Medical Specialty: Surgery
Sample Name: Ventriculostomy

PREOPERATIVE DIAGNOSIS: , Aqueductal stenosis.,POSTOPERATIVE DIAGNOSIS:,  Aqueductal stenosis.,TITLE OF PROCEDURE:  ,Endoscopic third ventriculostomy.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES:,  Bactiseal ventricular catheter with an Aesculap burr hole port.,SKIN PREPARATION:  ,ChloraPrep.,COMPLICATIONS: , None.,SPECIMENS: , CSF for routine studies.,INDICATIONS FOR OPERATION:  ,Triventricular hydrocephalus most consistent with aqueductal stenosis.  The patient having a long history of some intermittent headaches, macrocephaly.,OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in supine position with the head neutral.  The right frontal area was shaven and then the head was prepped and draped in a standard routine manner.  The area of the proposed scalp incision was infiltrated with 0.25% Marcaine with 1:200,000 epinephrine.  A curvilinear scalp incision was made extending from just posterior to bregma curving up in the midline and then going off to the right anterior to the coronal suture.  Two Weitlaner were used to hold the scalp open.  A burr hole was made just anterior to the coronal suture and then the dura was opened in a cruciate manner and the pia was coagulated.  Neuropen was introduced directly through the parenchyma into the ventricular system, which was quite large and dilated.  CSF was collected for routine studies.  We saw the total absence of __________  consistent with the congenital form of aqueductal stenosis and a markedly thinned down floor of the third ventricle.  I could bend the ventricular catheter and look back and see the aqueduct, which was quite stenotic with a little bit of chorioplexus near its opening.  The NeuroPEN was then introduced through the midline of the floor of the third ventricle anterior to the mamillary bodies in front of the basilar artery and then was gently enlarged using NeuroPEN __________  various motions.  We went through the membrane of Liliequist.  We could see the basilar artery and the clivus, and there was no significant bleeding from the edges.  The Bactiseal catheter was then left to 7 cm of length because of her macrocephaly and secured to a burr hole port with a 2-0 Ethibond suture.  The wound was irrigated out with bacitracin and closed using 3-0 Vicryl for the deep layer and a Monocryl suture for the scalp followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.
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DESCRIPTION: Endoscopic third ventriculostomy.

Endoscopic third ventriculostomy.

surgery, aqueductal stenosis, ventriculostomy, triventricular hydrocephalus, neuropen, endoscopic third ventriculostomy, endotracheal tube anesthesia, burr hole port, aqueductal,

The situation involves a surgical procedure to treat triventricular hydrocephalus due to aqueductal stenosis using endoscopic third ventriculostomy. This is a neurosurgical operation that targets issues in the brain's ventricular system. While the procedure is common for treating hydrocephalus, it is technically challenging and involves significant risks, such as bleeding or infection, and any complication could have serious implications due to the involvement of the brain. Consequently, the stakes are high as successful surgery is crucial for the patient's neurological health and overall well-being.


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

Medical Specialty: Emergency Room Reports
Sample Name: Urgent Cardiac Cath

PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest.  The right groin was prepped and draped in usual manner.  Under 2% lidocaine anesthesia, the right femoral artery was entered.  A 6-French sheath was placed.  The patient was already on anticoagulation.  Selective coronary angiograms were then performed using a left and a 3DRC catheter.  The catheters were reviewed.  The catheters were then removed and an Angio-Seal was placed.  There was some hematoma at the cath site.,RESULTS,1.  The left main was free of disease.,2.  The left anterior descending and its branches were free of disease.,3.  The circumflex was free of disease.,4.  The right coronary artery was free of disease.  There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,
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DESCRIPTION: Urgent cardiac catheterization with coronary angiogram.

emergency room reports, cardiac catheterization, coronary angiogram, angiogram

The situation involves an urgent cardiac catheterization performed on a patient who was in cardiac arrest, which inherently indicates a life-threatening, high-stakes medical situation. The procedure was conducted in an emergency setting, emphasizing the immediate need to address potential life-threatening coronary issues. However, the results were normal, alleviating immediate concerns but not lowering the stakes of the decision-making and procedural environment. Due to the patient's unstable condition requiring intubation and anticoagulation, the scenario is high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Multiple Meningiomas

CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and "complete resection" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.
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DESCRIPTION: Patient with stable expressive aphasia and decreased vision.

consult - history and phy., sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The case involves a 72-year-old woman with multiple recurrent meningiomas and their associated complications, such as expressive aphasia, decreased vision, and seizures. The patient has undergone numerous surgeries over more than a decade and has faced significant neurological symptoms as a result of her condition. The high frequency of surgeries and associated neurological symptoms indicate complex medical management requirements, which makes this scenario high-stakes. Additionally, the patient's age, history of regrowth of tumors, and serious post-operative complications add to the complexity and seriousness of the medical situation.


Medical Specialty: Neurology
Sample Name: Phenol Neurolysis & Botulinum Toxin Injection - 3

PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.
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DESCRIPTION: Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.

neurology, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin

The procedure involves phenol neurolysis and botulinum toxin injection for a patient with spastic diplegic cerebral palsy, which is a serious medical condition. However, the procedure went smoothly with no complications reported, indicating that the immediate high-stakes risk was managed effectively. Postoperative care is important, but the immediate pressure of the situation is relatively low because there were no complications. Thus, while the case involves a serious condition, the specific situation described is not acutely high-stakes.


Medical Specialty: Radiology
Sample Name: Renal Ultrasound

EXAM:,  Renal ultrasound.,HISTORY: , Renal failure, neurogenic bladder, status-post cystectomy.,TECHNIQUE: , Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,COMPARISON:,  Most recently obtained mm/dd/yy.,FINDINGS:,  The right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm.  The imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus.  There is no evidence of cortical thinning.,Incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,IMPRESSION:,1.  No evidence of hydronephrosis.,2.  Mass within the right lobe of the liver.  The patient apparently has a severe iodine allergy.  Further evaluation with MRI is recommended.,3.  The results of this examination were given to XXX in Dr. XXX office on mm/dd/yy at XXX,
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DESCRIPTION: Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy

radiology, lobe of the liver, status post cystectomy, renal ultrasound, renal failure, neurogenic bladder, bladder status, neurogenic, bladder, cystectomy, hydronephrosis, lobe, liver, ultrasound, mass, renal, kidneys/renal,

The findings from the renal ultrasound—while relevant—do not demonstrate immediate, life-threatening issues such as mass or hydronephrosis in the kidneys. The incidental finding of a liver mass requires attention and further evaluation with an MRI; however, it doesn't necessarily indicate an urgent scenario like acute kidney failure or life-threatening liver disease. The situation involves consideration of a previous iodine allergy, but the finding does not suggest it is an immediate crisis. The high-stakes element here is the identification and subsequent need for follow-up evaluation of a liver mass.


