Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 12

PROCEDURE: , Cardiac catheterization by:,a.  Left heart catheterization.,b.  Left ventriculography.,c.  Selective coronary angiography.,d.  Right femoral artery approach.,COMPLICATIONS:,  None.,MEDICATIONS,1.  IV Versed.,2.  IV fentanyl.,3.  Intravenous fluid administration.,4.  Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained.  Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed.  The patient was prepped, draped, and anesthetized in the usual manner.  Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery.  Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections.  Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections.  Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance.  Left ventricular angiogram was performed.  Pre and post angiogram LVEDP, LV, and aortic pressures were obtained.  At the end of the procedure catheters were removed and the introducer sheath was secured.  The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:,  LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal.  The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall.  Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction.  No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1.  ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch.  Angiographically the right coronary artery is normal.,2.  ,LEFT MAIN ARTERY:,  The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3.  ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex.  Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging.  The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment.  Otherwise, there is no evidence of atherosclerotic obstruction.,4.  ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex.  Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery.  These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome.  The patient will be treated medically.
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DESCRIPTION: Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.

The situation involves a medical procedure on a 70-year-old patient who presents with symptoms suggestive of an acute myocardial infarction and requires urgent diagnostic evaluation through heart catheterization and angiography. This is a high-stakes situation because of the potential severity of the patient's condition, the complexity of the procedures involved, and the need for timely and accurate diagnosis to guide treatment. Additionally, while the procedure reported no complications, the interpretation of findings and subsequent medical management are crucial, especially considering the diagnosis of Takasubo syndrome.


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

Medical Specialty: Orthopedic
Sample Name: Hardware Removal - Metatarsal

TITLE OF OPERATION:,1.  Removal of painful hardware, first left metatarsal.,2.  Excision of nonunion, first left metatarsal.,3.  Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1.  Nonunion of fractured first left metatarsal osteotomy.,2.  Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Nonunion of fractured first left metatarsal osteotomy.,2.  Painful hardware, first left metatarsal.,ANESTHESIA:,  General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:,  2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After general anesthesia was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was then inflated.  Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon.  The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the periosteum of the first left metatarsal.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft.  Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact.  The screws were sent to pathology for examination.  The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification.  The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding.  The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy.  Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished.  The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft.  Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent.  The area was flushed copiously flushed with saline.  The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material.  All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time.  The left ankle tourniquet was deflated.  Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels.  The patient was given specific instructions and education on how to continue caring for his left foot surgery.  The patient was also given pain medications, instructions on how to control his postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for his first postoperative appointment.
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DESCRIPTION: Removal of painful hardware, first left metatarsal.  Excision of nonunion, first left metatarsal.  Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.

orthopedic, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation, plates, ankle, vicryl, nonunion, screws,

The described orthopedic procedure is detailed and involves the removal of hardware and the excision of a nonunion in the first left metatarsal, followed by a bone graft and stabilization. While the procedure addresses significant pain and discomfort and involves careful surgical techniques, it is not life-threatening or involving critical systems like cardiovascular or neurological entities. The stakes are mostly concerned with the patient's mobility and pain management. Although it is important for the patient's quality of life and mobility, it doesn't approach the highest level of stakes common to critical surgeries or emergency interventions.

Filled in based on scale_labels and scale_label_confidence


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

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

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

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


Medical Specialty: Discharge Summary
Sample Name: Renal Disease - Discharge Summary

ADMISSION DIAGNOSES:,1.  Syncope.,2.  End-stage renal disease requiring hemodialysis.,3.  Congestive heart failure.,4.  Hypertension.,DISCHARGE DIAGNOSES:,1.  Syncope.,2.  End-stage renal disease requiring hemodialysis.,3.  Congestive heart failure.,4.  Hypertension.,CONDITION ON DISCHARGE: , Stable.,PROCEDURE PERFORMED: , None.,HOSPITAL COURSE: , The patient is a 44-year-old African-American male who was diagnosed with end-stage renal disease requiring hemodialysis three times per week approximately four to five months ago.  He reports that over the past month, he has been feeling lightheaded when standing and has had three syncopal episodes during this time with return of consciousness after several minutes.  He reportedly had this even while seated and denied overt dizziness.  He reports this lightheadedness is made even worse when standing.  He has had these symptoms almost daily over the past month.  He does report some confusion when he awakens.  He reports that he loses consciousness for two to three minutes.  Denies any bowel or bladder loss, although he reports very little urine output secondary to his end-stage renal disease.  He denied any palpitations, warmth, or diaphoresis, which is indicative of vasovagal syncope.  There were no witnesses to his syncopal episodes.  He also denied any clonic activity and no history of seizures.  In the emergency room, the patient was given fluids and orthostatics were checked.  At that time, orthostatics were negative; however, due to the fact that fluid had been given before, it is impossible to rule out orthostatic hypotension.  The patient presented to the hospital on Coreg 12.5 mg b.i.d. and lisinopril 10 mg daily secondary to his hypertension, congestive heart failure with dilated cardiomyopathy and end-stage renal disease.  Regarding his syncopal episodes, he was admitted with likely orthostatic hypotension.  Cardiology was consulted and their recommendations were to reduce the lisinopril to 5 mg daily.  At that time, the Coreg had been held secondary to hypotension.  Cardiology also ordered a nuclear medicine myocardial perfusion stress test.  Regarding the end-stage renal disease, Nephrology was consulted as the patient was due for hemodialysis treatment the day following admission.  Nephrology was able to perform dialysis on the patient and Renal concurred that the presyncopal symptoms were likely due to decreased intravascular volume in the postdialytic time frame.  Renal agreed with decreasing his lisinopril to 5 mg daily and decreasing the Coreg to 6.25 mg b.i.d.  They reported that the Procrit should be continued.  As previously indicated regarding the dilated cardiomyopathy, Cardiology ordered a nuclear medicine stress test to be performed.  Also, regarding the patient's hypertension, he actually was noted to have hypotension on admission, and as previously stated, the Coreg was originally discontinued and then it was restarted at 6.25 mg b.i.d. and the patient tolerated this well.  The patient's hospital course remained uncomplicated until September 17, 2007, the day the nuclear medicine stress test was scheduled.  The patient stated that he was reluctant to proceed with the test and he was afraid of needles and the risks associated with the test although the procedure was explained to the patient and the risks of the procedure were quit low, the patient proceeded to discharge himself against medical advice.,DISCHARGE INSTRUCTIONS/MEDICATIONS:,The patient left AMA.  No specific discharge instructions and medications were given.  At the time of the patient leaving AMA, his medications were as follows:,1.  Aspirin 81 mg p.o. daily.,2.  Multivitamin, Nephrocaps one cap p.o. daily.,3.  Fosrenol 500 mg chewable t.i.d.,4.  Lisinopril 2.5 mg daily.,6.  Coreg 3.125 mg p.o. b.i.d.,7.  Procrit 10,000 units inject every Tuesday, Thursday, and Saturday.,8.  Heparin 5000 units q.8h. subcutaneous for DVT prophylaxis.
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DESCRIPTION: Syncope, end-stage renal disease requiring hemodialysis, congestive heart failure, and hypertension.

