Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 8

DISCHARGE DIAGNOSES:,1.  Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2.  History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3.  History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal.  Transesophageal echocardiogram July 27, 2007, that was normal.  No evidence of vegetations.  CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm.  There were 2-3 additional tiny cysts in the right lobe.  The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers.  For further details of the admission, please see the previously dictated history and physical.  ,HOSPITAL COURSE:,  Gram-negative rod bacteremia.  The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers.  The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations.  The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides.  The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade.  We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver.  There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned.  I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah.  Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with.  I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet.  The patient, however, appeared to be responding well to levofloxacin.  I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime.  Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return.  A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin.  In addition, I told the patient that it would be my recommendation to get rid of the rats.  I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection.  I told her very clearly that she should, indeed, get rid of the animals.  The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following.,  ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated.  Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases.  I gave the patient the phone number to call on Monday for an appointment.  Additional followup is also with Dr. XYZ, her primary care physician.  Please note that 40 minutes was spent in the discharge.
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DESCRIPTION: A white female with a history of fevers.

discharge summary, abdomen and pelvis, gram negative rod, congenital genitourinary, genitourinary abnormalities, transesophageal echocardiogram, infectious diseases, leptospirosis serologies, gram negative, ct scan, identification, infections, levofloxacin, additional, discharge

The situation involves a patient with Gram-negative rod bacteremia, which is a potentially serious and life-threatening condition if not effectively treated. The stakes are elevated by the lack of final identification and susceptibilities for the bacteria, the possible zoonotic source of infection, and the need for the patient to remove potential carriers of infection, which the patient was initially reluctant to do. However, the patient appears to be responding well to treatment with levofloxacin, and close follow-up with medical professionals is arranged. Despite these follow-up measures and treatment in place, the potential ongoing risk presented by the presence of pet rats and the pending microbiology results contribute to a higher level of stakes in this scenario.


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

Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Interbody Fusion - 1

PREOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0).,POSTOPERATIVE DIAGNOSES:  ,1.  Herniated nucleus pulposus, C5-C6, greater than C6-C7 and C4-C5 with left radiculopathy.,2.  Cervical stenosis with cord compression, C5-C6 (723.0), with surgical findings confirmed.,PROCEDURES:  ,1.  Anterior cervical discectomy at C4-C5, C5-C6, and C6-C7 for neural decompression (63075, 63076, 63076).,2.  Anterior interbody fusion at C4-C5, C5-C6, and C6-C7 (22554, 22585, 22585) utilizing Bengal cages times three (22851).,3.  Anterior instrumentation for stabilization by Slim-LOC plate C4, C5, C6, and C7 (22846); with intraoperative x-ray times two.,ANESTHESIA:,  General.,SERVICE: , Neurosurgery.,OPERATION: , The patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner, and then the prevertebral space was encountered and prominent anterior osteophytes were well visualized once longus colli muscle was cauterized along its mesial border, and self-retaining retractors were placed to reveal the anterior osteophytic spaces.  Large osteophytes were excised with a rongeur at C4-5, C5-C6, and C6-C7 revealing a collapsed disc space and a #11 blade was utilized to create an annulotomy at all three interspaces with discectomies being performed with straight disc forceps removing grossly degenerated and very degenerated discs at C4-C5, then at C5-C6, then at C6-C7 sending specimen for permanent section to Pathology in a routine and separate manner.  Residual disc fragments were drilled away as drilling extended into normal cortical and cancellous elements in order to perform a wide decompression all the way posteriorly to the spinal canal itself finally revealing a ligament, which was removed in a similar piecemeal fashion with 1 and 2-mm micro Kerrison rongeurs also utilizing these instruments to remove prominent osteophytes, widely laterally bilaterally at each interspace with one at C4-C5, more right-sided.  The most prominent osteophyte and compression was at C5-C6 followed by C6-C7 and C4-C5 with a complete decompression of the spinal canal allowing the dura to finally bulge into the interspace at all three levels, once the ligaments were proximally removed as well and similarly a sign of a decompressed status.  The nerve roots themselves were inspected with a double ball dissector and found to be equally decompressed.  The wound was irrigated with antibiotic solution and hemostasis was well achieved with pledgets of Gelfoam subsequently irrigated away.  Appropriate size Bengal cages were filled with the patient's own bone elements and countersunk into position, filled along with fusion putty, and once these were quite tightly applied and checked, further stability was added by the placement of a Slim-LOC plate of appropriate size with appropriate size screws, and a post placement x-ray showed well-aligned elements.,The wound was irrigated with antibiotic solution again and inspected, and hemostasis was completely achieved and finally the wound was closed in a routine closure by approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was sterilely dressed, and incorporated a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in a routine fashion.  At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.
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DESCRIPTION: Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.

neurosurgery, herniated nucleus pulposus, radiculopathy, cervical stenosis, anterior instrumentation, stabilization, slim-loc, neural decompression, anterior cervical discectomy, cord compression, interbody fusion, bengal cages, interbody, compression, anterior, fusion, decompression, discectomy, cervical

The situation involves a complex neurosurgical procedure, specifically an anterior cervical discectomy and interbody fusion. Such procedures are inherently high-stakes due to the delicate nature of operating near the spinal cord and the potential for significant complications, such as nerve damage or infection. The outcome of the surgery can greatly affect the patient's quality of life, making it a high-stakes situation. However, the detailed description indicates no intraoperative complications, which suggests careful execution of the procedure.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Elevated Cardiac Enzymes

REASON FOR CONSULTATION:,  Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:,  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.  This is a consultation for evaluation of the same.  The patient is unable to give history.  History obtained through the family members.  As per the patient's son, he does not have history of cardiac disease.  He lives in Utah, presently spending few months in Arizona.  As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far.  No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1.  Vitamin supplementation.,2.  Prednisone.,3.  Cyclobenzaprine.,4.  Losartan 50 mg daily.,5.  Nifedipine 90 mg daily.,6.  Lasix.,7.  Potassium supplementation.,ALLERGIES:,  SULFA.,PERSONAL HISTORY:,  He is an ex-smoker.  Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same.  Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation.  No prior cardiac history.  Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally clear, rales are scattered.,HEART:  PMI displaced.  S1, S2 regular.  Systolic murmur, grade 2/6.,ABDOMEN:  Soft, nontender.,EXTREMITIES:  Chronic skin changes, markings in the lower extremities noted.  Pulses found palpable.  Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex.  Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11.  Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423.  Chest x-ray, no acute changes.,IMPRESSION:,1.  The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2.  Septicemia, septic shock secondary to cellulitis of the leg.,3.  Acute renal shutdown.,4.  Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1.  Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2.  Aggressive medical management including dialysis.,3.  From cardiac standpoint, conservative treatment at this juncture.  His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4.  Explained to patient's family in detail regarding condition which is critical which they are aware of.
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DESCRIPTION: Abnormal cardiac enzyme profile.  The patient is a 66-year-old gentleman, was brought into emergency room with obtundation.  The patient was mechanically ventilated originally.  His initial diagnosis was septic shock.  His labs showed elevated cardiac enzyme profile.