Medical Specialty: Dermatology
Sample Name: Facial Rhytids

HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids.  In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,RECOMMENDATIONS: , I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a "quick lift" type procedure certainly would address these issues.  I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.
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DESCRIPTION: Evaluation and recommendations regarding facial rhytids.

dermatology, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a cosmetic procedure recommendation (facelift) for a 57-year-old patient to address facial wrinkles and fullness in certain facial areas. While the procedure does carry inherent surgical risks such as bleeding, infection, nerve injury, and dissatisfaction with results, these are standard risks associated with elective cosmetic surgeries. The procedure is elective, and the decision is primarily driven by personal aesthetic desires rather than a life-threatening medical condition. Therefore, while the decision is important to the patient's personal preferences and quality of life, it does not pose a high-stakes situation in terms of immediate health or life-risking consequences.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Hypertension - Consult

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

cardiovascular / pulmonary, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary,

The situation involves an elderly patient with multiple significant cardiovascular issues including severe tricuspid regurgitation, pulmonary hypertension, and mild aortic stenosis. Complications such as a fall resulting in a hip fracture necessitating surgery introduce additional risks, particularly in someone with established cardiovascular conditions. While the immediate cardiac risks are managed and under control to some extent (e.g., controlled tachycardia and improved potassium levels), the surgery still poses a moderate-to-high risk given her age and cardiac history. The stakes are primarily related to surgical risks and the potential for cardiac complications during or after the procedure.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 22

PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:,  The patient is a 56-year-old female.  She was referred for a screening colonoscopy.  The patient has bowel movements every other day.  There is no blood in the stool, no abdominal pain.  She has hypertension, dyslipidemia, and gastroesophageal reflux disease.  She has had cesarean section twice in the past.  Physical examination is unremarkable.  There is no family history of colon cancer.,POSTOPERATIVE DIAGNOSIS: , Diverticulosis.,PROCEDURE IN DETAIL: , Procedure and possible complications were explained to the patient.  Ample opportunity was provided to her to ask questions.  Informed consent was obtained.  She was placed in left lateral position.  Inspection of perianal area was normal.  Digital exam of the rectum was normal.,Video Olympus colonoscope was introduced into the rectum.  The sigmoid colon is very tortuous.  The instrument was advanced to the cecum after placing the patient in a supine position.  The patient was well prepared and a good examination was possible.  The cecum was identified by the ileocecal valve and the appendiceal orifice.  Images were taken.  The instrument was then gradually withdrawn while examining the colon again in a circumferential manner.  Few diverticula were encountered in the sigmoid and descending colon.  Retroflex view of the rectum was unremarkable.  No polyps or malignancy was identified.,After obtaining images, the air was suctioned.  Instrument was withdrawn from the patient.  The patient tolerated the procedure well.  There were no complications.,SUMMARY OF FINDINGS:  ,Colonoscopy was performed to cecum and demonstrates the following:,1.  Mild-to-moderate diverticulosis.,2.  ,RECOMMENDATION:,1.  The patient was provided information on diverticulosis including dietary advice.,2.  She was advised repeat colonoscopy after 10 years.
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DESCRIPTION: Mild-to-moderate diverticulosis.  She was referred for a screening colonoscopy.  There is no family history of colon cancer.  No evidence of polyps or malignancy.

surgery, screening colonoscopy, colon cancer, colonoscopy, polyps, malignancy, sigmoid, rectum, cecum, diverticulosis

The situation involves a routine screening colonoscopy, where mild-to-moderate diverticulosis was discovered, but no polyps or malignancy were found. The patient was given dietary advice and advised to have another colonoscopy in 10 years. This indicates that the findings were not urgent or life-threatening. The procedure was straightforward, with no complications noted, and the recommendation for a 10-year follow-up suggests low immediate concern. While medical procedures inherently carry some risk, this specific scenario is relatively low-stakes in terms of urgency and severity.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Triple Lumen Catheter Insertion - 1

PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED:  ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:,  The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site.  The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:,  The patient's legal guardian was talked to.  All questions were answered and consent was obtained.  The patient was sterilely prepped and draped.  Approximately 4 cc of 1% lidocaine was injected into the inguinal site.  A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated.  A guidewire was then placed through the needle.  The needle was then removed.  The skin was ________ at the base of the wire and a dilator was placed over the wire.  The triple lumen catheters were then flushed with bacteriostatic saline.  The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed.  Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports.  Each port was closed off and also kept off.  Straight needle suture was then used to suture the triple lumen catheter down to the skin.  Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site.  The surgical site was then sterilely cleaned.  The patient tolerated the full procedure well.  There were no complications.  The nurse was then contacted to allow for access of the triple lumen catheter.
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DESCRIPTION: Need for intravenous access.  Insertion of a right femoral triple lumen catheter.  he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.

cardiovascular / pulmonary, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire

The insertion of a triple lumen catheter is a medical procedure that requires precision and care, particularly given the patient's condition. The procedure is deemed crucial as it facilitates the administration of total parenteral nutrition and other medications, which are critical for patients who cannot consume food orally. The patient's age and existing medical conditions, such as being ventilator-dependent and having respiratory failure, increase both the complexity and importance of the procedure, making it high-stakes. Potential complications, though not present in this case, could have serious implications on the patient’s health and recovery.


Medical Specialty: Radiology
Sample Name: Stress Test Dobutrex

INDICATIONS:,
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DESCRIPTION: Dobutrex stress test for abnormal EKG

Dobutrex stress test for abnormal EKG

radiology, dobutrex stress test, abnormal ekg, dobutrex, inferior abnormality, ischemic heart disease, ventricle, µg/kg/minute, stress test, stress,

In the context of radiology and cardiac evaluations, a Dobutrex stress test is conducted to assess the heart's function under stress-like conditions induced by medication. This is usually done when a patient cannot exercise physically. The stakes are relatively moderate as it involves monitoring of the heart and can identify potential issues that might need urgent attention, though it's performed under controlled conditions with medical supervision.