discharge summary, syncope, congestive heart failure, end-stage renal disease requiring hemodialysis, nuclear medicine, stress test, stage renal, renal disease, renal, disease, hemodialysis,

The presented discharge summary involves a patient with multiple serious medical conditions requiring careful management, including end-stage renal disease, congestive heart failure, and hypertension. The patient also signed out against medical advice (AMA), which can increase the risk of adverse outcomes since recommended follow-up care and testing (like the stress test) were not completed. Such situations have moderate to high stakes as they can impact the patient's health significantly, especially given their complex medical needs.


Medical Specialty: Radiology
Sample Name: Full-Field Digital Mammogram (FFDM) - 2

EXAM: , Screening full-field digital mammogram.,HISTORY:,  Screening examination of a 58-year-old female who currently denies complaints.  Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy.  The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: , Standard digital mammographic imaging was performed.  The examination was performed with iCAD Second Look Version 7.2.,COMPARISON: , Most recently obtained __________.,FINDINGS: , The right breast is again smaller than the left.  There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast.  The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue.  There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes.  A few benign-appearing microcalcifications are present.,No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified.  The skin is stable.  No enlarged axillary lymph node is seen.,IMPRESSION:,1.  No significant interval changes are seen.  No mammographic evidence of malignancy is identified.,2.  Annual screening mammography is recommended or sooner if clinical symptoms warrant.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.
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DESCRIPTION: Mammogram, bilateral full-field digital mammography FFDM (patient with positive history of breast cancer).

radiology, digital mammography, full-field digital mammogram, ffdm, second look version, field digital mammogram, digital mammogram, breast cancer, mammographic, icad, microcalcifications, mammogram, screening, digital, mammography, breast

The case involves a mammogram for a 58-year-old female with a history of breast cancer and family history of the same. Although this is a routine screening mammogram with a benign result (BIRADS Classification 2), cancer screenings inherently carry a degree of seriousness due to the potential implications of the findings. Given her past history and familial risk, this mammogram serves a critical role in her ongoing health monitoring. However, since the findings suggest no evidence of malignancy and merely confirm benign post-surgical and radiation changes, the immediate stakes seem moderate rather than high. The scenario requires attention but is currently stable.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Arthrodesis - 1

PREOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,POSTOPERATIVE DIAGNOSES: , C5-C6 disc herniation with right arm radiculopathy.,PROCEDURE:,1.  C5-C6 arthrodesis, anterior interbody technique.,2.  C5-C6 anterior cervical discectomy.,3.  C5-C6 anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws.,4.  Implantation of machine bone implant.,5.  Microsurgical technique.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,BACKGROUND INFORMATION AND SURGICAL INDICATIONS:  ,The patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain.  The pain has become more and more severe.  It runs to the thumb and index finger of the right hand and it is accompanied by numbness.  If he tilts his neck backwards, the pain shoots down the arm.  If he is working with the computer, it is very difficult to use his mouse.  He tried conservative measures and failed to respond, so he sought out surgery.  Surgery was discussed with him in detail.  A C5-C6 anterior cervical discectomy and fusion was recommended.  He understood and wished to proceed with surgery.  Thus, he was brought in same day for surgery on 07/03/2007.,DESCRIPTION OF PROCEDURE: , He was given Ancef 1 g intravenously for infection prophylaxis and then transported to the OR.  There general endotracheal anesthesia was induced.  He was positioned on the OR table with an IV bag between the scapulae.  The neck was slightly extended and taped into position.  A metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with Betadine and draped in the usual sterile fashion.,A linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle.  The incision was extended through skin, subcutaneous fat, and platysma.  Hemostasis was assured with Bovie cautery.  The anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath.  The trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine.  A Bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be C6-C7 disk based on x-rays and then around the C5-C6 disk space.  An intraoperative x-ray confirmed C5-C6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure.  A 15-blade knife was used to incise the C5-C6 disk and remove disk material. and distraction pins were inserted into C5-C6 and distraction placed across the disk space.  The operating microscope was then brought into the field and used throughout the case except for the closure.  Various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible.  Then, the Midas Rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body.  A nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament.  A Kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina.  A small amount of disk material was found at the right neural foramen.  After a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated.  A spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate.  So, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk.  The wound was thoroughly irrigated and inspected for hemostasis.  A Mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of C5-C6 to hold the bone into position and the wound was once again irrigated.  The patient was valsalved.  There was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers.  The 3-0 Vicryl was used to approximate platysma and 3-0 Vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin.  The wound was cleaned.,Mastisol was placed on the skin, and Steri-strips were used to approximate skin margins.  Sterile dressing was placed on the patient's neck.  He was extubated in the OR and transported to the recovery room in stable condition.  There were no complications.
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DESCRIPTION: Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant.  Disc herniation with right arm radiculopathy.

