Medical Specialty: Surgery
Sample Name: Scleral Buckle Opening - General Anesthesia

PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.
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DESCRIPTION: Scleral Buckle opening under general anesthesia.

surgery, retinal periphery, conjunctival peritomy, ophthalmoscopy, scleral, buckle, operating, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

This medical procedure involves performing a scleral buckle opening under general anesthesia, which already indicates that it's a moderately complex surgical procedure. General anesthesia introduces additional risks such as reactions or complications from anesthesia, and surgeries involving the eye require precision due to the sensitivity and critical nature of eyesight. As this is a surgical procedure potentially affecting vision, it would be considered moderately high-stakes due to the potential impact on the patient's health and quality of life if complications were to arise.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Neck & Back Pain

CHIEF COMPLAINT:,  Neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,HISTORY OF PRESENT ILLNESS:,  Ms. XYZ is a fairly healthy 69-year-old Richman, Roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  She has previously been under the care of Dr. Ninan Matthew in the 1990s and takes Maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  She is under the care of Dr. Bonaparte for hyperlipidemia and hypothyroidism.  She has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  In 2000, she developed "sciatica" mostly in her right lower extremity.,She is seen today with no outside imaging, except with MRI of her cervical spine and lumbar spine dated February of 2004.  Her cervical MRI reveals an 8 mm central spinal canal at C6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  Her lumbar MRI reveals lumbar spinal stenosis at L4-5 with multilevel facet arthropathy and spondylitic changes.,The patient has essentially three major pain complaints.,Her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  She complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  She has been told by Dr. Megahed in the past that she is not considered a surgical candidate.  She has done physical therapy twice as recently as three years ago for treatment of her symptoms.  She complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,Her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  Her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  There is no associated shortness of breath.  She denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  She denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  Her weight has been stable without any type of constitutional symptoms.,Her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  She complains of occasional subjective weakness to the right lower extremity.  Her pain is worse with sitting, standing and is essentially worse in the supine position.  Five years ago, she developed symptoms radiating in an L5-S1 distribution and within the last couple of years, began to develop numbness in the same distribution.  She has noted some subjective atrophy as well of the right calf.  She denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  She has treated her back symptoms with physical therapy as well.,She is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  She participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  Her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  Exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  Alleviating factors including sitting, applying heat and ice.,PAST MEDICAL HISTORY:,  As per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,PAST SURGICAL HISTORY:,  Cholecystectomy, eye surgery, D&C.,MEDICATIONS:,  Vytorin, Synthroid, Maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,ALLERGIES:,  Multiple.  All over-the-counter medications.  Toradol, Robaxin, Midrin, Darvocet, Naprosyn, Benadryl, Soma, and erythromycin.,FAMILY HISTORY:,  Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.,SOCIAL HISTORY:,  The patient is retired.  She is married with three grown children.  Has a high school level education.  Does not smoke, drink, or utilize any illicit substances.,OSWESTRY PAIN INVENTORY:,  Significant impact on every aspect of her quality of life.  She would like to become more functional.,REVIEW OF SYSTEMS:,  A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  Cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  Pulmonary review of systems negative.  GI review of systems is positive for irritable bowel and acid reflux symptoms.  Genitourinary, occasional stress urinary incontinence and history of remote hematuria.  She is postmenopausal and on hormone replacement.  Endocrine is positive for a low libido and thyroid disorder.  Integument:  Dry skin, itching and occasional rashes.  Immunologic is essentially negative.  Musculoskeletal:  As per HPI.  HEENT:  Jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  Neurological:  As per history of present illness.  Constitutional:  As history of present illness.,PHYSICAL EXAMINATION:,  Weight 180 pounds, temp 97.6, pulse 56, BP 136/72.  The patient walks with a normal gait pattern.  There is no antalgia, spasticity, or ataxia.  She can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  She can flex her lumbar spine and touch the floor with her fingertips.  Lumbar extension and ipsilateral bending provoke her axial back pain.  There is tenderness over the PSIS on the right and no particular pelvic asymmetry.,Head is normocephalic and atraumatic.  Cranial nerves II through XII are grossly intact.  Cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  The neck is supple.  The trachea is midline.  The thyroid is not particularly enlarged.  Lungs are clear to auscultation.  Heart has regular rate and rhythm with normal S1, S2.  No murmurs, rubs, or gallops.  The abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  Skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  I can radial, dorsalis pedis and posterior tibial pulses.  The nailbeds on her feet have trophic changes.  Brisk capillary refill is evident over both upper extremities.,Musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  She has chronic osteoarthritic changes evident over both hands.  There is mild restriction of range of motion of the right shoulder, but no active impingement signs.,Inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  Palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  There is no midline spinous process tenderness over the cervicothoracic regions.  Palpation of the articular pillars is met with mild provocation of pain.  Palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  There is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  The xiphoid process is not particularly tender.  There is no dermatomal sensory abnormality in the thoracic spine appreciated.  Mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,Neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  I cannot elicit S1 reflexes.  There are no long tract signs.  Negative Hoffman's, negative Spurling's, no clonus, and negative Babinski.  Motor examination of the upper, as well as lower extremities appears to be intact throughout.  I may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,SUMMARY OF DIAGNOSTIC IMAGING:,  As per above.,IMPRESSION:,1.  Osteoarthritis.,2.  Cervical spinal stenosis.,3.  Lumbar spinal stenosis.,4.  Lumbar radiculopathy, mostly likely at the right L5-S1 levels.,5.  History of mild spondylolisthesis of the lumbosacral spine at L4-L5 and right sacroiliac joint dysfunction.,6.  Chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,PLAN:  ,The natural history and course of the disease was discussed in detail with Mr. XYZ.  Greater than 80 minutes were spent facet-to-face at this visit.  I have offered to re-image her cervical and lumbar spine and have included a thoracic MR imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  I do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  Pending the results of her preliminary studies, this should be ruled out.  I will see her in followup in about two weeks with the results of her scans.
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DESCRIPTION: Initial evaulation - neck and back pain.

