses appreciatedcardiovascular jvd jugular venous distention carotid bruits bilaterally pacemaker pocket right upper thorax healed surgical incisions normal murmurs heaves thrills gout gallops trace edema dorsum feet ankles femoral pulses present without bruits posterior tibial pulses would palpable bilaterallyrespiratory breath sounds clear diminished throughout ap diameters expanded patient speaks full sentences wheezing accessory muscles used breathinggastrointestinal abdomen soft nontender bowel sounds active quadrants palpable pulses abdominal bruit appreciated hepatosplenomegalygenitourinary nonfocalmusculoskeletal muscle strength lower extremities bilaterally upper extremities bilaterally adequate range motionskin warm dry obvious rashes lesions ulcerations neurologic alert oriented place date speech clear focal motor sensory deficitspsychiatric talkative pleasant affect limited impulse control severe shortterm memory losslaboratory data blood work dated white count hemoglobin hematocrit platelets bun creatinine glucose potassium sodium calcium diagnostic data st jude pacemaker interrogation dated shows single chamber pacemaker vvir mode implant date paced right ventricle battery status eri lead ecg shows paced rhythm rate q waves baseline atrial fibrillation last measured ejection fraction significant decompensationimpressionplan sick sinus syndrome atrial fibrillation pacemaker dependent mild cardiomyopathy ejection fraction significant decompensation pacemaker battery end life requiring exchange dementia alzheimers disease short long term memory dysfunction dementia disables patient recognizing changes health status knowing needed seek appropriate health care dementia also renders patient incapable informed consent schedule patient pacemaker explain patient reimplantation device surgical suite require anesthesia assistance adequate sedation patient possesses behavioral risk secondary advanced dementia admit patient surgery postoperative care monitoring

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker. Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle. He also has a fairly advanced degree of Alzheimer's dementia and is living in an assisted care facility. The patient is unable to make his own health care decision and his daughter ABC has medical power of attorney. The patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her. For this reason the Casa Grande Regional Medical Center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated. Furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,PAST MEDICAL HISTORY:,1. Sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2. Dementia of Alzheimer's disease.,3. Gastroesophageal reflux disease.,4. Multiple pacemaker implantation and exchanges.,FAMILY HISTORY: , Unobtainable.,SOCIAL HISTORY: , The patient resides full time at ABC supervised living facility. He is nonsmoker, nondrinker. He uses wheelchair and moves himself about with his feet. He is independent of activities of daily living and dependent on independent activities of daily living.,ALLERGIES TO MEDICATIONS: , No known drug allergies.,MEDICATIONS: ,Omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,REVIEW OF SYSTEMS: , A 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes. Negative for recent falls. Positive for significant memory loss. All other review of systems is negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,VITAL SIGNS: Blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,HEENT: Head atraumatic and normocephalic. Eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy, thyromegaly, or thyroid masses appreciated.,CARDIOVASCULAR: No JVD or no jugular venous distention. No carotid bruits bilaterally. Pacemaker pocket right upper thorax with healed surgical incisions. S1 and S2 are normal. No S3 or S4. There are no murmurs. No heaves or thrills, gout, or gallops. Trace edema at dorsum of his feet and ankles. Femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,RESPIRATORY: Breath sounds are clear but diminished throughout AP diameters expanded. The patient speaks in full sentences. No wheezing, no accessory muscles used for breathing.,GASTROINTESTINAL: Abdomen is soft and nontender. Bowel sounds are active in all 4 quadrants. No palpable pulses. No abdominal bruit is appreciated. No hepatosplenomegaly.,GENITOURINARY: Nonfocal.,MUSCULOSKELETAL: Muscle strength in lower extremities is 4/5 bilaterally. Upper extremities are 5/5 bilaterally with adequate range of motion.,SKIN: Warm and dry. No obvious rashes, lesions, or ulcerations. ,NEUROLOGIC: Alert, not oriented to place and date. His speech is clear. There are no focal motor or sensory deficits.,PSYCHIATRIC: Talkative, pleasant affect with limited impulse control, severe short-term memory loss.,LABORATORY DATA:, Blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000. BUN 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,DIAGNOSTIC DATA:, St. Jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and VVIR mode, implant date 08/2000, 100% paced in right ventricle, battery status is ERI. A 12-lead ECG 12/15/08 shows 100% paced rhythm with rate of 80. No Q waves at the baseline of atrial fibrillation. Last measured ejection fraction 40% 12/08 with no significant decompensation.,IMPRESSION/PLAN:,1. Sick sinus syndrome.,2. Atrial fibrillation.,3. Pacemaker dependent.,4. Mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5. Pacemaker battery end of life requiring exchange.,6. Dementia of Alzheimer's disease with short and long term memory dysfunction. The dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care. Dementia also renders the patient incapable informed consent, schedule the patient for pacemaker. I explain the patient and reimplantation with any device in the surgical suite. He will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7. Admit the patient after surgery for postoperative care and monitoring. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. Actually the night before, he fell off his wheelchair and had lacerations on the face. As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then. The patient's wife is not able to give a history. The patient has not been getting Sinemet and his other home medications in the last 2 days. ,PAST MEDICAL HISTORY: ,Parkinson disease.,MEDICATIONS:, Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL:

history present illness patient yearold male brought ems complaint decreased level consciousness patient apparently lives wife found decreased status since last one day patient actually seen emergency room night injuries face possible elderly abuse adult protective services actually went patients house found decreased consciousness whole day wife actually night fell wheelchair lacerations face per wife states patient given entire mg xanax rather mg xanax decreased mental status since patients wife able give history patient getting sinemet home medications last days past medical history parkinson diseasemedications requip neurontin sinemet ambien xanaxallergies known drug allergiessocial history patient lives wifephysical examinationgeneral

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. Actually the night before, he fell off his wheelchair and had lacerations on the face. As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then. The patient's wife is not able to give a history. The patient has not been getting Sinemet and his other home medications in the last 2 days. ,PAST MEDICAL HISTORY: ,Parkinson disease.,MEDICATIONS:, Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL: ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria. He was treated on IV antibiotics, Dr. XYZ also saw the patient. Discharged home. Not taking any antibiotics. Today in the office, the patient denies any dysuria, gross hematuria, fever, chills. He is catheterizing 3 times a day, changing his catheter weekly. Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids. Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space. Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X. No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION: ,1. Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2. Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system. He is asymptomatic today. No complaints today.,PLAN:, Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above. Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so. He will call if any concerns. Follow up as previously scheduled in September for re-assessment. All questions answered. The patient is seen and evaluated by myself.

history present illness patient presents today consultation dr abcs office regarding history neurogenic bladder intermittent selfcatheterization times day however june seen er fever weakness possible urosepsis blood culture positive staphylococcus epidermidis well urine culture noted bacteria treated iv antibiotics dr xyz also saw patient discharged home taking antibiotics today office patient denies dysuria gross hematuria fever chills catheterizing times day changing catheter weekly history renal transplant followed dr x chronic steroids renal ultrasound june noted mild hydronephrosis renal transplant fluid pericapsular space creatinine july bun patient tells followed dr x interval complaints today issues catheterization gross hematuriaimpression neurogenic bladder patient catheterizing times day changing catheter times week reviewed technique catheterization issues recurrent urinary tract infection patient hospitalized twice within last months steroids renal transplant likely overall reducing immune system asymptomatic today complaints todayplan following detailed discussion patient elected proceed intermittent selfcatheterization changing catheter weekly technique discussed based recent culture place keflex nighttime prophylaxis next three months call concerns follow previously scheduled september reassessment questions answered patient seen evaluated

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day. However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis. He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria. He was treated on IV antibiotics, Dr. XYZ also saw the patient. Discharged home. Not taking any antibiotics. Today in the office, the patient denies any dysuria, gross hematuria, fever, chills. He is catheterizing 3 times a day, changing his catheter weekly. Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids. Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space. Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X. No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION: ,1. Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2. Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system. He is asymptomatic today. No complaints today.,PLAN:, Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above. Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so. He will call if any concerns. Follow up as previously scheduled in September for re-assessment. All questions answered. The patient is seen and evaluated by myself. ### Response: Consult - History and Phy., Urology

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He was seen a few weeks ago for routine followup, and he was noted for microhematuria. Due to his history of kidney stone, renal ultrasound as well as IVP was done. He presents today for followup. He denies any dysuria, gross hematuria or flank pain issues. Last stone episode was over a year ago. No history of smoking. Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis. IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis. The calcification previously noted on the ureter appears to be outside the course of the ureter. Otherwise unremarkable. This is discussed.,IMPRESSION: ,1. A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. The patient is asymptomatic. We have discussed surgical intervention versus observation. He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2. Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future. Urine sent for culture and sensitivity.,PLAN: , As above. The patient will follow up for cystoscopy, urine sent for cytology, continue hydration. Call if any concern. The patient is seen and evaluated by myself.

history present illness patient presents today consultation dr abcs office regarding seen weeks ago routine followup noted microhematuria due history kidney stone renal ultrasound well ivp done presents today followup denies dysuria gross hematuria flank pain issues last stone episode year ago history smoking daytime frequency nocturia good stream empties well incontinencecreatinine june ua time noted rbcs renal ultrasound revealed mm left intrarenal stone hydronephrosis ivp day revealed calcification left kidney without bilateral hydronephrosis calcification previously noted ureter appears outside course ureter otherwise unremarkable discussedimpression mm left intrarenal stone nonobstructing ultrasound ivp patient asymptomatic discussed surgical intervention versus observation indicates stone bothersome prefers observation need hydration goal making liters urine within hours discussed microhematuria discussed possible etiologies patient agreeable cystoscopy near future urine sent culture sensitivityplan patient follow cystoscopy urine sent cytology continue hydration call concern patient seen evaluated

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He was seen a few weeks ago for routine followup, and he was noted for microhematuria. Due to his history of kidney stone, renal ultrasound as well as IVP was done. He presents today for followup. He denies any dysuria, gross hematuria or flank pain issues. Last stone episode was over a year ago. No history of smoking. Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis. IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis. The calcification previously noted on the ureter appears to be outside the course of the ureter. Otherwise unremarkable. This is discussed.,IMPRESSION: ,1. A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. The patient is asymptomatic. We have discussed surgical intervention versus observation. He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2. Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future. Urine sent for culture and sensitivity.,PLAN: , As above. The patient will follow up for cystoscopy, urine sent for cytology, continue hydration. Call if any concern. The patient is seen and evaluated by myself. ### Response: Consult - History and Phy., Urology

HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg. He indicates that he has noticed some mild improvement of his symptoms, with no side effect. On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes. No chest pain, no nitroglycerin usage, no fever, no chills. No dysuria, gross hematuria, fever, chills. Daytime frequency every three hours, nocturia times 0, good stream. He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate. PSA 11.6. Dr. X's notes are reviewed.,IMPRESSION: ,1. Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects. The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time. We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2. Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate. The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy. However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed. The patient not to use them at the same time. Will call if any other concern. In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy. He declined scheduling this at this time. All questions answered.

history present illness patient presents today followup history erectile dysfunction last visit started cialis mg indicates noticed mild improvement symptoms side effect dose firm erection able penetrate lasting minutes chest pain nitroglycerin usage fever chills dysuria gross hematuria fever chills daytime frequency every three hours nocturia times good stream history elevated psa biopsy june year noted high grade pin mid left biopsy two specimens small evaluate psa dr xs notes reviewedimpression improvement erectile dysfunction low dose cialis side effects patient multiple risk factors denies using nitroglycerin cardiac issues time reviewed options increasing medication versus trying medications options penile prosthesis caverject injection use well working pump reviewed elevated psa patient recent biopsy showing highgrade pin well two specimens large enough evaluate patient tells met primary care physician discussion consideration repeating prostate ultrasound biopsy however would like meet dr x discuss prior biopsyplan following detailed discussion patient wishes proceed cialis mg samples provided well levitra mg may increase mg understand administration contraindication well potential side effects reviewed patient use time call concern meantime scheduled meet dr x prior psa consideration possible repeating prostate ultrasound biopsy declined scheduling time questions answered

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg. He indicates that he has noticed some mild improvement of his symptoms, with no side effect. On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes. No chest pain, no nitroglycerin usage, no fever, no chills. No dysuria, gross hematuria, fever, chills. Daytime frequency every three hours, nocturia times 0, good stream. He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate. PSA 11.6. Dr. X's notes are reviewed.,IMPRESSION: ,1. Some improvement of erectile dysfunction, on low dose of Cialis, with no side effects. The patient has multiple risk factors, but denies using any nitroglycerin or any cardiac issues at this time. We reviewed options of increasing the medication, versus trying other medications, options of penile prosthesis, Caverject injection use as well as working pump is reviewed.,2. Elevated PSA in a patient with a recent biopsy showing high-grade PIN, as well as two specimens not being large enough to evaluate. The patient tells me he has met with his primary care physician and after discussion, he is in consideration of repeating a prostate ultrasound and biopsy. However, he would like to meet with Dr. X to discuss these prior to biopsy.,PLAN: , Following detailed discussion, the patient wishes to proceed with Cialis 20 mg, samples are provided as well as Levitra 10 mg, may increase this to 20 mg and understand administration of each and contraindication as well as potential side effects are reviewed. The patient not to use them at the same time. Will call if any other concern. In the meantime, he is scheduled to meet with Dr. X, with a prior PSA in consideration of a possible repeating prostate ultrasound and biopsy. He declined scheduling this at this time. All questions answered. ### Response: SOAP / Chart / Progress Notes, Urology

HISTORY OF PRESENT ILLNESS: , The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0. No incontinence. No straining to urinate. Good stream, emptying well. No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION: ,1. The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2. Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily. She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention. All questions answered.

history present illness patient presents today followup dysuria gross hematuria fever chills continues urinary incontinence especially changing sitting standing position well urge incontinence voiding daytime every hour morning especially taking lasix tapers afternoon nocturia time incontinence straining urinate good stream emptying well bowel issues however also indicates using vaginal cream difficulty feels protrusion vagina concerned prolapseimpression patient noted improving retention urine postop vaginal reconstruction concerned possible vaginal prolapse especially using cream rule ascites gi issues lower extremity edemaplan following detailed discussion patient elected proceed continued flomax wean urecholine two times daily follow next week request dr x pelvic exam meantime obtain ct abdomen pelvis evaluate cause abdominal distention questions answered

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0. No incontinence. No straining to urinate. Good stream, emptying well. No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION: ,1. The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2. Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily. She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention. All questions answered. ### Response: SOAP / Chart / Progress Notes, Urology

HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. His urinary function had been stable until 2 days ago. Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks). His libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional. The bowel function is stable with occasional irritative hemorrhoidal symptoms. He has had no hematochezia. The PSA has been slowly rising in recent months. This month it reached 1.2.,PAIN ASSESSMENT: , Abdominal cramping in the past 2 days. No more than 1 to 2 of 10 in intensity.,PERFORMANCE STATUS: , Karnofsky score 100. He continues to work full-time.,NUTRITIONAL STATUS: , Appetite has been depressed over the past couple of days, and he has lost about 5 pounds. (Per him, mostly this week.),PSYCHIATRIC: , Some stress regarding upcoming IRS audits of clients.,REVIEW OF SYSTEMS: , Otherwise noncontributory.,MEDICATIONS,1. NyQuil.,2. Timolol eye drops.,3. Aspirin.,4. Advil.,5. Zinc.,PHYSICAL EXAMINATION,GENERAL: Pleasant, well-developed, gentleman in no acute distress. Weight is 197 pounds.,HEENT: Sclerae and conjunctivae are clear. Extraocular movement are intact. Hearing is grossly intact. The oral cavity is without thrush. There is minor pharyngitis.,LYMPH NODES: No palpable lymphadenopathy.,SKELETAL: No focal skeletal tenderness.,LUNGS: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft, nontender without palpable mass or organomegaly.,DIGITAL RECTAL EXAMINATION: There are external hemorrhoids. The prostate fossa is flat without suspicious nodularity. There is no blood on the examining glove.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: Without focal deficit.,IMPRESSION:, Concerning slow ongoing rise in PSA.,PLAN: , Discussed significance of this in detail with the patient. He understands the probability that there may be residual cancer although the location is unknown. For now there is no good evidence that early management affects the ultimate prognosis. Accordingly, he is comfortable with careful monitoring, and I have asked him to return here in 3 months with an updated PSA. I also suggested that he reestablish contact with Dr. X at his convenience.

