Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Complex Cyanotic Congenital Heart Disease

HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.
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DESCRIPTION: A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.

The situation involves managing a complex congenital heart condition in a pediatric patient, specifically with asplenia syndrome and various cardiac anomalies including cyanotic heart disease. The detailed history and procedural notes indicate multiple previous surgeries and interventions, significant current cardiovascular abnormalities, and ongoing surgical considerations. This context underscores the high stakes, as it involves life-threatening conditions requiring careful planning and execution of medical interventions. The management of these congenital defects is critical for the patient's life and health outcomes. Additionally, the cardiovascular specialty and the invasive procedures described, such as catheterization and stenting, support a high stakes assessment.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Shiley Tracheostomy Tube Insertion

OPERATION: , Insertion of a #8 Shiley tracheostomy tube.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.,Next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea.  The 2nd tracheal ring was identified.  Next, a #11-blade scalpel was used to make a trap door in the trachea.  The endotracheal tube was backed out.  A #8 Shiley tracheostomy tube was inserted, and tidal CO2 was confirmed when it was connected to the circuit.  We then secured it in place using 0 silk suture.  A sterile dressing was applied.  The patient tolerated the procedure well.
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DESCRIPTION: Insertion of a #8 Shiley tracheostomy tube.  A #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  Dissection was carried down using Bovie electrocautery to the level of the trachea.

cardiovascular / pulmonary, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube,

The procedure described is a tracheostomy tube insertion under general anesthesia, which is inherently a high-stakes surgery due to the necessity for controlling the airway, risk of complications such as infection, bleeding, or injury to the trachea and nearby structures, and requires precision. It is even more critical in emergency settings but remains significant in scheduled operations. Ensuring the patient tolerates the procedure well without complications is crucial.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation - 3

HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.
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DESCRIPTION: Patient with atrial fibrillation with slow ventricular response, partially due to medications.

The situation involves a complex medical case of a 77-year-old patient with multiple serious health conditions including inoperable cancer, atrial fibrillation, diabetes, hypertension, and a history of GI bleeding. The patient is not a candidate for several standard treatments due to the risk of bleeding and other complications, and there is consideration for hospice care. Given the patient's age, multiple comorbidities, and the inoperability of the cancer, these are high-stakes decisions as they will significantly impact the patient's quality of life and care options. Additionally, the mention of moving towards hospice care indicates end-of-life considerations, further underscoring the gravity of the situation.


Medical Specialty: Nephrology
Sample Name: CT Abdomen & Pelvis - 1

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

CT Abdomen and Pelvis with contrast

nephrology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct

The CT scan results show that there is no acute medical condition such as appendicitis or nephrolithiasis, and the relevant organs are unremarkable, meaning there are no acute findings that usually require immediate intervention. The patient has symptoms that prompted the scan, but the results do not indicate an urgent medical crisis. Therefore, the situation is not considered high-stakes from a critical health intervention perspective.


Medical Specialty: Neurosurgery
Sample Name: Lumbar Puncture

REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.
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DESCRIPTION: Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.

The situation involves a diagnostic lumbar puncture procedure on an 83-year-old woman with known lung cancer and potential neurological impairments. The procedure is conducted to rule out or confirm possible CSF malignancy, which could significantly impact her cancer management and overall prognosis. The patient's deteriorating physical abilities and the potential for malignancy in the CSF present high stakes in terms of health outcomes and necessary medical interventions. Although the immediate procedure is low-risk, the implications of its findings are high-stakes due to the possible need for urgent oncological interventions or changes in treatment if malignancy is confirmed.


