Medical Specialty: Pediatrics - Neonatal
Sample Name: Septal Defect Repair

TITLE OF OPERATION:,1.  Repair of total anomalous pulmonary venous connection.,2.  Ligation of patent ductus arteriosus.,3.  Repair secundum type atrial septal defect (autologous pericardial patch).,4.  Subtotal thymectomy.,5.  Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagnosed postnatally with total anomalous pulmonary venous connection.  Following initial stabilization, she was transferred to the Hospital for complete correction.,PREOP DIAGNOSIS:  ,1.  Total anomalous pulmonary venous connection.,2.  Atrial septal defect.,3.  Patent ductus arteriosus.,4.  Operative weight less than 4 kilograms (3.2 kilograms).,COMPLICATIONS: , None.,CROSS-CLAMP TIME: , 63 minutes.,CARDIOPULMONARY BYPASS TIME MONITOR:,  35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes.  Low flow perfusion 32 minutes.,FINDINGS:,  Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins.  Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence.  Nonobstructed ascending vein ligated.  Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin.  At completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,PROCEDURE: , After the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position.  Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines.  The patient was prepped and draped in the usual sterile fashion from chin to groins.  A median sternotomy incision was performed.  Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw.  A subtotal thymectomy was performed.  Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle.  A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure.  Pursestrings were deployed on the ascending aorta on the right.  Atrial appendage.  The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula.  With an ACT greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie.  Systemic cooling was started and the head was packed  and iced and systemic steroids were administered.  During cooling, traction suture was placed in the apex of the left ventricle.  After 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping.  Following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula.  The heart was then rotated to the right side and the venous confluence was exposed.  It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed.  The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture.  Following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir.  A right atriotomy was then performed during the period of circulatory arrest.  The atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture.  The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures.  The venous cannula was reinserted.  Cardiopulmonary bypass restarted and the aorta cross-clamp was released.  The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm.  Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains.  Venous decannulation was followed by aortic decannulation and administration of protamine sulfate.  All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic.  With good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires.  The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was transferred in very stable condition to the pediatric intensive care unit .,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.  Given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, Mrs. X (attending pediatric cardiac surgery at the Hospital) participated during the cross-clamp time of the procedure in quality of first assistant.
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DESCRIPTION: Repair of total anomalous pulmonary venous connection, ligation of patent ductus arteriosus, repair secundum type atrial septal defect (autologous pericardial patch), subtotal thymectomy, and insertion of peritoneal dialysis catheter.

pediatrics - neonatal, total anomalous pulmonary venous connection, patent ductus arteriosus, ligation, secundum type atrial septal defect, atrial septal defect, subtotal thymectomy, peritoneal dialysis catheter, cross clamp, cardiopulmonary bypass, pulmonary venous, atrial septal, septal defect, anomalous, venous, atrial, arteriosus, patent, ductus, septal, aorta, pulmonary,

The situation described involves a highly complex and intricate surgical procedure on a neonatal patient with serious congenital heart defects. The operation includes repair of a total anomalous pulmonary venous connection, ligation of a patent ductus arteriosus, and repair of an atrial septal defect, among other procedures, all of which are critical for the survival and proper cardiac function of the neonate. The stakes are extremely high given that the patient is a neonate (with a lower tolerance for surgical and postoperative complications) and any complications could have serious or fatal consequences. The need for precise surgical execution, stabilization of the patient’s hemodynamics, and post-operative care in the pediatric intensive care unit highlights the seriousness and urgency inherent in the procedure.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Cervical Spondylosis - Neuro Consult

REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity.  The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  This has subsequently resolved.  She started vigorous workouts in November 2005.  In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.  Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  She then started getting sensory sensations in the left hand and arm.  She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  Symptoms have been mildly progressive.  She is unaware of any trigger other than the vigorous workouts as mentioned above.  She has no associated bowel or bladder symptoms.  No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below.  She saw you for consultation and the possibility of surgical decompression was raised.  At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1.  Ocular migraines.,2.  Myomectomy.,3.  Infertility.,4.  Hyperglycemia.,5.  Asthma.,6.  Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet.  Of note, she does not drink or smoke.  She is married with two adopted children.  She is a paralegal specialist.  She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds.  Pain scale is 0.  A full general and neurological examination was personally performed and is documented on the chart.  Of note, she has a normal general examination.  Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk.  She has mild postural tremor in both arms.  She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities.  Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis.  She has hyperreflexia in her lower extremities, worse on the left.  Babinski's are downgoing.,PERTINENT DATA:  ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed.  MRI of the brain is broadly within normal limits.  MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema.  There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space.  I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN:  ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level.  She has a small disc at C3-C4 with less severe and only subtle cord compression.  History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother.  I am concerned about progressive symptoms.  Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis.  If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis.  I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation.  I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem.  I have recommended that she wear a hard collar while driving.  The results of my consultation were discussed with you telephonically.
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DESCRIPTION: Cervical spondylosis and kyphotic deformity.  She had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.

consult - history and phy., kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord,

The patient has a serious condition with cervical spondylosis and potential for myelopathy, which could lead to paralysis if untreated. The situation is compounded by the potential for acute paralysis from trauma, such as a car accident, highlighting the severity of the condition despite currently subtle symptoms. The risk of paralysis and the need for surgical intervention make this a high-stakes medical issue.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurology
Sample Name: EEG Monitoring Study

TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06.  The patient was recorded digitally using the 10-20 system of electrode placement.  Additional temporal electrodes and single channels of EOG and EKG were also recorded.  The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated.  Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION:  ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:,  There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event.  The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure.  At 1:38 p.m., the patient was instructed to begin hyperventilation.  Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated.  Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning.  Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed.  She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping.  Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name.  When asked what had just occurred, she replied that she was asleep and did not remember any event.  When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event.  Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:,  The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation.  No epileptiform activity is present.  One clinical event was induced with hyperventilation and photic stimulation.  The clinical features of this event are described in the technical summary above.  There was no epileptiform activity associated with this event.  This finding is consistent with a non-epileptic pseudoseizure.
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DESCRIPTION: This is a 95.5-hour continuous video EEG monitoring study.