history present illness patient returns followup evaluation months undergoing prostate fossa irradiation recurrent gleason adenocarcinoma urinary function stable days ago past couple days waking every hours associated abdominal cramping well bit sore throat wife cold weeks libido remains intact sexually functional erections dysfunctional bowel function stable occasional irritative hemorrhoidal symptoms hematochezia psa slowly rising recent months month reached pain assessment abdominal cramping past days intensityperformance status karnofsky score continues work fulltimenutritional status appetite depressed past couple days lost pounds per mostly weekpsychiatric stress regarding upcoming irs audits clientsreview systems otherwise noncontributorymedications nyquil timolol eye drops aspirin advil zincphysical examinationgeneral pleasant welldeveloped gentleman acute distress weight poundsheent sclerae conjunctivae clear extraocular movement intact hearing grossly intact oral cavity without thrush minor pharyngitislymph nodes palpable lymphadenopathyskeletal focal skeletal tendernesslungs clear auscultation bilaterallycardiovascular regular rate rhythmabdomen soft nontender without palpable mass organomegalydigital rectal examination external hemorrhoids prostate fossa flat without suspicious nodularity blood examining gloveextremities without clubbing cyanosis edemaneurologic without focal deficitimpression concerning slow ongoing rise psaplan discussed significance detail patient understands probability may residual cancer although location unknown good evidence early management affects ultimate prognosis accordingly comfortable careful monitoring asked return months updated psa also suggested reestablish contact dr x convenience

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma. His urinary function had been stable until 2 days ago. Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks). His libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional. The bowel function is stable with occasional irritative hemorrhoidal symptoms. He has had no hematochezia. The PSA has been slowly rising in recent months. This month it reached 1.2.,PAIN ASSESSMENT: , Abdominal cramping in the past 2 days. No more than 1 to 2 of 10 in intensity.,PERFORMANCE STATUS: , Karnofsky score 100. He continues to work full-time.,NUTRITIONAL STATUS: , Appetite has been depressed over the past couple of days, and he has lost about 5 pounds. (Per him, mostly this week.),PSYCHIATRIC: , Some stress regarding upcoming IRS audits of clients.,REVIEW OF SYSTEMS: , Otherwise noncontributory.,MEDICATIONS,1. NyQuil.,2. Timolol eye drops.,3. Aspirin.,4. Advil.,5. Zinc.,PHYSICAL EXAMINATION,GENERAL: Pleasant, well-developed, gentleman in no acute distress. Weight is 197 pounds.,HEENT: Sclerae and conjunctivae are clear. Extraocular movement are intact. Hearing is grossly intact. The oral cavity is without thrush. There is minor pharyngitis.,LYMPH NODES: No palpable lymphadenopathy.,SKELETAL: No focal skeletal tenderness.,LUNGS: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft, nontender without palpable mass or organomegaly.,DIGITAL RECTAL EXAMINATION: There are external hemorrhoids. The prostate fossa is flat without suspicious nodularity. There is no blood on the examining glove.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: Without focal deficit.,IMPRESSION:, Concerning slow ongoing rise in PSA.,PLAN: , Discussed significance of this in detail with the patient. He understands the probability that there may be residual cancer although the location is unknown. For now there is no good evidence that early management affects the ultimate prognosis. Accordingly, he is comfortable with careful monitoring, and I have asked him to return here in 3 months with an updated PSA. I also suggested that he reestablish contact with Dr. X at his convenience. ### Response: SOAP / Chart / Progress Notes, Urology

HISTORY OF PRESENT ILLNESS: , This 40-year-old white single man was hospitalized at XYZ Hospital in the mental health ward, issues were filled up by his sister and his mother. The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother. He has been in outpatient therapy with Jeffrey Silverberg for the past 10 years and Mr. Silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office.,The history includes the fact that the patient is the 3rd of 4 children. A brother who is approximately 8 years older, sexually abused brother who is 4 years older. The brother who is 8 years older lives in California and will contact the family, has had minimal contact for many years.,That brother in California is gay. The brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis. He said, he told his mother several years ago, but she did nothing about it.,The patient finished high school and with some struggle completed college at the University of Houston. He has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion. She has been concerned about patient's behavior and was instrumental in having him committed.,Reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened.,He had no or minimal psychiatric treatment growing up and after completing college worked in retail part time.,He states he injured his back about 10 yeas ago. He told he had disk problems but never had surgery. He subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself.,He has been on a variety of different medications including Celexa 40 mg and ADD medication different times, and reportedly has used amphetamines in the past, although he denies it at this time. He minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed.,He has never been psychiatrically hospitalized before.,MENTAL STATUS EXAMINATION:, Revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family's commitment. He says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother's wife what had happened. The brother has a child and wife became very upset with him.,Normocephalic. Pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded. His affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times.,Recent past memory were intact.,DIAGNOSES:,Axis I: Major depression rule out substance abuse.,Axis II: Deferred at this time.,Axis III: Noncontributory.,Axis IV: Family financial and social pressures.,Axis V: Global Assessment of Functioning 40.,RECOMMENDATION:, The patient will be hospitalized to assess.,Along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree. He says he has had several part time jobs, but never been able to sustain employment, although he would like to.

history present illness yearold white single man hospitalized xyz hospital mental health ward issues filled sister mother issues involved include fact last years disability psychiatric reasons working last several weeks month began call family talking fact sexually abused brother outpatient therapy jeffrey silverberg past years mr silverberg became concerned behavior called family told put hospital one point called police patient throwing cellphones tantrums officethe history includes fact patient rd children brother approximately years older sexually abused brother years older brother years older lives california contact family minimal contact many yearsthat brother california gay brother years older sexually abused patient age regular basis said told mother several years ago nothing itthe patient finished high school struggle completed college university houston sister approximately year half younger sexually abused brothers one occasion concerned patients behavior instrumental committedreportedly patient ran away home age abuse able tell family happenedhe minimal psychiatric treatment growing completing college worked retail part timehe states injured back yeas ago told disk problems never surgery subsequently put psychiatric disability depression states unable get bed times isolates keeps himselfhe variety different medications including celexa mg add medication different times reportedly used amphetamines past although denies time minimizes alcohol use appears problem appear problem isolates stays home situations brings people know well runs risk getting physically harmedhe never psychiatrically hospitalized beforemental status examination revealed somewhat disheveled yearold man clearly quite depressed somewhat shocked familys commitment says seen regular basis every time sees feels hurt acknowledged called brother abused told brothers wife happened brother child wife became upset himnormocephalic pleasant cooperative disheveled man thoughts somewhat guarded affect anxious depressed denied suicidal although family said talked timesrecent past memory intactdiagnosesaxis major depression rule substance abuseaxis ii deferred timeaxis iii noncontributoryaxis iv family financial social pressuresaxis v global assessment functioning recommendation patient hospitalized assessalong issues fact living disability fact family support time despite fact college degree says several part time jobs never able sustain employment although would like

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This 40-year-old white single man was hospitalized at XYZ Hospital in the mental health ward, issues were filled up by his sister and his mother. The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother. He has been in outpatient therapy with Jeffrey Silverberg for the past 10 years and Mr. Silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office.,The history includes the fact that the patient is the 3rd of 4 children. A brother who is approximately 8 years older, sexually abused brother who is 4 years older. The brother who is 8 years older lives in California and will contact the family, has had minimal contact for many years.,That brother in California is gay. The brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis. He said, he told his mother several years ago, but she did nothing about it.,The patient finished high school and with some struggle completed college at the University of Houston. He has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion. She has been concerned about patient's behavior and was instrumental in having him committed.,Reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened.,He had no or minimal psychiatric treatment growing up and after completing college worked in retail part time.,He states he injured his back about 10 yeas ago. He told he had disk problems but never had surgery. He subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself.,He has been on a variety of different medications including Celexa 40 mg and ADD medication different times, and reportedly has used amphetamines in the past, although he denies it at this time. He minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed.,He has never been psychiatrically hospitalized before.,MENTAL STATUS EXAMINATION:, Revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family's commitment. He says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother's wife what had happened. The brother has a child and wife became very upset with him.,Normocephalic. Pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded. His affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times.,Recent past memory were intact.,DIAGNOSES:,Axis I: Major depression rule out substance abuse.,Axis II: Deferred at this time.,Axis III: Noncontributory.,Axis IV: Family financial and social pressures.,Axis V: Global Assessment of Functioning 40.,RECOMMENDATION:, The patient will be hospitalized to assess.,Along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree. He says he has had several part time jobs, but never been able to sustain employment, although he would like to. ### Response: Consult - History and Phy.

HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **. Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. The baby was vertex presentation. The baby was dried, stimulated, and bulb suctioned. Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:, The mother is a **-year-old, G**, P** female with blood type **. She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative. Mother was group B strep **. Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:, Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS: Temperature **, heart rate **, respiratory rate **. Dextrose stick **. Ballard score by the RN is ** weeks. Birth weight is ** grams, which is the ** percentile for gestational age. Length is ** centimeters which is ** percentile for gestational age. Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL: **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT: Anterior fontanelle open and flat. Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags. Nares patent. Palate intact. Mucous membranes moist.,NECK: Full range of motion.,CARDIOVASCULAR: Normal precordium, regular rate and rhythm. No murmurs. Normal femoral pulses.,RESPIRATORY; Clear to auscultation bilaterally. No retractions.,ABDOMEN: Soft, nondistended. Normal bowel sounds. No hepatosplenomegaly. Umbilical stump is clean, dry, and intact.,GENITOURINARY: Normal tanner I **. Anus patent.,MUSCULOSKELETAL: Negative Barlow and Ortolani. Clavicles intact. Spine straight. No sacral dimple or hair tuft. Leg lengths grossly symmetric. Five fingers on each hand and five toes on each foot.,SKIN: Warm and pink with brisk capillary refill. No jaundice.,NEUROLOGICAL: Normal tone. Normal root, suck, grasp, and Moro reflexes. Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:, **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1. Routine newborn care.,2. Anticipatory guidance.,3. Hepatitis B immunization prior to discharge.,

history present illness week gestational age delivered gestational age determined last menstrual period consistent trimester ultrasound rupture membranes occurred prior delivery amniotic fluid clear baby vertex presentation baby dried stimulated bulb suctioned apgar scores one minute five minutespast medical historymaternal history mother yearold g p female blood type rubella immune hepatitis surface antigen negative rpr nonreactive hiv negative mother group b strep mothers past medical history prenatal care mother began prenatal care trimester least documented prenatal visits smoke drink alcohol use illicit drugs pregnancysurgical history medications medications taken pregnancy allergies family history social history physical examinationvital signs temperature heart rate respiratory rate dextrose stick ballard score rn weeks birth weight grams percentile gestational age length centimeters percentile gestational age head circumference centimeters percentile gestational agegeneral alert active nondysmorphicappearing infant acute distressheent anterior fontanelle open flat positive bilateral red reflexesears normal shape position pits tags nares patent palate intact mucous membranes moistneck full range motioncardiovascular normal precordium regular rate rhythm murmurs normal femoral pulsesrespiratory clear auscultation bilaterally retractionsabdomen soft nondistended normal bowel sounds hepatosplenomegaly umbilical stump clean dry intactgenitourinary normal tanner anus patentmusculoskeletal negative barlow ortolani clavicles intact spine straight sacral dimple hair tuft leg lengths grossly symmetric five fingers hand five toes footskin warm pink brisk capillary refill jaundiceneurological normal tone normal root suck grasp moro reflexes moves extremities equallydiagnostic studieslaboratory data assessment full term appropriate gestational age plan routine newborn care anticipatory guidance hepatitis b immunization prior discharge

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **. Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. The baby was vertex presentation. The baby was dried, stimulated, and bulb suctioned. Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:, The mother is a **-year-old, G**, P** female with blood type **. She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative. Mother was group B strep **. Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:, Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS: Temperature **, heart rate **, respiratory rate **. Dextrose stick **. Ballard score by the RN is ** weeks. Birth weight is ** grams, which is the ** percentile for gestational age. Length is ** centimeters which is ** percentile for gestational age. Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL: **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT: Anterior fontanelle open and flat. Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags. Nares patent. Palate intact. Mucous membranes moist.,NECK: Full range of motion.,CARDIOVASCULAR: Normal precordium, regular rate and rhythm. No murmurs. Normal femoral pulses.,RESPIRATORY; Clear to auscultation bilaterally. No retractions.,ABDOMEN: Soft, nondistended. Normal bowel sounds. No hepatosplenomegaly. Umbilical stump is clean, dry, and intact.,GENITOURINARY: Normal tanner I **. Anus patent.,MUSCULOSKELETAL: Negative Barlow and Ortolani. Clavicles intact. Spine straight. No sacral dimple or hair tuft. Leg lengths grossly symmetric. Five fingers on each hand and five toes on each foot.,SKIN: Warm and pink with brisk capillary refill. No jaundice.,NEUROLOGICAL: Normal tone. Normal root, suck, grasp, and Moro reflexes. Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:, **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1. Routine newborn care.,2. Anticipatory guidance.,3. Hepatitis B immunization prior to discharge., ### Response: Consult - History and Phy., General Medicine, Pediatrics - Neonatal

HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:, None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:, None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES: ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single. He is a student. He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL: The patient denies weight loss/gain, fever, chills.,ENMT: The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV: The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY: The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI: The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU: The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS: The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO: The patient had a loss of consciousness during the accident. He does not recall the details of the accident. Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH: Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY: Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air. The patient shows moderate obesity.,NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click or rub. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 3+ bilaterally, without audible bruits. Extremities show no edema or varicosities.,GASTROINTESTINAL: No palpable tenderness or masses. Liver and spleen are percussed but not palpable under the costal margins. No evidence for umbilical or groin herniae.,LYMPHATIC: No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL: Normal gait and station. The patient is on a stretcher. Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN: There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees. No induration or subcutaneous nodules to palpation.,NEUROLOGIC: Normal sensation by touch. The patient moves all four extremities.,PSYCHIATRIC: Oriented to time, place, and person. Appropriate mood and affect.,LABORATORY DATA: Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1. Concussion.,2. Facial abrasion.,3. Scalp laceration.,4. Knee abrasions.,PLANS/RECOMMENDATIONS:, Admitted for observation.

history present illness yearold male admitted emergency department fell bicycle wearing helmet hours ago loss consciousness patient complains neck painchronicinactive conditions nonepersonalfamilysocial historyillnesses noneprevious injuries minormedications noneprevious operations noneallergies none knownfamily history negative heart disease hypertension obesity diabetes cancer strokesocial history patient single student smoke drink alcohol consume drugsreview systemsconstitutional patient denies weight lossgain fever chillsenmt patient denies headaches nosebleeds voice changes blurry vision changes inloss visioncv patient denies chest pain sob supine palpitations edema varicose veins leg painsrespiratory patient denies sob wheezing sputum production bloody sputum coughgi patient denies heartburn blood stools loss appetite abdominal pain constipationgu patient denies painfulburning urination cloudydark urine flank pain groin painms patient denies joint painstiffness backaches tendonligamentsmuscle painsstrains bone achespains muscle weaknessneuro patient loss consciousness accident recall details accident otherwise negative blackouts seizures loss memory hallucinations weakness numbness tremors paralysispsych negative anxiety irritability apathy depression sleep disturbances appetite disturbances suicidal thoughtsintegumentary negative unusual hair lossbreakage skin lesionsdiscoloration unusual nail breakagediscolorationphysical examinationconstitutional blood pressure pulse rate respirations temperature saturation room air patient shows moderate obesityneck neck symmetric trachea midline masses crepitus palpated thyroid palpable enlarged smooth moves swallowing palpable massesrespirations normal respiratory effort intercostal retraction action accessory muscles normal breath sounds bilaterally rhonchi wheezing rubscardiovascular pmi palpable ics mcl thrills palpation easily audible audible murmur click rub abdominal aorta palpable audible abdominal bruits femoral pulses bilaterally without audible bruits extremities show edema varicositiesgastrointestinal palpable tenderness masses liver spleen percussed palpable costal margins evidence umbilical groin herniaelymphatic nodes mm neck axillae groinsmusculoskeletal normal gait station patient stretcher symmetric muscle strength normal tone without signs atrophy abnormal movementsskin hematoma forehead one occipital scalp abrasions upper extremities abrasions knees induration subcutaneous nodules palpationneurologic normal sensation touch patient moves four extremitiespsychiatric oriented time place person appropriate mood affectlaboratory data reviewed chest xray normal right hand xray normal mri head normaldiagnoses concussion facial abrasion scalp laceration knee abrasionsplansrecommendations admitted observation