The situation involves a complex medical evaluation of a patient with multiple chronic and potentially serious conditions related to spine and pain management. While the immediate scenario isn't life-threatening, it affects the quality of life significantly and requires careful management and follow-up, including imaging studies to rule out more severe issues like fractures or neoplasms. This makes it moderately high-stakes in a medical setting due to the complexities and potential for serious underlying issues.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Gastroenterology
Sample Name: Laparoscopy & Laparoscopic Appendectomy

PREOPERATIVE DIAGNOSIS: , Right lower quadrant abdominal pain, rule out acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Appendix.,COMPLICATIONS: , None.,BRIEF HISTORY: , This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation.  She admits to some nausea associated with it.  There have been no fevers, chills, and/or genitourinary symptoms.  The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant.  She had a leukocytosis of 12.8.  She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis.  Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy.  The risks, benefits, complications of the procedure, she gave us informed consent to proceed.,OPERATIVE FINDINGS:  ,Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged.  The left ovary revealed some follicular cysts.  There was no evidence of adnexal masses and/or torsion of the fallopian tubes.  The uterus revealed no evidence of mass and/or fibroid tumors.  The remainder of the abdomen was unremarkable.,OPERATIVE PROCEDURE: , The patient was brought to the operative suite, placed in the supine position.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient underwent general endotracheal anesthesia.  The patient also received a preoperative dose of Ancef 1 gram IV.  After adequate sedation was achieved, a #10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle.  Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg.  Once the abdomen was sufficiently insufflated, a 10 mm bladed trocar was inserted into the abdomen without difficulty.  A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored.  Next, a 5 mm port was inserted in the midclavicular line of the right upper quadrant region.  This was inserted under direct visualization.  Finally, a suprapubic 12 mm portal was created.  This was performed with #10 blade scalpel to create a transverse incision.  A bladed trocar was inserted into the suprapubic region.  This was done again under direct visualization.  Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum.  This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly.  Utilizing a endovascular stapling device, the appendix was transected and doubly stapled with this device.  Next, the mesoappendix was doubly stapled and transected with the endovascular stapling device.  The staple line was visualized and there was no evidence of bleeding.  The abdomen was fully irrigated with copious amounts of normal saline.  The abdomen was then aspirated.  There was no evidence of bleeding.  All ports were removed under direct visualization.  No evidence of bleeding from the port sites.  The infraumbilical and suprapubic ports were then closed.  The fascias were then closed with #0-Vicryl suture on a UR6 needle.  Once the fascias were closed, all incisions were closed with #4-0 undyed Vicryl.  The areas were cleaned, Steri-Strips were placed across the wound.  Sterile dressing was applied.,The patient tolerated the procedure well.  She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition.  She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course.
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DESCRIPTION: Diagnostic laparoscopy and laparoscopic appendectomy.  Right lower quadrant abdominal pain, rule out acute appendicitis.

gastroenterology, lower quadrant, diagnostic laparoscopy, acute appendicitis, laparoscopic appendectomy, abdomen, appendectomy, laparoscopy, appendix, suprapubic,

This medical scenario involves a diagnostic procedure followed by surgery to remove an inflamed appendix, which is a common and generally low-risk surgical procedure. However, the stakes are higher than minor medical treatments because it was necessary to quickly address acute appendicitis, which can lead to serious complications if untreated. The patient was undergoing a procedure to address acute suppurative appendicitis, a potentially serious condition if left untreated, but the surgery itself is routine and generally safe under controlled hospital settings when there are no complications during or post-operation. Given these factors, this situation can be considered moderately high-stakes.