The patient's condition is identified as critical, involving multiple severe health issues: septic shock, acute renal failure, pulmonary fibrosis, and elevated cardiac enzymes. These conditions present together in a 66-year-old patient who is mechanically ventilated, indicating high urgency and risk. The situation requires immediate and aggressive medical management, including dialysis and potential assessment for cardiac involvement through diagnostic imaging. Given the complexity and severity of the medical issues, along with the life-threatening nature of septic shock and organ failures, this situation is undoubtedly high-stakes.


Medical Specialty: Surgery
Sample Name: Cecal Polyp Resection

PREOPERATIVE DIAGNOSIS:,  Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA:  ,General oral endotracheal intubation.,PROCEDURE:,  After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  A bladed 11-mm port was inserted without difficulty.  Pneumoperitoneum was obtained using C02.  Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant.  There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel.  The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve.  This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice.  The appendix was somewhat retrocecal in position but otherwise looked normal.  The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye.  There was enough however in the wall to identify the location of the polyp.  The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table.  The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear.  I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon.  This new staple line was then opened on the back table and examined.  There was some residual polypoid material noted but the margins this time appeared to be clear.  The peritoneal cavity was then lavaged with antibiotic solution.  There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery.  The trocars were removed under direct vision.  No bleeding was noted.  The bladed trocar site was closed using a figure-of-eight O Vicryl suture.  All skin incisions were closed with running 4-0 Monocryl subcuticular sutures.  Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing.  The patient tolerated the procedure well without any complications.
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DESCRIPTION: Laparoscopic resection of cecal polyp.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.

surgery, polyp, laparoscopic resection, blunt dissection, kocher clamps, ileocecal valve, gia stapler, peritoneal cavity, cecal polyp, infiltrated, anesthetic

The procedure described is a laparoscopic resection of a cecal polyp. While any surgical procedure carries inherent risks, this is a routine laparoscopic procedure that appears to have been performed without complications. The patient's condition was stable throughout, and there were no post-operative complications. Although surgery can always have unforeseen risks, this specific operation is neither life-threatening nor highly complex. Thus, the stakes are relatively low compared to other, more dangerous surgical procedures.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiology Progress Note - 1

SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.,CHEST:  There is prolonged expiration.,CARDIOVASCULAR:  First and second heart sounds are heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ pedal swelling.,NEUROLOGIC:  The patient is asleep, but easily arousable.,LABORATORY DATA:,  PTT is 49.  INR is pending.  BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8.  AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia.  Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1.  Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.  Continue current treatment as per Cardiology.  We will consider adding ACE inhibitors as renal function improves.,2.  Acute pulmonary edema, resolved.,3.  Rapid atrial fibrillation, rate controlled.  The patient is on beta-blockers and digoxin.  Continue Coumadin.  Monitor INR.,4.  Coronary artery disease with ischemic cardiomyopathy.  Continue beta-blockers.,5.  Urinary tract infection.  Continue Rocephin.,6.  Bilateral perfusion secondary to congestive heart failure.  We will monitor.,7.  Chronic obstructive pulmonary disease, stable.,8.  Abnormal liver function due to congestive heart failure with liver congestion, improving.,9.  Rule out hypercholesterolemia.  We will check lipid profile.,10.  Tobacco smoking disorder.  The patient has been counseled.,11.  Hyponatremia, stable.  This is due to fluid overload.  Continue diuresis as per Nephrology.,12.  Deep venous thrombosis prophylaxis.  The patient is on heparin drip.
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DESCRIPTION: Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.

cardiovascular / pulmonary, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep,

The situation involves a patient with multiple complex and potentially life-threatening conditions such as congestive heart failure, rapid atrial fibrillation, coronary artery disease, and pulmonary issues, all of which require close monitoring and management. The ejection fraction of 25% indicates significant heart dysfunction, adding to the seriousness. While the patient is currently stable and not in acute distress, the nature of these conditions means that any changes could quickly become critical. This contributes to a high-stakes medical situation as ongoing treatment adjustments and monitoring are vital to prevent further complications.


Medical Specialty: Neurosurgery
Sample Name: Anterior Lumbar Fusion

PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:,  None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:,  Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body.  This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:,  The patient was placed under general endotracheal anesthesia.  The abdomen was prepped and draped in the usual fashion.  Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters.  I was able to remove additional disk space and score the vertebral bodies.  The rest of the disk removal was done with the curette, scraping the endplates.  I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place.  We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side.  This was filled with bone and BMP as well.  Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws.  Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness.  He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc.  MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5.  A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic.  An anterior lumbar interbody fusion was suggested.  Procedure, risks, and complications were explained.
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DESCRIPTION: Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.  Severe low back pain.

neurosurgery, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion,

The situation involves a detailed surgical procedure for anterior lumbar fusion on a patient suffering from severe low back pain. Surgeries, particularly neurosurgery procedures like spinal fusion, are generally high-stakes due to the complexity, risk of complications, and potential impacts on a patient's mobility and quality of life. Although this specific procedure went smoothly without complications, the inherent risks involved in neurosurgery make this a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Internal Jugular Vein Catheter Insertion

PREOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,PROCEDURE PERFORMED:  ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia.  The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time.  He is slightly short of breath with mild difficulty in breathing.  A pre-procedure x-ray was obtained, which showed no pneumothorax.  He did have a significant right pleural effusion and a mild left pleural effusion.  We decided to insert the catheter on the right side.,PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion.  1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein.  Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return.  The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty.  The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used.  The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty.  The guidewire was removed.  Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty.  The ports were flushed with injectable normal saline secondary to the patient going for dialysis today.  Thus, he will not need heparinization of the lines.  Again, he tolerated the procedure well.  A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.
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DESCRIPTION: Acute on chronic renal failure and uremia.  Insertion of a right internal jugular vein hemodialysis catheter.