surgery, herniation, radiculopathy, interbody, mystique, bone implant, anterior cervical discectomy, neural foramina, mystique plate, disc herniation, arm radiculopathy, cervical discectomy, disk space, disk, cervical, anterior, wound, discectomy,

The provided situation involves a surgical procedure, specifically an Anterior Cervical Discectomy & Arthrodesis, which addresses a significant medical condition affecting the cervical spine and causing radiculopathy. Surgery inherently carries high stakes due to the potential for complications, impact on the patient's health, and the requirement for a high level of skill and precision. The potential risks and the need for a successful outcome to relieve the patient's symptoms contribute to the high stakes of the situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: ER Report - COPD

CHIEF COMPLAINT:,  The patient is a 49-year-old Caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,HISTORY OF PRESENT ILLNESS:, The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multiple visits in the past. Today, the patient presents himself in severe respiratory distress. His wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath.,Today, his symptoms worsened and she brought him to the emergency room. To the best of her knowledge, there has been no fever. He has persistent chronic cough, as always. More complete history cannot be taken because of the patient’s acute respiratory decompensation.,PAST MEDICAL HISTORY:,  Hypertension and emphysema.,MEDICATIONS:,  Lotensin and some water pill as well as, presumably, an Atrovent inhaler.,ALLERGIES:,  None are known.,HABITS:,  The patient is unable to cooperate with the history.,SOCIAL HISTORY:,  The patient lives in the local area with his wife.,REVIEW OF BODY SYSTEMS:,  Unable, secondary to the patient’s condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 96 degrees, axillary. Pulse 128. Respirations 48. Blood pressure 156/100. Initial oxygen saturations on room air are 80.,GENERAL: Reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.,HEENT: Head is normocephalic and atraumatic.,NECK: The neck is supple without obvious jugular venous distention.,LUNGS: Auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.,HEART: Cardiac examination reveals sinus tachycardia, without pronounced murmur.,ABDOMEN: Soft to palpation.,Extremities: Without edema.,DIAGNOSTIC DATA:,  White blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. Chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, CO2 44, BUN 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. Troponin is 0.11. Urinalysis reveals yellow clear urine. Specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. No white cells and 0-2 red cells.,Chest x-ray suboptimal in quality, but without obvious infiltrates, consolidation or pneumothorax.,CRITICAL CARE NOTE:,  Critical care one hour.,Shortly after the patient’s initial assessment, the patient apparently began to complain of chest pain and appeared to the nurse to have mounting exhaustion and respiratory distress. Although O2 had been placed, elevating his oxygen saturations to the mid to upper 90s, he continued to complain of symptoms, as noted above. He became progressively more rapidly obtunded. The patient did receive one gram of magnesium sulfate shortly after his arrival, and the BiPAP apparatus was being readied for his use. However, the patient, at this point, became unresponsive, unable to answer questions, and preparations were begun for intubation. The BiPAP apparatus was briefly placed while supplies and medications were assembled for intubation. It was noted that even with the BiPAP apparatus, in the duration of time which was required for transfer of oxygen tubing to the BiPAP mask, the patient’s O2 saturations rapidly dropped to the upper 60 range.,All preparations for intubation having been undertaken, Succinylcholine was ordered, but was apparently unavailable in the department. As the patient was quite obtunded, and while the Dacuronium was being sought, an initial trial of intubation was carried out using a straight blade and a cupped 7.9 endotracheal tube. However, the patient had enough residual muscle tension to make this impractical and further efforts were held pending administration of Dacuronium 10 mg. After approximately two minutes, another attempt at intubation was successful. The cords were noted to be covered with purulent exudates at the time of intubation.,The endotracheal tube, having been placed atraumatically, the patient was initially then nebulated on 100% oxygen, and his O2 saturations rapidly rose to the 90-100% range.,Chest x-ray demonstrated proper placement of the tube. The patient was given 1 mg of Versed, with decrease of his pulse from the 140-180 range to the 120 range, with satisfactory maintenance of his blood pressure.,Because of a complaint of chest pain, which I myself did not hear, during the patient’s initial triage elevation, a trial of Tridil was begun. As the patient’s pressures held in the slightly elevated range, it was possible to push this to 30 mcg per minute. However, after administration of the Dacuronium and Versed, the patient’s blood pressure fell somewhat, and this medication was discontinued when the systolic pressure briefly reached 98.,Because of concern regarding pneumonia or sepsis, the patient received one gram of Rocephin intravenously shortly after the intubation. A nasogastric and Foley were placed, and an arterial blood gas was drawn by respiratory therapy. Dr. X was contacted at this point regarding further orders as the patient was transferred to the Intensive Care Unit to be placed on the ventilator there. The doctor’s call was transferred to the Intensive Care Unit so he could leave appropriate orders for the patient in addition to my initial orders, which included Albuterol or Atrovent q. 2h. and Levaquin 500 mg IV, as well as Solu-Medrol.,Critical care note terminates at this time.,EMERGENCY DEPARTMENT COURSE:,  See the critical care note.,MEDICAL DECISION MAKING (DIFFERENTIAL DIAGNOSIS):,  This patient has an acute severe decompensation with respiratory failure. Given the patient’s white count and recent history of pneumonia, the possibility of recurrence of pneumonia is certainly there. Similarly, it would be difficult to rule out sepsis. Myocardial infarction cannot be excluded.,COORDINATION OF CARE:,  Dr. X was contacted from the emergency room and asked to assume the patient’s care in the Intensive Care Unit.,FINAL DIAGNOSIS:,  Respiratory failure secondary to severe chronic obstructive pulmonary disease.,DISCHARGE INSTRUCTIONS:, The patient is to be transferred to the Intensive Care Unit for further management.
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DESCRIPTION: Patient in ER complaining of shortness of breath (COPD)