Medical Specialty: Gastroenterology
Sample Name: Gastroenteritis - Discharge Summary

ADMITTING DIAGNOSES,1.  Acute gastroenteritis.,2.  Nausea.,3.  Vomiting.,4.  Diarrhea.,5.  Gastrointestinal bleed.,6.  Dehydration.,DISCHARGE DIAGNOSES,1.  Acute gastroenteritis, resolved.,2.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This patient is a 56-year-old male, a patient of Dr. X with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time.  This patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse.  The patient was admitted into the ER and had trop x1 done, which was negative and ECG showed to be of normal sinus rhythm.,Lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count.  Upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs.  The patient's nausea, vomiting, and diarrhea did resolve during his hospital course.  Was placed on IV fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well.  The patient also denied any abdominal pain upon day of discharge.  The patient was also started on prednisone as per GI recommendations.  He was started on 60 mg p.o.  Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well.,PLAN: , The plan is to discharge the patient home.  He can resume his home medications of Prandin, Actos, Lipitor, Glucophage, Benicar, and Advair.  We will also start him on a tapered dose of prednisone for 4 weeks.  We will start him on 15 mg p.o. for seven days.  Then, week #2, we will start him on 40 mg for 1 week.  Then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop.  He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations.
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DESCRIPTION: Acute gastroenteritis, resolved.  Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.

gastroenterology, nausea, vomiting, diarrhea, gastrointestinal bleed, mesentery, hemoglobin, hematocrit, gastrointestinal, periumbilical, gastroenteritis, hemorrhoids

The situation involves a patient with acute gastroenteritis, resolved by discharge, alongside a gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology. While the patient's immediate condition has improved, the underlying cause of the gastrointestinal bleed and inflammation is still not identified. This poses potential risks and the need for further medical monitoring, making the situation moderately high-stakes due to the potential for serious complications if not properly followed up. Given the patient's complex medical history, including diabetes and COPD, managing the tapering steroid regimen and ensuring follow-up care adds to the complexity and seriousness of the case.


Medical Specialty: Orthopedic
Sample Name: Hamstring Release

PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia.  Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAIN:  ,None.,SPECIMENS:  ,None.,HISTORY AND PHYSICAL:  ,The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero.  The patient has diagnosis of autism as well.  The patient presented with bilateral knee flexion contractures, initially worse on right than left.  He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play.  The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed.  Risks and benefits of the surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures.  All questions were answered and mother and son agreed to above plan.,PROCEDURE NOTE:  ,The patient was taken to operating room and placed supine on operating table.  General anesthesia was administered.  The patient received Ancef preoperatively.  Nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  A small 3 cm incision was made over the distal medial hamstring.  Hamstring tendons were isolated and released in order of semitendinosus, semimembranosus, and sartorius.  The wound was then irrigated with normal saline and closed used 2-0 Vicryl and then 4-0 Monocryl.  The wound was cleaned and dried and dressed with Steri-Strips.  The area was infiltrated with total 10 mL of 0.25% Marcaine.  The wound was then covered with Xeroform, 4 x 4s, and Bias.  Tourniquet was released at 15 minutes.  The patient was then placed in knee immobilizer.  The patient tolerated the procedure well and subsequently taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The patient may weight bear as tolerated in his brace.  He will start physical therapy in another week or two.  The patient restricted from any PE for at least 6 week.  He may return to school on 01/04/2008.  He was given Vicodin for pain.
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DESCRIPTION: Left distal medial hamstring release.

Left distal medial hamstring release.

orthopedic, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring,

The procedure described is a common orthopedic surgery known as hamstring release, typically performed to improve mobility and address knee flexion contractures. While all surgeries carry some risk, this procedure is considered routine and the postoperative plan suggests an expectation of a smooth recovery. The patient has a history of a similar procedure, which was successful. There were no complications during the surgery, and the blood loss was minimal. Thus, the situation is not extremely high-stakes, but it is certainly significant as it involves surgery on a child with autism. The stakes primarily involve ensuring a successful outcome to maintain and enhance the child's quality of life.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Cataract Extraction