surgery, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein

The insertion of an internal jugular vein catheter for hemodialysis is a critical procedure, especially in a patient with acute on chronic renal failure and uremia. The procedure is necessary for renal replacement therapy, which is essential to manage the patient's condition. Any complications could have severe consequences, including potentially life-threatening outcomes. The procedure's success and complication-free outcome are crucial for the patient's immediate health needs, making this situation high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Pulmonary Angio

EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries.  No central embolism.  The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below.  There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35.  Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm.  Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed.  However, there is considerable change in the appearance of the lung fields.  There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis.  There are also extensive right lung consolidations, all new or increased significantly from the prior examination.  Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded.  There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here.  There is aortic root and arch and descending thoracic aortic calcification.  There are scattered regions of soft plaque intermixed with this.  The heart is not enlarged.  The left axilla is intact in regards to adenopathy.  The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound.  Spleen, adrenal glands, and upper kidneys appear unremarkable.  Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass.  There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1.  Again demonstrated is a large right chest wall mass.,2.  No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3.  New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4.  See above regarding other findings.
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DESCRIPTION: Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.

cardiovascular / pulmonary, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio

The examination involves several critical findings, including a large chest wall mass, potential metastatic disease, new pleural effusions, and lung consolidations. These findings could indicate serious underlying conditions such as cancer or severe lung disease, which require urgent medical evaluation and potential intervention to prevent deterioration of the patient's condition. Given the potential implications for the patient's health and the need for timely management, this situation can be considered high-stakes.


Medical Specialty: Surgery
Sample Name: Laparoscopic Appendectomy - 1

PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Ruptured appendicitis.,PROCEDURE:,  Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:,  This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers.  The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in usual sterile fashion.  A periumbilical incision was made.  The fascia was incised.  Peritoneal cavity entered bluntly.  A 10-mm trocar and scope was passed.  Peritoneal cavity was insufflated.  Five-mm ports placed in left lower and hypogastric areas.  On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus.  We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site.  We irrigated and suctioned out the right lower and pelvic areas.  We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips.  The patient was extubated in the operating table and taken back to recovery room.  The patient tolerated the procedure well.
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DESCRIPTION: Ruptured appendicitis.

Ruptured appendicitis.

surgery, ruptured appendicitis, acute appendicitis, laparoscopic appendectomy, laparoscopic, ruptured, abdominal, peritoneal, periumbilical, appendicitis, appendectomy,

The situation involves a medical procedure on a 4-year-old child diagnosed with ruptured appendicitis, which is a serious and potentially life-threatening condition that requires urgent surgical intervention. The child underwent a laparoscopic appendectomy, a common surgical procedure but with inherent risks, especially given the patient's age and the nature of the diagnosis. The successful completion of the procedure and the stable condition of the patient post-operatively are positive outcomes, but the stakes were high given the initial diagnosis and the age of the patient.


Medical Specialty: Urology
Sample Name: Inguinal Hernia Repair - 6

PREOPERATIVE DIAGNOSIS:,  Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Right inguinal hernia.,ANESTHESIA: , General.,PROCEDURE:  ,Right inguinal hernia repair.,INDICATIONS: , The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.  He had an inguinal hernia on physical exam in the Pediatric Surgery Clinic and is here now for elective repair.  We met with his parents and explained the surgical technique, risks, and talked to them about trying to perform a diagnostic laparoscopic look at the contralateral side to rule out an occult hernia.  All their questions have been answered and they agreed with the plan.,OPERATIVE FINDINGS:  ,The patient had a well developed, but rather thin walled hernia sac on the right.  The thinness of hernia sac made it difficult to safely cannulate through the sac for the laparoscopy.  Therefore, high ligation was performed, and we aborted the plan for laparoscopic view of the left side.,DESCRIPTION OF PROCEDURE: , The patient came to operating room and had an uneventful induction of general anesthesia.  Surgical time-out was conducted while we were preparing and draping his abdomen with chlorhexidine based prep solution.  During our time-out, we reiterated the patient's name, medical record number, weight, allergies status, and planned operative procedure.  I then infiltrated 0.25% Marcaine with dilute epinephrine in the soft tissues around the inguinal crease in the right lower abdomen chosen for hernia incision.  An additional aliquot of Marcaine was injected deep to the external oblique fascia performing the ilioinguinal and iliohypogastric nerve block.  A curvilinear incision was made with a scalpel and a combination of electrocautery and some blunt dissection and scissor dissection was used to clear the tissue layers through Scarpa fascia and expose the external oblique.  After the oblique layers were opened, the cord structure were identified and elevated.  The hernia sac was carefully separated from the spermatic cord structures and control of the sac was obtained.  Dissection of the hernia sac back to the peritoneal reflection at the level of deep inguinal ring was performed.  I attempted to gently pass a 3-mm trocar through the hernia sac, but it was rather difficult and I became fearful that the sac would be torn in proximal control and mass ligation would be less effective.  I aborted the laparoscopic approach and performed a high ligation using transfixing and a simple mass ligature of 3-0 Vicryl.  The excess sac was trimmed and the spermatic cord structures were replaced.  The external oblique fascia and Scarpa layers were closed with interrupted 3-0 Vicryl and skin was closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  Blood loss was less than 5 mL.  The hernia sac was submitted for specimen, and he was then taken to the recovery room in good condition.
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DESCRIPTION: Right inguinal hernia.   Right inguinal hernia repair.  The patient is a 4-year-old boy with a right inguinal bulge, which comes and goes with Valsalva standing and some increased physical activity.

urology, laparoscopic, external oblique fascia, oblique fascia, spermatic cord, cord structures, external oblique, hernia sac, inguinal hernia, sac, hernia, inguinal, fascia, repair, oblique,

The situation involves a surgical procedure on a 4-year-old boy for an inguinal hernia, which is a common pediatric condition but nonetheless requires careful consideration. While it is elective surgery, it still involves general anesthesia and a potential laparoscopic approach, which can be risky in young children. However, as the procedure was for a relatively routine hernia repair without complications and the patient tolerated it well, this situation, while important and involving medical care, does not constitute an extremely high-stakes situation but still carries significant responsibility and risk management.