neurology, video eeg monitoring study, eog, ekg, abnormal waveforms, photic stimulation, hyperventilation, eeg monitoring study, eeg monitoring, monitoring study, eeg, monitoring

The situation involves the interpretation of an EEG monitoring study in a neurologic patient, which includes assessing whether seizures are epileptic or non-epileptic (pseudoseizures). Although it is concerning for the patient to have seizure-like events, the EEG suggests these are non-epileptic pseudoseizures - meaning they are psychologically driven and not due to epilepsy. This distinction is important for treatment but does not pose immediate life-threatening outcomes. Hence, while dealing with neurological conditions is serious, this particular scenario of pseudoseizures is relatively moderate in urgency and stakes compared to true epileptic seizures.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Direct Laryngoscopy

PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.
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DESCRIPTION: Direct laryngoscopy and bronchoscopy.

Direct laryngoscopy and bronchoscopy.

cardiovascular / pulmonary, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis,

The situation involves a medical procedure on a patient with subglottic stenosis, a condition that can affect breathing. The procedure itself, direct laryngoscopy and bronchoscopy under general anesthesia, suggests potential risks associated with airway management, anesthesia, and the underlying condition. However, the procedure was reported as successful with no complications, and the patient was stable post-operation. While medical procedures generally carry inherent risks, the high stakes are mitigated by the successful outcome in this case.


Medical Specialty: Orthopedic
Sample Name: Foot pain Consultation

CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:,  Left Chopart joint sprain.,PLAN:,  I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.
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DESCRIPTION: Consultation for left foot pain.

Consultation for left foot pain.

orthopedic, foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness

The patient is a student-athlete recovering from a foot injury incurred during play, which impacts his ability to perform as a basketball player. While his role as an athlete introduces some level of urgency due to the importance of rehabilitation and future performance, it is not life-threatening. The immediate situation involves managing symptoms and ensuring proper recovery to prevent further injury. Given his ability to walk, albeit with a limp, and the current treatment plan focusing on rehabilitation, it's a moderate situation primarily concerning the athlete's sports career rather than a critical or life-altering medical emergency.


Medical Specialty: Surgery
Sample Name: BioArc Midurethral Sling

PREOPERATIVE DIAGNOSIS:,  Stress urinary incontinence, intrinsic sphincter deficiency.,POSTOPERATIVE DIAGNOSES: , Stress urinary incontinence, intrinsic sphincter deficiency.,OPERATIONS: , Cystoscopy, cystocele repair, BioArc midurethral sling.,ANESTHESIA:,  Spinal.,EBL: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY:  ,The patient is a 69-year-old female with a history of hysterectomy, complained of urgency, frequency, and stress urinary incontinence.  The patient had urodynamics done and a cystoscopy, which revealed intrinsic sphincter deficiency.  Options such as watchful waiting, Kegel exercises, broad-based sling to help with ISD versus Coaptite bulking agents were discussed.  Risks and benefits of all the procedures were discussed.  The patient understood and wanted to proceed with BioArc.  Risk of failure of the procedure, recurrence of incontinence due to urgency, mesh erosion, exposure, etc., were discussed.  Risk of MI, DVT, PE, and bleeding etc., were discussed.  The patient understood the risk of infection and wanted to proceed with the procedure.  The patient was told that due to the intrinsic sphincter deficiency, we will try to make the sling little bit tighter to allow better urethral closure, which may put her a high risk of retention versus if we make it too loose, then she may leak afterwards.,The patient understood and wanted to proceed with the procedure.,DETAILS OF THE OPERATION: , The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Foley catheter was placed.  Bladder was emptied.  Two Allis clamps were placed on the anterior vaginal mucosa.  Lidocaine 1% with epinephrine was applied, and hydrodissection was done.  Incision was made.  A bladder was lifted off of the vaginal mucosa.  The bladder cystocele was reduced.  Two stab incisions were placed on the lateral thigh over the medial aspect of the obturator canal.  Using BioArc needle, the needles were passed through under direct palpation through the vaginal incision from the lateral thigh to the vaginal incision.  The mesh arms were attached and arms were pulled back the outer plastic sheath and the excess mesh was removed.  The mesh was right at the bladder neck to the mid-urethra, completely covering over the entire urethra.,The sling was kept little tight, even though the right angle was easily placed between the urethra and the BioArc material.  The urethra was coapted very nicely.  At the end of the procedure, cystoscopy was done and there was no injury to the bladder.  There was good efflux of urine with indigo carmine coming through from both the ureteral openings.  The urethra was normal, seemed to have closed up very nicely with the repair.  The vaginal mucosa was closed using 0 Vicryl in interrupted fashion.  The lateral thigh incisions were closed using Dermabond.  Please note that the irrigation with antibiotic solution was done prior to the BioArc mesh placement.  The mesh was placed in antibiotic solution prior to the placement in the body.  The patient tolerated the procedure well.  After closure, Premarin cream was applied.  The patient was told to use Premarin cream postop.  The patient was brought to Recovery in stable condition.,The patient was told not to do any heavy lifting, pushing, pulling, and no tub bath, etc., for at least 2 months.  The patient understood.  The patient was to follow up as an outpatient.
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DESCRIPTION: Cystoscopy, cystocele repair, BioArc midurethral sling.

surgery, cystoscopy, cystocele repair, bioarc midurethral sling, sphincter, urinary incontinence, stress urinary incontinence, intrinsic sphincter deficiency, intrinsic sphincter, sphincter deficiency, incontinence, mesh, urethral, bioarc

The situation involves surgical treatment for stress urinary incontinence and intrinsic sphincter deficiency using a BioArc midurethral sling. This is a surgical procedure with inherent risks such as infection, retention, failure, and recurrence of incontinence. Although many risks are typical for surgery, the stakes are higher than routine medical care due to the potential for serious complications. However, it's not extremely high-stakes as the patient was stable post-surgery. The context suggests the procedure is standard for the condition, but surgical and post-operative risk management makes it moderately high-stakes.