Medical Specialty: Psychiatry / Psychology
Sample Name: Conversion Disorder

REASON FOR REFERRAL:  ,The patient was referred to me by Dr. X of Children's Hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder.  I had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time.  After his discharge, the patient was scheduled to see me for followup services.  This was a 90-minute intake that was completed on 10/10/2007 with the patient's mother.  I reviewed with her the treatment consent form as well as the boundaries of confidentiality, and she stated that she understood these concepts.,PRESENTING PROBLEMS:,  Please see the inpatient hospital progress note contained in his chart for additional background information.  The patient's mother reported that he continues with his conversion episodes.  She noted that they are occurring approximately 6 times a day.  They consist primarily of tremors, arching his back, and, by her report, doing some gang signs during the episode.  She reported that the conversion reactions had decreased after his hospitalization, and he had none for 3 days, but then, they began picking up again.  From information gathered from mother, it would suggest that she frequently does "status checks," where she asks him how he is doing, and that after she began checking on him more that he began having more conversion reactions.  In terms of what she does when he has a conversion reaction, she reported that primarily that she tries to keep him safe.  She puts a sheath under him because the carpeting is dirty.  She removes any furniture, she wraps his legs together so they do not knock together, she sits with him and she gives him attention and says "calm down, breathe" and after it is over, she continues to tell him to be calm and to breathe.  She denied that she gives them any more attention.  I strongly encouraged her to stop doing status checks, as this likely is reinforcing the behavior.  I also noted that while he certainly needs to be kept safe, that she does not want to give a lot of attention to this behavior, and that over time we will teach him ways of coping with this independently.  In regards to his mood, she reported that his mood is quite good.  She denied any sadness or irritability.  She denied anhedonia.  She reports that he is a little bit hard to get up in the morning.  He is going to bed at about 11, getting up at 8 or 9.  No changes in weight or eating were noted.  No changes in concentration, suicidal ideation, and any suicidal history was denied.  She denied symptoms of anxiety, although she did note that she thought he worried a little about going to school and some financial stress.  Other symptoms of psychopathology were denied.,DEVELOPMENTAL HISTORY: , The patient was reportedly a 7 pounds 12 ounces product of an unplanned and uncomplicated pregnancy and planned cesarean delivery.  Mother reported that she did receive prenatal care.  The use of alcohol, drugs, or tobacco during the pregnancy were denied.  She denied that he had any feeding or sleeping problems in the perinatal period.  She described him as a fussy and active baby, but he was described as a cuddly baby.  She noted that the pediatricians never expressed any concerns regarding his developmental milestones.  SHE REPORTED THAT HE IS ALLERGIC TO PENICILLIN.  Serious injures or toileting problems were denied as were a history of seizures.,FAMILY BACKGROUND: , The patient currently lives with his mother who is age 57 and with her partner who is age 40.  They have been together since 1994, and he is the only father figure that the patient has even known.  The father was previously in a relationship that resulted in an 11-year-old daughter who visits the patient's home every other weekend.  The patient's father's whereabouts are unknown.  There is no information on his family.  Mother stated that he discontinued his involvement in her life when she was about 3 months pregnant with the patient, and the patient has never met him.  As noted, there is no information on the paternal side of the family.  In terms of the mother's side of family, the maternal grandfather died in his 60s due to what mother described as "hardening of the arteries," and the maternal grandmother died in 2003 due to stroke.  There were 4 maternal aunts, one of them died at age 9 months from pneumonia, one of them died at 19 years old from what was described as a brain tumor, and there are 3 maternal uncles.  In terms of family relationships, it was reported that overall the patient tends to get along fairly well with his parents, who reported that the patient and her partner tend to compete for mother's attention, and she noted this is difficult at times.  She reported that the patient and her partner do not really do anything together.  Mother reported that there is no domestic violence in the home, but there is some marital conflict, and this is may be difficult for The patient, as it is carried on in Spanish, and he does not speak Spanish.  There also is some stress in the home due to the stepdaughter, as there are some concerns that her mother may be involved in drugs.  The mother reported that she attended high school, did not attend any college.  She denied learning problems.  She denied psychological problems or any drug/alcohol history.  In terms of the biological father, she reported he did not graduate from high school.  She did not know of learning problems, psychological problems.  She denied that he had a drug/alcohol history.  There is a family history of alcoholism in one of the maternal uncles as well as in the maternal grandfather.  It should be noted that the patient and his family live in a small 4-bedroom apartment, where privacy is very difficult.,SOCIAL BACKGROUND:,  She reported that the patient is able to make and keep friends, but he enjoys lifting weights, skateboarding, and that he recently had an opportunity to do rock climbing, he really enjoyed that.  I encouraged her to have him involved in physical activity, as this is good for discharge the stress, to encourage the weightlifting, as well as the skateboarding.  Mother is going to check further information regarding the rock climbing that the patient had been involved in, which was at it sounds like by her description as some sort of boys' and girls' type of club.  Abuse of drugs or alcohol were denied.  The patient was not described as being sexually active.,ACADEMIC BACKGROUND: , The patient is currently in the 10th grade.  At present, he is on independent studies, which began after his hospitalization.  The mother reported that the teacher, who had come to school saw one of his episodes, and stated that, they would not want him to be attending school.  I spoke with her very clearly and directly regarding the fact that it was probably not best for the patient to be on independent studies, that he needed to be returned to his normal school environment.  He has never had an episode at school, and he needs to be back with his peers, back in a regular environment, where he is under normal expectations.  I spoke with her regarding my concerns, regarding the fact that he is unsupervised during the day, and we do not want this turning into one big long vacation, where he is not getting his work done, and he gets himself in trouble.  Normally, he would be attending at High School.  The mother stated that she would contact them as well as check into possibly a 504-Plan.  She reported that he really does not to go back to High School.  He says, the "kids are bad;" however, she denied that he has any history of fighting.  She noted that he is stressed by the school, there have been some peer problems, possibly some bullying.  I noted these need to be addressed with the school, as she had not done so.  She stated that she would speak with a counselor.  She noted, however, that he has a history of not liking school and avoiding going to school.  She noted that he is somewhat behind in his work due to the hospitalization.  His grades traditionally are C's.  She denied any Special Education Services.,PREVIOUS COUNSELING: , Denied.,DIAGNOSTIC SUMMARY AND IMPRESSION: , Similar to my impression at the hospital, it would appear that the patient clearly qualifies for a diagnosis of conversion disorder.  It appears that there are multiple stressors in the family, and that the mother is reinforcing his conversion reaction.  I am also very concerned regarding the fact that he is not attending school and want him back in the normal school environment as quickly as possible.  My plan is to meet the patient at the next session to update the information regarding his functioning and to begin to teach him skills for reducing his stress and relaxing.,DSM-IV DIAGNOSES:  ,AXIS I:  Conversion disorder (300.11).,AXIS II:  No diagnosis (V71.09).,AXIS III:  No diagnosis.,AXIS IV:  Problems with primary support group, educational problems, and peer problems.,AXIS V:  Global Assessment of Functioning equals 60.
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DESCRIPTION: The patient was referred after he was hospitalized for what eventually was diagnosed as a conversion disorder.