The situation involves a patient with severe respiratory distress and respiratory failure due to chronic obstructive pulmonary disease (COPD), as well as possible pneumonia or sepsis, which are life-threatening conditions. The patient required critical interventions including intubation and ICU transfer. Immediate medical attention and critical care are essential to stabilize the patient's condition. Therefore, this situation is high-stakes because it involves significant risk to the patient's health and requires urgent and complex medical management.


Medical Specialty: Gastroenterology
Sample Name: Discharge Summary - 10

ADMITTING DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,DISCHARGE DIAGNOSES:,  Hiatal hernia, gastroesophageal reflux disease reflux.,SECONDARY DIAGNOSIS: , Postoperative ileus.,PROCEDURES DONE: , Hiatal hernia repair and Nissen fundoplication revision.,BRIEF HISTORY: , The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux.  Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia.  Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals.  He is also having reflux symptoms again.  He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication.,HOSPITAL COURSE: , Mr. A was admitted to the adolescent floor by Brenner Children's Hospital after his procedure.  He was stable at that time.  He did complain of some nausea.  However, he did not have any vomiting at that time.  He had an NG tube in and was n.p.o.  He also had a PCA for pain management as well as Toradol.  On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed.  Over the next several days, his hospital course proceeded as follows.  He continued to complain of some nausea; however, he did not ever have any vomiting.  Eventually, the Foley catheter was discontinued and he had excellent urine output without any complications.  He ambulated frequently.  He remained n.p.o. for three days.  He also had the NG tube in during that time.  On postoperative day #4, he began to have some flatus, and the NG tube was discontinued.  He was advanced to a liquid diet and tolerated this without any complications.  At this time, he was still using the PCA for pain control.  However, he was using it much less frequently than on days #1 and #2 postoperatively.  After tolerating the full liquid diet without any complications, he was advanced to a soft diet and his pain medications were transitioned to p.o. medications rather than the PCA.  The PCA was discontinued.  He tolerated the soft diet without any complications and continued to have flatus frequently.  On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications.  His pain was well controlled with p.o. pain medications.  He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues.,DISCHARGE CONDITION:,  Stable.,DISPOSITION: , Discharged to home.,DISCHARGE INSTRUCTIONS: , The patient was discharged to home with instructions for maintaining a soft diet.  It was also recommended that he does not drink any soda postoperatively.  He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting.  He will be able to attend school when it starts in a few weeks.  However, he is not going to be able to play football in the near future.  He was given prescription for pain medication upon discharge.  He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns.
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DESCRIPTION: Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux.

The situation involves the discharge of a patient who has undergone a complex surgical procedure (hiatal hernia repair and revision of Nissen fundoplication). The patient has been stable postoperatively, with no major complications, and comprehensive discharge instructions have been provided. Although postoperative care and follow-up are critical, the immediate post-discharge situation described appears to be stable, with the patient able to manage at home. This reduces the stakes, as the risks and dangers are mitigated through careful observation and instructions.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Occupational Medicine Consult

ALLOWED CONDITION: , Right shoulder sprain and right rotator cuff tear (partial).,CONTESTED CONDITION:,  AC joint arthrosis right aggravation.,DISALLOWED CONDITION: ,
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DESCRIPTION: Occupational medicine consult with questions-answers and records review.

The situation involves consulting on a medical case related to occupational medicine, specifically concerning injuries like a right shoulder sprain and a partial tear in the rotator cuff. While these medical conditions can significantly affect a patient's quality of life and the ability to work, the stakes are comparatively lower than those involving life-threatening conditions. The contested and disallowed nature of conditions suggests a complex situation possibly involving workers' compensation, impacting potential compensation or medical leave current or future claims, which can elevate the personal stakes for the patient. However, from a broader medical perspective, the situation is not immediately life-critical.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - COPD

PROCEDURES:,1.  Chest x-ray on admission, no acute finding, no interval change.,2.  CT angiography, negative for pulmonary arterial embolism.,3.  Nuclear myocardial perfusion scan, abnormal.  Reversible defect suggestive of ischemia, ejection fraction of 55%.,DIAGNOSES ON DISCHARGE:,1.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.,2.  Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic.,3.  Diabetes mellitus type 2.,4.  Anemia, hemoglobin and hematocrit stable.,5.  Hypokalemia, replaced.,6.  History of coronary artery disease status post stent placement 2006-2008.,7.  Bronchitis.,HOSPITAL COURSE:  ,The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea.  The patient started on IV steroid, bronchodilator as well as antibiotics.,He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea.  He was evaluated by Cardiology Dr. X, who proceeded with stress test.  Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic.  The patient's last cardiac cath was in 2008.,The patient clinically significantly improved and wants to go home.  His hemoglobin on admission was 8.8, and has remained stable.  He is afebrile, hemodynamically stable.,ALLERGIES: , LISINOPRIL AND PENICILLIN.,MEDICATIONS ON DISCHARGE:,1.  Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.,2.  Levaquin 750 mg p.o. daily for 5 more days.,3.  Protonix 40 mg p.o. daily.,4.  The patient can continue other current home medications at home.,FOLLOWUP APPOINTMENTS:,1.  Recommend to follow up with Cardiology Dr. X's office in a week.,2.  The patient is recommended to see Hematology Dr. Y in the office for workup of anemia.,3.  Follow up with primary care physician's office tomorrow.,SPECIAL INSTRUCTIONS:,1.  If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.,2.  Discussed about discharge plan, instructions with the patient by bedside.  He understands and agreed.  Also discussed discharge plan instructions with the patient's nurse.
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DESCRIPTION: Chest x-ray on admission, no acute finding, no interval change.  CT angiography, negative for pulmonary arterial embolism.  Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.