Medical Specialty: Radiology
Sample Name: CT Brain

CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT, on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC.,MEDS: ,Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs.,PMH:, 1) Heart murmur dx age 5 years.,FHX:, Unremarkable.,SHX:, Employed cook. Denied ETOH/Tobacco/illicit drug use.,EXAM:, BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response.,MOTOR: Dense left flaccid hemiplegia.,SENSORY: Less responsive to PP on left.,COORD: Unable to test.,Station and Gait: Not tested.,Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present.,GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen.,COURSE:, 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres.
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DESCRIPTION: CT brain (post craniectomy) - RMCA stroke and SBE.

radiology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness,

The situation involves a complex medical case with a young patient experiencing severe complications, including a RMCA stroke and subsequent neurological and cardiac issues. This is high-stakes due to the patient's young age, the critical nature of the stroke (potential life-threatening), and the need for major surgeries (craniectomy and mitral valve replacement). Moreover, the case involves ongoing neurological impairments, seizures, and requires continuous medical management, making it critical to ensure accurate and effective medical interventions.


Medical Specialty: Nephrology
Sample Name: Nephrectomy - Radical

PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient underwent general anesthesia with endotracheal intubation.  An orogastric was placed and a Foley catheter placed.  He was placed in a modified flank position with the hips rotated to 45 degrees.  Pillow was used to prevent any pressure points.  He was widely shaved, prepped, and draped.  A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus.  The incision was made through the premarked site through the skin and subcutaneous tissue.  The aponeurosis of the external oblique was incised in the direction of its fibers.  Muscle-splitting incision was made in the internal oblique and transversus abdominis.  The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring.  Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions.  Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially.  This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava.  Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed.  The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery.  The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device.  After the arteries had been divided, the renal vein was divided again using a stapling device.  The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed.  Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel.  Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion.  The estimated blood loss was negligible.  There were no complications.  The patient tolerated the procedure well and left the operating room in satisfactory condition.
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DESCRIPTION: Right radical nephrectomy and assisted laparoscopic approach.

nephrology, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical,

The procedure described is a right radical nephrectomy, which involves the complete removal of a kidney due to conditions such as a renal mass, potentially cancerous. This is a major surgical operation with significant implications for the patient's health, as it involves the removal of an entire organ and the management of potential malignancy. The stakes are heightened by the complexity of the procedure and the risks associated with major surgeries, such as complications with anesthesia, blood loss, and post-operative recovery. However, the procedure went smoothly with no complications and minimal blood loss, indicating good management and planning by the surgical team. The stakes might be considered moderate due to the nature of the procedure and the potential implications for the patient's long-term health, but successful execution lowers immediate high-stakes concerns.


Medical Specialty: Surgery
Sample Name: Endoscopy

PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:,  Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1.  Severe duodenitis.,2.  Gastroesophageal junction small ulceration seen.,3.  No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position.  Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction.  Advanced into the upper part of the stomach into the antrum.  The duodenum showed extreme duodenitis and the scope was then brought back.  Retroflexion was performed, which was normal.  Scope was then brought back slowly.  Duodenitis was seen and a little bit of ulceration seen at GE junction.,FINDING: , Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.
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DESCRIPTION: Upper gastrointestinal endoscopy.

Upper gastrointestinal endoscopy.

surgery, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding

The situation involves a medical procedure, specifically an endoscopy, which is used to investigate symptoms like anemia. The findings include severe duodenitis and a small ulceration at the gastroesophageal junction, though no major active bleeding is noted. While the procedure itself and the findings are significant, they are not life-threatening at the moment. There's potential for serious conditions given the symptoms and findings, but immediate risks seem controlled, making this medium stakes. This is important enough to require medical attention and planning for potential treatment or management, but not an immediate life-or-death scenario.


Medical Specialty: Surgery
Sample Name: Cardioversion - Direct Current

PROCEDURE: , Direct current cardioversion.,REASON FOR PROCEDURE: , Atrial fibrillation.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits including risk of stroke.  The patient understands as well as her husband.  The patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium.  There was spontaneous echocardiogram contrast noticed.  The patient was on anticoagulation with Lovenox, received already 3 mg of Versed and 25 mcg of fentanyl for the TEE followed by next 2 mg of Versed for total of 5 mg of Versed.  The pads applied in the anterior and posterior approach.  With synchronized biphasic waveform at 150 J, one shock was successful in restoring sinus rhythm.  The patient had some occasional PACs noticed with occasional sinus tachycardia.  The patient had no immediate post-procedure complications.  The rhythm was maintained and 12-lead EKG was requested.,IMPRESSION:  ,Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.
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DESCRIPTION: Direct current cardioversion.  Successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.

surgery, thrombus, atrium, echocardiogram, transesophageal, direct current cardioversion, atrial fibrillation, sinus rhythm, sinus, rhythm, cardioversion

Direct current cardioversion is a significant medical procedure involving electrical shocks to the heart to restore a normal rhythm, critical for patients with atrial fibrillation. While it can be relatively routine for trained professionals, it carries risks such as stroke, especially if clots are present, which adds a degree of high-stakes concern. The successful outcome without complications somewhat mitigates the stakes, but given the serious nature of cardiac procedures, it's still a high-stakes situation.