psychiatry / psychology, developmental history, academic background, global assessment of functioning, normal school environment, conversion reactions, conversion disorder, conversion, background, environment, peers, disorder, axis,

Conversion disorder, also known as functional neurological symptom disorder, involves symptoms such as tremors or other physical manifestations that cannot be attributed to any medical condition. Although the immediate physical health dangers might not be substantial, it can have significant impacts on a patient's mental health, social relationships, and educational achievements, particularly in a child or adolescent. The stakes here involve the child’s ability to function socially and academically, which are critical for future development. There are also concerns about the reinforcement of symptoms through the mother's reactions, pointing to the need for careful management to avoid worsening of the condition and to encourage independence in managing stress. The involvement of school and peer-related issues complicates the situation further, highlighting the need for a coordinated approach. However, this is not an immediate life-threatening condition, hence the stakes are high but not critical.


Medical Specialty: Neurology
Sample Name: Video EEG

TIME SEEN: , 0734 hours and 1034 hours.,TOTAL RECORDING TIME: , 27 hours 4 minutes.,PATIENT HISTORY: , This is a 43-year-old female with a history of events concerning for seizures.  Video EEG monitoring is performed to capture events and/or identify etiology.,VIDEO EEG DIAGNOSES,1.  AWAKE:  Normal.,2.  SLEEP:  No activation.,3.  CLINICAL EVENTS:  None.,DESCRIPTION: , Approximately 27 hours of continuous 21-channel digital video EEG monitoring was performed.  The waking background is unchanged from that previously reported.  Hyperventilation produced no changes in the resting record.  Photic stimulation failed to elicit a well-developed photic driving response.,Approximately five-and-half hours of spontaneous intermittent sleep was obtained.  Sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is normal video EEG monitoring for a patient of this age.  No interictal epileptiform activity was identified.  The patient had no clinical events during the recording.  Clinical correlation is required.
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DESCRIPTION: This is a 43-year-old female with a history of events concerning for seizures.  Video EEG monitoring is performed to capture events and/or identify etiology.

neurology, electroencephalography, eeg monitoring, video eeg, seizures, eeg,

The use of video EEG monitoring for a patient with a history of seizures is important for diagnosis and treatment planning. However, the results of the monitoring were normal, with no clinical events or significant findings during the recording period. This indicates that there is no immediate medical emergency or critical decision to be made based on the current results. Nonetheless, further clinical correlation is required to guide ongoing patient management, which is vital for ensuring proper care. The stakes pertain to ensuring accurate diagnosis and treatment in the long term, but there is no urgent high-stakes situation based on this particular set of results.


Medical Specialty: Consult - History and Phy.
Sample Name: C. Diff Colitis Consult

REASON FOR CONSULT:  ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea.  After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin.  She was also placed on IV Reglan because of nausea and vomiting.  In spite of the above, her white count still continues to be elevated today.  On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X.  Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,No history of smoking, alcohol, or drug use.  She lives at home.,HOME MEDICATIONS:  ,She is on atenolol and Mevacor.,ALLERGIES:  NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:  ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness.  She denies any cough, sputum production, or dysuria at this time.  Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL:  She is awake and alert, currently in no apparent distress.,VITAL SIGNS:  She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT:  Pupils are round and reactive to light and accommodation.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2 are present.  No rales appreciated.,ABDOMEN:  She does have tenderness to palpation all over with some mild rebound tenderness also.  No guarding noted.  Bowel sounds present.,EXTREMITIES:  No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89.  UA on 6/18/2009 showed no evidence of UTI.  Sodium today 130, potassium 2.7, and creatinine 0.4.  AST and ALT on 6/20/2009 were normal.  Blood cultures from admission were negative.  Urine culture on admission was negative.  C. diff was positive.  Stool culture was negative.,ASSESSMENT:,1.  A 72-year-old female with Clostridium difficile colitis.,2.  Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3.  Leukocytosis secondary to above, mild improvement today though.,4.  Bilateral pleural effusion by CT of the chest, although could represent thickening.,5.  New requirement for oxygen, rule out pneumonia.,6.  Hypertension.,PLAN:,1.  Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2.  Continue p.o. vancomycin.  Add Florastor to help replenish the gut flora.,3.  Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4.  We will check a chest x-ray especially given her new requirement for oxygen.
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DESCRIPTION: The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff,  presents to the hospital with abdominal pain, cramping, and persistent diarrhea.

This is a medical consult for a 72-year-old patient with Clostridium difficile colitis, a potentially serious intestinal condition. The patient is experiencing symptoms such as abdominal pain and diarrhea, and has an elevated white blood cell count, indicating an ongoing infection or inflammation. The presence of pleural effusion and the requirement for oxygen further complicate the clinical picture. The treatment plan includes aggressive management of the C. diff infection and close monitoring for potential deterioration, which could necessitate surgical intervention. Given the patient's age, medical history, and current symptoms, the stakes are high as there is a risk of severe complications, including dehydration, sepsis, and other systemic effects.