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:, None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:, None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES: ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single. He is a student. He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL: The patient denies weight loss/gain, fever, chills.,ENMT: The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV: The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY: The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI: The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU: The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS: The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO: The patient had a loss of consciousness during the accident. He does not recall the details of the accident. Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH: Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY: Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air. The patient shows moderate obesity.,NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click or rub. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 3+ bilaterally, without audible bruits. Extremities show no edema or varicosities.,GASTROINTESTINAL: No palpable tenderness or masses. Liver and spleen are percussed but not palpable under the costal margins. No evidence for umbilical or groin herniae.,LYMPHATIC: No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL: Normal gait and station. The patient is on a stretcher. Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN: There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees. No induration or subcutaneous nodules to palpation.,NEUROLOGIC: Normal sensation by touch. The patient moves all four extremities.,PSYCHIATRIC: Oriented to time, place, and person. Appropriate mood and affect.,LABORATORY DATA: Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1. Concussion.,2. Facial abrasion.,3. Scalp laceration.,4. Knee abrasions.,PLANS/RECOMMENDATIONS:, Admitted for observation. ### Response: Consult - History and Phy., Emergency Room Reports

HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia. He comes to the emergency room on his own with 3-day history of back pain. He is on no medicines. He does live with a room mate. Appetite is decreased. No diarrhea, vomiting. Voiding well. Bowels have been regular. Denies any abdominal pain. Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine. The patient is not sure of his immunizations. The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid. None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute, respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL: He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT: Normal.,NECK: Supple.,CHEST: Clear.,HEART: Regular.,ABDOMEN: Soft. He has pain over the mid to lower spine.,SKIN: Color is normal.,EXTREMITIES: He moves all extremities well.,NEUROLOGIC: Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids. Also that he will get morphine and Benadryl combination. The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour. CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4. Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect. The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m. He received morphine 5 mg and Benadryl 25 mg. I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning. He stated that he has a job interview in the morning. The resident service did come to evaluate him. The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration. He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION: ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.

history present illness yearold known male sickle cell anemia comes emergency room day history back pain medicines live room mate appetite decreased diarrhea vomiting voiding well bowels regular denies abdominal pain complains slight headaches main concern back ache extends lower tspine lumbosacral spine patient sure immunizations patient sickle cell hemoglobin followed hematology clinicallergies patient allergic tylenol codeine states get morphine along benadrylmedications previously folic acid none present timepast surgical history surgeries pastfamily history positive diabetes hypertension cancersocial history denies smoking drug usagephysical examination vital signs examination patient temp degrees tympanic pulse recorded per minute subsequently noted per minute respiratory rate per minute blood pressure recheck blood pressure general alert speaks full sentences appear distressheent normalneck supplechest clearheart regularabdomen soft pain mid lower spineskin color normalextremities moves extremities wellneurologic age appropriateer course indicated patient drawing labs giving iv fluids also get morphine benadryl combination patient ordered liter ns hour maintained halfnormal saline hour cbc done showed white blood cells hemoglobin gdl hematocrit platelets segs lymphs monos chemistries done essentially normal except total bilirubin mgdl indirect patient initially received morphine diphenhydramine repeated pm received morphine mg benadryl mg subsequently spoke dr x decided admit patientthe patient initially stated wanted observed er given pain control fluids wanted go home morning stated job interview morning resident service come evaluate resident service spoke dr x decided admit hematology service control pain iv hydration transitioned po medications hopefully discharged time make interview tomorrowimpression sickle cell crisisdifferential diagnosis venoocclusive crisis diskitis

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia. He comes to the emergency room on his own with 3-day history of back pain. He is on no medicines. He does live with a room mate. Appetite is decreased. No diarrhea, vomiting. Voiding well. Bowels have been regular. Denies any abdominal pain. Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine. The patient is not sure of his immunizations. The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid. None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute, respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL: He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT: Normal.,NECK: Supple.,CHEST: Clear.,HEART: Regular.,ABDOMEN: Soft. He has pain over the mid to lower spine.,SKIN: Color is normal.,EXTREMITIES: He moves all extremities well.,NEUROLOGIC: Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids. Also that he will get morphine and Benadryl combination. The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour. CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4. Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect. The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m. He received morphine 5 mg and Benadryl 25 mg. I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning. He stated that he has a job interview in the morning. The resident service did come to evaluate him. The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration. He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION: ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis. ### Response: Emergency Room Reports, Hematology - Oncology

HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging. She was doing well until about 2 days ago, when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rectal bleeding. She was brought to the Hospital with some loose stool. She was found to be dehydrated. She was given IV fluid bolus, but then she started bleeding from G-tube site. There was some fresh blood coming out of the G-tube site. She was transferred to PICU. She is hypertensive. Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007. Right above knee amputation.,ALLERGIES:, None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:, Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000. KUB showed large stool with dilated small and large bowel loops. Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1. Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000. PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL: She is intubated.,HEENT: Atraumatic. She is intubated.,LUNGS: Good air entry bilaterally. No rales or wheezing.,ABDOMEN: Distended. Decreased bowel sounds.,GENITALIA: Grossly normal female.,CNS: She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy. She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN: ,Plan is to give vitamin K, FFP, blood transfusion. Consider upper endoscopy. Procedure and informed consent discussed with the family.

history present illness yearold female patient admitted today history gagging well days ago developed gagging vomiting fever history constipation normally passes stool every two days giving enema rectal bleeding brought hospital loose stool found dehydrated given iv fluid bolus started bleeding gtube site fresh blood coming gtube site transferred picu hypertensive intensivist dr x requested come look upper endoscopy find site bleedingpast medical history peho syndrome infantile spasm right knee amputation developmental delay gtube fundoplicationpast surgical history gtube fundoplication right knee amputationallergies nonediet npo home pediasure ounces times day gtube ounces water per daymedications albuterol pulmicort miralax g week carnitine phenobarbital depakene reglanfamily history positive cancerpast laboratory evaluation wbc hemoglobin hematocrit platelet kub showed large stool dilated small large bowel loops sodium potassium chloride co bun creatinine ast increased alt increased albumin total bilirubin earlier morning hemoglobin hematocrit platelets pt increased inr increased ptt increasedphysical examination vital signs temperature degrees fahrenheit pulse per minute respirations per minute weight kggeneral intubatedheent atraumatic intubatedlungs good air entry bilaterally rales wheezingabdomen distended decreased bowel soundsgenitalia grossly normal femalecns sedatedimpression yearold female patient history passage blood gtube site coagulopathy history gtube fundoplication developmental delay peho syndrome progressive encephalopathy optic atrophyplan plan give vitamin k ffp blood transfusion consider upper endoscopy procedure informed consent discussed family

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging. She was doing well until about 2 days ago, when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rectal bleeding. She was brought to the Hospital with some loose stool. She was found to be dehydrated. She was given IV fluid bolus, but then she started bleeding from G-tube site. There was some fresh blood coming out of the G-tube site. She was transferred to PICU. She is hypertensive. Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007. Right above knee amputation.,ALLERGIES:, None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:, Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000. KUB showed large stool with dilated small and large bowel loops. Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1. Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000. PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL: She is intubated.,HEENT: Atraumatic. She is intubated.,LUNGS: Good air entry bilaterally. No rales or wheezing.,ABDOMEN: Distended. Decreased bowel sounds.,GENITALIA: Grossly normal female.,CNS: She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy. She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN: ,Plan is to give vitamin K, FFP, blood transfusion. Consider upper endoscopy. Procedure and informed consent discussed with the family. ### Response: Consult - History and Phy., Gastroenterology, Pediatrics - Neonatal

HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia.,PAST MEDICAL HISTORY:, Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use. The patient is currently employed.,FAMILY HISTORY:, Unremarkable.,PHYSICAL EXAMINATION:,GENERAL: This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS: Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.,HEENT: Funduscopic examination normal. He has oral thrush.,LYMPH: He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK: No goiter, no jugular venous distention.,CHEST: Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART: Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN: Soft and nontender.,GENITOURINARY: Normal.,RECTAL: Unremarkable.,SKIN: The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8. Hemoglobin 14, white count 7100, platelet count 515. Total protein 10, albumin 3.1, AST 131, ALT 31. Urinalysis shows 1+ protein, trace blood. Total bilirubin 2.4, direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room air. Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1. Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2. Thrush.,3. Elevated unconjugated bilirubins.,4. Hepatitis.,5. Elevated globulin fraction.,6. Renal insufficiency.,7. Subcutaneous nodules.,8. Risky sexual behavior in 1982 in Haiti.,PLAN:,1. Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2. Begin intravenous Bactrim and erythromycin.,3. Begin prednisone.,4. Oxygen.,5. Nystatin swish and swallow.,6. Dermatologic biopsy of lesions.,7. Check HIV and RPR.,8. Administer Pneumovax, tetanus shot and Heptavax if indicated.

history present illness yearold black man apparent past medical history presented emergency room chief complaint weakness malaise dyspnea exertion approximately one month patient also reports pound weight loss denies fever chills sweats denies cough diarrhea mild anorexiapast medical history essentially unremarkable except chest wall cysts apparently biopsied dermatologist past given benign diagnosis recent ppd negative august medications noneallergies known drug allergiessocial history occasionally drinks nonsmoker patient participated homosexual activity haiti described active denies intravenous drug use patient currently employedfamily history unremarkablephysical examinationgeneral thin black cachectic man speaking full sentences oxygenvital signs blood pressure heart rate change orthostatics temperature degrees fahrenheit respirations heent funduscopic examination normal oral thrushlymph marked adenopathy including right bilateral epitrochlear posterior cervical nodesneck goiter jugular venous distentionchest bilateral basilar crackles egophony right left middle lung fieldsheart regular rate rhythm murmur rub gallopabdomen soft nontendergenitourinary normalrectal unremarkableskin patient multiple subcutaneous mobile nodules chest wall nontender pale palms laboratory xray data sodium potassium bun creatinine hemoglobin white count platelet count total protein albumin ast alt urinalysis shows protein trace blood total bilirubin direct bilirubin arterial blood gases ph pc p room air electrocardiogram shows normal sinus rhythm chest xray shows bilateral alveolar interstitial infiltratesimpression bilateral pneumonia suspect atypical pneumonia rule pneumocystis carinii pneumonia tuberculosis thrush elevated unconjugated bilirubins hepatitis elevated globulin fraction renal insufficiency subcutaneous nodules risky sexual behavior haitiplan induced sputum rule pneumocystis carinii pneumonia tuberculosis begin intravenous bactrim erythromycin begin prednisone oxygen nystatin swish swallow dermatologic biopsy lesions check hiv rpr administer pneumovax tetanus shot heptavax indicated

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia.,PAST MEDICAL HISTORY:, Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use. The patient is currently employed.,FAMILY HISTORY:, Unremarkable.,PHYSICAL EXAMINATION:,GENERAL: This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS: Blood pressure 96/56, heart rate 120. No change with orthostatics. Temperature 101.6 degrees Fahrenheit. Respirations 30.,HEENT: Funduscopic examination normal. He has oral thrush.,LYMPH: He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK: No goiter, no jugular venous distention.,CHEST: Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART: Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN: Soft and nontender.,GENITOURINARY: Normal.,RECTAL: Unremarkable.,SKIN: The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8. Hemoglobin 14, white count 7100, platelet count 515. Total protein 10, albumin 3.1, AST 131, ALT 31. Urinalysis shows 1+ protein, trace blood. Total bilirubin 2.4, direct bilirubin 0.1. Arterial blood gases: pH 7.46, pC02 32, p02 46 on room air. Electrocardiogram shows normal sinus rhythm. Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1. Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2. Thrush.,3. Elevated unconjugated bilirubins.,4. Hepatitis.,5. Elevated globulin fraction.,6. Renal insufficiency.,7. Subcutaneous nodules.,8. Risky sexual behavior in 1982 in Haiti.,PLAN:,1. Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2. Begin intravenous Bactrim and erythromycin.,3. Begin prednisone.,4. Oxygen.,5. Nystatin swish and swallow.,6. Dermatologic biopsy of lesions.,7. Check HIV and RPR.,8. Administer Pneumovax, tetanus shot and Heptavax if indicated. ### Response: Consult - History and Phy., General Medicine

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

history present illness yearold black male stage iv chronic kidney disease likely secondary hiv nephropathy presents clinic followup missed prior clinic appointments last seen clinic dr x first time met patient patients history renal insufficiency dates back hospitalized hivassociated complication unclear exact reason hospitalization time diagnosed renal insufficiency followed renal clinic approximately one year baseline creatinine time initially diagnosed renal insufficiency noncompliant haart regimen since time compliant treatment hiv seeing dr infectious disease clinic currently threedrug antiretroviral therapy last cd count hiv complications since last seen clinic patient also followed dr z outpatient va clinic abcd although seen approximately one year patient av fistula placed late latest blood work shows serum creatinine represents gfr potassium laboratories drawn infectious disease doctor results prompted recommendation return clinic evaluation complaint patient time difficulty sleeping given ambien primary care doctor helped significantly difficulty sleeping says trouble getting sleep ambien allow sleep two hours awake tired day taking daytime naps history excessive snoring apneic periods history falling asleep work driving never formal sleep study continue work sales local butcher shopreview systems denies change appetite actually gained weight recent months denies nausea vomiting abdominal discomfort denies pruritus denies lower extremity edema systems reviewed negativepast medical history stage iv chronic kidney disease recent gfr hiv diagnosed recent cd count hyperlipidemia hypertension secondary hyperparathyroidism status post right upper extremity av fistula fall history right brachial plexus palsy recent lower back pain status post lumbar steroid injectionallergies says vitamin caused headachesmedications kaletra daily epivir one daily ziagen two daily lasix mg bid valsartan mg bid ambien mg qhssocial history lives abcd employed sales counter local butcher shop continues smoke one pack cigarettes daily past years denies alcohol illicit substancesfamily history mother deceased said type paralysis died father deceased age head neck cancer yearold brother typetwo diabetes blindness secondary diabetic retinopathy yearold brother hypertension sister thyroid diseasephysical examinationvital signs weight pounds temperature pulse blood pressure automatic cuff manual cuff heent oropharynx clear without thrush ulcerationneck supple without lymphadenopathy thyromegalyheart regular normal murmurs rubs gallops jvdlungs clear auscultation bilaterally without wheezes rhonchi cracklesabdomen soft nontender nondistended without abdominal bruit organomegalymusculoskeletal difficulty abduction right shoulderaccess right forearm av fistula audible bruit palpable thrill sign stenosis vascular access looks like ready useextremities peripheral edemaskin bruises petechiae rashlabs sodium potassium chloride bicarbonate bun creatinine gfr albumin protein ast alt alkaline phosphatase total bilirubin calcium phosphorus pth corrected calcium wbc hemoglobin platelet total cholesterol triglycerides ldl hdl ferritin iron percent sat impression yearold black male stage iv chronic kidney disease likely secondary hiv nephropathy although history renal biopsy noncompliant renal clinic presents today followup recommendation infection disease doctorsrecommendations renal serum creatinine progressively worsening creatinine last time saw today represents gfr stage iv chronic kidney disease vascular access appears ready use difficulty sleeping possible represents early signs uremia otherwise signs symptoms uremia time going touch base dialysis educator try get patient dialysis teaching classes already received literature dialysis teaching yet enrolled classes encouraged continue exercise right forearm also going contact transplant coordinator see evaluated possible transplant given progression chronic kidney disease anticipate need start dialysis soon hypertension added labetolol mg bid antihypertensive regimen shows signs point volume overload although demonstrate future lasix could increased goal blood pressure would less hyperkalemia going instruct lowpotassium diet decrease valsartan mg daily return one week recheck potassium potassium continues remain elevated may require initiation dialysis bone metabolism pth elevated going add phoslo mg tid meals corrected calcium would like avoid calciumcontaining phosphate bonders situation acid base bicarbonate initiate sodium bicarbonate mg three tablets tid anemia hemoglobin goal stage chronic kidney disease iron stores adequate