Medical Specialty: Radiology
Sample Name: Radionuclide Stress Test

INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:,  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.,2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL:  ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.,2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.,2.  Mild hypertensive cardiomyopathy with an EF of 48%.,3.  Poor exercise capacity due to cardiovascular deconditioning.,4.  Suboptimally controlled blood pressure on today's exam.
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DESCRIPTION: Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.

radiology, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia

The situation involves assessing potential cardiovascular conditions, specifically exploring the possibility of obstructive coronary artery disease (CAD) through a radionuclide stress test. While the test results exclude obstructive CAD, the patient's symptoms and test results indicate other issues such as mild hypertensive cardiomyopathy and suboptimal blood pressure control. These conditions are concerning but not immediately life-threatening since the test ruled out obstructive CAD, which could have required urgent intervention. However, managing these conditions is important to prevent future cardiac events, making it a moderately high-stakes situation regarding long-term health management.


Medical Specialty: Surgery
Sample Name: Mesothelioma - Pleural Biopsy

PREOPERATIVE DIAGNOSIS: , Right pleural effusion and suspected malignant mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Right pleural effusion, suspected malignant mesothelioma.,PROCEDURE: , Right VATS pleurodesis and pleural biopsy.,ANESTHESIA:,  General double-lumen endotracheal.,DESCRIPTION OF FINDINGS: , Right pleural effusion, firm nodules, diffuse scattered throughout the right pleura and diaphragmatic surface.,SPECIMEN: , Pleural biopsies for pathology and microbiology.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid 1.2 L and 1.9 L of pleural effusion drained.,INDICATIONS: , Briefly, this is a 66-year-old gentleman who has been transferred from an outside hospital after a pleural effusion had been drained and biopsies taken from the right chest that were thought to be consistent with mesothelioma.  Upon transfer, he had a right pleural effusion demonstrated on x-ray as well as some shortness of breath and dyspnea on exertion.  The risks, benefits, and alternatives to right VATS pleurodesis and pleural biopsy were discussed with the patient and his family and they wished to proceed.,PROCEDURE IN DETAIL:  ,After informed consent was obtained, the patient was brought to the operating room and placed in supine position.  A double-lumen endotracheal tube was placed.  SCDs were also placed and he was given preoperative Kefzol.  The patient was then brought into the right side up, left decubitus position, and the area was prepped and draped in the usual fashion.  A needle was inserted in the axillary line to determine position of the effusion.  At this time, a 10-mm port was placed using the knife and Bovie cautery.  The effusion was drained by placing a sucker into this port site.  Upon feeling the surface of the pleura, there were multiple firm nodules.  An additional anterior port was then placed in similar fashion.  The effusion was then drained with a sucker.  Multiple pleural biopsies were taken with the biopsy device in all areas of the pleura.  Of note, feeling the diaphragmatic surface, it appeared that it was quite nodular, but these nodules felt as though they were on the other side of the diaphragm and not on the pleural surface of the diaphragm concerning for a possibly metastatic disease.  This will be worked up with further imaging study later in his hospitalization.  After the effusion had been drained, 2 cans of talc pleurodesis aerosol were used to cover the lung and pleural surface with talc.  The lungs were then inflated and noted to inflate well.  A 32 curved chest tube chest tube was placed and secured with nylon.  The other port site was closed at the level of the fascia with 2-0 Vicryl and then 4-0 Monocryl for the skin.  The patient was then brought in the supine position and extubated and brought to recovery room in stable condition.,Dr. X was present for the entire procedure which was right VATS pleurodesis and pleural biopsies.,The counts were correct x2 at the end of the case.
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DESCRIPTION: Right pleural effusion and suspected malignant mesothelioma.

surgery, double-lumen, endotracheal, pleural surface, chest tube, pleural biopsy, malignant mesothelioma, vats pleurodesis, pleural biopsies, pleural effusion, pleural, vats, pleurodesis, mesothelioma,

The procedure described involves a biopsy and surgical intervention for suspected malignant mesothelioma. This is significant because mesothelioma is a serious cancer that affects the lining of the lungs and can be life-threatening. The procedure's outcome could significantly impact the patient's treatment options and prognosis. However, the operation itself, a pleural biopsy and pleurodesis, is a standard surgical procedure. The surgery's stakes are therefore moderately high due to the potential confirmation of a cancer diagnosis and its implications.


Medical Specialty: Orthopedic
Sample Name: MRI Cervical Spine - 1

EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.
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DESCRIPTION: MRI cervical spine.

MRI cervical spine.

orthopedic, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,

The situation involves an orthopedic assessment of a cervical spine MRI, identifying several normal findings and some degenerative changes. While the findings include issues such as degenerative disc disease and borderline central canal stenosis, the report does not indicate any immediate life-threatening conditions. The situation primarily involves diagnosing and understanding the extent of degenerative changes, which can guide management and treatment plans but does not present an immediate high-stakes medical emergency.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chronic Atrial Fibrillation