The discharge summary outlines a patient's medical condition and the plan for post-hospital care, which is crucial for their recovery and ongoing health management. However, the patient has been evaluated and is stable enough for discharge, with a follow-up care plan that includes appointments with specialists and a primary care physician. Although the presence of multiple conditions like COPD, coronary artery disease, and diabetes increases the complexity and potential risk, the acuteness of the situation has been managed, making it not extremely high-stakes at discharge. The stakes related to the discharge process include ensuring the patient adheres to follow-up appointments and instructions, but this is a common and manageable part of healthcare, typically not extremely high-stakes.


Medical Specialty: Surgery
Sample Name: Hematoma Evacuation

PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1.  Right temporal lobe intracerebral hemorrhage.,2.  Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1.  Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  Biopsy of dura.,3.  Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:,  Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently.  This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today.  She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  There is significant mass effect.  There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team.  Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed.  The patient was positioned supine with a three-point Mayfield head pin holder.  Her scalp was prepped and draped in a sterile manner.  Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  The scalp was resected anteriorly.  The subdural scar was noted, and hemostasis was achieved using Bovie cautery.  The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety.  The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected.  It was quite full.  The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur.  The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax.  The dura pack-up stitches were noted around the periphery from the previous craniotomy.  This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure.  Using a #15 blade, a new durotomy was then made.  Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface.  Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  The parenchyma of the brain did not appear normal.  It was quite vascular.  Furthermore, there was a hematoma mixed in with the brain itself.  Thus a core biopsy was then performed in the temporal tip.  The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  No attempt was made to enter into the sylvian fissure.  Once hemostasis was meticulously achieved, the brain was inspected.  It still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  DuraGen was then used for duraplasty because of the resected dura.  The bone flap was then repositioned using Lorenz plating system.  Then a medium Hemovac drain was placed in subdural space.  Temporalis muscle was approximated using 2-0 Vicryl.  The galea was then reapproximated using inverted 2-0 Vicryl.  The scalp was then reapproximated using staples.  The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  The pupils are 3 mm bilaterally reactive to light.  I accompanied her and transported her to the ICU where I signed out to the ICU attending.
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DESCRIPTION: Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.  Biopsy of dura.

The situation involves an emergency craniotomy for the evacuation of an intracerebral hematoma along with a biopsy of a temporal lobe lesion, which is causing a significant mass effect. The patient's condition was life-threatening, involving acute symptoms such as hemiplegia, loss of consciousness, and loss of bowel/urine control, suggesting severe neurological involvement. The high stakes are underscored by the need for immediate surgical intervention to prevent potential further neurological deterioration or death. Additionally, the procedure involved complex intracranial surgery, which inherently carries high risks and high stakes.


Medical Specialty: Discharge Summary
Sample Name: Ectopic Pregnancy - Discharge Summary

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

discharge summary, anemia, blood loss, ruptured ectopic pregnancy, gestational sac, ectopic pregnancy, hemoperitoneum, gestational, ruptured, pregnancy, ectopic,

The situation involves a medical professional handling the discharge summary of a patient who underwent surgery for a ruptured ectopic pregnancy. Ectopic pregnancy is a serious medical condition that can be life-threatening due to risks such as severe internal bleeding. Although the immediate surgical intervention was successful and the patient is being discharged, the situation remains relatively high-stakes due to the potential for complications post-discharge, such as infection or prolonged recovery issues, as well as the necessity for follow-up care. Additionally, ensuring the patient adheres to the follow-up plan and manages their anemia effectively is crucial to prevent further health deterioration.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Uterine Suction Curettage

PREOPERATIVE DIAGNOSIS: , A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,POSTOPERATIVE DIAGNOSIS:,  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,PROCEDURE: , Exam under anesthesia with uterine suction curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,INDICATIONS:  ,The patient is a 29-year-old gravida 5, para 1-0-3-1, with an LMP at 12/18/05.  The patient was estimated to be approximately 10-1/2 weeks so long in her pregnancy.  She began to have heavy vaginal bleeding and intense lower pelvic cramping.  She was seen in the emergency room where she was found to be hemodynamically stable.  On pelvic exam, her cervix was noted to be 1 to 2 cm dilated and approximately 90% effaced.  There were bulging membranes protruding through the dilated cervix.  These symptoms were consistent with the patient's prior experience of spontaneous miscarriages.  These findings were reviewed with her and options for treatment discussed.  She elected to proceed with an exam under anesthesia with uterine suction curettage.  The risks and benefits of the surgery were discussed with her and knowing these, she gave informed consent.,PROCEDURE:  ,The patient was taken to the operating room where she was placed in the seated position.  A spinal anesthetic was successfully administered.  She was then moved to a dorsal lithotomy position.  She was prepped and draped in the usual fashion for the procedure.  After adequate spinal level was confirmed, a bimanual exam was again performed.  This revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size.  The previously noted cervical exam was confirmed.  The weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution.  This solution was then removed approximately 10 minutes later with dry sterile gauze sponge.  The anterior cervical lip was then attached with a ring clamp.  The tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied.  The tissue dislodged revealing fluid mixed with blood as well as an apparent 10-week fetus.  The placental tissue was then gently tractioned out as well.  A size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity.  With the vacuum tubing applied in rotary motion, a moderate amount of tissue consistent with products of conception was evacuated.  The sharp curette was then utilized to probe the endometrial surface.  A small amount of additional tissue was then felt in the posterior uterine wall.  This was curetted free.  A second pass was then made with a vacuum curette.  Again, the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered.  A final pass was then made with a suction curette.,The ring clamp was then removed from the anterior cervical lip.  There was only a small amount of bleeding following the curettage.  The weighted speculum was then removed as well.  The bimanual exam was repeated and good involution was noted.  The patient was taken down from the dorsal lithotomy position.  She was transferred to the recovery room in stable condition.  The sponge and instrument count was performed and found to be correct.  The specimen of products of conception and 10-week fetus were submitted to Pathology for further evaluation.  The estimated blood loss for the procedure is less than 10 mL.
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DESCRIPTION: Exam under anesthesia with uterine suction curettage.  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.