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

HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep.",MEDICATIONS: , Current medications are as previously noted. Changes include reduction in prednisone from 9 to 6 mg by mouth every morning. She continues to take Ativan 1 mg every six hours as needed. She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs: Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest. Chest is clear. Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used. She used it for greater than 4 hours per night on 67% of night surveyed. Her estimated apnea/hypopnea index was 3 per hour. Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy. She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%). Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour. Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%. During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1. Obesity hypoventilation syndrome. The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity. In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2. Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute. The breathing pattern is that of cluster or Biot's breathing throughout sleep. The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3. Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4. Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep. These will include, (1). Decrease in evening doses of MS Contin, (2). Modest weight loss of approximately 10 to 20 pounds, and (3). Instituting Automated Servo Ventilation via nasal mask. With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements. I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed. I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time. She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation. Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing.

history present illness yearold woman history polyarteritis nodosa mononeuritis multiplex involving lower extremities severe sleep apnea returns followup following overnight sleep study cpap oxygen evaluate difficulty initiating maintaining sleep returns today review results inpatient study performed approximately two weeks agoin meantime patient reports continues substantial doses opiate medication control leg pain mononeuritis multiplexshe also takes lasix lower extremity edemathe patient reports generally initiates sleep cpap rips mask tosses turns throughout night terrible quality sleepmedications current medications previously noted changes include reduction prednisone mg mouth every morning continues take ativan mg every six hours needed takes imipramine mg bedtimeher ms contin dose mg every hours immediate release morphine preparation mg mouth every hours neededfindings vital signs blood pressure pulse respiratory rate weight pounds pounds earlier month height feet inches temperature degrees sao room air rest chest clear extremities show lower extremity pretibial edema erythemalaboratories arterial blood gas room air showed ph pco po cpap compliance monitoring past two three weeks showed average use hours minutes nights used used greater hours per night night surveyed estimated apneahypopnea index per hour average leak flow liters per minutethe patients overnight sleep study performed inpatient sleep study routine hospitalization intravenous gamma globulin therapy slept total sleep time minutes minutes bed sleep efficiency approximately sleep stage distribution relatively normal stage stage ii stage iii iv stage rem sleepthere periodic limb movements sleepthere evidence severe predominantly central sleep apnea nonrem sleep episodes per hour rem sleep episodes per hour oxyhemoglobin saturations nonrem sleep fluctuated baseline average low rem sleep baseline oxyhemoglobin saturation decreased sleepdisordered breathing episodesof note sleep study performed cpap cm ho oxygen liters per minuteassessment obesity hypoventilation syndrome patient evidence wellcompensated respiratory acidosis probably primarily related severe obesity addition may contribution large doses opiates standing doses gabapentin severe central sleep apnea cpap cmho supplemental oxygen liters per minute breathing pattern cluster biots breathing throughout sleep primary etiology probably opiate use contribution exacerbation severe obesity acts lower baseline oxyhemoglobin saturation worsen desaturations apneic episodes mononeuritis multiplex pain requiring significant substantial doses analgesia hypoxemia primarily due obesity hypoventilation presumably basilar atelectasis combination vq mismatch shunt basisplans overall impression treat patients sleep disruption measures decrease central sleep apnea sleep include decrease evening doses ms contin modest weight loss approximately pounds instituting automated servo ventilation via nasal mask regard latter patient returning trial asv examine effect sleepdisordered breathing patternsin addition patient benefit modest diuresis improvement oxygenation well nocturnal desaturation oxygen requirements encouraged patient increase dose lasix mg mouth every morning previously prescribed also asked add lasix additional late afternoon evening dose lasix mg mouth time instructed take one two ktab evening dose lasix meqin addition obtain complete set pulmonary function studies evaluate patient underlying causes parenchymal lung disease may interfere oxygenation workup hypoxemia may include highresolution ct scanning evidence significant pulmonary restriction andor reductions diffusion capacity evident pulmonary function testing

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep.",MEDICATIONS: , Current medications are as previously noted. Changes include reduction in prednisone from 9 to 6 mg by mouth every morning. She continues to take Ativan 1 mg every six hours as needed. She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs: Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest. Chest is clear. Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used. She used it for greater than 4 hours per night on 67% of night surveyed. Her estimated apnea/hypopnea index was 3 per hour. Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy. She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%). Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour. Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%. During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1. Obesity hypoventilation syndrome. The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity. In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2. Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute. The breathing pattern is that of cluster or Biot's breathing throughout sleep. The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3. Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4. Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep. These will include, (1). Decrease in evening doses of MS Contin, (2). Modest weight loss of approximately 10 to 20 pounds, and (3). Instituting Automated Servo Ventilation via nasal mask. With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements. I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed. I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time. She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation. Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing. ### Response: General Medicine, SOAP / Chart / Progress Notes

HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot. The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks. I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1. Diabetes mellitus type 2.,2. Diabetic nephropathy.,3. Chronic kidney disease, stage 4.,4. Hypertension.,5. Hypercholesterolemia and hyperlipidemia.,6. Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:, Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:, NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out. Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better. Denies any fever and chills. Denies any dysuria, frequency or hematuria. States that the urine output was decreased considerably, and she could not urinate. Denies any cough, hemoptysis or sputum production. Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General: The patient is alert and oriented, in no acute distress.,Vital Signs: Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20. The patient's weight is 105.6 kg.,Head: Normocephalic.,Neck: Supple. No JVD. No adenopathy.,Chest: Symmetric. No retractions.,Lungs: Clear.,Heart: RRR with no murmur.,Abdomen: Obese, soft, and nontender. No rebound. No guarding.,Extremity: She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date. The patient's white cell is 12.7, hematocrit 26.1. The patient has 90% segs and 0% bands. Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9. Sed rate was 121. BNP was 851. Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1. Urinary tract infection.,2. Acute gouty attack.,3. Diabetes mellitus with diabetic nephropathy.,4. Hypertension.,5. Hypercholesterolemia.,6. Peripheral vascular disease, status post recent PTA in the right side.,7. Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment. We will add allopurinol 50 mg daily. This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results.

history present illness yearold female past medical history chronic kidney disease stage history diabetes mellitus diabetic nephropathy peripheral vascular disease status post recent pta right leg admitted hospital swelling right hand left foot patient says right hand swollen painful could move fingers also left foot swollen painful could move toes came emergency room diagnosed gout gouty attacks asked see patient regarding chronic kidney diseasepast medical history diabetes mellitus type diabetic nephropathy chronic kidney disease stage hypertension hypercholesterolemia hyperlipidemia peripheral vascular disease status post recent last week pta right lower extremitysocial history negative smoking drinkingcurrent home medications novolog units meal lantus units bedtime crestor mg daily micardis mg daily imdur mg daily amlodipine mg daily coreg mg bid lasix mg daily ecotrin mg daily calcitriol mcg dailyreview systems patient denies complaints states right hand left foot swollen painful came emergency room also could urinate states soon put foley ml urine came also started steroids colchicine pain improving swelling getting better denies fever chills denies dysuria frequency hematuria states urine output decreased considerably could urinate denies cough hemoptysis sputum production denies chest pain orthopnea paroxysmal nocturnal dyspneaphysical examinationgeneral patient alert oriented acute distressvital signs blood pressure temperature pulse respirations patients weight kghead normocephalicneck supple jvd adenopathychest symmetric retractionslungs clearheart rrr murmurabdomen obese soft nontender rebound guardingextremity pretibial edema bilaterally lower extremity also left foot dorsum left foot also right hand swollen tender move toes also fingers extremitieslab tests showed urine culture negative date patients white cell hematocrit patient segs bands serum sodium potassium chloride bicarb glucose bun creatinine calcium uric acid yesterday sed rate bnp urinalysis showed white cells protein blood red blood cells alsoimpression urinary tract infection acute gouty attack diabetes mellitus diabetic nephropathy hypertension hypercholesterolemia peripheral vascular disease status post recent pta right side chronic kidney disease stage plan time agree treatment add allopurinol mg daily secondary patient already colchicine also discontinue micardis increase lasix bid follow lab results

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot. The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks. I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1. Diabetes mellitus type 2.,2. Diabetic nephropathy.,3. Chronic kidney disease, stage 4.,4. Hypertension.,5. Hypercholesterolemia and hyperlipidemia.,6. Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:, Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:, NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out. Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better. Denies any fever and chills. Denies any dysuria, frequency or hematuria. States that the urine output was decreased considerably, and she could not urinate. Denies any cough, hemoptysis or sputum production. Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General: The patient is alert and oriented, in no acute distress.,Vital Signs: Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20. The patient's weight is 105.6 kg.,Head: Normocephalic.,Neck: Supple. No JVD. No adenopathy.,Chest: Symmetric. No retractions.,Lungs: Clear.,Heart: RRR with no murmur.,Abdomen: Obese, soft, and nontender. No rebound. No guarding.,Extremity: She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date. The patient's white cell is 12.7, hematocrit 26.1. The patient has 90% segs and 0% bands. Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9. Sed rate was 121. BNP was 851. Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1. Urinary tract infection.,2. Acute gouty attack.,3. Diabetes mellitus with diabetic nephropathy.,4. Hypertension.,5. Hypercholesterolemia.,6. Peripheral vascular disease, status post recent PTA in the right side.,7. Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment. We will add allopurinol 50 mg daily. This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results. ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain. The patient was well visiting in ABC, with her daughter that evening. She had pain in her left posterior pelvic and low back region. They came back to XYZ the following day. By the time they got here, she was in severe pain and had fever. They came straight to the emergency room. She was admitted. She had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. Multiple blood studies have been done including cultures, febrile agglutinins, etc. She has had run a higher blood glucose to the normal and she has been on sliding scale insulin. She was not known previously to be a diabetic. All x-rays have not been helpful as far as to determine the etiology of her discomfort. MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.,PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: , She was not known to be a diabetic until this admission. She had been hypertensive. She has been on medications and has been controlled. She has not had hyperlipidemia. She has had no thyroid problems. There has been no asthma, bronchitis, TB, emphysema or pneumonia. No tuberculosis. She has had no breast tumors. She has had no chest pain or cardiac problems. She has had gallbladder surgery. She has not had any gastritis or ulcers. She has had no kidney disease. She has had a hysterectomy. She has had 9 pregnancies and 8 living children. She had A&P repair. She had a sacral abscess after a spinal. It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal. There have been fractures and no significant arthritis. She has been quite active at her ranch in Mexico. She raises goats and cattle. She drives a tractor and in short, has been very active.,PHYSICAL EXAMINATION:, She is a short female, alert. She is shivering. She has ice in her axilla and behind her neck. She is febrile to 101 degrees F. She is alert. Her complaint is that of hip pain in the posterior sacroiliac joint area. She moves both her upper extremities well. She can move her right leg well. She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint. She cannot stand, sit or turn without severe pain. She has normal knee reflexes. No ankle reflexes. She has bounding tibial pulses. No sensory deficit. She says she knows when she has to void. She has a healed scar in the upper sacral region. There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.,PLAN: , My plan is to do a triple-phase bone scan. I am suspecting an infection possibly in the left sacroiliac joint. It is probably some type of bacterium, the etiology of which is undetermined. She has had a normal white count despite her fever. There has been a history of brucellosis in the past, but her titers at this time are negative. Continue medication which included antibiotics and also the Motrin and Darvocet.,

history present illness yearold female admitted fever chills left pelvic pain patient well visiting abc daughter evening pain left posterior pelvic low back region came back xyz following day time got severe pain fever came straight emergency room admitted temperature degrees f spiking ever since left sacroiliac type hip pain multiple blood studies done including cultures febrile agglutinins etc run higher blood glucose normal sliding scale insulin known previously diabetic xrays helpful far determine etiology discomfort mris lumbar spine pelvis thighs unremarkable inflammatory process degenerative disk disease lumbar spine hip pathology swollen inguinal nodes bilaterallypast medical history review systems known diabetic admission hypertensive medications controlled hyperlipidemia thyroid problems asthma bronchitis tb emphysema pneumonia tuberculosis breast tumors chest pain cardiac problems gallbladder surgery gastritis ulcers kidney disease hysterectomy pregnancies living children ap repair sacral abscess spinal sounds like pilonidal cyst took operations heal fractures significant arthritis quite active ranch mexico raises goats cattle drives tractor short activephysical examination short female alert shivering ice axilla behind neck febrile degrees f alert complaint hip pain posterior sacroiliac joint area moves upper extremities well move right leg well actually move left hip knee without much discomfort pain radiates sacroiliac joint cannot stand sit turn without severe pain normal knee reflexes ankle reflexes bounding tibial pulses sensory deficit says knows void healed scar upper sacral region bruising around buttocks daughter says bed lying backplan plan triplephase bone scan suspecting infection possibly left sacroiliac joint probably type bacterium etiology undetermined normal white count despite fever history brucellosis past titers time negative continue medication included antibiotics also motrin darvocet

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain. The patient was well visiting in ABC, with her daughter that evening. She had pain in her left posterior pelvic and low back region. They came back to XYZ the following day. By the time they got here, she was in severe pain and had fever. They came straight to the emergency room. She was admitted. She had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. Multiple blood studies have been done including cultures, febrile agglutinins, etc. She has had run a higher blood glucose to the normal and she has been on sliding scale insulin. She was not known previously to be a diabetic. All x-rays have not been helpful as far as to determine the etiology of her discomfort. MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.,PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: , She was not known to be a diabetic until this admission. She had been hypertensive. She has been on medications and has been controlled. She has not had hyperlipidemia. She has had no thyroid problems. There has been no asthma, bronchitis, TB, emphysema or pneumonia. No tuberculosis. She has had no breast tumors. She has had no chest pain or cardiac problems. She has had gallbladder surgery. She has not had any gastritis or ulcers. She has had no kidney disease. She has had a hysterectomy. She has had 9 pregnancies and 8 living children. She had A&P repair. She had a sacral abscess after a spinal. It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal. There have been fractures and no significant arthritis. She has been quite active at her ranch in Mexico. She raises goats and cattle. She drives a tractor and in short, has been very active.,PHYSICAL EXAMINATION:, She is a short female, alert. She is shivering. She has ice in her axilla and behind her neck. She is febrile to 101 degrees F. She is alert. Her complaint is that of hip pain in the posterior sacroiliac joint area. She moves both her upper extremities well. She can move her right leg well. She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint. She cannot stand, sit or turn without severe pain. She has normal knee reflexes. No ankle reflexes. She has bounding tibial pulses. No sensory deficit. She says she knows when she has to void. She has a healed scar in the upper sacral region. There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.,PLAN: , My plan is to do a triple-phase bone scan. I am suspecting an infection possibly in the left sacroiliac joint. It is probably some type of bacterium, the etiology of which is undetermined. She has had a normal white count despite her fever. There has been a history of brucellosis in the past, but her titers at this time are negative. Continue medication which included antibiotics and also the Motrin and Darvocet., ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. The patient also has a positive history of smoking in the past. At the present time, he is admitted for continued,management of respiratory depression with other medical complications. The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter. In addition, he also developed cardiac complications including atrial fibrillation. The patient was evaluated by the cardiologist as well as the pulmonary service and Urology. He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008. He subsequently underwent cardiac arrest and he was resuscitated at that time. He was intubated and placed on mechanical ventilatory support. Subsequent weaning was unsuccessful. He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1. Albuterol.,2. Pacerone.,3. Theophylline,4. Lovenox.,5. Atrovent.,6. Insulin.,7. Lantus.,8. Zestril.,9. Magnesium oxide.,10. Lopressor.,11. Zegerid.,12. Tylenol as needed.,ALLERGIES:, PENICILLIN.,PAST MEDICAL HISTORY:,1. History of coal miner's disease.,2. History of COPD.,3. History of atrial fibrillation.,4. History of coronary artery disease.,5. History of coronary artery stent placement.,6. History of gastric obstruction.,7. History of prostate cancer.,8. History of chronic diarrhea.,9. History of pernicious anemia.,10. History of radiation proctitis.,11. History of anxiety.,12. History of ureteral stone.,13. History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker. No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated. Rapidly moving his upper extremities. No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General: The patient is currently agitated with some level of distress. He has rapid respiratory rate. He is responsive to verbal commands by looking at the eyes.,Vital Signs: As per the monitors are stable.,Extremities: Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas. There is also edema of the forearm extending up to the mid upper arm area. Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect. There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1. Ulceration of bilateral upper extremities.,2. Cellulitis of upper extremities.,3. Lymphedema of upper extremities.,4. Other noninfectious disorders of lymphatic channels.,5. Ventilatory-dependent respiratory failure.