REASON FOR VISIT:,  This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:,  I last saw her in 09/2008.  Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  She was found to have a fast heart rate in the atrial fibrillation.  She was also found to be in heart failure and so they diuresed her.  They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise.  My plan advent is to control her heart rate.  This has been a bit difficult with her retaining fluid.  We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights.  I think these are manifestations of heart failure.  She has peripheral edema.  She is short of breath when she tries to walk a city block.  I believe she takes her medications as directed, but I am never sure she actually is taking them correctly.  In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute.  There is a nonspecific IVCD.  This is unchanged from her last visit except that her heart rate is faster.  In addition, I reviewed her echocardiogram done at XYZ.  Her ejection fraction is 50% and she has paradoxical septal motion.  Her right ventricular systolic pressure is normal.  There are no significant valvular abnormalities.,MEDICATIONS:  ,1.  Fosamax - 70 mg weekly.,2.  Lisinopril - 20 mg daily.,3.  Metformin - 850 mg daily.,4.  Amlodipine - 5 mg daily.,5.  Metoprolol - 150 mg twice daily.,6.  Warfarin - 5 mg daily.,7.  Furosemide - none.,8.  Potassium - none.,9.  Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:,  On my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit.  She is breathing 1two times per minute and it is unlabored.  Eyelids are normal.  She has vitiligo.  Pupils are round and reactive to light.  Conjunctivae are clear and sclerae are anicteric.  There is no oral thrush or central cyanosis.  She has marked keloid formation on both sides of her neck, the left being worse than the right.  The jugular venous pressure is elevated.  Carotids are brisk are without bruits.  Lungs are clear to auscultation and percussion.  The precordium is quiet.  The rhythm is irregularly irregular.  She has a variable first and second heart sounds.  No murmurs today.  Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  She has no clubbing or cyanosis, but does have 1+ peripheral edema.  Distal pulses are good.  On neurological examination, her mentation is normal.  Her mood and affect are normal.  She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES:  ,1.  Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2.  Heart failure and she needs more diuretic.,3.  High blood pressure controlled.,4.  Hyperlipidemia.,5.  Diabetes mellitus type 2.,6.  Nonspecific intraventricular conduction delay.,7.  History of alcohol abuse.,8.  Osteoporosis.,9.  Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic.  There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.
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DESCRIPTION: A routine return appointment for a 71-year-old woman with chronic atrial fibrillation.  Chief complaint today is shortness of breath.

The patient is a 71-year-old woman with chronic atrial fibrillation and heart failure, making her situation inherently high-stakes due to the serious nature of these conditions. However, this is a routine appointment and while she has presented with shortness of breath and some mismanagement of medications, she is under medical care with a clear plan in place to manage her symptoms. The plan involves increasing medication and closely monitoring her heart rate and fluid levels. Given the situation and her need for potential intervention (pacemaker and AV node ablation), this represents a significant but managed risk, as heart failure and atrial fibrillation can have serious outcomes if not properly controlled.


Medical Specialty: Podiatry
Sample Name: Arthroplasty - Hammertoe

PREOPERATIVE DIAGNOSIS:,  Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe.  The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe.  The patient presents n.p.o. since mid night last night and consented to sign in the chart.  H&P is complete.,PROCEDURE IN DETAIL:,  After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position.  Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time.  Restraining, a lap belt was then placed around the patient's abdomen while laying on the table.  After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia.  The foot was then prepped and draped in the normal sterile orthopedic manner.  The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg.  The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed.  A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup.  Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue.  Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin.  This was performed with the combination of blunt and dull dissection.  Care was taken to avoid proper digital arteries and neurovascular bundles as were identified.  Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint.  The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure.  Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup.  It was elevated with fresh #15 blade.  The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally.  Following this, the distal portion of the tendon was identified in a like manner.  The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone.  The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues.  Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected.  Care was taken to avoid the deep flexor tendon.  The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology.  The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment.  The digit was also noted to be in rectus alignment.  Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity.  Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue.  Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin.  The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site.  Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin.  The toe was bandaged using 4 x 4s, Kling, and Coban.  The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe.  Total tourniquet time for the case was 30 minutes.  While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot.  The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain.  The patient was also given prescription for cane to aid in ambulation.  The patient will followup with Dr. X on Tuesday in his office for postoperative care.  The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit.  The patient tolerated the procedure well and the anesthesia with no complications.
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DESCRIPTION: Arthroplasty of the right second digit.  Hammertoe deformity of the right second digit.

podiatry, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon

The situation described is about a surgical procedure for correcting a hammertoe deformity in a patient's toe. While surgery can inherently carry some degree of risk, this particular procedure is routine and quite common in podiatry, especially since the patient is a 77-year-old male who has not responded to conservative treatments. The details provided show that the procedure was meticulously carried out with no complications, and the patient tolerated it well. Thus, the stakes involved are not life-threatening, and the post-operative care instructions suggest that the patient is expected to recover with routine follow-up. Given these considerations, the situation does not qualify as high-stakes.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 1

PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids.  The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS:  ,The procedure was done under general anesthesia given by Dr. Marino Fernandez.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  A history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure.  The opportunity for questions was provided, and informed consent was obtained.  Once the consent was obtained, the patient was sedated with IV medications and intubated by Dr. Fernandez and placed in the supine position.  Then, the tip of the XP-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus.  We did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose.  Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum.  We noticed that the patient had several ulcers in the first portion of the duodenum.  Then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there.  Then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for CLOtest.  By retroflexed view, at the level of the body of the stomach, I could see that the patient had the lower esophageal sphincter loose.  Finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken.  At the end, air was suctioned from the stomach, and the endoscope was removed out of the patient's mouth.  The patient tolerated the procedure well with no complications.,FINAL IMPRESSION:  ,1.  Duodenal ulcers.,2.  Loose lower esophageal sphincter.,PLAN:,1.  To start omeprazole 20 mg a day.,2.  To review the biopsies.,3.  To return the patient back to clinic in 1 to 2 weeks.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.

gastroenterology, esophagogastroduodenoscopy, esophageal, biopsies, endoscope

The procedure involves a medical intervention on a very young child, which inherently involves higher stakes due to the need for anesthesia and the potential complications associated with such a procedure (e.g., bleeding, perforation, infection). Despite being performed successfully without complications, the nature of the diagnosis, addressing symptoms like dysphagia, and uncovering conditions such as duodenal ulcers and a loose lower esophageal sphincter contribute to the high-stakes nature because these conditions can significantly impact the child's health both in the short and long term. Additionally, the follow-up medications and review of biopsies are crucial steps in managing and potentially treating the underlying issues effectively.