obstetrics / gynecology, spontaneous, incomplete abortion, uterine suction curettage, fetus, anterior cervical lip, spontaneous incomplete abortion, bimanual exam, ring clamp, suction curettage, uterine, curettage, suction

The situation involves a medical procedure to address a spontaneous, incomplete abortion at 10.5 weeks of pregnancy. Although the procedure is routine and reported to have no complications, it involves the loss of a pregnancy and a surgical intervention, which are significant events emotionally and medically for the patient. Given the potential for serious emotional impact and the need for surgical intervention, while the immediate medical risks are low, the overall situation is moderately high-stakes for the patient's well-being.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych H&P - 1

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

psychiatry / psychology, history of present illness:, global assessment of functioning, mental status examination, major depression, psychiatric, abuse, behavior, depression, mental health, mental health ward, psychiatric disability, sexually abused, substance abuse, health,

This situation involves a patient with a complex psychiatric history, major depression, potential substance abuse, and a history of sexual abuse trauma. The patient is experiencing significant difficulties in functioning, including being unable to sustain employment and substantial social isolation. The fact that the patient has been hospitalized at the recommendation of a long-term therapist and at the family's urging increases the stakes, as the hospitalization is meant to prevent deterioration and address any potential risk of self-harm or harm from others. Additionally, the history of sexual abuse and ongoing family conflict further complicates the situation and underscores the need for careful mental health evaluation and intervention. Although there is no immediate life-threatening condition, the multifaceted issues and potential risks involved qualify this as a moderately high-stakes scenario in psychiatry.


Medical Specialty: Pain Management
Sample Name: Lumbar Epidural Steroid Injection - 3

PREOPERATIVE DIAGNOSIS:  ,Lumbar radiculopathy, 724.4.,POSTOPERATIVE DIAGNOSIS:,  Lumbar radiculopathy, 724.4.,PROCEDURE:,  Lumbar epidural steroid injection.,ANESTHESIOLOGIST:,  Monitored anesthesia care,INJECTATE USED:,  10 mL of 0.5% lidocaine and 80 mg of Depo-Medrol.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,DETAILS OF THE PROCEDURE:,  The patient arrived at the preoperative holding area where informed consent, stable vital signs, and intravenous access were obtained.  A thorough discussion of the potential risks, benefits, and complications was made prior to the procedure including potential for post-dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and/or nerve root injury, infection, bleeding and even death.  There were no known EKG, chest X-ray, or laboratory contraindications to the procedure.,The patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury.  Arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort.,The L4-L5 interspace was identified fluoroscopically.  A left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0.5% Lidocaine initially through a #25-gauge 5/8-inch needle later a #22-gauge 1-1/2-inch needle.,A number #18-gauge Tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of L5.  Needle tip position was confirmed in the anterior posterior fluoroscopic view.  The epidural space was located with the loss of pulsation technique.  Aspiration of the syringe was negative for blood or cerebrospinal fluid.  One millimeter of 0.9% preservative was injected with good loss resistance noted.,DISCHARGE SUMMARY:,  Following the completion of this procedure, the patient underwent monitoring in the recovery room and was discharged, to be followed as an outpatient.
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DESCRIPTION: Lumbar epidural steroid injection for lumbar radiculopathy.

The procedure described is a lumbar epidural steroid injection, which is a common treatment for lumbar radiculopathy. While the procedure is generally safe and routine in pain management, there are potential risks, such as neurological injury, infection, or bleeding, discussed with the patient beforehand. Though these risks add some stakes to the procedure, the overall situation is not critically high-stakes, partly due to the thorough preparation and precautionary measures, such as anesthesia and fluoroscopic guidance, minimizing potential complications. Furthermore, no complications were recorded during or after the procedure.


Medical Specialty: Consult - History and Phy.
Sample Name: Bunion & Pes Planovalgus Deformity

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

consult - history and phy., x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion

The situation involves a 57-year-old female patient with a recurrent bunion deformity and pes planovalgus deformity, which are causing her significant pain and discomfort. Her job involves standing all day, which likely exacerbates her symptoms. The stakes are primarily related to her quality of life, ability to work comfortably, and potential surgical outcomes. While this is an important medical situation for the patient, it is not life-threatening. The discussion of surgical vs. conservative treatment indicates a non-emergency scenario, focusing more on elective procedures with potential risks and recovery time considerations.


Medical Specialty: Emergency Room Reports
Sample Name: Angina - Consult

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

The patient is a 68-year-old woman with a history of angina, hypertension, and previous cardiac interventions, presenting with recurrent arm pain that is responsive to nitroglycerin. This scenario involves risk of unstable angina, potential myocardial infarction, or complications from a recently placed stent. These conditions are serious and can be life-threatening if not managed promptly. Admission to the hospital for close monitoring and further assessment is necessary, which underscores the high-stakes nature of the situation.