history present illness yearold male previous history working coalmine significant exposure silica resultant pneumoconiosis fibrosis lung patient also positive history smoking past present time admitted continuedmanagement respiratory depression medical complications patient treated multiple problems jefferson hospital prior coming including abdominal discomfort due ureteral stone resultant hydronephrosis hydroureter addition also developed cardiac complications including atrial fibrillation patient evaluated cardiologist well pulmonary service urology cystoscopy performed left ureteral stone removed well insertion left ureteral stent subsequently underwent cardiac arrest resuscitated time intubated placed mechanical ventilatory support subsequent weaning unsuccessful tracheostomy placedcurrent medications albuterol pacerone theophylline lovenox atrovent insulin lantus zestril magnesium oxide lopressor zegerid tylenol neededallergies penicillinpast medical history history coal miners disease history copd history atrial fibrillation history coronary artery disease history coronary artery stent placement history gastric obstruction history prostate cancer history chronic diarrhea history pernicious anemia history radiation proctitis history anxiety history ureteral stone history hydronephrosissocial history patient previously smoker could obtained tracheostomy presentlyfamily history noncontributory present condition review previous chartssystems review patient currently agitated rapidly moving upper extremities history regarding systems could elicited patientphysical examgeneral patient currently agitated level distress rapid respiratory rate responsive verbal commands looking eyesvital signs per monitors stableextremities inspection upper extremities reveals extreme xerosis skin multiple areas ecchymosis skin tears level stage ii especially dorsum hands forearm areas also edema forearm extending mid upper arm area palpation upper extremities reveals fibrosis prominent right forearm area maximum edema elbow area ulnar aspect also scabbing possibly earlier skin tears upper side forearm areaimpression ulceration bilateral upper extremities cellulitis upper extremities lymphedema upper extremities noninfectious disorders lymphatic channels ventilatorydependent respiratory failure

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. The patient also has a positive history of smoking in the past. At the present time, he is admitted for continued,management of respiratory depression with other medical complications. The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter. In addition, he also developed cardiac complications including atrial fibrillation. The patient was evaluated by the cardiologist as well as the pulmonary service and Urology. He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008. He subsequently underwent cardiac arrest and he was resuscitated at that time. He was intubated and placed on mechanical ventilatory support. Subsequent weaning was unsuccessful. He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1. Albuterol.,2. Pacerone.,3. Theophylline,4. Lovenox.,5. Atrovent.,6. Insulin.,7. Lantus.,8. Zestril.,9. Magnesium oxide.,10. Lopressor.,11. Zegerid.,12. Tylenol as needed.,ALLERGIES:, PENICILLIN.,PAST MEDICAL HISTORY:,1. History of coal miner's disease.,2. History of COPD.,3. History of atrial fibrillation.,4. History of coronary artery disease.,5. History of coronary artery stent placement.,6. History of gastric obstruction.,7. History of prostate cancer.,8. History of chronic diarrhea.,9. History of pernicious anemia.,10. History of radiation proctitis.,11. History of anxiety.,12. History of ureteral stone.,13. History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker. No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated. Rapidly moving his upper extremities. No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General: The patient is currently agitated with some level of distress. He has rapid respiratory rate. He is responsive to verbal commands by looking at the eyes.,Vital Signs: As per the monitors are stable.,Extremities: Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas. There is also edema of the forearm extending up to the mid upper arm area. Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect. There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1. Ulceration of bilateral upper extremities.,2. Cellulitis of upper extremities.,3. Lymphedema of upper extremities.,4. Other noninfectious disorders of lymphatic channels.,5. Ventilatory-dependent respiratory failure. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable.,NECK: Supple without adenopathy.,CHEST: Clear including the sternal wound.,CARDIOVASCULAR: A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU: Deferred.,EXTREMITIES: Examination of extremities reveals no embolic phenomenon.,SKIN: Free of lesions.,NEUROLOGIC: Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN: ,1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels.,2. Repeat Q-fever serology.,3. Comprehensive metabolic panel and CBC.,4. Return to clinic in 4 weeks.,5. Clotting times are being followed by Dr. X.

history present illness followup visit yearold male currently receiving doxycycline mg mouth twice daily well hydroxychloroquine mg mouth three times day qfever endocarditis also taking digoxin aspirin warfarin furosemide mother reports problems loose stools per day since september tolerates relatively well increased frequency recentlymark recently underwent surgery childrens hospital replacement pulmonary homograft valve resection pulmonary artery pseudoaneurysm insertion goretex membrane pericardial substitute tolerated procedure well well home since timephysical examinationvital signs temperature pulse respirations blood pressure weight kg height cmgeneral appearance welldeveloped wellnourished slightly obese slightly dysmorphic male obvious distressheent remarkable badly degenerated left lower molar funduscopic exam unremarkableneck supple without adenopathychest clear including sternal woundcardiovascular systolic murmur heard best upper left sternal borderabdomen soft enlarged spleen however given obesity cannot accurately measure sizegu deferredextremities examination extremities reveals embolic phenomenonskin free lesionsneurologic grossly within normal limitslaboratory data doxycycline level obtained outpatient less hydroxychloroquine level obtained time undetectable note doxycycline level obtained hospital mcgml qfever serology obtained positive phase antibodies phase ii antibodies improvement previous elevated titers studies pulmonary valve tissue removed surgery pendingimpression qfever endocarditisplan continue doxycycline hydroxychloroquine carefully questioned mother compliance concomitant use dairy products taking medications assures compliant medications however repeat hydroxychloroquine doxycycline levels repeat qfever serology comprehensive metabolic panel cbc return clinic weeks clotting times followed dr x

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable.,NECK: Supple without adenopathy.,CHEST: Clear including the sternal wound.,CARDIOVASCULAR: A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU: Deferred.,EXTREMITIES: Examination of extremities reveals no embolic phenomenon.,SKIN: Free of lesions.,NEUROLOGIC: Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN: ,1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels.,2. Repeat Q-fever serology.,3. Comprehensive metabolic panel and CBC.,4. Return to clinic in 4 weeks.,5. Clotting times are being followed by Dr. X. ### Response: Cardiovascular / Pulmonary, SOAP / Chart / Progress Notes

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

history present illness followup yearold african american gentleman stage iv chronic kidney disease secondary polycystic kidney disease creatinine ranged past months since following trying get educated endstage kidney disease unsuccessful getting classes last visit really stressed importance taking medications adequately missing doses returns today much better blood pressure control also brought machine home states blood pressure readings better gone transplant orientation class yet dialysis education yet discussed past also needs followup elevated psa past done years likely need cardiac clearance ever able evaluate transplantreview systems really negative continues feel well denies problems shortness breath chest pain swelling legs nausea vomiting appetite remains goodcurrent medications vytorin mg one day rocaltrol micrograms day carvedilol mg twice day cozaar mg twice day lasix mg dayphysical examinationvital signs exam blood pressure pulse current weight kg blood pressure markedly improved previous readings general thin african american gentleman distress lungs clear cardiovascular regular rate rhythm normal appreciate murmur abdomen soft soft systolic murmur left lower sternal border rubs gallops extremities significant edemalaboratory data today indicates creatinine stable ionized calcium intact pth hemoglobin stable epo yet ua negativeimpression chronic kidney disease stage iv secondary polycystic kidney disease estimated gfr ml per minute uremic symptoms hypertension finally better controlled metabolic bone disease anemiarecommendation needs number things done terms followup education gave information dialysis education transplant instructed needs go classes also gave websites get find information made changes medications getting blood work done prior next visit check psa needs get back see urology last psa see see back weeks

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

HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:, The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst. The patient was kept in observation for 24 hours. The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac. The patient was admitted to the hospital. A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000. The diagnosis of a possible ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9. Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery. The hospital course was uneventful. There was no fever reported. The abdomen was soft. She had a normal bowel movement. The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,FINAL DIAGNOSES:,1. Right ruptured ectopic pregnancy with hemoperitoneum.,2. Anemia secondary to blood loss.,PLAN: , The patient will be dismissed on pain medication and iron therapy.

history present illness case yearold white female admitted hospital pelvic pain vaginal bleeding patient positive hcg negative sonogram hcg titer hospital course patient admitted hospital diagnosis possible incomplete abortion rule ectopic pregnancy rupture corpus luteal cyst patient kept observation hours sonogram stated gestational sac small mass within uterus could represent gestational sac patient admitted hospital repeat hcg titer done day came back following day came back diagnosis possible ruptured ectopic pregnancy established patient taken surgery laparotomy performed findings right ruptured ectopic pregnancy right salpingectomy performed complications patient received units red packed cells admission hemoglobin afternoon dropped following morning based findings severe abdominal pain made diagnosis ectopic proved confirmed surgery hospital course uneventful fever reported abdomen soft normal bowel movement patient dismissed followed office daysfinal diagnoses right ruptured ectopic pregnancy hemoperitoneum anemia secondary blood lossplan patient dismissed pain medication iron therapy

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: , This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000.,HOSPITAL COURSE:, The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst. The patient was kept in observation for 24 hours. The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac. The patient was admitted to the hospital. A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000. The diagnosis of a possible ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9. Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery. The hospital course was uneventful. There was no fever reported. The abdomen was soft. She had a normal bowel movement. The patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,FINAL DIAGNOSES:,1. Right ruptured ectopic pregnancy with hemoperitoneum.,2. Anemia secondary to blood loss.,PLAN: , The patient will be dismissed on pain medication and iron therapy. ### Response: Discharge Summary, Obstetrics / Gynecology

HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him. This was not preceded by lightheadedness. He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia. He started using a walker from that time, prior to that he was able to walk approximately two miles per day. He again had a fall in August of 2008 after his legs gave way. Again, there was no lightheadedness associated with this. He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this. He did not, however, return to the pre-July baseline. In October of 2008, after another fall, he was found to have pneumonia again and shingles. He is currently in a Chronic Rehabilitation Unit. He cannot use a walker and uses a wheelchair for everything. He states that his hands have been numb, involving all the fingers of both hands for the past three weeks. He is also losing muscle bulk in his hands and has noticed some general weakness of his hands. He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse. He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs. He does not report any cramps, problems with swallowing or problems with breathing. He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder. He has had some problems with blood pressure drops, and does feel presyncopal when he stands. He also reports that he has no feeling in his feet, and that his feet feel like sponges. This has been present for about nine months. He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1. Pneumonia. He has had recurrent episodes of pneumonia, which started at approximately age 20. These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year. He is usually treated with antibiotics and then discharged. There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2. He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement. The patient does not have any history of diabetes and does not report any other medical problems. He has lost approximately 18 pounds in the past month.,3. He had an appendectomy in the 1940s.,4. He had an ankle resection in 1975.,SOCIAL HISTORY: ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars. He has not smoked for the past 27 years. He hardly ever uses alcohol. He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:, He has no medication or food allergies.,REVIEW OF SYSTEMS:, Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair. His pain score was 0.,APPEARANCE: No acute distress. He is pleasant and well-groomed.,HEENT: Atraumatic, normocephalic. No carotid bruits appreciated.,LUNGS: There were few coarse crackles in both lung bases.,CARDIOVASCULAR: Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs. The pulse was regular and of normal volume.,ABDOMEN: Soft with no masses and normal bowel sounds. There were no carotid bruits.,EXTREMITIES: No contractures appreciated.,NEUROLOGICAL EXAM:,MSE: His orientation, language, calculations, 100-7 tests were all normal. There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES: Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations. His palatal movement was normal and gag reflex was normal.,MOTOR: Strength was decreased in all muscle groups as follows: Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4. Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1. There was atrophy in both hands and general atrophy of the lower limb muscles. The feet were both cold and showed dystrophic features. Fasciculations were present mainly in the hands. There was evidence of dysmetria and past pointing in the left hand.,REFLEXES: Reflexes were 0 in all sites in the arms and legs. The jaw reflex was 2+. Vibration was severely decreased at the elbow and wrist and was absent in the fingers. Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee. Joint position sense was absent in the toes and severely decreased in the fingers. Pin perception was absent in the feet and was decreased to the upper thighs. Pin was decreased or absent in the fingers and decreased above the elbows. The same distribution of sensory loss was found with monofilament testing.,COORDINATION: Coordination was barely normal in the right hand. Rapid alternating movements were decreased in the left hand greater than the right hand. The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports. There were extensive patient reports, all of which were reviewed. A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate. An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis. A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis. The posterior circulation showed a slightly dominant right vertebral artery with no stenosis. There was no significant stenosis, but there was minor extracranial stenosis noted. An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration. There was also no significant sinusitis or mastoiditis. This was an essentially normal brain MRI. A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal. An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1. The glucose was 86. TSH performed in January 2009 was 1.57, which is within the normal range. Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal. A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT. The ECG was non-diagnostic. There was normal regional wall motion of the left ventricle. The left ventricular ejection fraction was 68%, which is within the normal range for males. A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5. At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis. There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4. An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION: ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings. He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities. His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia. According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008. As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy. There was no involvement of the tongue on EMG. The laboratory testing as indicated below failed to show a specific cause for the neuropathy. We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic. This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease. In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents. The patient did not receive any of these. It may also be seen as part of a paraneoplastic syndrome. Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking. We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation. The verbal reports of these possibly did not show any evidence of a cancer. We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm. The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm. This showed evidence of severe axonal loss. There was no evidence of a vasculitis. The vessels did show some mild intimal changes that would be consistent with atherosclerosis. There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections. The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping. Again, there was no evidence of inflammation or vasculitis. Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy. Specifically, there is no history of HIV exposure. We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis. At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed. I have discussed these issues at length with the patient and with his son. We also addressed whether or not there might be a previously undiagnosed inherited neuropathy. I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2. However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1. Nerve conduction and EMG will be performed today. The results were indicated above.,2. The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12. These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7. The B12 was greater than 2000. The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative. The B12 level was greater than 2000. Liver function tests were normal. The glucose was 90. ESR was 10. Hemoglobin A1c was 5.5.,3. A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4. CT of chest, abdomen and pelvis.,5. Whole body gallium scan for evidence of an underlying neoplasm.,6. The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7. We have not made any changes to his medication. He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day. Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8. Followup will be as determined by the family.