Medical Specialty: Surgery
Sample Name: Colonoscopy & Polypectomy - 3

PREOPERATIVE DIAGNOSIS:,  Alternating hard and soft stools.,POSTOPERATIVE DIAGNOSIS:,Sigmoid diverticulosis.,Sessile polyp of the sigmoid colon.,Pedunculated polyp of the sigmoid colon.,PROCEDURE: , Total colonoscopy with biopsy and snare polypectomy.,PREP:,  4/4.,DIFFICULTY:,  1/4.,PREMEDICATION AND SEDATION: , Fentanyl 100, midazolam 5.,INDICATION FOR PROCEDURE:,  A 64-year-old male who has developed alternating hard and soft stools.  He has one bowel movement a day.,FINDINGS: , There is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding.  There was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous.,DESCRIPTION OF PROCEDURE: , Preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided.  Preoperative physical examination was performed.  Informed consent was obtained.  The patient was placed in the left lateral decubitus position.  Premedications were given slowly by intravenous push.  Rectal examination was performed, which was normal.  The scope was introduced and passed with minimal difficulty to the cecum.  This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice.  The scope was slowly withdrawn, the mucosa carefully visualized.  It was normal in its entirety until reaching the sigmoid colon.  Sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding.  In addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp.  A snare was placed on the stalk of the polyp and divided with electrocautery.  The polyp was recovered and sent for pathologic examination.  Examination of the stalk showed good hemostasis.  The scope was slowly withdrawn and the remainder of the examination was normal.,ASSESSMENT: , Diverticular disease.  A diverticular disease handout was given to the patient's wife and a high fiber diet was recommended.  In addition, 2 polyps, one of which is assuredly an adenoma.  Patient needs a repeat colonoscopy in 3 years.
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DESCRIPTION: Total colonoscopy with biopsy and snare polypectomy.

surgery, total colonoscopy with biopsy, colonoscopy with biopsy, total colonoscopy, snare polypectomy, sigmoid diverticulosis, sessile polyp, pedunculated polyp, diverticular disease, sigmoid colon, colonoscopy, polypectomy, biopsy, diverticulosis, inflammation, adenomatous, sessile, sigmoid,

This situation involves a medical procedure called a colonoscopy and polypectomy, which is generally routine but can involve moderate risks, such as perforation of the colon or bleeding, especially due to the removal of polyps. However, in this documented case, the procedure appears to have been conducted without complications, and the findings have been managed appropriately with planned follow-up. Thus, while medical procedures inherently carry some risk, this specific scenario does not suggest an immediate high level of critical stakes.


Medical Specialty: Surgery
Sample Name: Tympanomastoidectomy

PREOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,POSTOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,OPERATIVE PROCEDURE:,1.  Left canal wall down tympanomastoidectomy with ossicular chain reconstruction.,2.  Microdissection.,3.  NIM facial nerve monitoring for three hours.,COMPLICATIONS:  ,None.,FINDINGS:,  There is an extremely large canal cholesteatoma, which eroded most of the posterior and superior canal wall.  There was a significant amount of myringosclerosis and tympanosclerosis.  There is some mild erosion of the lenticular process of the incus.  The facial nerve was normal.  We removed the incus, removed the head of the malleus, and placed a titanium-PORP from the stapes capitulum to a cartilage graft.,PROCEDURE: , The patient was taken to the operating room, placed under general anesthetic and intubated without difficulty.  The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure.  There was no abnormal activity during this case.  We inspected the ear canal, identified the huge defect, which was completely filled with cerumen.  Through the ear canal, we removed as much as we could and then infiltrated the canal and postauricular area with 1:100,000 of epinephrine.,We prepped and draped the ear in a sterile fashion.  We reopened the previously used postauricular incision and dissected down the mastoid cortex.  We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone.  A #6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out.  We went all the way to the mastoid antrum.  We finished a complete mastoidectomy with identification of the tegmen, sigmoid sinus.  We removed the lateral aspect of the mastoid tip.  We lowered the facial ridge.  The incudostapedial joint was already membranous in nature, we went ahead and used the joint knife and removed the incus.  We separated the incus from the stapes and then removed it.  We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity.,There was no cholesteatoma within the middle ear space, but there was roughly 40% surface area perforation.  The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic; this was removed.  There was also a large focus of tympanosclerosis between the stapes crura, which was impinging the ability of the stapes to move.  We carefully dissected this out.  This did seem to improve the mobility of the stapes somewhat.  At this point, there was a near total perforation.  There was only a minimal amount of anterior remnant of the drum left.  We tried to go ahead and harvest the temporalis fascia, but there was really only wisps of this fascia in place.  He had already had a previous tympanoplasty, but even outside the areas where the graft was taken, the temporalis muscle was quite atrophied and lumpy, and I suspect this was due to his chronic disease and long history of corticosteroid usage.  We harvested a few pieces as best as we could.  We went ahead and did a meatoplasty by making a canal incision in the 6 o'clock and 12 o'clock positions.  We excised cartilage posteriorly and inferiorly to enlarge the meatus.  This cartilage was thin and used for cartilage tympanoplasty.  We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it.  We did cut a titanium-PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap.  A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants.  We placed a layer of Gelfoam lateral to the graft, closed the postauricular incision in layers and put 2 Merocel packs in the ear.  Glasscock dressing was applied.  The patient was awakened from anesthesia and taken to the recovery room in stable condition.  He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week.
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DESCRIPTION: Left canal wall down tympanomastoidectomy with ossicular chain reconstruction, microdissection, NIM facial nerve monitoring for three hours.

surgery, cholesteatoma, gelfoam, glasscock dressing, microdissection, nim, canal, canal wall, cerumen, facial nerve, incus, myringosclerosis, ossicular chain reconstruction, titanium-porp, tympanomastoidectomy, tympanosclerosis, facial nerve monitoring, ear canal, cartilage, ear,

The medical procedure described, a tympanomastoidectomy with ossicular chain reconstruction, is a complex surgical procedure involving the ear, particularly necessary due to the presence of cholesteatoma. The potential risks involved, such as damage to the facial nerve, hearing loss, and infection, make it a high-stakes situation despite the absence of any immediate complications during the surgery. The procedure's complexity, the potential impact on the patient's hearing and facial nerve function, and the intensive preoperative and postoperative care required all contribute to the high-stakes nature of this situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Lower back pain