Medical Specialty: General Medicine
Sample Name: H&P - Gen Med - 2

HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency department with pulseless electrical activity. Her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. She became acutely unresponsive. She was noted to have worsening of her breathing. She took several of her MDIs and then was placed on her CPAP. He went to notify EMS and when he returned, she was found to not be breathing. He stated that she was noted to have no breathing in excess of 10 minutes. He states that the EMS system arrived at the home and she was found not breathing. The patient was intubated at the scene and upon arrival to Erlanger Medical Center, she was found to have pupils fixed and dilated. She was seen by me in the emergency department and was on Neo-Synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state.,REVIEW OF SYSTEMS:, Review of systems was not obtainable.,PAST MEDICAL HISTORY:, Diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia.,PAST SURGICAL HISTORY:, Noncontributory to above.,FAMILY HISTORY:, Mother with history of coronary artery disease.,SOCIAL HISTORY:, The patient is married. She uses no ethanol, no tobacco and no illicits. She has a very support family unit.,MEDICATIONS:, Augmentin; Detrol LA; lisinopril.,IMMUNIZATIONS:, Immunizations were up to date for influenza, negative for Pneumovax.,ALLERGIES:, PENICILLIN.,LABORATORY AT PRESENTATION:, White blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. Sodium 148, potassium 5.2, BUN 30, creatinine 2.2 and glucose 216. PT was 22.4.,RADIOLOGIC DATA:, Chest x-ray revealed a diffuse pulmonary edema.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 97/52, pulse of 79, respirations 16, O2 sat 100%.,HEENT: The patient's pupils were again, fixed and dilated and intubated on the monitor.,CHEST: Poor air movement bilateral with bilateral rales.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: The abdomen was obese, nondistended and nontender.,EXTREMITIES: Left diabetic foot had oozing pus drainage from the foot.,GU: Foley catheter was in place.,IMPRESSION AND PLAN:,1. Acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: Will continue ventilator support. Will rule out pulmonary embolus, rule out myocardial infarction. Continue pressors. The patient is currently on dopamine, Neo-Synephrine and Levophed.,2. Acute respiratory distress syndrome: Will continue ventilatory support.,3. Questionable sepsis: Will obtain blood cultures, intravenous vancomycin and Rocephin given.,4. Hypotensive shock: Will continue pressors. Will check random cortisol. Hydrocortisone was added.,Further inpatient management for this patient will be provided by Dr. R. The patient's status was discussed with her daughter and her husband. The husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. He states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. Will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. The family will make an assessment and final decision concerning her long-term management after a 24 hour period.
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DESCRIPTION: History of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer, anemia, and left lower extremity cellulitis.

The situation involves a 71-year-old patient in critical condition with multiple comorbidities. She has been intubated and is presenting with severe symptoms consistent with cardiac arrest (pulseless electrical activity) and hypotensive shock, requiring immediate and aggressive medical intervention, including ventilatory support and multiple medications to manage shock and possible sepsis. The presence of fixed and dilated pupils suggests significant neurological compromise. The patient's history of diabetes, atrial fibrillation, and other conditions complicate her treatment and prognosis. The scenario is high-stakes due to the potential for rapid deterioration and the life-threatening nature of her condition.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - 4

SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.
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DESCRIPTION: Counting calorie points, exercising pretty regularly, seems to be doing well

consult - history and phy., overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly

The situation involves a patient who is actively managing her diet and weight, attending support groups, and achieving positive results. While dietary management and weight loss can have significant long-term health implications, the scenario described does not involve immediate or severe health risks. It is a routine follow-up dietary consult, and the patient appears to be doing well, with weight loss and engagement in support systems. High-stakes scenarios in medical contexts typically involve acute medical interventions, life-threatening conditions, or significant changes in health status.


Medical Specialty: Consult - History and Phy.
Sample Name: Peripheral Effusion - Consult

REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.
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DESCRIPTION: Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.