history present illness patient yearold righthanded man reports approximately one half years ago fell walking living room bedroom time reports legs gave away fell reported lightheadedness fell slightly confused aware happening around able get shortly falling according patient son subsequently returned back normalhe well rd july legs gave way preceded lightheadedness rushed hospital found pneumonia fall blamed pneumonia started using walker time prior able walk approximately two miles per day fall august legs gave way lightheadedness associated found pneumonia admitted hospital went rehabilitation able use walker however return prejuly baseline october another fall found pneumonia shingles currently chronic rehabilitation unit cannot use walker uses wheelchair everything states hands numb involving fingers hands past three weeks also losing muscle bulk hands noticed general weakness hands however note strength hands normal since july clearly getting worse aware fasciculations legs starting august present lower legs thighs report cramps problems swallowing problems breathing reports constipation alternating diarrhea although loss control either bowel bladder problems blood pressure drops feel presyncopal stands also reports feeling feet feet feel like sponges present nine months also lost joint position sense feet approximately nine monthspast medical history pneumonia recurrent episodes pneumonia started approximately age treated repeatedly years average tended episode pneumonia every five years although far frequent past year usually treated antibiotics discharged known history bronchiectasis inherited lung disease another chronic pulmonary cause repeated pneumonia catheter placed urinary retention urologist told thinks may due prostate enlargement patient history diabetes report medical problems lost approximately pounds past month appendectomy ankle resection social history patient stopped smoking years ago smoked approximately two packs day combined cigarettes cigars smoked past years hardly ever uses alcohol currently retiredfamily history family history neuropathy pes cavus foot deformities neuromuscular diseases aunt history type ii diabetescurrent medications fludrocortisone mg po qd midodrine mg po qid cymbalta mg po per day prilosec mg po per day lortab mg po per day amoxil mg po per day vitamin b mcg weekly vitamin units per day metamucil prn entericcoated aspirin day colace mg po qd senokot three tablets po prn reglan mg po qh xanax mg po qh prn ambien mg po qhs prn dilaudid mg tablets po qh prn protonix mg per day megace mg per dayallergies medication food allergiesreview systems please see health questionnaire clinical notes todaygeneral physical examinationvital signs bp p weight could measured wheelchair pain score appearance acute distress pleasant wellgroomedheent atraumatic normocephalic carotid bruits appreciatedlungs coarse crackles lung basescardiovascular revealed normal first second heart sound third fourth heart sound murmurs pulse regular normal volumeabdomen soft masses normal bowel sounds carotid bruitsextremities contractures appreciatedneurological exammse orientation language calculations tests normal atrophy fasciculations arms legscranial nerves cranial nerve examination normal exception mild atrophy tongue possible fasciculations palatal movement normal gag reflex normalmotor strength decreased muscle groups follows deltoid biceps triceps wrist extensors finger extensors finger flexors interossei hip flexors hip extensors knee extensors knee flexors foot dorsiflexion plantar flexion eversion toe extension toe flexion atrophy hands general atrophy lower limb muscles feet cold showed dystrophic features fasciculations present mainly hands evidence dysmetria past pointing left handreflexes reflexes sites arms legs jaw reflex vibration severely decreased elbow wrist absent fingers vibration absent toes ankle bilaterally severely decreased knee joint position sense absent toes severely decreased fingers pin perception absent feet decreased upper thighs pin decreased absent fingers decreased elbows distribution sensory loss found monofilament testingcoordination coordination barely normal right hand rapid alternating movements decreased left hand greater right hand patient unable stand therefore gait rombergs test balance could assesseddiagnostic studies previous diagnostic studies patient reports extensive patient reports reviewed previous xray study lateral chest performed october showed poor inspiration basilar atelectasis infiltrate xray cervical thoracic lumbar spine showed evidence lumbar spinal stenosis cta neck without contrast performed november showed minor stenosis left carotid mild hard soft plaque right carotid approximately stenosis posterior circulation showed slightly dominant right vertebral artery stenosis significant stenosis minor extracranial stenosis noted mri brain without contrast performed november showed evidence acute infarct major vascular occlusion abnormal enhancement gadolinium administration also significant sinusitis mastoiditis essentially normal brain mri cbc performed january showed elevated white cell count low red cell count elevated mch rest study normal electrolyte study performed january showed sodium low calcium low low protein albumin glucose tsh performed january within normal range vitamin b greater normal folate normal myocardial stress study performed december showed normal myocardial perfusion persantine cardiolite spect ecg nondiagnostic normal regional wall motion left ventricle left ventricular ejection fraction within normal range males ct lumbar spine without contrast performed december showed broadbased disc bulge ls addition broadbased disc bulge also osteophyte complex evidence flavum hypertrophy without canal stenosis severe bilateral neural foraminal stenosis ls moderate neural foraminal stenosis echocardiogram performed november showed mild left atrial enlargement normal left ventricular systolic function mild concentric left ventricular hypertrophy scleral degenerative changes aortic mitral apparatus mild mitral regurgitation mild tricuspid regurgitation mild moderate aortic regurgitationdiagnostic impression patient presents severe neuropathy marked large fiber sensory well motor findings diffusely weak well atrophic muscle groups upper lower extremities although disproportionately weak lower extremities proprioceptive vibratory loss severe distal upper lower extremities signifying either severe sensory neuropathy involvement dorsal root ganglia according history carefully checked initial onset symptoms goes back one half years although significant progression condition since july indicated diagnostic studies including detailed nerve conduction emg test today showed evidence severe sensory motor axonal neuropathy addition evidence diffuse polyradiculopathy involvement tongue emg laboratory testing indicated failed show specific cause neuropathy still however waiting paraneoplastic antibodies send lab mayo clinic type severe sensorimotor neuropathy significant proprioceptive loss may seen several conditions including peripheral nerve vasculitis due variety disorders sle sjogrens rheumatoid arthritis mixed connective tissue disease addition may also seen certain toxins particularly chemotherapeutic agents patient receive may also seen part paraneoplastic syndrome although patient specific clinical symptoms cancer noted pound weight loss past month remote history smoking requested obtain ct chest abdomen pelvis acute rehabilitation verbal reports possibly show evidence cancer also request obtain gallium scan see evidence unsuspected neoplasm patient undergo nerve muscle biopsy radial nerve biceps muscle biopsy left arm showed evidence severe axonal loss evidence vasculitis vessels show mild intimal changes would consistent atherosclerosis perivascular changes however clear evidence necrotizing vasculitis even multiple sections muscle biopsy showed severe muscle fiber atrophy evidence fiber grouping evidence inflammation vasculitis evaluation far also shown evidence amyloid neuropathy evidence monoclonal gammopathy sarcoidosis past history significant toxin infective cause neuropathy specifically history hiv exposure would await results gallium scan paraneoplastic antibodies see helpful making diagnosis point severity axonal nature neuropathy specific therapy reverse course illness unless find specific etiology stopped reversed discussed issues length patient son also addressed whether might previously undiagnosed inherited neuropathy think unlikely given short history rapid progression disorderthere also family history detect neuropathy patient typical phenotype chronic inherited neuropathy charcotmarietooth disease type however since seen patient one occasion know previous examination showed two years ago cannot certain may presence neuropathy preceding thisplan nerve conduction emg performed today results indicated following laboratory studies requested including electrolytes cbc thyroid function tests b ana creactive protein complement cryoglobulins doublestranded dna antibodies folate level hemoglobin ac immunofixation electrophoresis panca canca protein electrophoresis rheumatoid factor paraneoplastic antibody studies requested mayo clinic b studies showed minor changes included low sodium level previously noted low creatinine low calcium low total protein b greater immunoelectrophoresis ana doublestranded dna anca hemoglobin ac folate cryoglobulins complement creactive protein normal negative b level greater liver function tests normal glucose esr hemoglobin ac left radial sensory left biceps biopsy requested performed interpreted indicated ct chest abdomen pelvis whole body gallium scan evidence underlying neoplasm patient go rehabilitation facility acute rehabilitation training made changes medication mild orthostatic changes however adequately controlled midodrine dose mg three times day needed mg four times day usually uses lower dose three times day mg three times day followup determined family

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him. This was not preceded by lightheadedness. He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia. He started using a walker from that time, prior to that he was able to walk approximately two miles per day. He again had a fall in August of 2008 after his legs gave way. Again, there was no lightheadedness associated with this. He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this. He did not, however, return to the pre-July baseline. In October of 2008, after another fall, he was found to have pneumonia again and shingles. He is currently in a Chronic Rehabilitation Unit. He cannot use a walker and uses a wheelchair for everything. He states that his hands have been numb, involving all the fingers of both hands for the past three weeks. He is also losing muscle bulk in his hands and has noticed some general weakness of his hands. He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse. He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs. He does not report any cramps, problems with swallowing or problems with breathing. He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder. He has had some problems with blood pressure drops, and does feel presyncopal when he stands. He also reports that he has no feeling in his feet, and that his feet feel like sponges. This has been present for about nine months. He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1. Pneumonia. He has had recurrent episodes of pneumonia, which started at approximately age 20. These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year. He is usually treated with antibiotics and then discharged. There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2. He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement. The patient does not have any history of diabetes and does not report any other medical problems. He has lost approximately 18 pounds in the past month.,3. He had an appendectomy in the 1940s.,4. He had an ankle resection in 1975.,SOCIAL HISTORY: ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars. He has not smoked for the past 27 years. He hardly ever uses alcohol. He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:, He has no medication or food allergies.,REVIEW OF SYSTEMS:, Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair. His pain score was 0.,APPEARANCE: No acute distress. He is pleasant and well-groomed.,HEENT: Atraumatic, normocephalic. No carotid bruits appreciated.,LUNGS: There were few coarse crackles in both lung bases.,CARDIOVASCULAR: Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs. The pulse was regular and of normal volume.,ABDOMEN: Soft with no masses and normal bowel sounds. There were no carotid bruits.,EXTREMITIES: No contractures appreciated.,NEUROLOGICAL EXAM:,MSE: His orientation, language, calculations, 100-7 tests were all normal. There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES: Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations. His palatal movement was normal and gag reflex was normal.,MOTOR: Strength was decreased in all muscle groups as follows: Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4. Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1. There was atrophy in both hands and general atrophy of the lower limb muscles. The feet were both cold and showed dystrophic features. Fasciculations were present mainly in the hands. There was evidence of dysmetria and past pointing in the left hand.,REFLEXES: Reflexes were 0 in all sites in the arms and legs. The jaw reflex was 2+. Vibration was severely decreased at the elbow and wrist and was absent in the fingers. Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee. Joint position sense was absent in the toes and severely decreased in the fingers. Pin perception was absent in the feet and was decreased to the upper thighs. Pin was decreased or absent in the fingers and decreased above the elbows. The same distribution of sensory loss was found with monofilament testing.,COORDINATION: Coordination was barely normal in the right hand. Rapid alternating movements were decreased in the left hand greater than the right hand. The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports. There were extensive patient reports, all of which were reviewed. A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate. An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis. A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis. The posterior circulation showed a slightly dominant right vertebral artery with no stenosis. There was no significant stenosis, but there was minor extracranial stenosis noted. An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration. There was also no significant sinusitis or mastoiditis. This was an essentially normal brain MRI. A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal. An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1. The glucose was 86. TSH performed in January 2009 was 1.57, which is within the normal range. Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal. A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT. The ECG was non-diagnostic. There was normal regional wall motion of the left ventricle. The left ventricular ejection fraction was 68%, which is within the normal range for males. A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5. At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis. There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4. An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION: ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings. He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities. His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia. According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008. As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy. There was no involvement of the tongue on EMG. The laboratory testing as indicated below failed to show a specific cause for the neuropathy. We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic. This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease. In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents. The patient did not receive any of these. It may also be seen as part of a paraneoplastic syndrome. Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking. We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation. The verbal reports of these possibly did not show any evidence of a cancer. We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm. The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm. This showed evidence of severe axonal loss. There was no evidence of a vasculitis. The vessels did show some mild intimal changes that would be consistent with atherosclerosis. There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections. The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping. Again, there was no evidence of inflammation or vasculitis. Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy. Specifically, there is no history of HIV exposure. We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis. At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed. I have discussed these issues at length with the patient and with his son. We also addressed whether or not there might be a previously undiagnosed inherited neuropathy. I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2. However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1. Nerve conduction and EMG will be performed today. The results were indicated above.,2. The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12. These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7. The B12 was greater than 2000. The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative. The B12 level was greater than 2000. Liver function tests were normal. The glucose was 90. ESR was 10. Hemoglobin A1c was 5.5.,3. A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4. CT of chest, abdomen and pelvis.,5. Whole body gallium scan for evidence of an underlying neoplasm.,6. The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7. We have not made any changes to his medication. He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day. Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8. Followup will be as determined by the family. ### Response: Consult - History and Phy., Neurology

HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity . , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities. , ,MEDICATIONS: , Claritin for allergic rhinitis. , ,ALLERGIES: , None. , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2. He is sitting upright, alert and oriented, and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. Abdomen: Soft.

history present illness initial clinic visit yearold man seen new onset right shoulder pain states began approximately one week ago lifting stacks cardboard motion describes essentially picking stack cardboard waist level twisting right delivering approximately waist level sometimes throw stacks little bit well states felt popping sensation since time persistent shoulder pain lifting activities localizes pain posterior lesser extent lateral aspect shoulder upper extremity review systems focal lateral posterior shoulder pain without suggestion cervical radiculopathies denies chronic cardiac pulmonary gi gu neurologic musculoskeletal endocrine abnormalities medications claritin allergic rhinitis allergies none physical examination blood pressure respirations pulse temperature sitting upright alert oriented acute distress skin warm dry gross neurologic examination normal ent examination reveals normal oropharynx nasopharynx tympanic membranes neck full range motion adenopathy thyromegaly cardiovascular regular rate rhythm lungs clear abdomen soft

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity . , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities. , ,MEDICATIONS: , Claritin for allergic rhinitis. , ,ALLERGIES: , None. , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2. He is sitting upright, alert and oriented, and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. Abdomen: Soft. ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS:, A 14-day-old was seen by private doctor because of blister. On Friday, she was noted to have a small blister near her umbilicus. They went to their doctor on Saturday, culture was drawn. It came back today, growing MRSA. She has been doing well. They put her on bacitracin ointment near the umbilicus. That has about healed up. However today, they noticed a small blister on her left temporal area. They called the private doctor. They direct called the Infectious Disease doctor here and was asked that they come into the hospital. Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications. The child has not had any fever. She has not been lethargic or irritable. She has been eating well up to 2 ounces every feed. Eating well and sleeping well. No other changes have been noted.,PAST MEDICAL HISTORY:, She was born full term. No complications. Home with mom. No hospitalization, surgeries, allergies.,MEDICATIONS: , As noted.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No ill contacts. No travel or changes in living condition.,REVIEW OF SYSTEMS: ,Ten systems were asked, all of them were negative except as noted above.,PHYSICAL EXAMINATION: ,GENERAL: Awake, alert female, no acute distress at this time.,HEENT: Fontanelle soft and flat. PERRLA. EOMI. Conjunctivae are clear. TMS are clear. Nares are clear. Mucous membranes pinks and moist. Throat clear. No oral lesions.,NECK: Supple.,LUNGS: Clear.,HEART: Regular rate and rhythm. Normal S1, S2. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding, no rebound. No rashes seen.,EXTREMITIES: Capillary refill is brisk. Good distal pulses.,NEUROLOGIC: Cranial nerves II through XII intact. 5/5 strength in all extremities.,SKIN: Her umbilicus looks completely clear. There is no evidence of erythema. The area that the parents point where the blister was, appears to be well healed. There is no evidence of lesion noted, at this time. On her left temple area and just inside her hairline, there is a small vesicle. It is not a pustule. It is almost flat and it has minimal fluid underneath that. There is no surrounding erythema, tenderness. I have inspected the body, head to toe. No other areas of lesions seen.,EMERGENCY DEPARTMENT COURSE: , I spoke with Infectious Disease, Dr. X. He states, we should treat for MRSA with Bactrim p.o. There has been no evidence of jaundice with this little girl. Hibiclens and Bactroban. I spoke with Dr. X's associate to call back after Dr. X recommended a Herpes culture be done, just for completeness and that was done. Blood culture was done here to make sure she did not have MRSA in her blood, which clinically, she does not appear to have. She was discharged in stable condition.,IMPRESSION: , Methicillin-resistant Staphylococcus aureus infection.,PLAN: , MRSA Instructions were given as above and antibiotics were prescribed. To follow up with their doctor.