DIAGNOSIS:,  Nuclear sclerotic and cortical cataract, right eye.,OPERATION:,  Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:,  The patient was taken to the operating room and placed on the table in the supine position.  Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff.  Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage.  The patient was then prepped and draped in the usual sterile fashion for eye surgery.  With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle.  With Westcott scissors, a fornix-based conjunctival flap was made.  The surgical limbus was identified and hemostasis obtained with wet-field cautery.  With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea.  A stab incision was made at 2 o'clock with a 15-degree blade.  With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber.  Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique.  Hydrodissection was performed with Balanced Salt Solution.  Phacoemulsification was performed in a two-headed nuclear fracture technique.  The remaining cortical material was removed with irrigation and aspiration handpiece.  The posterior capsule remained intact and vacuumed with minimal suction.  The posterior chamber intraocular lens was obtained.  It was inspected, irrigated, inserted into the posterior chamber without difficulty.  Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound.  There was no aqueous leak even with digital pressure.  The conjunctiva was pulled back into position with wet-field cautery.  A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given.  Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture.  The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.
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DESCRIPTION: Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.

ophthalmology, extracapsular cataract extraction, phacoemulsification, nuclear sclerotic, cortical cataract, extraction with intraocular lens, cataract extraction, intraocular lens, intraocular, extracapsular, implantation, conjunctival, cataract, chamberNOTE

In this scenario, we are dealing with a surgical procedure, which inherently carries some risks due to the nature of surgery, including general risks such as infection or complications from anesthesia, as well as specific risks related to ophthalmic surgery like inflammatory responses or incorrect lens placement. However, phacoemulsification with cataract extraction is a common and low-risk procedure under experienced hands, with a high success rate and generally minor complications. The provided details indicate a standard procedure without any noted complications. Therefore, the stakes are not considered extremely high, though very competent care is necessary.


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

GROSS DESCRIPTION:,A.  Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line.  There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B.  Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C.  Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung.  The lung is inflated with formalin.  There is a 12.0 cm staple line on the lateral surface, inked blue.  There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line.  The overlying pleura is puckered.,D.  Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E.  Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A.  Right upper lobe wedge lung biopsy:  Poorly differentiated non-small cell carcinoma.  Tumor Size:  0.8 cm.  Arterial (large vessel) invasion:  Not seen.  Small vessel (lymphatic) invasion:  Not seen.  Pleural invasion:  Not identified.  Margins of excision:  Negative for malignancy.,B.  Biopsy, 10R lymph node:  Anthracotically pigmented lymphoid tissue, negative for malignancy.,C.  Right upper lobe, lung:  Moderately differentiated non-small cell carcinoma,(adenocarcinoma).  Tumor Size:  1.3 cm.  Arterial (large vessel) invasion:  Present.  Small vessel (lymphatic) invasion:  Not seen.  Pleural invasion:  Not identified.  Margins of excision:  Negative for malignancy.,D.  Biopsy, 4R lymph nodes:  Lymphoid tissue, negative for malignancy.,E.  Biopsy, subcarinal lymph node:  Lymphoid tissue, negative for malignancy.,COMMENTS:,  Pathologic examination reveals two separate tumors in the right upper lobe.  They appear histologically distinct, suggesting they are separate primary tumors (pT1).  The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.  The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation.
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DESCRIPTION: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.

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

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


Medical Specialty: Surgery
Sample Name: Shiley Tracheostomy Tube Insertion

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

surgery, tracheostomy, shiley tracheostomy tube, sternal notch, bovie electrocautery, tracheostomy tube, electrocautery, endotracheal, shiley, tube,

The situation involves a surgical procedure to insert a tracheostomy tube, which is inherently high-stakes due to the need to maintain an open airway for the patient. This is a significant medical intervention requiring general anesthesia, precision, and the potential for serious complications if not performed correctly. The situation is critical for the patient's breathing and overall survival, making it high-stakes.


Medical Specialty: Orthopedic
Sample Name: Austin-Akin Bunionectomy

TITLE OF OPERATION:,1.  Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  Weil osteotomy with internal screw fixation, first right metatarsal.,3.  Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1.  Bunion deformity, right foot.,2.  Dislocated second right metatarsophalangeal joint.,3.  Hammertoe deformity, second right digit.,ANESTHESIA:,  Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:,  60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES:  ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size.  One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg.  The right foot was then prepped, scrubbed, and draped in a normal sterile technique.  The right ankle tourniquet was then inflated.  Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique.  One screw measured 16 mm, second screw measured 18 mm in length.  Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  Fixation of the osteotomy was found to be excellent.  The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system.  Upon insertion of the screw, using AO technique, the wire was removed.  The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  Fixation of the osteotomy was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  Range of motion of that joint was uninhibited.  The area was flushed copiously with saline.  Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision.  Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped and cauterized.  The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  Upon insertion of the screw, using AO technique, the wire was then removed.  Fixation of the osteotomy with 2.0 screw was found to be excellent.  The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  Range of motion of the second right metatarsophalangeal joint was found to be excellent.  Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues.  Then, 4-0 Vicryl was used to approximate the skin incision.  Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint.  The island of skin between the two semi-elliptical incisions was resected in toto.  The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint.  A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  The area was copiously flushed with saline.  The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions.  Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right ankle tourniquet was deflated, time was 60 minutes.  Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.
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DESCRIPTION: Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.  Weil osteotomy with internal screw fixation, first right metatarsal.  Arthroplasty, second right PIP joint.