Medical Specialty: Endocrinology
Sample Name: Diabetes Mellitus - SOAP Note - 2

SUBJECTIVE:,  I am asked to see the patient today with ongoing issues around her diabetic control.  We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals.  Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change.  What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin.  The staff reports to me that her appetite is good and that she is eating as well as ever.  I talked to Anna today.  She feels a little fatigued.  Otherwise, she is doing well.,PHYSICAL EXAMINATION:  ,Vitals as in the chart.  The patient is a pleasant and cooperative.  She is in no apparent distress.,ASSESSMENT AND PLAN: , Diabetes, still with some problematic low blood glucoses, most notably in the morning.  To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning.  She will get 55 units in the morning.  I am also decreasing once again her Humalog sliding scale insulin prior to meals.  I will review the blood glucoses again next week.,
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DESCRIPTION: Patient today with ongoing issues with diabetic control.

endocrinology, diabetic control, insulin prior to meals, low blood glucoses, sliding scale, lantus insulin, diabetes, mellitus, lantus, glucoses,

The situation involves managing a patient's diabetes treatment plan, which is important for her health, particularly given the ongoing issue of low blood glucose levels. In the context of healthcare, diabetes management significantly impacts a patient's wellbeing. However, while important, this scenario typically represents a common challenge in endocrinology and does not generally involve immediate life-threatening risks unless the symptoms escalate or are mismanaged. The medical practitioner seems to be making calculated decisions based on patient data and plans to monitor the patient regularly. Therefore, while patient care is always important, this does not represent an extreme high-stakes scenario.


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

Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Interbody Fusion - 2

PREOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2.  Cervical spondylosis.,3.  Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1.  Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2.  Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3.  Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION:  ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section.  Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation.  Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.
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DESCRIPTION: Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.

orthopedic, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,

The procedure described is an anterior cervical discectomy and fusion, which is a major surgery involving the removal of a herniated or degenerative disc in the neck to relieve spinal cord or nerve pressure and stabilize the affected section of the spine. This type of surgery addresses serious conditions such as myelopathy and cervical stenosis, which can cause significant pain and neurological complications. While this procedure is performed routinely in neurosurgery, it carries potential risks and complications, including infection, nerve damage, and issues related to anesthesia. The meticulous description of the procedure indicates careful management to prevent complications, suggesting a significant level of risk. Given the potential consequences if the surgery does not go as planned, the stakes are relatively high for the patient’s health and quality of life.


Medical Specialty: Ophthalmology
Sample Name: Browlift, Blepharoplasty, & Rhytidectomy

PREOPERATIVE DIAGNOSES:,1.  Eyebrow ptosis.,2.  Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3.  Cervical facial aging with submental lipodystrophy.,OPERATION:,1.  Hairline biplanar temporal browlift.,2.  Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3.  Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia.  Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid.  The lower limb of the fusiform ellipse was at the superior palpebral fold.  A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim.  This was performed bilaterally and symmetrically and the skin was removed.  Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket.  An incision was made over the superior orbital rim.  Subperiosteal dissection was performed over the forehead.  The dissection proceeded medially.  The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion.  A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm.  A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid.  The incision was made in the lower lid just beneath the lashline.  Subcutaneous dissection was performed over the pretarsal and preseptal muscle.  Dissection was then proceeded down to the inferior orbital rim.  The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim.  The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle.  The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally.  The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow.  The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid.  The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition.  The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides.  Closure was performed with interrupted 6-0 silk suture for the lower lid.  The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy.  Incisions were made in preauricular area, postauricular area, mastoid and occipital area.  Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline.  Submental lipectomy was performed through the incision in the submental crease.  Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery.  A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia.  This was performed bilaterally and symmetrically.  Hemostasis was achieved with electrocautery.  The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed.  The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture.  Drains were placed prior to final closure.  A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture.  Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing.  Scleral eye protectors were removed.  Maxitrol eye ointment was placed followed by Swiss therapy eye pads.  The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV.
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DESCRIPTION: Hairline biplanar temporal browlift, quadrilateral blepharoplasty, canthopexy, cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.

ophthalmology, eyebrow ptosis, dermatochalasia, hairline, jackson-pratt, swiss therapy, arcus marginalis, blepharoplasty, browlift, canthopexy, fat transposition, inferior orbital rim, lipectomy, lipodystrophy, lower eyelid, purse-string, rhytidectomy, string smas elevation, suborbicularis oculi, frontalis muscle, pds suture, smas elevation, submental lipectomy, upper eyelid, subperiosteal dissection, lower lid, prolene suture, lower eyelids, orbital rim, lower, eyelids, sutured, subcutaneous, eyebrow, orbital,

The situation involves complex surgical procedures in the field of ophthalmology and facial plastic surgery, specifically addressing conditions like eyebrow ptosis and dermatochalasia. While these procedures can be categorized as elective cosmetic/aesthetic surgeries, they do carry inherent surgical risks and require precise execution to ensure patient safety and desired outcomes. Specific risks include complications related to anesthesia, potential for postoperative infections, or suboptimal aesthetic results. However, these procedures are generally not life-threatening and are considered routine in the cosmetic surgery domain, making them moderately high-stakes in terms of medical outcomes but not critically life-threatening.


Medical Specialty: Hematology - Oncology
Sample Name: Lymphoblastic Leukemia - Consult

CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon.  History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual "lump" posteriorly.  The left testicle has continued to be painful off and on since.  In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain.  Physical therapy was prescribed and the discomfort temporarily improved.  In December, he noted onset of increasing fatigue.  He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities.  He has lost 10 pounds since December and feels his appetite has decreased.  Night sweats and cough began in December, for which he was treated with a course of Augmentin.  However, both of these problems have continued.  He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007).  Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain.  He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000.  CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found.  He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis.  Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT).  Continuous intravenous unfractionated heparin infusion was continued.  Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected.  Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation.  This study showed moderately increased diffuse bone marrow metabolic activity.  Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood.  These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia.  The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES.  HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS:  ,1.  Lovenox 60 mg subcutaneously q.12h. initiated.,2.  Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3.  Protonix 40 mg intravenous (IV) daily.,4.  Vicodin p.r.n.,5.  Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY:  ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY:  ,Two half-brothers, ages 26 and 28, both in good health.  Parents are in good health.  A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s.  A maternal great-uncle developed leukemia around age 50.  A maternal great-grandfather had bone cancer around age 80.  His paternal grandfather died of colon cancer at age 73, which he had had since age 68.  Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY:  ,The patient is a student at the University majoring in biology.  He lives in a dorm there.  His parents live in Breckenridge.  He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication.  He has had acne for about two years, which he describes as mild to moderate.  He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION:  ,GENERAL:  Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS:  At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN:  Mild facial acne.,HEENT:  Extraocular muscles (EOMs) intact.  Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR:  A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS:  Clear to auscultation with an occasional productive cough.,ABDOMEN:  Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL:  Mild swelling of the dorsal aspect of the right foot and distal right leg.  Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY:  Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC:  Exam showed him to be oriented x4.  Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA:  ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets.  Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal.  LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively.  Calcium was also slightly low at 8.8 mg/dL.  Low molecular weight heparin test was low at 0.27 units/mL.  PT was 11.8, INR 1.2, and fibrinogen 374.  Urinalysis was normal.,ASSESSMENT: , 1.  Newly diagnosed high-risk acute lymphoblastic leukemia.,2.  Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3.  Probable chronic left epididymitis.,PLAN: , 1.  Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2.  Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3.  Ultrasound/Doppler of the testicles.,4.  Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,
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DESCRIPTION: Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.

The case involves a young patient recently diagnosed with high-risk acute lymphoblastic leukemia (ALL) and extensive deep vein thrombosis. Managing ALL requires urgent initiation of appropriate chemotherapy, and the extensive DVT adds complexity, posing a significant threat to the patient's life due to the risk of further thrombosis or embolism. The condition requires careful coordination among specialists and is time-sensitive.