The situation involves a 70-year-old female patient with a complex medical history including recurrent pneumonia, COPD, emphysema, and a history of lung cancer with metastasis. The current issue at hand is a moderate pericardial effusion with early signs of tamponade, which is a potentially life-threatening condition if not addressed in a timely manner. The patient is also undergoing a CT surgery consult for a pericardial window to address the effusion, indicating an urgent medical intervention is planned. Given the potential for rapid deterioration without intervention, this situation is relatively high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal ROS Template - 2

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.
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DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

consult - history and phy., nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness,

The content provided is a template for a normal review of systems (ROS) in a medical consultation. It lists multiple negative findings across various body systems, suggesting a patient's report of no issues in these areas. This is standard practice in medical documentation and does not indicate any immediate concern or high-risk conditions. Such templates are used as checklists to ensure all relevant systems are reviewed and documented as negative where appropriate. Therefore, the situation itself is not inherently high-stakes, as it is part of routine documentation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Supraventricular Tachycardia - Consult

HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.
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DESCRIPTION: The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.

cardiovascular / pulmonary, congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,

The situation involves a 4-month-old patient with supraventricular tachycardia and significant cyanotic congenital heart disease. This is a critical condition requiring careful management, including medication and potential surgical intervention to ensure adequate pulmonary blood flow and manage heart function. Timely and accurate decisions are crucial to the patient's survival and long-term health, making it a high-stakes situation.


Medical Specialty: Lab Medicine - Pathology
Sample Name: Lung Biopsy Pathology Report - 1

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.
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DESCRIPTION: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.

lab medicine - pathology, lung biopsy, wedge, lobe, pathologic, lymph node', node', lymphoid, malignancy, lung, lymph, biopsy

The pathology report outlines findings of two separate lung tumors identified as non-small cell carcinoma, one of which shows poorly differentiated features and the other moderately differentiated characteristics with arterial invasion. Despite there being no evidence of lymphatic or pleural invasion, the identification of separate primary tumors and arterial invasion indicate a significant concern for the patient, as it directly relates to the management and prognosis of lung cancer. Decisions regarding further surgical interventions, chemotherapy, or radiation therapy may be needed. This information affects patient treatment plans and ultimately their prognosis, thus classifying the situation as high-stakes.


Medical Specialty: Surgery
Sample Name: Debridement - Shoulder

TITLE OF OPERATION:  ,1.  Incision and drainage with extensive debridement, left shoulder.,2.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3.  Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections.  Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES:  ,1.  Deep extensive infection, left total shoulder arthroplasty.,2.  Biceps tenosynovitis.,3.  Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE:  ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder.  He was then placed Beach chair position and all bony prominences were well padded.  Pillows were placed around his knees to protect his sciatic nerve.  He was brought to the side of the table and secured with towels and tape.  The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch.  Left upper extremity was then prepped and draped in usual sterile fashion.  Unfortunately, preoperative antibiotics were given prior to the procedure.  This occurred due to lack of communication between the surgical staff and the anesthesia staff.  The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped.  Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made.  The patient's had a cephalic vein, it was identified and protected throughout the case.  It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible.  The patient did have significant scar from this point on and did bleed from many surfaces throughout the case.  As a result, he was transfused 1 unit postoperatively.  He did not have any problems during the case except for one small drop of blood pressure.  However this was due primarily because of the extensive scarring of his proximal humerus.  He had scar between the anterior capsular structures and the conjoint tendon.  Also there was significant scar between the deltoid and the proximal humerus.  The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve.  Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3.  This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid.  As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material.  There was some suggestion of a synovitis type reaction also inside this cystic area.  This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment.  This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm.  All of the mucinous material and fibrinous material was removed from the proximal humerus.  This was fairly extensive debridement.  All of this was sent to pathology and also sent for culture and sensitivity.  It should be noted that Gram stain became as multiple white blood cells but no organism seen.  The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it.  There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous.  This was also removed.  Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever.  It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever.  As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion.  The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps.  It was tracked proximally and transverse ligament released.  The biceps tendon was flat and somewhat erythematous.  As a result, it released and tagged with an 0 Vicryl suture.  It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures.  The joint was then entered and noted significant synovitis throughout the entire glenoid.  This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set.  Unfortunately, this device would not hold the proximal humerus and we could not get the component to release.  As a result, bone contact of the metal proximally was released using a straight osteotome.  Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it.  There was no cement.  There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate.  This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection.  It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid.  The glenoid component was very carefully dissected free and found to be very loose.  It was essentially removed with digital dissection.  There was no remaining cement in the cavity itself.  The patient's glenoid was very carefully debrided.  The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself.  This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation.  Rather than place a spacer, it was elected to use antiobiotic beads.  This was with antibiotic impregnated cement with one package with 3 gram of vancomycin.  These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region.  These three did not have a Prolene attached to them.  The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon.  There was essentially no capsule left purely to close over the proximal humerus.  It was electively the proximal humerus.  A portion of bone intact because it did have some bleeding surfaces.  Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and shoulder immobilizer.  The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case.  This was a significantly scarred patient which required extra dissection and attention.  Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case.  Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis.  The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case.  This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever.
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DESCRIPTION: Incision and drainage with extensive debridement, left shoulder.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).  Implantation of antibiotic beads, left shoulder.