orthopedic, austin-akin bunionectomy, weil osteotomy, internal screw fixation, first right metatarsal, metatarsophalangeal joint, hammertoe deformity, extensor digitorum longus, austin akin bunionectomy, threaded cannulated screw, semi elliptical incisions, ankle tourniquet, surgical neck, cannulated screws, pip joint, proximal phalanx, fixation, metatarsophalangeal, proximal, screw, metatarsal, osteotomy, austin, joint, tourniquet, osteomed, phalanx, incision,

The described surgical procedure involves multiple complex operations on the patient's right foot, including an Austin-Akin bunionectomy, a Weil osteotomy, and a PIP joint arthroplasty. These procedures require precise surgical skills and carry inherent risks, such as bleeding, infection, and complications related to anesthesia. However, the estimated blood loss is minimal, and the patient was stable post-surgery with a clear recovery plan. While the surgery is certainly significant due to its complexity and potential impact on the patient's mobility and quality of life, it is not life-threatening or extremely high-stakes in nature. It falls more in the mid-stakes range as it is important for the patient's health and requires specialized skills but does not immediately impact life-or-death scenarios.


Medical Specialty: Surgery
Sample Name: I&D - Penoscrotal Abscess

PREOPERATIVE DIAGNOSIS: , Penoscrotal abscess.,POSTOPERATIVE DIAGNOSIS:,  Penoscrotal abscess.,OPERATION: , Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.,BRIEF HISTORY: , The patient is a 75-year-old male presented with penoscrotal abscess.  Options such as watchful waiting, drainage, and antibiotics were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, completely the infection turning into necrotizing fascitis, Fournier's gangrene were discussed.  The patient already had significant phimotic changes and disfigurement of the penis.  For further debridement the patient was told that his penis is not going to be viable, he may need a total or partial penectomy now or in the future.  Risks of decreased penile sensation, pain, Foley, other unexpected issues were discussed.  The patient understood all the complications and wanted to proceed with the procedure.,DETAIL OF THE OPERATION:  ,The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual fashion.  Pictures were taken prior to starting the procedure for documentation.  The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection.  The penile area was opened up distally to allow the pus to come out.  The dissection around the proximal scrotum was done to make sure there are no other pus pockets.  The corporal body was intact, but the distal part of the corpora was completely eroded and had a fungating mass, which was biopsied and sent for permanent pathology analysis.,Urethra was identified at the distal tip, which was dilated and using 23-French cystoscope cystoscopy was done, which showed some urethral narrowing in the distal part of the urethra.  The rest of the bladder appeared normal.  The prostatic urethra was slightly enlarged.  There are no stones or tumors inside the bladder.  There were moderate trabeculations inside the bladder.  Otherwise, the bladder and the urethra appeared normal.  There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma.  Again biopsies were sent for pathology analysis.  Prior to urine irrigation anaerobic aerobic cultures were sent, irrigation with over 2 L of fluid was performed.  After irrigation, packing was done with Kerlix.  The patient was brought to recovery in a stable condition.  Please note that 18-French Foley was kept in place.  Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible, but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied.  The patient was brought to Recovery in a stable condition after applying 0.5% Marcaine about 20 mL were injected around for local anesthesia.
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DESCRIPTION: Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.

surgery, i&d, penoscrotal, penile biopsy, cystoscopy, urethral dilation, incision and drainage, fungating mass, penoscrotal abscess, abscess, urethral,

This surgical case details a complex medical situation involving a 75-year-old male with a penoscrotal abscess and significant complications, including potential necrotizing fasciitis and the need for a penectomy. The presence of a fungating mass raises the possibility of squamous cell carcinoma, further compounding the stakes. The risks associated with the procedure, including potential for serious infection (Fournier's gangrene), and the need for extensive surgical intervention highlight the high-stakes nature of the situation, particularly given the patient's age and the severe nature of the conditions being treated.