Medical Specialty: Surgery
Sample Name: Saphenous Vein - Ligation & Stripping

PREOPERATIVE DIAGNOSIS:,  Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1.  Ligation and stripping of left greater saphenous vein to the level of the knee.,2.  Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:,  None.,BRIEF HISTORY:,  This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity.  The patient has had painful varicose veins for number of years.  He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins.  It was recommended that the patient undergo a saphenous vein ligation and stripping.  He was explained the risks, benefits, and complications of the procedure including intractable pain.  He gave informed consent to proceed.,OPERATIVE FINDINGS:,  The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee.  Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly.  Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE:  ,The patient was marked preoperatively in the Preanesthesia Care Unit.  The patient was brought to the operating suite, placed in the supine position.  The patient underwent general endotracheal intubation.  After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline.  A diagonal incision was created in the direction of the inguinal crease on the left.  A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified.  The vein was isolated with a right angle.  The vein was followed proximally until a multiple tributary branches were identified.  These were ligated with #3-0 silk suture.  The dissection was then carried to the femorosaphenous vein junction.  This was identified and #0 silk suture was placed proximally and distally and ligated in between.  The proximal suture was tied down.  Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein.  An incision was created at the level of the knee.  The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated.  The distal end of the vein stripping device was then passed through at its most proximal location.  The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity.  Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg.  Multiple incisions were created with a #15 blade scalpel.  The incisions were carried down with electrocautery.  Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified.  The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed.  Additionally, some segments were removed.  The stripping approach would be vein stripping device.  Multiple branches of the saphenous vein were then ligated and/or removed.  Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat.  Bleeding was controlled with direct pressure.  All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture.  The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions.  The leg was then wrapped with a sterile Kerlix.  Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression.  The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition.  He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.
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DESCRIPTION: Ligation and stripping of left greater saphenous vein to the level of the knee.  Stripping of multiple left lower extremity varicose veins.  Varicose veins.

surgery, varicose veins, saphenous vein, stripping, ligation, vein stripping, lower extremity, saphenous, varicose, vein, ligated,

The situation involves a surgical procedure for alleviating pain from varicose veins through ligation and stripping. While surgery always carries some level of risk and the need for anesthesia implies a moderate medical risk, this is a standard elective surgery commonly performed to improve quality of life rather than a life-saving procedure. There were no complications reported during the surgery, and the patient was stable post-operation, which suggests a controlled and routine surgical environment.


Medical Specialty: General Medicine
Sample Name: Recurrent Abscesses - Consult

REASON FOR CONSULTATION: , Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.,HISTORY OF PRESENT ILLNESS:,  A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas.  She would usually have pustular type of lesion that would eventually break and would be quite painful.  The drainage would be malodorous.  It would initially not be infected as far as she knows, but then could eventually become infected.  She stated that this first started after she had her first born about 2 years ago.  She had recurrences of these abscesses and had pain, actually hospitalized at Hospital approximately a year and a half ago for about 1-1/2 months.  She was treated with multiple courses of antibiotics.  She had biopsies done.  She was seen by Dr. X.  Reportedly, she had a HIV test done that was negative.  She had been seen by a dermatologist who said that she had a problem with her sweat glands.  She has been on multiple courses of antibiotics.  She never had any fevers.  She has pain, drainage, and reportedly there was some bleeding in the area of the perineum/vaginal area.,PAST MEDICAL HISTORY:,1.  History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years.  Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa.  Probably, she has had Staphylococcus infection associated with it as well.,2.  Reported history of asthma.,GYNECOLOGIC HISTORY: , G3, P1.  She is currently 5 months' pregnant.,ALLERGIES: , None.,MEDICATIONS: , Her medication had been Augmentin.,SOCIAL HISTORY: , She is followed by a gynecologist in Bartow.  She is not an alcohol or tobacco user.  She is not married.  She has a 2-year-old child.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , The patient has been complaining of diarrhea about 5 or 6 times a day for several weeks now.,PHYSICAL EXAMINATION,GENERAL:
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DESCRIPTION: Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.   In the past, Accutane has been used.

The patient's condition involves recurrent abscesses, which are painful and can become infected, and she is pregnant, which adds complexity to her treatment. The condition is suggestive of hidradenitis suppurativa, which can significantly affect the quality of life and poses management challenges, especially in pregnancy. However, it's a chronic condition typically managed with medical treatment and poses moderate medical risk, given there is no immediate mention of life-threatening symptoms or complications. The stakes are elevated slightly due to her pregnancy and previous hospitalization.


Medical Specialty: Podiatry
Sample Name: Onychomycosis - 2

S:,  The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.,PRIMARY MEDICAL HISTORY:,  Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.,MEDICATIONS: , Refer to chart.,ALLERGIES: , PENICILLIN AND ASPIRIN.,O: , The patient  presents in wheelchair, verbal and alert.  Vascular:  She has absent pedal pulses bilaterally.  Trophic changes include absent hair growth and mycotic nails.  Skin texture is dry and shiny.  Skin color is rubor.  Classic findings are temperature change and edema +1.  Nails:  Hypertrophic with crumbly subungual debris, # 1 right and #1 left.,A:,1.  Onychomycosis present, #1 right and #1 left.,2.  Peripheral vascular disease as per classic findings.,3.  Pain on palpation.,P: , Nails #1 right and #1 left were debrided for length and thickness.  All the nails were reduced.  The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails.
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DESCRIPTION: Onychomycosis present, #1 right and #1 left.

podiatry, length and thickness, mycotic nails, classic findings, onychomycosis, nails,

The situation involves a podiatry appointment focused on onychomycosis (fungal nail infection) treatment in a patient with a complex medical history, including adenocarcinoma and peripheral vascular disease. While the patient has several serious health conditions, the immediate treatment discussed is primarily for nail management. Although untreated onychomycosis in such a patient could exacerbate her overall health due to potential for infection or pain exacerbation, the nature of the appointment is routine nail care. Hence, while not trivial, the stakes are not at the most critical level since the core issue addressed is not life-threatening in itself.