Medical Specialty: Autopsy
Sample Name: Autopsy - 4

FINAL DIAGNOSIS: ,I. Ligature strangulation.,A. Circumferential ligature with associated ligature furrow of neck.,B. Abrasions and petechial hemorrhages, neck.,C. Petechial hemorrhages, conjunctival surfaces of eyes and skin of face.,II. Craniocerebral injuries.,A. Scalp contusion.,B. Linear, comminuted fracture of right side of skull.,C. Linear pattern of contusions of right cerebral hemisphere.,D. subarachnoid and subdural hemorrhage.,E. Small contusions, tips of temporal lobes.,III. Abrasion of right cheek.,IV. Abrasion/contusion, posterior right shoulder.,V. Abrasions of left lower back and posterior left lower leg.,VI. Abrasion and vancular congestion of vaginal mucosa.,VII. Ligature of right wrist.,TOXICOLOGIC STUDIES ,Blood ethanol - none detected.,Blood drug screen - no drugs detected.,CLINOCOPATHOLIGICAL CORRELATION:, Cause of death of this six year old female is asphyxia by strangulation associated with craniocerebral trauma. ,The body of this six year old female was first seen by me after I was called to an address XYZ, on 12/26/96. I arrived at the scene approximately 8 PM on 12/26 and entered the house where the decedent's body was located at approximately 8:20 PM. ,A brief examination of the body disclosed a ligature around the neck and a ligature around the right wrist. Also noted was a small area of abrasion or contusion below the right ear on the lateral aspect of the right cheek. A prominent dried abrasion was present on the lower left neck. After examining the body, I left the residence at approximately 8:30 PM. ,EXTERNAL EVIDENCE OF INJURY:, Located just below the right ear at the right angle of the mandible, 1.5 inches below the right external auditory canal is a 3/8 x 1/4 inch area of rust colored abrasion. In the lateral aspect of the left lower eyelid on the inner conjunctival surface is a 1 mm in maximum dimension petechial hemorrhage. Very fine, less than 1 mm petechial hemorrhages are present on the skin of the upper eyelids bilaterally as well as on the lateral left cheek. On everything the left upper eyelid there are much smaller, less than 1 mm petechial hemorrhages located on the conjunctival surface. Possible petechial hemorrhages are also seen on the conjunctival surfaces of the right upper and lower eyelids, but liver mortis on this side of the face makes definite identification difficult. ,A deep ligature furrow encircles the entire neck. The width of the furrow varies from one- eight of an inch to five/sixteenths of an inch and is horizontal in orientation, with little upward deviation. The skin of the anterior neck above and below the ligature furrow contains areas of petechial hemorrhage and abrasion encompassing an area measuring approximately 3 x 2 inches. The ligature furrow crosses the anterior midline of the neck just below the laryngeal prominence, approximately at the level of the cricoid cartilage. It is almost completely horizontal with slight upward deviation from the horizontal towards the back of the neck. The midline of the furrow mark on the anterior neck is 8 inches below the top of the head. The midline of the furrow mark on the posterior neck is 6.75 inches below the top of the head. ,The area of abrasion and petechial hemorrhage of the skin of the anterior neck includes on the lower left neck, just to the left of the midline, a roughly triangular, parchment-like rust colored abrasion which measures 1.5 inches in length with a maximum width of 0.75 inches. This roughly triangular shaped abrasion is obliquely oriented with the apex superior and lateral. The remainder of the abrasions and petechial hemorrhages of the skin above and below the anterior projection of the ligature furrow are nonpatterned, purple to rust colored, and present in the midline, right, and left areas of the anterior neck. The skin just above the ligature furrow along the right side of the neck contains petechial hemorrhage composed of multiple confluent very small petechial hemorrhages as well as several larger petechial hemorrhages measuring up to one-sixteenth and one-eight of an inch in maximum dimension. Similar smaller petechial hemorrhages are present on the skin below the ligature furrow on the left lateral aspect of the neck. Located on the right side of the chin is a three-sixteenths by one-eight of an inch area of superficial abrasion. On the posterior aspect of the right shoulder is a poorly demarcated, very superficial focus of abrasion/contusion which is pale purple in color and measures up to three-quarters by one-half inch in maximum dimension. Several linear aggregates of petechial hemorrhages are present in the anterior left shoulder just above deltopectoral groove. These measure up to one inch in length by one-sixteenth to one-eight of an inch in width. On the left lateral aspect of the lower back, approximately sixteen and one-quarter inches and seventeen and one-half inches below the level of the top of the head are two dried rust colored to slightly purple abrasions. The more superior of the two measures one-eight by one-sixteenth of an inch and the more inferior measures three-sixteenths by one-eight of an inch. There is no surrounding contusion identified. On the posterior aspect of the left lower leg, almost in the midline, approximately 4 inches above the level of the heel are two small scratch-like abrasions which are dried and rust colored. They measure one-sixteenth by less than one- sixteenth of an inch and one-eight by less than one-sixteenth of an inch respectively. ,On the anterior aspect of the perineum, along the edges of closure of the labia majora, is a small amount of dried blood. A similar small amount of dried and semifluid blood is present on the skin of the fourchette and in the vestibule. Inside the vestibule of the vagina and along the distal vaginal wall is reddish hyperemia. This hyperemia is circumferential and perhaps more noticeable on the right side and posteriorly. The hyperemia also appears to extend just inside the vaginal orifice. A 1 cm red-purple area of abrasion is located on the right posterolateral area of the 1 x 1 cm hymeneal orifice. The hymen itself is represented by a rim of mucosal tissue extending clockwise between the 2 and 10:00 positions. The area of abrasion is present at approximately the 7:00 position and appears to involve the hymen and distal right lateral vaginal wall and possibly the area anterior to the hymen. On the right labia majora is a very faint area of violent discoloration measuring approximately one inch by three-eighths of an inch. Incision into the underlying subcutaneous tissue discloses no hemorrhage. A minimal amount of semiliquid thin watery red fluid is present in the vaginal vault. No recent or remote anal or other perineal trauma is identified. ,REMAINDER OF EXTERNAL EXAMINATION:, The unembalmed, well developed and well nourished Caucasian female body measures 47 inches in length and weighs an estimated 45 pounds. ,No scalp trauma is identified. The external auditory canals are patent and free of blood. The eyes are green and the pupils equally dilated. The sclerae are white. The nostrils are both patent and contain a small amount of tan mucous material. The teeth are native and in good repair. The tongue is smooth, pink-tan and granular. No buccal mucosal trauma is seen. The frenulum is intact. There is slight drying artifact of the tip of the tongue. On the right cheek is a pattern of dried saliva and mucous material which does not appear to be hemorrhagic. The neck contains no palpable adenopathy or masses and the trachea and larynx are midline. The chest is symmetrical. Breasts are prepubescent. The abdomen is flat and contains no scars. No palpable organomegaly or masses are identified. The external genitalia are that of a prepubescent female. No pubic hair is present. The anus is patent. Examination of the extremities is unremarkable. ,The fingernails of both hands are of sufficient length for clipping. Examination of the back is unremarkable. There is dorsal 3+ to 4+ livor mortis which is nonblanching. Livor mortis is also present on the right side of the face. At the time of the initiation of the autopsy there is mild 1 to 2+ rigor mortis of the elbows and shoulders with more advanced 2 to 3+ rigor mortis of the joints of the lower extremities. ,INTERNAL EXAM:, The anterior chest musculature is well developed. No sternal or rib fractures are identified. ,MEDIASTINUM: ,The mediastinal contents are normally distributed. The 21 gm thymus gland has a normal external appearance. The cut sections are finely lobular and pink-tan. No petechial hemorrhages are seen. The aorta and remainder of the mediastinal structures are unremarkable. ,BODY CAVITIES: ,The right and left thoracic cavities contain approximately 5 cc of straw colored fluid. The pleural surfaces are smooth and glistening. The pericardial sac contains 3-4 cc of straw colored fluid and the epicardium and pericardium are unremarkable. The abdominal contents are normally distributed and covered by a smooth glistening serosa. No intra-abdominal accumulation of fluid or blood is seen. ,LUNGS: ,The 200 gm right lung and 175 gm let lung have a normal lobar configuration. An occasional scattered subpleural petechial hemorrhage is seen on the surface of each lung. The cut sections of the lungs disclose an intact alveolar architecture with a small amount of watery fluid exuding from the cut surfaces with mild pressure. The intrapulmonary bronchi and vasculature are unremarkable. No evidence of consolidation is seen. ,HEART: ,The 100 gm heart has a normal external configuration. There are scattered subepicardial petechial hemorrhages over the anterior surface of the heart. The coronary arteries are normal in their distribution and contain no evidence of atherosclerosis. The tan- pink myocardium is homogeneous and contains no areas of fibrosis or infarction. The endocardium is unremarkable. The valve cusps are thin, delicate and pliable and contain no vegetation or thrombosis. The major vessels enter and leave the heart in the normal fashion. The foramen ovale is closed. ,AORTA AND VENA CAVA: ,The aorta is patent throughout its course as are its major branches. No atherosclerosis is seen. The Vena Cava is unremarkable. ,SPLEEN: ,The 61 gm spleen has a finely wrinkled purple capsule. Cut sections are homogeneous and disclose readily identifiable red and white pulp. No intrinsic abnormalities are identified. ,ADRENALS: ,The adrenal glands are of normal size and shape. A golden yellow cortex surmounts a thin brown-tan medullary area. No intrinsic abnormalities are identified.
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DESCRIPTION: Autopsy - Ligature strangulation and craniocerebral injuries.

The situation involves the autopsy of a six-year-old female victim who suffered a violent death by ligature strangulation accompanied by craniocerebral injuries. This case likely relates to a criminal investigation, given the details of asphyxia and trauma. The high-stakes nature arises from the need for precise forensic analysis to determine the circumstances of the death, which can have significant legal implications, including potential homicide charges. The sensitivity is heightened by the victim's age and the nature of the injuries.