HISTORY OF PRESENT ILLNESS:,  Patient is a 50-year-old white male complaining of continued lower back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.  He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after which he "felt it" in his lower back.  The following day (two days ago), he states he rode to Massachusetts and Maine to pick up clients.  He feels that this aggravated his chronic back pain as well.  He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture.  He is being prescribed Ultram, Celebrex, gabapentin, and amitriptyline by his PCP for his chronic back pain.  He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain.,The patient did self-refer to another physician, who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives, particularly the medications that the patient feels that he needs.  Patient states he did not do this because he was feeling well at that time.,The patient did present to our emergency room last night, at which time he saw Dr. X.  He was given a prescription for 12 Vicodin as well as some to take home last night.  The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend.  Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines.  He is on several medications, the list of which is attached to the chart.,MEDICATIONS: , In addition to the aforementioned medications, he is on Cymbalta, pantoprazole, and a multivitamin.,ALLERGIES:,  HE IS ALLERGIC TO RELAFEN (ITCHING).,SOCIAL HISTORY: , The patient is married and lives with his wife.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse is elevated at 105.  Temp and other vitals signs are all within normal limits.,GENERAL:  Patient is a middle-aged white male who is sitting on the stretcher in no acute distress.,BACK:  Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine, more so on the right than on the left.  There is a well-healed upper lumbar incision from his previous L1-L2 fusion.  There is no erythema, ecchymosis, or soft-tissue swelling.  Mobility is generally very good without obvious signs of discomfort.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,MUSCULOSKELETAL:  With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg.  There is some mild discomfort on internal and external rotation of the hips as well.  DTRs are 1+ at the knees and trace at the ankles.,I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication, which the patient feels that he needs, and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a "good day."  I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe, then on a "bad day," he will have nowhere else to turn.  I explained to him that some emergency physicians do chose to use opiates for a short term as Dr. X did last night.  It is unclear if the patient is looking for a different opiate medication, but I do not think it is wise to give him more, particularly as he has not even filled the prescription that was given to him last night.  I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back (Celebrex, tramadol, amitriptyline, gabapentin, and the Vicodin that he was given last night).  I did suggest that we could try a different anti-inflammatory if he felt that the Celebrex is not helping.  The patient is agreeable to this.,ASSESSMENT,1.  Lumbar muscle strain.,2.  Chronic back pain.,PLAN: , At this point in time, I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible.  Rx for Voltaren 75 mg tabs, dispensed 20, sig. one p.o. q.12h. for pain instead of Celebrex.  He may continue with his other medications as directed but not the methadone or Darvocet.  I did urge him to reschedule his pain clinic appointment as he was urged to do originally.  If unimproved this week, he should follow up with Dr. Y.
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DESCRIPTION: Lumbar muscle strain and chronic back pain.  Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.

consult - history and phy., back pain, lumbar muscle strain, chronic back pain, illness, lower, medications,

The situation involves managing a patient's chronic back pain, medication use, and advising on appropriate medical follow-ups, which are important but not life-threatening or immediately dangerous. The stakes are related to managing pain effectively and responsibly, especially considering the use of opiate medications, but there is no indication of an acute medical emergency. The primary concerns involve ensuring the patient adheres to appropriate care pathways and managing his medication responsibly given the chronic nature of his condition. Though there is an aspect of addiction and medication management, which is significant, it doesn't elevate the situation to high-stakes from a medical emergency perspective.


Medical Specialty: Radiology
Sample Name: Coronary CT Angiography (CCTA) - 5

COMPARISON STUDIES:, None.,MEDICATION: ,  Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.
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DESCRIPTION: A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.

This coronary CT angiography report reveals several key findings relevant to the patient's cardiac health. There are concerns of flow-limiting lesions, calcific plaques, and myocardial thinning consistent with chronic infarction. Although there is no definitive evidence of high-grade stenosis or occlusion, the potential for severe cardiovascular complications exists due to the presence of calcification and flow obstruction in critical coronary vessels. Given the patient's history of ischemic cardiomyopathy and the presence of an implanted defibrillator, the situation is high-stakes as it could impact patient's treatment decisions, potentially altering the course of management and care. Any misinterpretation or delay in recognizing flow-limiting lesions could lead to critical outcomes.


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

Medical Specialty: Office Notes
Sample Name: Gen Med Office Note - 1

HISTORY OF PRESENT ILLNESS:, The patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. He has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%. The main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure. During his hospital stay, he was commenced on metoprolol for rate control, and given that he had atrial fibrillation, he was also started on warfarin, which his INR has been followed up by the Homeless Clinic. For his congestive cardiac failure, he was restarted on Digoxin and lisinopril. For his hyperthyroidism, we restarted him on PTU and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy. He was restarted on PTU and discharged from the hospital on this medication. While in the hospital, it was also noted that he abused cigarettes and cocaine, and we advised strongly against this given the condition of his heart. It was also noted that he had elevated liver function tests, which an ultrasound was normal, but his hepatitis panel was pending. Since his discharge, his hepatitis panel has come back normal for hepatitis A, B, and C. Since discharge, the patient has complained of shortness of breath, mainly at night when lying flat, but otherwise he states he has been well and compliant with his medication.,MEDICATIONS:, Digoxin 250 mcg daily, lisinopril 5 mg daily, metoprolol 50 mg twice daily, PTU (propylthiouracil) 300 mg orally four times a day, warfarin variable dose based on INR.,PHYSICAL EXAMINATION:,VITAL SIGNS: He was afebrile today. Blood pressure 114/98. Pulse 92 but irregular. Respiratory rate 25.,HEENT: Obvious exophthalmus, but no obvious lid lag today.,NECK: There was no thyroid mass palpable.,CHEST: Clear except for occasional bibasilar crackles.,CARDIOVASCULAR: Heart sounds were dual, but irregular, with no additional sounds.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: Mild +1 peripheral edema in both legs.,PLAN:, The patient has also been attending the Homeless Clinic since discharge from the hospital, where he has been receiving quality care and they have been looking after every aspect of his health, including his hyperthyroidism. It is our recommendation that a TSH and T4 be continually checked until the patient is euthymic, at which time he should attend endocrine review with Dr. Huffman for further treatment of his hyperthyroidism. Regarding his atrial fibrillation, he is moderately rate controlled with metoprolol 50 mg b.i.d. His rate in clinic today was 92. He could benefit from increasing his metoprolol dose, however, in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s, and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure. Regarding his congestive cardiac failure, he currently appears stable, with some variation in his weight. He states he has been taking his wife's Lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema. We should consider adding him on a low-dose furosemide tablet to be taken either daily or when his weight is above his target range. A Digoxin level has not been repeated since discharge, and we feel that this should be followed up. We have also increased his lisinopril to 5 mg daily, but the patient did not receive his script upon departing our clinic. Regarding his elevated liver function tests, we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel, but yet the liver function tests should be followed up.
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DESCRIPTION: Patient has a past history of known hyperthyroidism and a recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%.

office notes, congestive cardiac failure, ejection fraction, atrial fibrillation, congestive cardiac, cardiac failure, office, lisinopril, metoprolol, hepatitis, fibrillation, hyperthyroidism, atrial, cardiac, congestive,