surgery, incision and drainage, shoulder arthroplasty, extensive debridement, uncemented humeral, biomet, cemented, antibiotic beads, biceps tenosynovitis, rotator cuff tear, total shoulder arthroplasty, proximal humerus, vicryl sutures, glenoid, tendon, proximal, humerus, beads, shoulder, incision,

The surgical situation described here involves a complex shoulder surgery addressing a deep infection, rotator cuff tears, and removal of previous shoulder arthroplasty components. The procedure involves significant risks such as potential for ongoing infection, blood loss, damage to nerves or arteries, and complex repair work given the patient's significant scar tissue from previous surgeries. The stakes are high due to the potential for severe complications if the surgery does not go as planned, impacting the patient's mobility and quality of life. Furthermore, the technical difficulty and time requirement exceeding typical revision surgery underscore the significance.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 39

Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction.,At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief.,Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management.,Past Medical History:,Asthma,Allergic Rhinitis,Medications:,loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies:, PCN, but has tolerated cephalosporins in the past.,Social History:, No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.,Family History:, HTN, father with SLE, uncle with Addison’s Disease.,Physical Exam:,T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry.,Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly.,Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages.,Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex.,Skin: no rash, ecchymosis, or petechiae,STUDIES:,EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst.,AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible.,MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features.,Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm.,CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus.,Hospital Course:, The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed.
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DESCRIPTION: Patient with abdominal pain, nausea, vomiting, fever, altered mental status.

The situation involves a 55-year-old male with multiple symptoms such as abdominal pain, nausea, vomiting, fever, and altered mental status. Significant findings include lab abnormalities, pulmonary symptoms, hypotension, and development of deep venous thrombosis (DVT). The patient required ICU admission after experiencing hypotensive episodes and confusion, which were not adequately resolved with IV fluids. These clinical presentations suggest serious conditions that could potentially be life-threatening, such as sepsis or severe infection, requiring careful and urgent medical management. The complexity and severity of the patient's condition, along with ICU admission, makes this a high-stakes medical situation.


Medical Specialty: Pediatrics - Neonatal
Sample Name: URI & Eustachian Congestion

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.
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DESCRIPTION: Viral upper respiratory infection (URI) with sinus and eustachian congestion.  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.

pediatrics - neonatal, upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar

The situation involves a 14-year-old patient with symptoms of a viral upper respiratory infection and eustachian congestion. While the symptoms can be uncomfortable and require monitoring to ensure they don't develop into more serious infections like pneumonia or otitis media, the current assessment and management plan are typical and low-risk. The patient is not in immediate danger, and clear instructions for managing symptoms and follow-up care are provided. Since the suggested treatment involves over-the-counter medication and monitoring, this situation is standard in a pediatric setting.