Medical Specialty: Orthopedic
Sample Name: Knee Replacement

PREOPERATIVE DIAGNOSIS: , Left medial compartment osteoarthritis of the knee.,POSTOPERATIVE DIAGNOSIS:,  Left medial compartment osteoarthritis of the knee.,PROCEDURE  PERFORMED:,  Left unicompartmental knee replacement.,COMPONENTS USED:,  Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene component.,COMPLICATIONS:,  None.,TOURNIQUET TIME: , 59 minutes.,BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: , A 55-year-old female who had previously undergone a Biomet Oxford unicompartmental knee replacement on the right side.  She has done quite well with this.  She now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed supine on the operating room table.  After appropriate anesthesia, the left lower extremity was identified with a time out procedure.  Preoperative antibiotics were given.  Left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet.  The tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used.  Soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed.  The anterior fat pad was removed.  The knee was then examined.  The ACL was found to be intact.  The lateral compartment had very minimal arthritis.  There were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild.  Following this, the tibial external alignment guide was placed and pinned into place in the appropriate place.  Tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection.  Following this resection, the femoral intramedullary guide was placed without difficulty.  The femoral cutting guide was then placed and referenced off of this femoral intramedullary guide.  Once in the appropriate position, it was pinned and drilled.  This was removed, and the posterior cutting block was inserted.  It was impacted into place.  Posterior bone cut was made for the medium femoral component.  Next, a zero spigot was used and the distal femur was reamed.  Following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well.  Next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit.  Next, the tibia was prepared.  The tibial tray was pinned into place, and the cuts for the keel of the tibia were made.  These were removed with a small osteotome from the set.  Following this, a trial tibial with the keel was placed and it did fit nicely.  After this, all trial components were removed.  The knee was copiously irrigated.  Cement was begun mixing.  Drill holes were used along the femur for cement interdigitation.  The wound was cleaned and dried.  Cement was placed on the tibia.  Tibial tray was impacted into place.  Excess cement was removed.  Tibia was placed in the femur.  Femoral component was impacted into place.  Excess cement was removed.  It was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened.  Following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size.  A 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion.  The intramedullary rod removed from the femur.  The wound was irrigated with normal saline.  The retinaculum was closed with #1 PDS, 2-0 Monocryl was used for the subcutaneous tissue and staples used for the skin.  A sterile dressing was placed.  Tourniquet was then desufflated.  Sponge and needle counts were correct at the end of the procedure.  Dr. Jinnah was present for the surgery.  The patient was transferred to the recovery room in stable condition.  She will be weightbearing as tolerated in the left lower extremity and will be maintained on Lovenox for DVT prophylaxis.  Prior to closure, the posterior capsule was injected with the joint cocktail.
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DESCRIPTION: Left medial compartment osteoarthritis of the knee.  Left unicompartmental knee replacement.

orthopedic, knee replacement, osteoarthritis, osteoarthritis of the knee, excess cement was removed, medium femoral component, medial compartment osteoarthritis, unicompartmental knee replacement, medium femoral, femoral intramedullary, intramedullary guide, medial compartment, femoral component, tibial tray, lower extremity, unicompartmental knee, tibial, knee, tourniquet, intramedullary, extension, flexion, compartment, unicompartmental, replacement, femoral, cement,

The knee replacement procedure detailed is a routine orthopedic surgery, done to relieve pain and improve function in patients with osteoarthritis. While it is an invasive procedure requiring precision, it is commonly performed and has a high success rate, especially given the absence of complications and minimal blood loss reported. The procedure description does not indicate any unusual risk factors or complications that would elevate it to a high-stakes situation. Therefore, the stakes of the operation are moderate, as standard surgical protocols and postoperative care would generally ensure patient safety and procedural efficacy.


Medical Specialty: Consult - History and Phy.
Sample Name: TIA - Cosult

REASON FOR CONSULTATION: , This 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours.  However, the chart indicates that she had recurrent TIAs x3 yesterday, each lasting about 5 minutes with facial drooping and some mental confusion.  She had also complained of blurred vision for several days.  She was brought to the emergency room last night, where she was noted to have a left carotid bruit and was felt to have recurrent TIAs.,CURRENT MEDICATIONS: , The patient is on Lanoxin, amoxicillin, Hydergine, Cardizem, Lasix, Micro-K and a salt-free diet.  ,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FINDINGS:  ,Admission CT scan of the head showed a densely calcified mass lesion of the sphenoid bone, probably representing the benign osteochondroma seen on previous studies.  CBC was normal, aside from a hemoglobin of 11.2.  ECG showed atrial fibrillation.  BUN was 22, creatinine normal, CPK normal, glucose normal, electrolytes normal.,PHYSICAL EXAMINATION: , On examination, the patient is noted to be alert and fully oriented.  She has some impairment of recent memory.  She is not dysphasic, or apraxic.  Speech is normal and clear.  The head is noted to be normocephalic.  Neck is supple.  Carotid pulses are full bilaterally, with left carotid bruit.  Neurologic exam shows cranial nerve function II through XII to be intact, save for some slight flattening of the left nasolabial fold.  Motor examination shows no drift of the outstretched arms.  There is no tremor or past-pointing.  Finger-to-nose and heel-to-shin performed well bilaterally.  Motor showed intact neuromuscular tone, strength, and coordination in all limbs.  Reflexes 1+ and symmetrical, with bilateral plantar flexion, absent jaw jerk, no snout.  Sensory exam is intact to pinprick touch, vibration, position, temperature, and graphesthesia.,IMPRESSION: , Neurological examination is normal, aside from mild impairment of recent memory, slight flattening of the left nasolabial fold, and left carotid bruit.  She also has atrial fibrillation, apparently chronic.  In view of her age and the fact that she is in chronic atrial fibrillation, I would suspect that she most likely has had an embolic phenomenon as the cause of her TIAs.,RECOMMENDATIONS:,  I would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated, in which case you might consider it best to do an angiography and consider endarterectomy.  In view of her age, I would be reluctant to recommend Coumadin anticoagulation.  I will be happy to follow the patient with you.
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DESCRIPTION: A 92-year-old female had a transient episode of slurred speech and numbness of her left cheek for a few hours.

consult - history and phy., atrial fibrillation, carotid bruit, slurred speech, numbness, calcified mass lesion, neurological examination, tias, carotid, benign,

This situation involves a 92-year-old patient with recurrent transient ischemic attacks (TIAs), slurred speech, numbness, and a left carotid bruit, likely caused by embolic events due to chronic atrial fibrillation. The risks associated with untreated TIAs include the progression to a full stroke, which can result in significant morbidity or mortality, especially in an elderly patient with chronic health issues. The consultation is high-stakes due to the potential for serious health consequences if the condition is not managed appropriately.