The situation involves the health management of a patient with multiple serious chronic conditions: hyperthyroidism, atrial fibrillation, and congestive heart failure with low ejection fraction. These conditions are high-risk due to potential life-threatening events, especially considering the low ejection fraction and irregular heart rate. The patient also uses substances detrimental to his heart health and has limited healthcare access, indicated by attendance to a Homeless Clinic, which introduces further complexity and uncertainty in managing his health. Therefore, the stakes are high as the management of these conditions can significantly influence patient outcomes, and poor management might result in severe exacerbations or even mortality.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: IV Procainamide Infusion

PREOPERATIVE DIAGNOSIS: , Syncopal episodes with injury.  See electrophysiology consultation.,POSTOPERATIVE DIAGNOSES:,1.  Normal electrophysiologic studies.,2.  No inducible arrhythmia.,3.  Procainamide infusion negative for Brugada syndrome.,PROCEDURES:,1.  Comprehensive electrophysiology studies with attempted arrhythmia induction.,2.  IV Procainamide infusion for Brugada syndrome.,DESCRIPTION OF PROCEDURE:, The patient gave informed consent for comprehensive electrophysiologic studies.  She received small amounts of intravenous fentanyl and Versed for conscious sedation.  Then 1% lidocaine local anesthesia was used.  Three catheters were placed via the right femoral vein; 5-French catheters to the right ventricular apex and right atrial appendage; and a 6-French catheter to the His bundle.  Later in the procedure, the RV apical catheter was moved to RV outflow tract.,ELECTROPHYSIOLOGICAL FINDINGS:,  Conduction intervals in sinus rhythm were normal.  Sinus cycle length 768 ms, PA interval 24 ms, AH interval 150 ms, HV interval 46 ms.  Sinus node recovery times were also normal at 1114 ms.  Corrected sinus node recovery time was normal at 330 ms.  One-to-one AV conduction was present to cycle length 480 ms, AH interval 240 ms, HV interval 54 ms.  AV nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms.  RA-ERP was 250 ms.  With ventricular pacing, there was VA disassociation present.,Since there was no evidence for dual AV nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for SVT.,Programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts.  Drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness.  There was no inducible VT.  Longest run was 5 beats of polymorphic VT, which is a nonspecific finding.  From the apex 400-600 with 2 extrastimuli were delivered, again with no inducible VT.,Procainamide was then infused, 20 mg/kg over 10 minutes.  There were no ST segment changes.  HV interval after IV Procainamide remained normal at 50 ms.,ASSESSMENT: , Normal electrophysiologic studies.  No evidence for sinus node dysfunction or atrioventricular block.  No inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for Brugada syndrome.,PLAN: , The patient will follow up with Dr. X.  She recently had an ambulatory EEG.  I will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes.  Reveal event monitor was considered, but not placed since she has only had one single episode.
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DESCRIPTION: Comprehensive electrophysiology studies with attempted arrhythmia induction and IV Procainamide infusion for Brugada syndrome.

cardiovascular / pulmonary, arrhythmia, attempted arrhythmia induction, conduction, sinus rhythm, electrophysiologic studies, sinus node, iv procainamide, brugada syndrome, electrophysiology, sinus, ventricular,

The scenario involves a cardiovascular procedure where a comprehensive electrophysiology study and a Procainamide infusion are performed to rule out Brugada syndrome as a cause for syncopal episodes. While the procedure itself is moderately invasive and carries certain risks, the findings indicate normal results with no inducible arrhythmias or Brugada syndrome detected. The patient's condition appears stable, with the plan only involving follow-up consultations unless symptoms reoccur. Although medical procedures are generally high-stakes due to potential risks and the importance of accurate diagnosis and intervention, this specific scenario is not extremely high-stakes given the normal findings and lack of immediate danger to the patient.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Leg Pain - Progress Note

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

The scenario describes a routine medical follow-up for a 44-year-old man experiencing low back pain with a history of right leg pain. The patient's symptoms have improved with medication and physical therapy. There are no indications of immediate severe complications or life-threatening conditions, and the patient's presentation during the exam was stable and without acute distress. His situation involves managing discomfort and monitoring for potential exacerbations of his condition. The stakes are not high because it pertains to ongoing management rather than an urgent or critical situation.


Medical Specialty: Urology
Sample Name: Prostatectomy - Nerve Sparing

PREOPERATIVE DIAGNOSIS:  ,Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATION PERFORMED:,  Radical retropubic nerve-sparing prostatectomy without lymph node dissection.,ESTIMATED BLOOD LOSS: , 450 mL.,REPLACEMENT:,  250 mL of Cell Saver and crystalloid.,COMPLICATIONS: , None.,INDICATIONS OF SURGERY: , This is a 67-year-old man with needle biopsy proven to be Gleason 6 adenocarcinoma in one solitary place on the right side of the prostate.  Due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Injury to the adjacent viscera.,6.  Deep venous thrombosis.,PROCEDURE IN DETAIL: , Prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room.  Epidural anesthesia and general endotracheal anesthesia were administered by Dr. A without any difficulty.  The patient was shaved, prepped, and draped using the usual sterile technique.  A sterile 16-French Foley catheter was then placed with clear urine drained.  A midline infraumbilical incision was performed by using a #10 scalpel blade.  The rectus fascia and the subcutaneous space were opened by using the Bovie.  Transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly.  A Bookwalter retractor was then placed.  The area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected.  Given this patient's low Gleason score and low PSA with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy.  The endopelvic fascia was opened bilaterally by using the Metzenbaum scissors.  Opening was enlarged by using sharp dissection.  Small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device.  The dorsal aspect of the prostate was bunched up by using 2-0 silk sutures.  The deep dorsal vein complex was bunched up by using Allis also and ligated by using 0 Vicryl suture in a figure-of-eight fashion.  With the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the Bovie.  Deeper near the urethra, the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra could then be easily identified.  Nearly two-third of the urethra from anteriorly to posteriorly was opened by using Metzenbaum scissors.  This exposed the blue Foley catheter.  Anastomotic sutures were then placed on to the urethral stump using 2-0 Monocryl suture.  Six of these were placed evenly spaced out anteriorly to posteriorly.  The Foley catheter was then removed.  This allowed for better traction of the prostate laterally.  Lateral pelvic fascia was opened bilaterally.  This effectively released the neurovascular bundle from the apex to the base of the prostate.  Continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat.  The prostate was then dissected from laterally to medially from this opening in the perirectal fat.  The floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate.  Maximal length of ureteral stump was preserved.  The prostate was carefully lifted cephalad by using gentle traction with fine forceps.  The prostate was easily dissected off the perirectal fat using sharp dissection only.  Absolutely, no traction to the neurovascular bundle was evident at any point in time.  The dissection was carried out easily until the seminal vesicles could be visualized.  The prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side.  The bladder neck was then dissected out by using a bladder neck dissection method.  Unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy.  Once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles.  This was developed without any difficulty.  Both vas deferens were identified, hemoclipped and transected.  The seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis.  About two-thirds of the seminal vesicles were able to be removed.  The tip was left behind.  Using the bipolar Gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected.  This was performed on the left side and then the right side.  This completely freed the prostate.  The prostate was sent for permanent section.  The opening in the bladder neck was reduced by using two separate 2-0 Vicryl sutures.  The mucosa of the bladder neck was everted by using 4-0 chromic sutures.  Small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature.  The ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures.  The previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck.  This was performed by using a French ***** needle.  A 20-French Foley catheter was then inserted and the sutures were sequentially tied down.  A 15 mL of sterile water was inflated to balloon.  The bladder anastomosis to the urethra was performed without any difficulty.  A 19-French Blake Drain was placed in the left pelvis exiting the right inguinal region.  All instrument counts, lap counts, and latex were verified twice prior to the closure.  The rectus fascia was closed in running fashion using #1 PDS.  Subcutaneous space was closed by using 2-0 Vicryl sutures.  The skin was reapproximated by using metallic clips.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
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DESCRIPTION: Radical retropubic nerve-sparing prostatectomy without lymph node dissection.