history present illness dayold seen private doctor blister friday noted small blister near umbilicus went doctor saturday culture drawn came back today growing mrsa well put bacitracin ointment near umbilicus healed however today noticed small blister left temporal area called private doctor direct called infectious disease doctor asked come hospital mom states diagnosed mrsa buttocks well medications child fever lethargic irritable eating well ounces every feed eating well sleeping well changes notedpast medical history born full term complications home mom hospitalization surgeries allergiesmedications notedimmunizations uptodatefamily history negativesocial history ill contacts travel changes living conditionreview systems ten systems asked negative except noted abovephysical examination general awake alert female acute distress timeheent fontanelle soft flat perrla eomi conjunctivae clear tms clear nares clear mucous membranes pinks moist throat clear oral lesionsneck supplelungs clearheart regular rate rhythm normal murmurabdomen soft nontender positive bowel sounds guarding rebound rashes seenextremities capillary refill brisk good distal pulsesneurologic cranial nerves ii xii intact strength extremitiesskin umbilicus looks completely clear evidence erythema area parents point blister appears well healed evidence lesion noted time left temple area inside hairline small vesicle pustule almost flat minimal fluid underneath surrounding erythema tenderness inspected body head toe areas lesions seenemergency department course spoke infectious disease dr x states treat mrsa bactrim po evidence jaundice little girl hibiclens bactroban spoke dr xs associate call back dr x recommended herpes culture done completeness done blood culture done make sure mrsa blood clinically appear discharged stable conditionimpression methicillinresistant staphylococcus aureus infectionplan mrsa instructions given antibiotics prescribed follow doctor

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS:, A 14-day-old was seen by private doctor because of blister. On Friday, she was noted to have a small blister near her umbilicus. They went to their doctor on Saturday, culture was drawn. It came back today, growing MRSA. She has been doing well. They put her on bacitracin ointment near the umbilicus. That has about healed up. However today, they noticed a small blister on her left temporal area. They called the private doctor. They direct called the Infectious Disease doctor here and was asked that they come into the hospital. Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications. The child has not had any fever. She has not been lethargic or irritable. She has been eating well up to 2 ounces every feed. Eating well and sleeping well. No other changes have been noted.,PAST MEDICAL HISTORY:, She was born full term. No complications. Home with mom. No hospitalization, surgeries, allergies.,MEDICATIONS: , As noted.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No ill contacts. No travel or changes in living condition.,REVIEW OF SYSTEMS: ,Ten systems were asked, all of them were negative except as noted above.,PHYSICAL EXAMINATION: ,GENERAL: Awake, alert female, no acute distress at this time.,HEENT: Fontanelle soft and flat. PERRLA. EOMI. Conjunctivae are clear. TMS are clear. Nares are clear. Mucous membranes pinks and moist. Throat clear. No oral lesions.,NECK: Supple.,LUNGS: Clear.,HEART: Regular rate and rhythm. Normal S1, S2. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding, no rebound. No rashes seen.,EXTREMITIES: Capillary refill is brisk. Good distal pulses.,NEUROLOGIC: Cranial nerves II through XII intact. 5/5 strength in all extremities.,SKIN: Her umbilicus looks completely clear. There is no evidence of erythema. The area that the parents point where the blister was, appears to be well healed. There is no evidence of lesion noted, at this time. On her left temple area and just inside her hairline, there is a small vesicle. It is not a pustule. It is almost flat and it has minimal fluid underneath that. There is no surrounding erythema, tenderness. I have inspected the body, head to toe. No other areas of lesions seen.,EMERGENCY DEPARTMENT COURSE: , I spoke with Infectious Disease, Dr. X. He states, we should treat for MRSA with Bactrim p.o. There has been no evidence of jaundice with this little girl. Hibiclens and Bactroban. I spoke with Dr. X's associate to call back after Dr. X recommended a Herpes culture be done, just for completeness and that was done. Blood culture was done here to make sure she did not have MRSA in her blood, which clinically, she does not appear to have. She was discharged in stable condition.,IMPRESSION: , Methicillin-resistant Staphylococcus aureus infection.,PLAN: , MRSA Instructions were given as above and antibiotics were prescribed. To follow up with their doctor. ### Response: Emergency Room Reports

HISTORY OF PRESENT ILLNESS:, A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache. Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved. She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay. She continues to have some left-sided jaw pain. Denies any headache, fever, cough, or sore throat. She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that. She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:, Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:, Ibuprofen.,SOCIAL HISTORY:, She is a nonsmoker.,REVIEW OF SYSTEMS:, As above. No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General: A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs: Weight: 121 pounds. Temperature: 97.9 degrees.,Skin: Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes: PERRLA. Conjunctivae are clear.,Ears: Left TM with some effusion. Right TM is clear. Canals are clear. External auricles are nontender to manipulation.,Nose: Nasal mucosa is pink and moist without discharge.,Throat: Nonerythematous. No tonsillar hypertrophy or exudate.,Neck: Supple without adenopathy or thyromegaly.,Lungs: Clear. Respirations are regular and unlabored.,Heart: Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1. Serous otitis.,2. Atopic dermatitis.,PLAN:,1. Nasacort AQ two sprays each nostril daily.,2. Duraphen II one b.i.d.,3. Refills Cutivate cream 0.05% to apply to affected areas b.i.d. Recheck p.r.n.

history present illness yearold female history atopic dermatitis comes clinic complaint left otalgia headache symptoms started approximately three weeks ago difficulty hearing although greatly improved leftsided sinus pressure actually went dentist teeth hurting however teeth okay continues leftsided jaw pain denies headache fever cough sore throat used cutivate cream past atopic dermatitis good results needing refill also problems sinusitis past chronic leftsided headachefamily history reviewed unchangedallergies cephalexincurrent medications ibuprofensocial history nonsmokerreview systems nausea vomiting diarrheaphysical examinationgeneral welldeveloped wellnourished female conscious alert acute distressvital signs weight pounds temperature degreesskin reveals scattered erythematous plaques mild lichenification nuchal region behind kneeseyes perrla conjunctivae clearears left tm effusion right tm clear canals clear external auricles nontender manipulationnose nasal mucosa pink moist without dischargethroat nonerythematous tonsillar hypertrophy exudateneck supple without adenopathy thyromegalylungs clear respirations regular unlaboredheart regular rate rhythm rate beats per minuteassessment serous otitis atopic dermatitisplan nasacort aq two sprays nostril daily duraphen ii one bid refills cutivate cream apply affected areas bid recheck prn

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS:, A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache. Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved. She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay. She continues to have some left-sided jaw pain. Denies any headache, fever, cough, or sore throat. She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that. She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:, Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:, Ibuprofen.,SOCIAL HISTORY:, She is a nonsmoker.,REVIEW OF SYSTEMS:, As above. No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General: A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs: Weight: 121 pounds. Temperature: 97.9 degrees.,Skin: Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes: PERRLA. Conjunctivae are clear.,Ears: Left TM with some effusion. Right TM is clear. Canals are clear. External auricles are nontender to manipulation.,Nose: Nasal mucosa is pink and moist without discharge.,Throat: Nonerythematous. No tonsillar hypertrophy or exudate.,Neck: Supple without adenopathy or thyromegaly.,Lungs: Clear. Respirations are regular and unlabored.,Heart: Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1. Serous otitis.,2. Atopic dermatitis.,PLAN:,1. Nasacort AQ two sprays each nostril daily.,2. Duraphen II one b.i.d.,3. Refills Cutivate cream 0.05% to apply to affected areas b.i.d. Recheck p.r.n. ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS:, A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis.,ALLERGIES:, She is allergic to Sulfa.,CURRENT MEDICATIONS:, Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General: A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress. Mood is dysthymic. Affect is tearful.,Skin: Without rash.,Eyes: PERRLA. Conjunctivae are clear.,Neck: Supple with adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur.,ASSESSMENT:,1. Postsurgical menopause.,2. Mood swings.,PLAN:, I spent about 30 minutes with the patient discussing treatment options. I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer. We will try starting her back on Wellbutrin XL 150 mg daily. She may increase to 300 mg daily after three to seven days. Samples provided initially. If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy. I also recommended increasing her exercise. We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile. Follow up here in two weeks or sooner if any other problems. She is needing her annual breast exam as well.

history present illness yearold female comes clinic complaint mood swings tearfulness problematic last several months worsening point impairing work boss asks actually drugs said stated may needed meaning taking medications patient prescribed wellbutrin past responded well however time prescribed obsessivecompulsive type disorder relating overeating therefore insurance would cover medication antidepressants past suicidal ideation difficulty concentrating rapid mood swings tearfulness insomnia denies hot flashes night sweats underwent tah bso december family history benign breast lump mother however paternal grandmother breast cancer patient denies palpitations urinary incontinence hair loss concerns recently treated sinusitisallergies allergic sulfacurrent medications recently finished minocin duraphen ii dmphysical examinationgeneral welldeveloped wellnourished female conscious alert oriented times three acute distress mood dysthymic affect tearfulskin without rasheyes perrla conjunctivae clearneck supple adenopathy thyromegalylungs clearheart regular rate rhythm without murmurassessment postsurgical menopause mood swingsplan spent minutes patient discussing treatment options believe moods would greatly benefit hormone replacement therapy however reluctant family history breast cancer try starting back wellbutrin xl mg daily may increase mg daily three seven days samples provided initially obtaining adequate relief medication alone suggest explore use hormone replacement therapy also recommended increasing exercise also obtain screening lab work including cbc ua tsh chemistry panel lipid profile follow two weeks sooner problems needing annual breast exam well

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS:, A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis.,ALLERGIES:, She is allergic to Sulfa.,CURRENT MEDICATIONS:, Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General: A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress. Mood is dysthymic. Affect is tearful.,Skin: Without rash.,Eyes: PERRLA. Conjunctivae are clear.,Neck: Supple with adenopathy or thyromegaly.,Lungs: Clear.,Heart: Regular rate and rhythm without murmur.,ASSESSMENT:,1. Postsurgical menopause.,2. Mood swings.,PLAN:, I spent about 30 minutes with the patient discussing treatment options. I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer. We will try starting her back on Wellbutrin XL 150 mg daily. She may increase to 300 mg daily after three to seven days. Samples provided initially. If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy. I also recommended increasing her exercise. We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile. Follow up here in two weeks or sooner if any other problems. She is needing her annual breast exam as well. ### Response: Consult - History and Phy., General Medicine

HISTORY OF PRESENT ILLNESS:, A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss. He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma. There was also a question of liver metastases at that time.,OPERATION PERFORMED:, Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right. The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant. Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula. Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review. Approximately eight biopsies were taken of the left upper lobe.

history present illness yearold gentleman presented emergency room chest pain cough hemoptysis shortness breath recent pound weight loss ct scan done chest demonstrated bilateral hilar adenopathy extension subcarinal space well large cm right hilar mass consistent primary lung carcinoma also question liver metastases timeoperation performed fiberoptic bronchoscopy endobronchial biopsiesthe bronchoscope passed airway noted large friable tumor blocking bronchus intermedius right tumor extended carina involving lingula left upper lobe appearing malignant approximately biopsies taken tumorattention directed left upper lobe lingula epinephrine already instilled multiple biopsies taken lingula left upper lobe placed separate container histologic review approximately eight biopsies taken left upper lobe

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS:, A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss. He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma. There was also a question of liver metastases at that time.,OPERATION PERFORMED:, Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right. The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant. Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula. Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review. Approximately eight biopsies were taken of the left upper lobe. ### Response: Cardiovascular / Pulmonary, Surgery

HISTORY OF PRESENT ILLNESS:, Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:, The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis. There were come concentric rings present. There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus. Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis. There was no stricture or Barrett mucosa. The bony and the antrum of the stomach are normal without any acute peptic lesions. Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia. There were no acute lesions and no evidence of ulcer, tumor, or polyp. The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal. Adverse reactions: None.,FINAL IMPRESSION: ,Esophageal changes suggestive of eosinophilic esophagitis. Biopsies throughout the length of the esophagus were obtained for microscopic analysis. There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.

history present illness briefly yearold male problems dysphagia solids recently food impacted lower esophagus upper endoscopy evaluate esophagus edema inflammation food impaction resolved look stricture may need dilated mucosal abnormalityprocedure performed egdprep cetacaine spray mcg fentanyl iv mg versed ivfindings tip endoscope introduced esophagus entire length esophagus dotted numerous white punctate lesions suggestive eosinophilic esophagitis come concentric rings present erosion flame hemorrhage friability distal esophagus biopsies throughout entire length esophagus cm obtained look eosinophilic esophagitis stricture barrett mucosa bony antrum stomach normal without acute peptic lesions retroflexion tip endoscope body stomach revealed normal cardia acute lesions evidence ulcer tumor polyp pylorus easily entered first second third portions duodenum normal adverse reactions nonefinal impression esophageal changes suggestive eosinophilic esophagitis biopsies throughout length esophagus obtained microscopic analysis evidence stricture barrett abnormalities upper gi tract

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS:, Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:, The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis. There were come concentric rings present. There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus. Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis. There was no stricture or Barrett mucosa. The bony and the antrum of the stomach are normal without any acute peptic lesions. Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia. There were no acute lesions and no evidence of ulcer, tumor, or polyp. The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal. Adverse reactions: None.,FINAL IMPRESSION: ,Esophageal changes suggestive of eosinophilic esophagitis. Biopsies throughout the length of the esophagus were obtained for microscopic analysis. There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract. ### Response: Gastroenterology, Surgery

HISTORY OF PRESENT ILLNESS:, I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history. By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor. She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension. She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done. She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg. Other findings were not significantly changed including pericardial effusion description. She has a history of longstanding hypertension. She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion. She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula. She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1. Norvasc 10 mg once a day.,2. Aspirin 81 mg once a day.,3. Colace 200 mg two at bedtime.,4. Labetalol 100 mg p.o. b.i.d.,5. Nephro-Vite one tablet p.o. q.a.m.,6. Dilantin 100 mg p.o. t.i.d.,7. Renagel 1600 mg p.o. t.i.d.,8. Sensipar 120 mg p.o. every day.,9. Sertraline 100 mg p.o. nightly.,10. Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM: ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%. Height is 5 feet 1 inch, weight 147 pounds. On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted. HEENT shows the cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins are difficult to assess, but do not appear clinically distended. No carotid bruits. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla. No rub, no gallop. PMI is nondisplaced. Abdomen: Soft, nondistended. CVA is benign. Extremities with no significant edema. Pulses appear grossly intact. She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change. The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one. Echocardiogram results as above. Chest x-ray shows mild pulmonary vascular congestion. BNP shows 3788. Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90. Troponin was 0.40 followed by 0.34. INR 1.03 on 05/18/07. White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time. She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report. One of the questions we were asked was whether the patient would be a candidate for Coumadin. Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk. If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year. I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1. Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin. Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2. The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3. Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade. I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification. I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4. Continue Norvasc for history of hypertension as well as labetalol.,5. The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6. Continue Dilantin for history of seizures.