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

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

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


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Atrial Fibrillation - 1

REASON FOR CONSULTATION: , Atrial fibrillation and shortness of breath.,HISTORY OF PRESENTING ILLNESS: , The patient is an 81-year-old gentleman.  The patient had shortness of breath over the last few days, progressively worse.  Yesterday he had one episode and got concerned and came to the Emergency Room, also orthopnea and paroxysmal dyspnea.  Coronary artery disease workup many years ago.  He also has shortness of breath, weakness, and tiredness.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,MEDICATIONS: , Thyroid supplementation, atenolol 25 mg daily, Lasix, potassium supplementation, lovastatin 40 mg daily, and Coumadin adjusted dose.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY:,  Married, ex-smoker, and does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,SURGICAL HISTORY: , As above.,PRESENTATION HISTORY: , Shortness of breath, weakness, fatigue, and tiredness.  The patient also relates history of questionable TIA in 1994.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, tiredness.,HEENT:  No history of cataracts, blurry vision or glaucoma.,CARDIOVASCULAR:  Arrhythmia, congestive heart failure, no coronary artery disease.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea, no vomiting, hematemesis, or melena.,UROLOGICAL:  Some frequency, urgency, no hematuria.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,SKIN:  Chronic skin changes.,CNS:  History of TIA.  No CVA, no seizure disorder.,ENDOCRINE:  Nonsignificant.,HEMATOLOGICAL:  Nonsignificant.,PSYCHOLOGICAL:  No anxiety or depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair, decreased in basal areas.  No rales or wheezes.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft and nontender.  Bowel sounds present.,EXTREMITIES:  Chronic skin changes.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,LABORATORY DATA: , H&H stable 30 and 39, INR of 1.86, BUN and creatinine within normal limits, potassium normal limits.  First set of cardiac enzymes profile negative.  BNP 4810.,Chest x-ray confirms unremarkable findings.  EKG reveals atrial fibrillation, nonspecific ST-T changes.,IMPRESSION:
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DESCRIPTION: Atrial fibrillation and shortness of breath.  The patient is an 81-year-old gentleman with shortness of breath, progressively worsening, of recent onset. History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.

The situation involves an 81-year-old patient with atrial fibrillation, a serious cardiac condition that can lead to stroke or heart failure if not managed properly. The patient is experiencing worsening shortness of breath, which could indicate a worsening of their cardiovascular status. Given the patient's age, history of hypertension, elevated cholesterol, and positive family history for coronary artery disease, these symptoms are concerning and could lead to serious health complications if not managed promptly. Thus, the stakes are high as this is potentially life-threatening.


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

Medical Specialty: Hospice - Palliative Care
Sample Name: Hospice Visit - AIDS

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.  His viral load in July of 2007 was 254,000 and CD4 count was 7.  He was recently admitted for debility and possible pneumonia.  He was started on antiretroviral therapy, as well as Cipro and Flagyl and was also found to have pleural effusion on the right.  His history is also significant for pancreatitis and transient renal failure during last hospitalization.  He became frustrated since he was not getting better and discontinued all antibiotics.  When taken home yesterday, he had symptoms consistent with a partial bowel obstruction.  He was vomiting and had no bowel movements for a few days.  Last night, was able to have a bowel movement and has not vomited since then.  He was able to take small amounts of food.  He now has persistent cough productive of clear sputum and some shortness of breath.  He also complains of pain at his KS lesions on the right leg and left thigh, especially when touched, although that pain is incidental and not present when he is simply lying down.  He has overall weakness.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS: , Acetaminophen 650 mg q.6h. p.r.n. fever, which he has not been using, Motrin 400 mg q.6h. p.r.n. pain, which has not helped.  His pain and dexamethasone with guaifenesin 5-10 mL q.4h. p.r.n. cough.,ALLERGIES:,  He has no known allergies.,SOCIAL HISTORY: , The patient is now staying with his mother.  He is the youngest of six children.  Code Status:  DNR.  His brother is the health care proxy.,PHYSICAL EXAMINATION:,  Blood pressure 140/80, pulse 120, and respirations 28.  Temperature 103.9.  General Appearance: Ill-looking young man, diaphoretic.  PERRLA, 3 mm.  Oral mucosa moist without lesions.  Lungs:  Diminished breath sounds in the right middle lower lobe.  Heart:  RRR without murmurs.  Abdomen:  Distended with soft and nontender.  Diminished bowel sounds.  Extremities:  Without cyanosis or edema.  There is a large Kaposi's sarcoma on the right medial leg and left medial proximal thigh, which is somewhat tender.  Neurological Exam:  Cranial nerves II through XII are grossly intact.  There is normal tone.  Power is 4/5.  DTRs nonreactive.  Normal fine touch.  Mental Status:  The patient is somnolent, but arousable.  Withdrawn affect.  Normal speech and though process.,ASSESSMENT AND PLAN:,1.  AIDS complicated with multiple opportunistic infections with poor performance status, which suggested a limited prognosis of less than six months.  He will benefit from home hospice care and he declined any further antibiotic or antiretroviral treatments.,2.  Pain, which is somatic nociceptive from KS lesions.  The patient has not tolerated morphine in the past.  We will start oxycodone 5 mg q.2h. as needed.,3.  Cough.  We will use oxycodone with the same indication as well.,4.  Fever.  We encouraged him to use Tylenol as needed.,5.  Insomnia.  We will use lorazepam 0.25-0.5 mg at bedtime as needed.,6.  Psychosocial.  We discussed his coping with the diagnosis.  He is fully aware of his limited prognosis.  Supportive counseling was provided to his mother.,Length of the encounter was one hour; more than half spent on exchange of information.,
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DESCRIPTION: Hospice care for a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma.

hospice - palliative care, hospice, aids, cd4 count, code status, dnr, kaposi's sarcoma, length of the encounter, cryptococcal infection, exchange of information, health care proxy, home hospice, home hospice care, hospice care, hospitalization, viral load, bowel, infection

The patient is in a severely deteriorated health condition due to AIDS and multiple complications such as cryptococcal infection, disseminated MAC, and Kaposi's sarcoma. His prognosis is assessed to be less than six months, and he has declined further aggressive treatment. The situation is high-stakes as it involves end-of-life care, ensuring comfort, managing symptoms, and providing emotional and psychosocial support to both the patient and his family during a highly sensitive and critical period.


Medical Specialty: Radiology
Sample Name: Adenosine Nuclear Scan

INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86.  EKG, normal sinus rhythm.  Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74.  EKG remained the same.  No symptoms were noted.,SUMMARY:,1.  Nondiagnostic adenosine stress test.,2.  Nuclear interpretation as below.,NUCLEAR INTERPRETATION:,  Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 58%.  End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 58% by gated SPECT.
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DESCRIPTION: Adenosine with nuclear scan as the patient unable to walk on a treadmill.  Nondiagnostic adenosine stress test.  Normal nuclear myocardial perfusion scan.

radiology, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,

The test is conducted to assess a patient's heart function due to their inability to perform a treadmill exercise test. The outcome of the nuclear scan seems normal with no indication of heart defects or significant issues. While the test is part of assessing potential severe conditions like coronary artery disease, the results being normal suggest there are no immediate high-risk findings from this test. However, the context of evaluating heart health always carries some level of stakes due to the organ's essential nature.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Cone Biopsy

PREOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,POSTOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,OPERATION PERFORMED:,  Cervical cone biopsy, dilatation & curettage.,SPECIMENS:  ,Cone biopsy, endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with a Pap smear showing probable adenocarcinoma in situ.  The patient was advised to have cone biopsy to fully assess endocervical glands.,FINDINGS: , During the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable.  The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered and she was placed in the lithotomy position.  The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction.  Angle stitches of 0 Vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices.  The cervix was stained with Lugol's iodine solution. ,After the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os.  The specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm.  A Kevorkian curette was used to obtain endocervical curettings.  The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture.  Upon completion of the suture placement, the endocervical canal was sounded to assure patency.  A prophylactic application of Monsel's solution completed the procedure.  ,The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.  Final sponge, needle, and instrument counts were.
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DESCRIPTION: Cervical cone biopsy, dilatation & curettage

obstetrics / gynecology, cervical carcinoma in situ, cervical cone biopsy, endometrial curettings, endocervical, endometrial, dilatation & curettage, carcinoma in situ, cone biopsy, dilatation, curettage, carcinoma, vicryl, curettings, vagina, sutures, cervix, cervical, cone, biopsy,

This scenario involves a surgical procedure, which inherently carries certain risks, such as anesthetic complications, bleeding, or infection. The context of this procedure is particularly critical because it relates to the diagnosis of cervical carcinoma in situ, a pre-cancerous condition that requires precise surgical intervention. The stakes are further elevated by the need for accurate diagnosis and prevention of progression to invasive cancer. Also, the procedure involves the use of anesthesia, which increases the risk factors. Therefore, the situation is high-stakes from both a medical and patient safety perspective.


Medical Specialty: Neurology
Sample Name: Encephalopathy  - Rehab Consult

ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:,  Diminished function secondary to above.,HISTORY:  ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed.  He had a shunt placed and was stabilized medically.  He has gotten a return of function to the legs and was started on some early therapy.  Significant functional limitations have been identified and ongoing by the rehab admission team.  Significant functional limitations have been ongoing.  He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1.  Tylenol as needed.  ,2.  Peri-Colace b.i.d.,SOCIAL HISTORY:,  He is a nonsmoker and nondrinker.  Prior boxer.  He lives in a home where he would need to be independent during the day.  Family  relatives intermittently available.  Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills.  Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  Memory at minimal assist.  Walking at supervision., REVIEW OF SYSTEMS:  ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS:  The patient is afebrile with vital signs stable.,HEENT:  Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR:  Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended,  positive bowel sounds.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  The calves are soft and nontender bilaterally.,NEUROLOGIC:  No focal, motor or sensory losses through the lower extremities.  He moves upper and lower extremities well.  Bulk and tone normal in the upper and lower extremities.  Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,
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DESCRIPTION: Encephalopathy related to normal-pressure hydrocephalus.

The patient's situation involves a neurological condition, normal-pressure hydrocephalus, for which he has received surgical treatment (a shunt). Post-surgery, he is undergoing rehabilitation to regain independence. Though the situation is medically significant and involves a serious condition, the fact that he is stable, has started therapy, and the rehabilitation is progressing suggests that the immediate risks are not extremely high. Moreover, he does not exhibit any acute, life-threatening symptoms at present. However, achieving functional independence is crucial for his quality of life, making it a significant concern.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Weight Loss on Phentermine

SUBJECTIVE:,  She is here for a followup on her weight loss on phentermine.  She has gained another pound since she was here last.  We talked at length about the continued plateau she has had with her weight.  She gained a pound the month before and really has not been able to get her weight any farther down than she had when her lowest level was 136.  She is frustrated with this as well.  We agree that if she continues to plateau she really should not stay on phentermine.  We would not want her to take it to maintain her weight but only to help her get her weight down, and she may have really lost any benefit from it, and she agrees.,REVIEW OF SYSTEMS:,  Otherwise negative.  She has no specific complaints.  No shortness of breath, chest pain or palpitations.,PHYSICAL EXAM:,Vital signs:  Her blood pressure is fine.  Her diastolic is a little bit high, but otherwise okay.,General:  She appears in good spirits.  No apparent distress.,HEENT:  Negative.,Neck:  Supple without bruits.,Chest:  Clear.,Cardiac exam:  Regular without extra sounds.,ASSESSMENT:,  Weight loss on phentermine, really has plateaued.,PLAN:,  If she does not lose weight in the next month we will probably consider having her go off the phentermine.  If she does lose a couple of pounds, then we will keep her on it until she gets closer to her goal of 135 and then try to keep her there for one or two months and then stop.  She agrees with this plan.
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DESCRIPTION: Followup on weight loss on phentermine.

Followup on weight loss on phentermine.

soap / chart / progress notes, followup, phentermine, plateau, weight, weight loss, weight loss on phentermine, loss

The situation involves a patient who is on phentermine for weight loss but has plateaued in her progress. While the patient and doctor are frustrated with the lack of progress, the overall health of the patient appears stable with mostly normal examination results and no urgent complaints or concerning symptoms like shortness of breath or chest pain. The discussion revolves around adjusting medication strategy based on future weight changes. Phentermine can have long-term health implications, but the decision being considered is not critical or life-threatening at this moment. The stakes are related to managing obesity but do not involve immediate risks to life or urgent health crises.


Medical Specialty: Surgery
Sample Name: EGD & Colonoscopy

PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Normal colon with no evidence of bleeding.,2.  Hiatal hernia.,3.  Fundal gastritis with polyps.,4.  Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN:  ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes.  She has been anemic as well with no gross evidence of blood loss.  She has had a decreased appetite with weight loss greater than 20 lb over the past few months.  After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids.  The colonoscope was inserted into the rectum and air was insufflated.  The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum.  There were no polyps, masses, diverticuli, or areas of inflammation.  The scope was then slowly withdrawn carefully examining all walls.  Air was aspirated.  Once in the rectum, the scope was retroflexed.  There was no evidence of perianal disease.  No source of the anemia was identified.,Attention was then taken for performing an EGD.  The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx.  The esophagus was easily intubated and traversed.  There were no abnormalities of the esophagus.  The stomach was entered and was insufflated.  The scope was coursed along the greater curvature towards the antrum.  Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______.  It was not clear if this represents a healing ulcer or neoplasm.  Several biopsies were taken.  The mass was soft.  The pylorus was then entered.  The duodenal bulb and sweep were examined.  There was no evidence of mass, ulceration, or bleeding.  The scope was then brought back into the antrum and was retroflexed.  In the fundus and body, there was evidence of streaking and inflammation.  There were also several small sessile polyps, which were removed with biopsy forceps.  Biopsy was also taken for CLO.  A hiatal hernia was present as well.  Air was aspirated.  The scope was slowly withdrawn.  The GE junction was unremarkable.  The scope was fully withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes.  We will await the biopsy reports and further recommendations will follow.
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DESCRIPTION: EGD and colonoscopy.  Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.

surgery, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy,

This situation involves a medical procedure performed to diagnose potential causes of anemia and other symptoms in a patient. The findings include a normal colon, hiatal hernia, fundal gastritis with polyps, and a potentially concerning antral mass, which could indicate serious conditions like neoplasm. The stakes are elevated due to the need to identify the nature of the antral mass and the patient's anemia, which can affect treatment decisions and outcomes. While the immediate procedure was routine and the patient is stable, the potential implications of the findings could significantly impact the patient's health status.