Medical Specialty: Consult - History and Phy.
Sample Name: URI & Eustachian Congestion

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.
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DESCRIPTION: Viral upper respiratory infection (URI) with sinus and eustachian congestion.  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.

consult - history and phy., upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar

The situation involves a common viral upper respiratory infection in a teenage patient, accompanied by sinus and eustachian congestion. The symptoms are typical and not severe, with the patient appearing only mildly ill. The plan includes the use of over-the-counter medication with a low likelihood of complications. While any medical condition has some level of importance, this situation is very typical and manageable, and does not currently involve any high-risk factors or severe symptoms.


Medical Specialty: Consult - History and Phy.
Sample Name: Supraventricular Tachycardia - Consult

HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  The patient is exclusively breast fed and feeding approximately 2 hours.  Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:,  Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS:  Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT:  Normocephalic with no bruit detected.  She had symmetric shallow breath sounds clear to auscultation.  She had full symmetrical pulses.,HEART:  There is normoactive precordium without a thrill.  There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN:  Soft.  Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:,  Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  There is a prominent thymus.  An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  There is a large inlet ventricular septal defect as pulmonary atresia.  The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  There was a small vertical ductus as a sole source of pulmonary artery blood flow.  The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1.  The patient's case was presented to the cardiothoracic surgical consultant, Dr. X.  The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure.  The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  These findings and recommendations were reviewed with the parents via a Spanish interpreter.
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DESCRIPTION: The patient is a 4-month-old who presented with supraventricular tachycardia and persistent cyanosis.

consult - history and phy., congenital heart disease, cyanotic, ductal-dependent, pulmonary blood flow, ventricular septal defect, blood flow, supraventricular tachycardia, tachycardia, ventricular, supraventricular, shunt, heart, pulmonary,

The situation involves a 4-month-old infant with complex congenital heart disease and a history of supraventricular tachycardia, which is a serious medical issue. The infant requires immediate medical treatment and careful planning for future surgical interventions to manage their condition. The stakes are high because this concerns a young patient with a life-threatening condition requiring specialized care and decision-making that will have significant implications on their health and survival.


Medical Specialty: Pain Management
Sample Name: Knee Injection - 1

PROCEDURE: , Right knee joint steroid injection.,PREOPERATIVE DIAGNOSIS:,  Osteoarthritis of the right knee.,POSTOPERATIVE DIAGNOSIS:,  Osteoarthritis of the right knee.,PROCEDURE:  ,The patient was apprised of the risks and the benefits of the procedure and consented.  The patient's right knee was sterilely prepped with Betadine.  A 4 mg of dexamethasone was drawn up into a 5 mL syringe with a 3 mL of 1% lidocaine.  The patient was injected with a 1.5-inch 25-gauze needle at the medial aspect of his right flexed knee.  There were no complications.  The patient tolerated the procedure well.  There was minimal bleeding.  The patient was instructed to ice his knee upon leaving clinic and refrain from overuse over the next 3 days.  The patient was instructed to go to the emergency room with any usual pain, swelling, or redness occurred in the injected area.  The patient was given a followup appointment to evaluate response to the injection to his increased range of motion and reduction of pain.
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DESCRIPTION: Osteoarthritis of the right knee.  Right knee joint steroid injection.

pain management, injection, knee joint, steroid injection, osteoarthritis, knee

The procedure described is a knee injection for osteoarthritis, a common and generally low-risk procedure. The patient was informed of the potential risks and benefits, experienced no complications, and was given routine aftercare instructions. While any medical procedure carries some risk, this one is well-established with a low likelihood of severe complications, making it low-stakes in the context of medical interventions.


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

Medical Specialty: General Medicine
Sample Name: Female Physical Exam - 2

FEMALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,Neck:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,Abdomen:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Reveals normal female external genitalia.  Speculum exam reveals vaginal mucosa to be pink and rugous.  Cervix appears normal.  Bimanual exam reveals uterus to be within normal limits.  Adnexa are normal without masses appreciated.  There is no cervical motion tenderness.,Rectal Exam:  Normal rectal tone.  No masses are appreciated.  Hemoccult is negative.,Extremities:  Reveal no clubbing, cyanosis, or edema.,Joint Exam:  Reveals no tenosynovitis.,Integumentary:  Normal breast tissue without lumps or masses.  There are no skin changes over the breasts.  Axillae are free of masses.,Neurologic:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,Psychiatric:  Grossly normal.,Dermatologic:  No lesions or rashes.
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DESCRIPTION: Sample female physical exam.