history present illness kindly asked see ms abc yearold woman cardiology consultation regarding atrial fibrillation anticoagulation fallthe patient somnolent time arouse unable provide much history review chart appears fell states got rocking chair could get floor states hours later able get floorthe patient denies chest pain clear shortness breathpast medical history includes endstage renal disease hypertension follows dr x office known smalltomoderate sized pericardial effusion since apparently followed appears patient interested diagnostic pericardiocentesis done echocardiogram today please see also report shows stable smalltomoderate sized pericardial effusion without tamponade normal left ventricular ejection fraction mild concentric left ventricular hypertrophy mildly dilated right ventricular size normal right ventricular ejection fraction moderate mitral regurgitation severe tricuspid regurgitation severe pulmonary hypertension estimated pa systolic pressure mmhg compared prior echocardiogram done previously mitral regurgitation mild previously pa systolic pressure estimated mmhg findings significantly changed including pericardial effusion description history longstanding hypertension hemodialysis since renal failure history ministrokes documented several years ago history seizure disorder history right upper extremity edema right breast enlargement right subclavian vein occlusion history hypertension depression hyperlipidemia sensipar tertiary hyperparathyroidismpast surgical history includes cholecystectomy post fistula left arm failed right arm used including number operative procedures fistula follows dr regarding neurovascular surgerymedications admission norvasc mg day aspirin mg day colace mg two bedtime labetalol mg po bid nephrovite one tablet po qam dilantin mg po tid renagel mg po tid sensipar mg po every day sertraline mg po nightly zocor mg po nightlyallergies medications per chart nonefamily history unable obtain patient becomes quite sleepy talkingsocial history unable obtain patient becomes quite sleepy talkingreview systems unable obtain patient becomes quite sleepy talkingphysical exam temperature blood pressure ranges pulse respiratory rate saturation height feet inch weight pounds general exam pleasant elderly woman arouse voice becomes quite sleepy apparently improvement admitted heent shows cranium normocephalic atraumatic moist mucosal membranes neck veins difficult assess appear clinically distended carotid bruits lungs clear auscultation anteriorly wheezes cardiac exam regular rate holosystolic murmur heard radiation left apex towards left axilla rub gallop pmi nondisplaced abdomen soft nondistended cva benign extremities significant edema pulses appear grossly intact evidence right upper extremity edema apparently chronicdiagnostic datalab data ekgs reviewed including shows atrial fibrillation left anterior fascicular block poor rwave progression compared one done really significant change atrial fibrillation appears present since least ekg done ekg significantly changed recent one echocardiogram results chest xray shows mild pulmonary vascular congestion bnp shows sodium potassium chloride bicarbonate bun creatinine troponin followed inr white blood cell count hematocrit platelet count impression ms abc yearold woman admitted hospital fall history vascular dementia history somewhat unreliable seems somnolent time chronic atrial fibrillation documented least present since found ekg report dr x shows atrial fibrillation per report one questions asked whether patient would candidate coumadin clearly given history small ministrokes think coumadin would appropriate given chronic atrial fibrillation main issue fall risk felt significant fall risk would strongly recommend coumadin patient states fallen twice past year would defer decision dr z dr xy know patient well may physical therapy consult appropriate help adjudicaterecommendations fall assessment per dr z dr xy possible pt consult felt appropriate patient felt significant fall risk would put coumadin given history small strokes documented chart chronic atrial fibrillation reasonable heart rate control current labetalol patient elevated bnp suspect due severe pulmonary hypertension renal failure light normal lv function would make evaluation aggressive diuresis regarding minimal troponin elevation feel diagnosis especially setting pulmonary hypertension smalltomoderate sized stable pericardial effusion longstanding since tell evidence tamponade would defer usual cardiologist dr x whether outpatient stress evaluation appropriate risk stratification find patient prior cardiac stress test felt subtle reversibility anterior wall felt may artifact rather true ischemia normal lv function seen study well continue norvasc history hypertension well labetalol patient felt significant fall risk least continue aspirin mg day secondary cva thromboprophylaxis albeit understanding inferior coumadin continue dilantin history seizures

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS:, I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history. By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor. She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension. She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done. She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg. Other findings were not significantly changed including pericardial effusion description. She has a history of longstanding hypertension. She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion. She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula. She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1. Norvasc 10 mg once a day.,2. Aspirin 81 mg once a day.,3. Colace 200 mg two at bedtime.,4. Labetalol 100 mg p.o. b.i.d.,5. Nephro-Vite one tablet p.o. q.a.m.,6. Dilantin 100 mg p.o. t.i.d.,7. Renagel 1600 mg p.o. t.i.d.,8. Sensipar 120 mg p.o. every day.,9. Sertraline 100 mg p.o. nightly.,10. Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM: ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%. Height is 5 feet 1 inch, weight 147 pounds. On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted. HEENT shows the cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins are difficult to assess, but do not appear clinically distended. No carotid bruits. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla. No rub, no gallop. PMI is nondisplaced. Abdomen: Soft, nondistended. CVA is benign. Extremities with no significant edema. Pulses appear grossly intact. She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change. The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one. Echocardiogram results as above. Chest x-ray shows mild pulmonary vascular congestion. BNP shows 3788. Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90. Troponin was 0.40 followed by 0.34. INR 1.03 on 05/18/07. White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time. She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report. One of the questions we were asked was whether the patient would be a candidate for Coumadin. Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk. If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year. I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1. Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin. Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2. The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3. Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade. I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification. I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4. Continue Norvasc for history of hypertension as well as labetalol.,5. The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6. Continue Dilantin for history of seizures. ### Response: Cardiovascular / Pulmonary, Consult - History and Phy.

HISTORY OF PRESENT ILLNESS:, In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine. Two weeks later she saw a nephrologist at ABCDE were she worked at that time. An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased. No particular treatment was advised. She was laid off 6 months later. In 2004, she began working at The ABCD Hospital and began seeing Dr. A. She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work. She began seeing Dr. B and was put on Procrit and Renagel. She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step. She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7. She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma. Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:, She is on several medications. She is not on a renal diet yet. Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:, She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:, She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:, None.,COPING STRATEGIES:, She used to exercise vigorously, but has stopped at this time. She enjoys watching movies with her children.,COMPLIANCE:, She feels she watches her diet and medication regimen very closely. She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:, She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:, None.,PAST AND PRESENT DRUG USE:, None.,LEGAL ISSUES:, None.,TATTOOS:, None.,MARITAL STATUS: LENGTH OF THE TIME MARRIED:, She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:, Xyz is 62 and in good health.,CHILDREN:, Four, all are in good health.,FATHER:, Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:, Dolorous Massey is 63 and in good health.,SIBLINGS:, Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:, None.,PERSONS LIVING IN HOUSEHOLD:, Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:, She is close to her brother.,HIGHEST LEVEL OF EDUCATION:, She has 2 years of college at ABCD College. She is a licensed LVN.,MILITARY SERVICE:, None.

history present illness patient blood test routine screening revealed anemia elevated creatinine two weeks later saw nephrologist abcde worked time ultrasound revealed parenchymal disease tissue around kidney diseased particular treatment advised laid months later began working abcd hospital began seeing dr put procrit could keep stringent appointment scheduled injection work began seeing dr b put procrit renagel advised go dialysis felt enough information drastic step saw endocrinologist thyroid problem blood work showed creatinine referred dr xyz found parathyroid scan may adenoma creatinine treatment impact disease several medications renal diet yet energy good still working full timetransplant first mentioned treatment option wanted transplant ever since dialysis first mentionedemotional reaction diagnosis treatment course frustrated lack information exactly caused renal failure real feeling helplessness efforts pursue understandingother significant medical historysurgeries bartholin cyst removed psychiatric history nonecoping strategies used exercise vigorously stopped time enjoys watching movies childrencompliance feels watches diet medication regimen closely said communicates daily dr xyzpast present smoking began smoking cigarettes day stopped yearpast present alcohol use nonepast present drug use nonelegal issues nonetattoos nonemarital status length time married married yearsage health spouse xyz good healthchildren four good healthfather father died age cardiac cancermother dolorous massey good healthsiblings ben doherty died age automobile accident steven doherty good healthprevious marriages duration nonepersons living household sixrelationship family membersidentified primary support system close brotherhighest level education years college abcd college licensed lvnmilitary service none

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS:, In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine. Two weeks later she saw a nephrologist at ABCDE were she worked at that time. An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased. No particular treatment was advised. She was laid off 6 months later. In 2004, she began working at The ABCD Hospital and began seeing Dr. A. She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work. She began seeing Dr. B and was put on Procrit and Renagel. She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step. She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7. She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma. Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:, She is on several medications. She is not on a renal diet yet. Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:, She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:, She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:, None.,COPING STRATEGIES:, She used to exercise vigorously, but has stopped at this time. She enjoys watching movies with her children.,COMPLIANCE:, She feels she watches her diet and medication regimen very closely. She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:, She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:, None.,PAST AND PRESENT DRUG USE:, None.,LEGAL ISSUES:, None.,TATTOOS:, None.,MARITAL STATUS: LENGTH OF THE TIME MARRIED:, She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:, Xyz is 62 and in good health.,CHILDREN:, Four, all are in good health.,FATHER:, Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:, Dolorous Massey is 63 and in good health.,SIBLINGS:, Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:, None.,PERSONS LIVING IN HOUSEHOLD:, Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:, She is close to her brother.,HIGHEST LEVEL OF EDUCATION:, She has 2 years of college at ABCD College. She is a licensed LVN.,MILITARY SERVICE:, None. ### Response: Nephrology

HISTORY OF PRESENT ILLNESS:, Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss. At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46. She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:, Significant for hypertension, for which the patient takes Norvasc and Lopressor for. She also suffers from high cholesterol and is on lovastatin for this. She has depression, for which she takes citalopram. She also stated that she had a DVT in the past prior to her hysterectomy. She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones. She also had a hysterectomy in 1994 secondary to hemorrhage. The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker. She is married, with 2 children aged 22 and 28. She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY: ,Significant for high blood pressure and diabetes as well as cancer on her father side. He did pass away from congestive heart failure. Mother suffers from high blood pressure, cancer, and diabetes. Her mother has passed away secondary to cancer. She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling. The patient also wears glasses for vision and has dentures. She does complain of shortness of breath with exertion. She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain. The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease. She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION: ,The patient is a well-nourished, well-developed female, in no distress. Eye Exam: Pupils equal and reactive to light. Extraocular motions are intact. Neck Exam: No cervical lymphadenopathy. Midline trachea. No carotid bruits. Nonpalpable thyroid. Neuro Exam: Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted. Lung Exam: Clear breath sounds without rhonchi or wheezes. Cardiac Exam: Regular rate and rhythm without murmur or bruits. Abdominal Exam: Positive bowel sounds. Soft, nontender, obese, and nondistended abdomen. Lap cholecystectomy scars noted. No obvious hernias. No organomegaly appreciated. Lower extremity Exam: Edema 1+. Dorsalis pedis pulses 2+.,ASSESSMENT: ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery. The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels. I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy. Also the patient will meet with the dietitian and psychologist as per her usual routine. I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.

history present illness ms yearold female presented bariatric surgery service consideration laparoscopic rouxeny gastric bypass patient states overweight approximately years tried multiple weight loss modalities past including weight watchers nutrisystem jenny craig tops cabbage diet grape fruit diet slimfast richard simmons well overthecounter measures without longterm sustainable weight loss time presentation practice feet inches tall weight pounds body mass index obesityrelated comorbidities includes hypertension hypercholesterolemiapast medical history significant hypertension patient takes norvasc lopressor also suffers high cholesterol lovastatin depression takes citalopram also stated dvt past prior hysterectomy also suffers thyroid disease past though unclear nature thispast surgical history significant cholecystectomy gallstones also hysterectomy secondary hemorrhage patient denies abdominal surgeriesmedications norvasc mg po daily lopressor tartrate mg po bid lovastatin mg po bedtime citalopram mg po daily aspirin mg three times day currently stopped vitamin premarin mg one tablet po daily currently stopped omega fatty acids vitamin units q weeklyallergies patient denies allergies medications latexsocial history patient homemaker married children aged lifelong nonsmoker nondrinkerfamily history significant high blood pressure diabetes well cancer father side pass away congestive heart failure mother suffers high blood pressure cancer diabetes mother passed away secondary cancer two brothers one passed away brain cancerreview systems significant ankle swelling patient also wears glasses vision dentures complain shortness breath exertion also suffers hemorrhoids frequent urination night well weightbearing joint pain patient denies ulcerative colitis crohn disease bleeding diathesis liver disease kidney disease denies chest pain cardiac disease cancer strokephysical examination patient wellnourished welldeveloped female distress eye exam pupils equal reactive light extraocular motions intact neck exam cervical lymphadenopathy midline trachea carotid bruits nonpalpable thyroid neuro exam gross motor strength upper lower extremities equal bilaterally focal neuro deficits noted lung exam clear breath sounds without rhonchi wheezes cardiac exam regular rate rhythm without murmur bruits abdominal exam positive bowel sounds soft nontender obese nondistended abdomen lap cholecystectomy scars noted obvious hernias organomegaly appreciated lower extremity exam edema dorsalis pedis pulses assessment patient yearold female body mass index suffering obesityrelated comorbidities including hypertension hypercholesterolemia presents practice consideration gastric bypass surgery patient appears excellent candidate surgery would benefit greatly surgical weight loss management obesityrelated comorbiditiesplan preparation surgery obtain usual baseline laboratory values including baseline vitamin levels recommended patient undergo upper gi series prior surgery due find upper gi anatomy also patient meet dietitian psychologist per usual routine recommended approximately six eight weeks medifast patient obtain preoperative weight loss preparation surgery

### Instruction: find the medical speciality for this medical test. ### Input: HISTORY OF PRESENT ILLNESS:, Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss. At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46. She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:, Significant for hypertension, for which the patient takes Norvasc and Lopressor for. She also suffers from high cholesterol and is on lovastatin for this. She has depression, for which she takes citalopram. She also stated that she had a DVT in the past prior to her hysterectomy. She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones. She also had a hysterectomy in 1994 secondary to hemorrhage. The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker. She is married, with 2 children aged 22 and 28. She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY: ,Significant for high blood pressure and diabetes as well as cancer on her father side. He did pass away from congestive heart failure. Mother suffers from high blood pressure, cancer, and diabetes. Her mother has passed away secondary to cancer. She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling. The patient also wears glasses for vision and has dentures. She does complain of shortness of breath with exertion. She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain. The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease. She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION: ,The patient is a well-nourished, well-developed female, in no distress. Eye Exam: Pupils equal and reactive to light. Extraocular motions are intact. Neck Exam: No cervical lymphadenopathy. Midline trachea. No carotid bruits. Nonpalpable thyroid. Neuro Exam: Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted. Lung Exam: Clear breath sounds without rhonchi or wheezes. Cardiac Exam: Regular rate and rhythm without murmur or bruits. Abdominal Exam: Positive bowel sounds. Soft, nontender, obese, and nondistended abdomen. Lap cholecystectomy scars noted. No obvious hernias. No organomegaly appreciated. Lower extremity Exam: Edema 1+. Dorsalis pedis pulses 2+.,ASSESSMENT: ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery. The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels. I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy. Also the patient will meet with the dietitian and psychologist as per her usual routine. I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery. ### Response: Consult - History and Phy.

HISTORY OF PRESENT ILLNESS:, Ms. Connor is a 50-year-old female who returns to clinic for a wound check. The patient underwent an APR secondary to refractory ulcerative colitis. Subsequently, she developed a wound infection, which has since healed. On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound. She describes no drainage or erythema from her bottom. She is having good ostomy output. She does not describe any fevers, chills, nausea, or vomiting. The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy. She has been taking Percocet for this pain and it does work. She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain. She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds. This is a pleasant female in no acute distress. The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar. There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant. There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter. I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less. I have counseled her on refraining from soft drinks and fruit drinks. I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy. She also had questions about her occasional abdominal pain. I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain. I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain. The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery. This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping. I told her that I felt that this would continue to improve as it has done over the past two months since her surgery. I told her to continue doing hand exercises as she has been doing and this seems to be working for her. Overall, I think she has healed from her surgery and is doing very well. Again, her quality of life is significantly improved. She is happy with her performance. We will see her back in six months just for a general routine checkup and see how she is doing at that time.