Medical Specialty: Radiology
Sample Name: MRI Brain - Bilateral Thalamic Strokes

CC:, Sudden onset blindness.,HX:, This 58 y/o RHF was in her usual healthy state, until 4:00PM, 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to "severe blurring" enroute to a local ER, but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved.,PMH:, 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD, relieved with NSAIDs.,FHX/SHX:, Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.,Unremarkable FHx.,MEDS:, none.,EXAM:, Vitals: 36.9C.  HR 93.  BP 151/93.  RR 22.  98% O2Sat.,MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.,CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact.,Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk.,Sensory: Withdrew to PP in all extremities.,Gait: ND.,Reflexes: 2+/2+ throughout UE, 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally.,Gen exam: unremarkable.,COURSE: ,MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH, FT4, CRP, ESR, GS, PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.,She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd.
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DESCRIPTION: MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.

radiology, blindness, mri, transthoracic echocardiogram, transesophageal echocardiogram, tsh, ft4, crp, esr, gs, pt/ptt, bilateral thalamic strokes, sudden onset blindness, mri brain, thalamic strokes, brain, thalamic, strokes,

This case involves a sudden and significant medical event: bilateral thalamic strokes leading to sudden onset blindness, altered consciousness, and neurocognitive impairments in a patient. Strokes represent a severe medical condition with potential life-threatening consequences if not promptly diagnosed and treated. The neurological symptoms indicate a critical situation requiring urgent medical evaluation to prevent further deterioration and optimize long-term outcomes. The diagnosis of bilateral thalamic strokes, a specific and serious condition, necessitates rapid and specialized care. Consequently, this scenario qualifies as a high-stakes medical situation.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 16

PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis.  Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction.  There was no evidence of either inflammation or a fistulous opening.  The scope was withdrawn.  A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position).  Some purulent material could be expressed through the opening.  There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material.  Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable.  In addition, scars were noted in the perianal area.  The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position.  The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek.  There were no other abnormalities noted.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal colonoscopy to the terminal ileum.,2.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1.  Continue antibiotics.,2.  Followup with Dr. X.,3.  If drainage persists, consider surgical drainage.
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DESCRIPTION: Colonoscopy.   Rectal bleeding and perirectal abscess.  Normal colonoscopy to the terminal ileum.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.

surgery, olympus, colonoscope, rectal bleeding, perianal abscess, terminal ileum, anal verge, anorectal, fistulous, ileum, verge, rectum, anal, perianal, colonoscopy, abscess

The described situation involves a patient undergoing a colonoscopy due to rectal bleeding and a perirectal abscess. The procedure found a perianal abscess but no significant complications or abnormalities within the colon itself. While the diagnosis involves a condition that requires monitoring and could lead to surgery if drainage persists, the immediate outcome of the procedure shows no severe or life-threatening findings. Therefore, the situation is clinically important but not highly critical at this moment.


Medical Specialty: Orthopedic
Sample Name: Physical Therapy - Synovitis

DIAGNOSIS:,  Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.  The patient states that on 10/02/08, the patient fell in a grocery store.  He reports slipping on a grape that was on the floor.  The patient states he went to the emergency room and then followed up with his primary care physician.  The patient was then ultimately referred to Physical Therapy.  After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs.  The report was available at the time of the evaluation.  The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1.  Tramadol.,2.  Diclofenac.,3.  Advil.,4.  Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation.  The patient does deny pain at night.  The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES:  ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE:  ,Upon observation, the patient is ambulating with a significant antalgic gait pattern.  However, he is not using any assistive device.  The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion.  Right knee active range of motion is 0 to 126 degrees.,STRENGTH:  ,Strength is 3/5 for left knee, 4+/5 for right knee.  The patient denies any pain upon light and deep palpation at the knee joints.  There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint.  The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS:  ,The patient performed a six-minute walk test.  He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:,  The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1.  Increased pain.,2.  Decreased range of motion.,3.  Decreased strength.,4.  Decreased ability to perform functional activities and work tasks.,5.  Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1.  Patient will demonstrate independence with the home exercise program.,2.  Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3.  The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4.  The patient will demonstrate 4/5 strength for the left knee.,5.  The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1.  The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2.  The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3.  Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4.  The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS:  ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1.  Therapeutic exercise with home exercise program.
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DESCRIPTION: Synovitis - anterior cruciate ligament tear of the left knee.  The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain.   The patient fell in a grocery store.  He reports slipping on a grape that was on the floor.

The situation involves a patient with knee trauma and synovitis due to a fall. While it affects the patient's ability to work and perform daily activities, the physical therapy prognosis is good with the likelihood of significant improvement if the patient adheres to the treatment plan. The stakes are not life-threatening but do impact the patient's quality of life and ability to work.


Medical Specialty: Radiology
Sample Name: Ultrasound OB

REASON FOR EXAM: , Followup for fetal growth. , ,INTERPRETATION: , Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. ,FETAL BIOMETRY:  ,BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL =  6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%.  Estimated fetal weight is 2,001 grams.  ,The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm.  ,A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth.  The placenta is posterofundal and grade 2., ,IMPRESSION: , Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05.  There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05.  The examination of 4/04/05 questioned an echogenic focus within the left ventricle.  The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.
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DESCRIPTION: Ultrasound OB - followup for fetal growth.

radiology, amniotic fluid volume, placenta, posterofundal, intrauterine pregnancy, followup for fetal growth, ultrasound ob, cephalic presentation, abdomen circumference, circumference ratio, echogenic focus, fetal growth, fetal,

The scenario involves a follow-up ultrasound for monitoring fetal growth, which is a standard procedure in prenatal care to ensure the well-being of a developing fetus. While it involves assessing important health indicators for the fetus, it is part of routine monitoring rather than an emergency or critical situation. The examination suggests normal growth and development with no significant abnormalities noted. Thus, the stakes are moderate, emphasizing careful monitoring rather than immediate concern.