Sample female physical exam.

general medicine, female physical examination, bimanual exam, heent, hemoccult, ii through xii, breast tissue, cardiovascular, dermatologic, external genitalia, integumentary, joint exam, lymphadenopathy, neck, neurologic, physical examination, rectal exam, skin changes, speculum exam, female physical, extremities, masses, oropharynx,

The situation involves a routine female physical examination described in detailed medical terms. It represents a standard process in general medicine aiming to assess a patient's health status. While the accuracy and thoroughness of documentation is important, it is a low-stakes scenario because it does not indicate any immediate medical concerns or actions requiring urgent intervention.


Medical Specialty: Surgery
Sample Name: Nasolabial Fold Elevation

PREOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1.  Left midface elevation with nasolabial fold elevation.,2.  Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service.  The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity.  In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry.  The patient was seen in consultation and felt to be a surgical candidate for improvement.  Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication.  The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table.  Dose of antibiotics was given to the patient.  Compression devices were placed on the lower extremities to prevent the knee embolic events.  The patient was turned to 180 degrees.  The ETT tube was secured and the area was then prepped and draped in usual sterile fashion.  A head wrap was then placed on the position and we then began our local.  Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access.  Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves.  This was done bilaterally.  We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue.  We continued down to the lateral orbital rim until we identified periosteum.  We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially.  Care was taken to preserve the infraorbital nerve and that was visualized after elevation.  We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw.  After this was then carried out, we then clipped and cut as well as the end of the screw.  Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl.  Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry.  Excess skin along the incision was then removed as well the skin from just lateral to the canthus.  Care was taken to leave the orbicularis muscle down.  We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case.  A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour.  This was carried out using a 15 blade down to subcutaneous tissue.  The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture.  At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally.  As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision.  We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only.  This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease.  Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements.  Dr. Y was available and participated in the portions of the case as well.
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DESCRIPTION: Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.

The procedure involves cosmetic surgery for correcting facial deformities due to a previous nasolabial flap reconstruction. While surgery always carries some inherent risk, including potential for infection, scarring, and anesthesia complications, the stakes associated with this particular surgery seem to be relatively low from a life-threatening standpoint. The estimated blood loss is minimal, and the patient's condition was stable both pre- and post-operation. The primary goals appear to be aesthetic, aiming to improve symmetry and contour. Therefore, the situation does not involve immediately life-threatening conditions or complex emergency interventions.


Medical Specialty: Consult - History and Phy.
Sample Name: Insect Sting

HISTORY OF PRESENT ILLNESS:,  Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today.  He did not note any immediate reaction.  Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath.  He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction.  He did windup taking Benadryl at that time.  He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT:  Head is normocephalic and atraumatic.  The face shows no edema.  The tongue is not swollen and the airway is widely patent.,NECK:  No stridor.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,EXTREMITIES:  Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals.  There was some slight edema of the fourth digit, on which he still is wearing his wedding band.  The right hand shows no reaction.  The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty.  Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting.  I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction.  I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone.  I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction.  If he is not improved in the next four days, follow up with his PCP for a re-exam.
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DESCRIPTION: Local reaction secondary to insect sting.  Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today.

consult - history and phy., stung by a bee, local reaction, insect sting, reaction, insect, bee, knee, edema, sting, swelling, hand

The patient's condition, a local reaction from an insect sting, is not presenting with severe or systemic symptoms such as difficulty breathing, tongue swelling, or anaphylaxis, which would necessitate emergency care. The patient has been effectively managed with antihistamines and there is a follow-up plan in place should symptoms not improve. This scenario is typical for many regional allergic reactions to insect stings, which are generally not life-threatening.