urology, prostate cancer, foley catheter, gleason, psa, prostate, adenocarcinoma, bladder neck, core biopsy, figure-of-eight, lymph node dissection, nerve-sparing, prostatectomy, rectus fascia, retropubic, bladder neck dissection, dorsal vein complex, nerve sparing, perirectal fat, seminal vesicles, sutures, bladder, urethra, posteriorly, seminal, vesicles, fascia, neck, dissection,

The case involves a surgical procedure for prostate cancer, which is a serious medical condition. While the patient tolerated the procedure well, the nature of surgery, potential for complications like incontinence, impotence, or injury, and the fact that cancer treatment is involved, qualify this as a high-stakes scenario. However, the absence of immediate complications and stability of the patient post-procedure somewhat mitigate the stakes. Hence, it is important to be vigilant post-operatively to ensure recovery and assess long-term outcomes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: URI - SOAP

SUBJECTIVE:,  Mom brings patient in today because of sore throat starting last night.  Eyes have been very puffy.  He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday.  He has had low-grade fever and just felt very run down, appearing very tired.  He is still eating and drinking well, and his voice has been hoarse but no coughing.  No shortness of breath, vomiting, diarrhea or abdominal pain.,PAST MEDICAL HISTORY:,  Unremarkable.  There is no history of allergies.  He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.,FAMILY HISTORY: , Noncontributory.  No one else at home is sick.,OBJECTIVE:,General:  A 13-year-old male appearing tired but in no acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color.  Good light reflex.  Oropharynx pink and moist.  No erythema or exudate.  Some drainage is seen in the posterior pharynx.  Nares:  Swollen, red.  No drainage seen.  No sinus tenderness.  Eyes are clear.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink, moist mucous membranes.  No rash.,LABORATORY:,  Strep test is negative.  Strep culture is negative.,RADIOLOGY:,  Water's View of the sinuses is negative for any sinusitis or acute infection.,ASSESSMENT:,  Upper respiratory infection.,PLAN:,  At this point just treat symptomatically.  I gave him some samples of Levall for the congestion and as an expectorant.  Push fluids and rest.  May use ibuprofen or Tylenol for discomfort.
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DESCRIPTION: Sore throat - Upper respiratory infection.

soap / chart / progress notes, soap, uri, upper respiratory infection, water's view, congestion, light reflex, sore throat, respiratory, strep, infection,

The situation described is a medical consultation for a 13-year-old male with symptoms consistent with an upper respiratory infection (URI). While the patient exhibits discomfort symptoms such as a sore throat, puffy eyes, and tiredness, the objective findings and lab results do not indicate a severe illness or immediate health threat. There is no evidence of strep throat or sinusitis, and the child is in no acute distress according to the objective examination. The plan of care involves symptomatic treatment and is quite routine for a URI, which is a common and generally low-stakes medical condition unless complications develop, which are not present here.


Medical Specialty: Radiology
Sample Name: HCT - Pituitary Mass

CC:, HA and vision loss.,HX: ,71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.,FHX:, HTN, stroke, coronary artery disease, melanoma.,SHX:, Quit smoking 15 years ago.,MEDS:, Lanoxin, Capoten, Lasix, KCL, ASA, Voltaren, Alupent MDI,PMH: ,CHF, Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.,EXAM: ,35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS, Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.,LAB:, CBC, PT/PTT, General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL, glucose 58mg/DL, RBC 2800/mm3, WBC 1/mm3. ANA, RF, TSH, FT4 were WNL.,IMPRESSION:, CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,COURSE:, The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS, RAPD OS, bilateral optic disk pallor (OS > OD), CN3 palsy and bilateral temporal field loss, OS >> OD . ESR, CRP, MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) , The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS, elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92.
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DESCRIPTION: Sellar HCT - Pituitary mass

Sellar HCT - Pituitary mass

radiology, sellar, hct, htn, pituitary, aneurysm, brain ct, cataclysmic, coronary artery disease, headache, intracranial mass, loss of vision, mass, melanoma, palsy, sneeze, stroke, temporal arteritis, vision loss, bilateral babinski signs, sellar enlargement, pituitary mass, temporal, vision,

The case involves a patient experiencing severe neurological and visual symptoms potentially linked to a pituitary mass, with a detailed course of investigation and treatment. The medical condition described, pituitary apoplexy, can be life-threatening due to the risk of sudden vision loss and potential hormonal imbalances. The patient has multiple chronic health issues complicating the diagnostic and treatment process. The high complexity and risk of serious outcomes make this a high-stakes situation, particularly given the necessity to properly diagnose and manage such a rare condition effectively in a 71-year-old patient with a significant medical history.