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

Medical Specialty: Surgery
Sample Name: Superior Labrum Lesions Repair

PROCEDURE IN DETAIL:,  After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder was performed.  It revealed no patholigamentous laxity.  We then placed the patient into a beach-chair position, maintaining a neutral alignment of the head, neck, and thorax.  The shoulder was then prepped and draped in the usual sterile fashion.  We then injected the glenohumeral joint with 60 cc of sterile saline solution.  A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  Through this incision, a blunt trocar was placed.,We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution.  An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint.,We found that the articular surface was in good condition.  The biceps was found to be intact.  There was a SLAP tear noted just posterior to the biceps.  Pictures were taken.  No Bankart or Hill-Sachs lesions were noted.  The rotator cuff was examined and there were no undersurface tears.  Pictures were again taken.,We then made a lateral portal going through the muscle belly of the rotator cuff.  A drill hole was made and then knotless suture anchor was placed to repair this.  Pictures were taken.  We then washed out the joint with copious amounts of sterile saline solution.  It was drained.  Our 3 incisions were closed using 3-0 nylon suture.  A pain pump catheter was introduced into the shoulder joint.  Xeroform, 4 x 4s, ABDs, tape, and sling were placed.,The patient was successfully taken out of the beach-chair position, extubated and brought to the recovery room in stable condition.  I then went out and spoke with the patient's family, going over the case, postoperative instructions, and followup care.
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DESCRIPTION: Superior labrum anterior and posterior lesion repair.

surgery, laxity, patholigamentous, superior labrum, saline solution, anterior, superior, lesions, repair, sterile, joint, shoulder,

The situation described is a surgical procedure to repair a superior labrum anterior and posterior lesion (SLAP tear) in the shoulder. Surgery inherently involves high stakes due to the potential risks of complications such as infection, anesthesia reactions, or failure of the repair, which could impact the patient's health significantly. However, shoulder arthroscopy is generally a routine and well-practiced procedure for experienced surgical teams. Considering the controlled nature of the operation described, including protocols for patient positioning, anesthesia, and postoperative care, it is not at the extreme end of high-stakes surgical operations but still carries inherent risks typical of surgical procedures.


Medical Specialty: Consult - History and Phy.
Sample Name: Worker's Compensation Injury

CHIEF COMPLAINT:,  Worker’s compensation injury.,HISTORY OF PRESENT ILLNESS:,  The patient is a 21-year-old Hispanic female.  She comes in today with her boyfriend.  The patient speaks English fairly well, but her primary language is Spanish.  Her boyfriend does help to make sure that she understands what we are talking about.  The patient seems to understand our conversation fairly well.  She works at Norcraft and injured her right thumb on 09/10/2004 at 12:15 a.m.  She was pushing a cart and mashed her thumb between the cart and the wall.  This was at the finishing room in Norcraft.  She went ahead and went to work yesterday, which was the 14th, but was not able to work on the 13th.  She has swelling in her thumb.  It hurt only if it is pushed on.  It was the distal end of her thumb that was mashed.  She has not noticed any numbness or tingling or weakness.  She has not sought any treatment for this, is not taking any pain medications.  She did try soaking it in warm salt water and did not notice any improvement.,MEDICATIONS: , None.,ALLERGIES: , None.,PAST MEDICAL HISTORY:,  Possible history of chicken pox, otherwise no other medical illnesses.  She has never had any surgery.,FAMILY HISTORY: , Parents and two siblings are healthy.  She has had no children.,SOCIAL HISTORY:,  The patient is single.  She lives with her boyfriend and his father.  She works at Norcraft.  She wears seatbelt 30% of the time.  I encouraged her to use them all of the time.  She is a nonsmoker, nondrinker.,VACCINATIONS: , She thinks she got a tetanus vaccine in childhood, but does not know for sure.  She does not think she has had a tetanus booster recently.,REVIEW OF SYSTEMS:,Constitutional:  No fevers, chills, or sweats.,Neurologic:  She has had no numbness, tingling, or weakness.,Musculoskeletal:  As above in HPI.  No other difficulties.,PHYSICAL EXAMINATION:,General:  This is a well-developed, well-nourished, very pleasant Hispanic female, in no acute distress.,Vital Signs:  Weight:  121.4.  Blood pressure:  106/78.  Pulse:  64.  Respirations:  20.  Temperature:  96.,Extremities:  Examination of the right hand reveals the distal end of the thumb to be swollen especially just proximal to the nail bed.  The nail bed is pushed up.  I can see hematoma below the nail bed, although it does appear to be intact.  She has some blue fingernail polish on her nail also, but that is starting to come off.  She is able to bend her thumb normally at the DIP joint.  She has no discomfort doing that.  Sensation is intact over the entire thumb.  She has normal capillary refill.  There is some erythema and swelling noted especially over the posterior thumb just proximal to the nail bed.  I am not feeling any fluctuance.  I do not think it is a collection of pus.  There is no drainage.  She does have some small fissures in the skin where I think she did injure it with this smashing injury, but no deep lacerations at all.  It looks like there may be some mild cellulitis at the site of her injury.,LABORATORY:,  X-ray of the thumb was obtained and I do not see any sign of fracture or foreign body.,ASSESSMENT:,  Blunt trauma to the distal right thumb without fracture.  I think there is some mild cellulitis developing there.,PLAN:,1.  We will give a tetanus diphtheria booster.,2.  We will start Keflex 500 mg one p.o. q.i.d. x 7 days.  I would recommend that she can return to work, but she is not to do any work that requires the use of her right thumb.  I would like to see her back on Monday, the 20th in the morning and we can see how her thumb is doing at that time.  If she is noticing any difficulties with increased redness, increased warmth, increased pain, pus-like drainage, or any other difficulties, she is to go ahead and give us a call.  Otherwise I will be seeing her back on Monday.
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DESCRIPTION: Blunt trauma to the distal right thumb without fracture.  Worker’s Compensation Injury

The situation involves a worker's compensation injury, which carries implications for the patient's employment status, medical care, and financial compensation. However, the specific case described involves a relatively common minor injury, a blunt trauma to the thumb without fracture, which is not life-threatening or disabling. The main concerns are managing mild cellulitis and ensuring appropriate medical follow-up. The stakes are moderate primarily due to the need to prevent infection and manage return-to-work conditions, but it overall doesn't constitute a high-stakes medical emergency.