Medical Specialty: Gastroenterology
Sample Name: Colon Polyps - Genetic Counseling

REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps.  The patient reports her first polyps noted at the age of 50.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  She does have an identical twice who is the one of the 11 who has never had a history of polyps.  She also has history of several malignancies in the family.  Her father died of a brain tumor at the age of 81.  There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement.  Her sister died at the age of 65 breast cancer.  She has two maternal aunts with history of lung cancer both of whom were smoker.  Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer.  There is no other cancer history.,PAST MEDICAL HISTORY:,  Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin.  She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married.  She was born and raised in South Dakota.  She moved to Colorado 37 years ago.  She attended collage at the Colorado University.  She is certified public account.  She does not smoke.  She drinks socially.,REVIEW OF SYSTEMS:  ,The patient denies any dark stool or blood in her stool.  She has had occasional night sweats and shortness of breath, and cough associated with her asthma.  She also complains of some acid reflux as well as anxiety.  She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Genetic counseling for a strong family history of colon polyps.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.

gastroenterology, family history, strong family history, precancerous polyps, brain tumor, lung cancer, genetic counseling, colon polyps, polyps,

The situation involves a patient with a strong family history of colon polyps and several family members with precancerous conditions or cancers, suggesting a genetic predisposition. This could indicate a potential hereditary cancer syndrome, which is critical to identify and manage. Genetic counseling can provide important preventive health strategies and decisions about surveillance. While it does not necessarily present an immediate life-or-death scenario, it could have significant long-term implications on the patient's and her family's health.


Medical Specialty: Surgery
Sample Name: Cataract Extraction - 1

PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:,  Peribulbar.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine drops.  A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg.  A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.  The Honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmHg.  The eye was prepped with a Betadine solution and draped in the usual sterile fashion.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic.  A 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap.  The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula.  Phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit.  Gentle vacuuming of the central posterior capsule was performed.  The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,The intraocular lens was folded, inserted into the capsular bag and then un-folded.  The trailing haptic was tucked underneath the anterior capsular rim.  The lens was shown to center very well.  Therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction.  The wound was shown to be watertight.  Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied and a Fox shield taped firmly in place.,The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.  A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine.

surgery, phacoemulsification, hydrodissection, peribulbar block, irrigation and aspiration, honan balloon, anterior chamber, anterior capsular, aspiration unit, capsular bag, cataract extraction, intraocular lens, cataract, extraction, peribulbar, lidocaine, viscoelastic, chamber, epinephrine, anterior, capsular, lens, intraocular, eye,

The described procedure is an extracapsular cataract extraction, which is a common surgical procedure with a generally low risk of complications, especially when done by experienced surgeons. The document mentions no complications during the procedure. While any surgical procedure carries some risk, cataract surgery is widely considered routine and is performed frequently with high success rates. Thus, the situation involves a typical surgical procedure with low chances of complications, indicating relatively low stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy - Discharge Summary - 1

ADMISSION DIAGNOSES:,1.  Menometrorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,DISCHARGE DIAGNOSES:,1.  Menorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,OPERATION PERFORMED:  ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL:  ,The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries.  She is having increasing menometrorrhagia and dysmenorrhea.  Ultrasound shows a small uterine fibroid.  She has failed oral contraceptives and surgical therapy is planned.,PAST HISTORY: , Significant for reflux.,SURGICAL HISTORY:  ,Tubal ligation.,PHYSICAL EXAMINATION: , A top normal sized uterus with normal adnexa.,LABORATORY VALUES:  ,Her discharge hemoglobin is 12.4.,HOSPITAL COURSE: , She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia.  Postoperatively, she has done well.  Bowel and bladder function have returned normally.  She is ambulating well, tolerating a regular diet.  Routine postoperative instructions given and said follow up will be in four weeks in the office.,DISCHARGE MEDICATIONS: , Preoperative meds plus Vicodin for pain.,DISCHARGE CONDITION: , Good.
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DESCRIPTION: Total vaginal hysterectomy.   Menometrorrhagia, dysmenorrhea, and small uterine fibroids.

obstetrics / gynecology, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids,

The discharge summary describes a hysterectomy, a common surgical procedure to treat uterine conditions such as menorrhagia, dysmenorrhea, and fibroids. While surgery generally carries risks, a hysterectomy is routine in gynecological practices for treating these conditions, particularly when other treatments have failed. The patient appears to be recovering well post-operation, with normal function restored and a stable condition at discharge. This indicates that although the situation involves surgery, it is not a high-stakes emergency or life-threatening situation.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 28

HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness.  The patient apparently lives with his wife and was found to have a decreased status since the last one day.  The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse.  When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife.  Actually the night before, he fell off his wheelchair and had lacerations on the face.  As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then.  The patient's wife is not able to give a history.  The patient has not been getting Sinemet and his other home medications in the last 2 days.  ,PAST MEDICAL HISTORY:  ,Parkinson disease.,MEDICATIONS:,  Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL:
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DESCRIPTION: The patient brought in by EMS with a complaint of a decreased level of consciousness.

general medicine, level of consciousness, parkinson disease, altered mental status, dehydration, elderly abuse, decreased level of consciousness, ems, parkinson, consciousness, xanax, sinemet, decreased,

The situation involves an elderly patient with a decreased level of consciousness and possible medication mismanagement, which could be indicative of elder abuse or neglect. Additionally, the patient has Parkinson's disease and is missing critical medication, which may worsen his condition. The history also includes recent facial injuries. This combination of factors makes it a high-stakes situation because it involves immediate healthcare concerns, potential legal and ethical implications, and the need for urgent intervention to ensure the patient's safety.