Medical Specialty: Orthopedic
Sample Name: Arthroscopy & Chondroplasty

PREOPERATIVE DIAGNOSES:,1.  Chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,POSTOPERATIVE DIAGNOSES:,1.  Grade-IV chondromalacia patella.,2.  Patellofemoral malalignment syndrome.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with partial chondroplasty of patella.,2.  Lateral retinacular release.,3.  Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,TOURNIQUET TIME: , Approximately 70 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , Grade-IV chondromalacia noted to the central and lateral facet of the patella.  There was a grade II to III chondral changes to the patellar groove.  The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle.  The medial lateral meniscus showed small amounts of degeneration, but no frank tears were seen.  The articular surfaces and the remainder of the knee appeared intact.  Cruciate ligaments also appeared intact to direct stress testing.,HISTORY:  ,This is a 36-year-old Caucasian female with a long-standing history of right knee pain.  She has been diagnosed in the past with chondromalacia patella.  She has failed conservative therapy.  It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer (anterior medialization of the tibial tubercle) to release stress from her femoral patellofemoral joint.  She elected to proceed with the surgical intervention.  All risks and benefits of the surgery were discussed with her.  She was in agreement with the treatment plan.,PROCEDURE: , On 09/04/03, she was taken to Operating Room at ABCD General Hospital.  She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department.  Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion.  A stab incision was made in inferolateral and parapatellar regions.  Through this the cannula was placed and the knee was inflated with saline solution.  Intraoperative pictures were obtained.  The above findings were noted.  Second portal site was initiated in the inferomedial parapatellar region.  Through this, a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris.  Next, the camera was placed through the inferomedial portal.  An arthroscopic Bovie was placed through the inferolateral portal.  A release of lateral retinaculum was then performed using the Bovie.  Hemostasis was controlled with electrocautery.  Next, the knee was suctioned dry.  An Esmarch was used to exsanguinate the lower extremity.  Tourniquet was inflated to 325 mmHg.  An oblique incision was made along the medial parapatellar region of the knee.  The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery.  The retinaculum was then incised in line with the incision.  The patellar tendon was identified.  The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris.  Next, an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact.  The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle.  It was then held in place with a Steinmann pin.  Following this, a two 4.5 mm cannulated screws, partially threaded, were drilled in place using standard technique to help fixate the tibial tubercle.  There was excellent fixation noted.  The Q-angle was noted to be decreased to approximately 15 degrees.  She was transferred approximately 1 cm in length.  The wound was copiously irrigated and suctioned dry.  The medial retinaculum was then plicated causing further medialization of the patella.  The retinaculum was reapproximated using #0 Vicryl.  Subcuticular tissue were reapproximated with #2-0 Vicryl.  Skin was closed with #4-0 Vicryl running PDS suture.  Sterile dressing was applied to the lower extremities.  She was placed in a Donjoy knee immobilizer locked in extension.  It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet.  She was transferred to recovery room in apparent stable and satisfactory condition.,Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint.  She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia.
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DESCRIPTION: Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws.  Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.

orthopedic, diagnostic arthroscopy, patellofemoral malalignment syndrome, cannulated, partial chondroplasty, retinacular, chondromalacia patella, tibial tubercle, patella, tubercle, arthroscopy, tourniquet, chondroplasty, chondromalacia, patellofemoral,

The situation involves a surgical procedure for a patient with advanced degenerative knee conditions, specifically grade-IV chondromalacia patella and patellofemoral malalignment syndrome. The surgery, including diagnostic arthroscopy, chondroplasty, lateral retinacular release, and tibial tubercle transfer, indicates an attempt to alleviate pain and improve knee function. This is a complex procedure that requires general anesthesia and involves multiple steps to correct structural issues in the knee. The stakes are elevated due to the inherent risks associated with surgery, the moderate complexity of the procedure, and the fact that the patient has a poor prognosis due to advanced degenerative changes. However, the surgical procedure described is relatively routine within orthopedics, and there were no reported complications. The immediate risk to the patient's life is low, but the procedure's outcome is critical for the patient's mobility and quality of life.


Medical Specialty: Speech - Language
Sample Name: Barium Swallow Study & Speech Evaluation

CURRENT MEDICATIONS:,  Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY:  ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management.  A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis.  The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration.  A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps.  Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes.  On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS:  ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve.  He reported no discomfort on the inhalation; however, he felt some resistance on exhalation.  Instructions were given on care placement and cleaning of the Passy-Muir valve.  The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day.  The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion.  Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis.  The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation.  The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities.  The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1.  Completion of modified barium swallow study.,2.  The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3.  The patient will increase laryngeal elevation by 50% for airway protection.,4.  The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5.  The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6.  The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1.  The patient will improve secretion management to tolerable levels.,2.  The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3.  The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve.
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DESCRIPTION: The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities.  The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs.  A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.

The scenario involves a patient who has undergone treatment for head and neck cancer, leading to significant swallowing difficulties that could affect his nutritional intake and overall health. The stakes are moderately high because proper swallowing is crucial for the patient's quality of life, safety from aspiration, and eventual goal of eating by mouth. The patient's current condition could lead to complications such as aspiration pneumonia if not properly managed. However, the patient is receiving a planned course of treatment with clear goals and monitoring, reducing immediate life-and-death risks, which are more common in other critical medical scenarios.