Medical Specialty: Neurosurgery
Sample Name: Suboccipital Craniectomy

TITLE OF OPERATION: , Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,INDICATION FOR SURGERY: , The patient with a large 3.5 cm acoustic neuroma.  The patient is having surgery for resection.  There was significant cerebellar peduncle compression.  The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex.  The case took 12 hours.  This was more difficult and took longer than the usual acoustic neuroma.,PREOP DIAGNOSIS: , Right acoustic neuroma.,POSTOP DIAGNOSIS: , Right acoustic neuroma.,PROCEDURE:,  The patient was brought to the operating room.  General anesthesia was induced in the usual fashion.  After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area.  A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion.  The incision was made and cautery was used to expose the suboccipital bone.  Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus.  The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum.  The dura leaves were held back with the 4-0 Nurolon.  The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated.  Laterally, the arachnoid was very thick.  This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified.  The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa.  Initially two retractors were used, one on the tentorium and one inferiorly.  The arachnoid was taken down off the tumor.  There were multiple blood vessels on the surface, which were bipolared.  The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion.  This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized.  The redundant capsule was bipolared and cut out to get further access to the center of the tumor.  Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex.  It was very difficult to identify the 7th nerve complex.  The brainstem was identified above the complex.  Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain.  Attention was then taken to try identify the 7th nerve complex.  There were multitude of veins including the lateral pontine vein, which were coming right into this area.  The lateral pontine vein was maintained.  Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem.  A number 1 and number 2 microinstruments were then used to began to develop the plane.  This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed.  A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve.  Cavitron was used to debulk the lesion and then further dissection was carried out.  The nerve stimulated beautifully at the brainstem level throughout this.  The tumor continued to be mobilized off the lateral pontine vein until it was completely off.  The Cavitron was used to debulk the lesion out back laterally towards the area of the porus.  The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus.  At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus.  There was minimal bulk remaining intracranially.  All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem.  Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,I then scrubbed back into case once Dr. X had completed removing this portion of the tumor.  There was no tumor remaining at this point.  I placed some Norian in the porus to seal any air cells, although there were no palpated.  An intradural space was then irrigated thoroughly.  There was no bleeding.  The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time.  The dura was then closed with 4-0 Nurolons in interrupted fashion.  A muscle plug was used over one area.  Duragen was laid and strips over the suture line followed by Hemaseel.  Gelfoam was set over this and then a titanium cranioplasty was carried out.  The wound was then irrigated thoroughly.  O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,The patient was extubated and taken to the ICU in stable condition.
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DESCRIPTION: Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.

neurosurgery, suboccipital, craniectomy, microscope, cranioplasty, acoustic neuroma, cerebellar peduncle, nerve complex, brainstem, nurolon, cavitron, kerrison, leksell, lateral pontine vein, suboccipital craniectomy, nerve, tumor

The scenario involves a complex neurosurgical procedure: a right suboccipital craniectomy for the resection of a large acoustic neuroma, which was complicated by the tumor's size and its adherence to critical structures like the cerebellar peduncle and brainstem. This procedure required significant surgical skill and precision, was of extended duration (12 hours), and involved close proximity to critical brain structures and nerves. The outcome can significantly impact the patient's neurological functions and overall prognosis, thus classifying it as high-stakes. Furthermore, any complications could lead to severe consequences, including neurological deficits or life-threatening issues.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Smoking Cessation

CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:,  The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking.  She is a new patient today.  She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE:  ,Well developed and well nourished.  She does not appear to be in any acute distress.  Cardiovascular:  Regular rhythm.  No murmurs, gallops, or rubs.  Capillary refill less than 3 seconds.  Peripheral pulses are 2+ bilaterally.  Respiratory:  Her lungs are clear to auscultation bilaterally with good effort.  No tenderness to palpation over chest wall.  Musculoskeletal:  She has full range of motion of all four extremities.  No tenderness to palpation over long bones.  Skin:  Warm and dry.  No rashes or lesions.  Neuro:  Alert and oriented x3.  Cranial nerves II-XII are grossly intact.  No focal deficits.,PLAN: , I did refill her medications.  I have requested that she have her primary doctor forward her records to me.  I have discussed Chantix and its use and success rate.  She was given a prescription, as well as a coupon.  She is to watch for any worsening signs or symptoms.  She verbalized understanding of discharge instructions and prescriptions.  I would like to see her back to proceed with her preventive health measures.
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DESCRIPTION: The patient needs refills on her Xanax

The patient needs refills on her Xanax

consult - history and phy., quit smoking, chantix, mesothelioma, smoking, xanax, refills

The situation involves a patient with mesothelioma, a serious cancer diagnosis, who requires medication management for anxiety and smoking cessation. Managing smoking cessation is important for the patient's health, especially given her existing medical condition. However, the immediate situation described—refilling Xanax and starting Chantix (for smoking cessation)—does not seem life-threatening. There is a moderate risk due to potential complications from mesothelioma, but the doctor is managing the situation by coordinating care with specialists and ensuring the patient understands her treatment plan. Therefore, while important for managing the patient’s health, this is not extremely high-stakes compared to, for example, an acute medical emergency.


Medical Specialty: Surgery
Sample Name: Granuloma Excision

PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:,  General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation on her left lateral thigh below the greater trochanter, which was described by her parents as a birthmark.  This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat, slightly hyperpigmented lesion.  Although no isolated injury event can be recalled, the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh, and it has been treated with topical cautery in her primary care doctor's office, but with recurrence.  She is here today for excision.,OPERATIVE FINDINGS: , The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room, had an uneventful induction of general anesthesia.  We conducted a surgical time-out, reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today.  Preparation and draping was __________ ensued with a chlorhexidine based prep solution.  The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1.2 cm.  This entire area was infiltrated with 0.25% Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a #15 scalpel blade, excising the pyogenic granuloma, its base, and a small rim of surrounding normal skin.  Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle-tip electrocautery pencil.  The wound was closed in layers with a deep dermal roll of 5-0 Monocryl stitches supplemented by 5-0 intradermal Monocryl and Steri-Strips for final skin closure.  The patient tolerated the procedure well.  This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma.  Blood loss was less than 5 mL and there were no complications.
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DESCRIPTION: Pyogenic granuloma, left lateral thigh.   Excision of recurrent pyogenic granuloma.

surgery, trochanter, granuloma, pyogenic granuloma, vascular malformation, pyogenic, vascular, malformation, thigh,

The procedure described is a routine surgical excision of a pyogenic granuloma on a 12-year-old patient. It is performed under general anesthesia, which is common but not particularly high-risk for a simple excision. Pyogenic granulomas are generally benign and treatable growths, and the report indicates no complications, minimal blood loss, and a routine post-operative course. Given this, the procedure is not considered high-stakes compared to more complex or life-threatening surgeries.


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

Medical Specialty: Surgery
Sample Name: Flexible Fiberoptic Bronchoscopy

PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1.  Severe tracheobronchitis.,2.  Mild venous engorgement with question varicosities associated pulmonary hypertension.,3.  Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a.  Right lower lobe bronchoalveolar lavage.,b.  Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite.  The patient had previously been on Coumadin and then heparin.  Heparin was discontinued approximately one-and-a-half hours prior to the procedure.  The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx.  Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure.  Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure.  The patient was premedicated with 50 mg of Demerol and 2 mg of Versed.  After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx.  There was minimal redundant oral soft tissue in the oropharynx.  There was mild erythema.  Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied.  Vocal cord motion was normal.  The bronchoscope was then advanced through the larynx into the trachea.  There was evidence of moderate inflammation with prominent vascular markings and edema.  No frank blood was visualized.  The area was suction clear of copious amounts of clear white secretions.  Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem.  The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe.  There was significant amount of inflammation, induration, and vascular tortuosity in these regions.  No frank blood was identified.  No masses or lesions were identified.  There was senile bronchiectasis with slight narrowing and collapse during the exhalation.  The air was suctioned clear.  The bronchoscope was withdrawn and advanced into the right main stem.  Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized.  Again significant amounts of tracheobronchitis was noted with vascular infiltration.  In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this.  The bronchoscope was removed and advanced into the right middle and right lower lobe.  There was marked injection and inflammation in these regions.  In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region.  Again, white clear secretions were identified.  No masses or other processes were noted.  The area was suctioned clear.  A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe.  The bronchoscope was then withdrawn and readvanced into the right upper lobe.  Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained.  Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine.  The area remained clear.  No further hemorrhage was identified.  The bronchoscope was subsequently withdrawn.  The patient tolerated the procedure well and was stable throughout the procedure.  No further hemoptysis was identified.  The patient was sent to Recovery in good condition.
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DESCRIPTION: Flexible fiberoptic bronchoscopy with right lower lobe bronchoalveolar lavage and right upper lobe endobronchial biopsy.  Severe tracheobronchitis, mild venous engorgement with question varicosities associated pulmonary hypertension, right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.

surgery, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope

The situation involves a surgical procedure known as a flexible fiberoptic bronchoscopy, which includes several complexities like performing bronchial lavage and endobronchial biopsy. This procedure was indicated due to persistent hemoptysis of unclear etiology, which can be a serious condition. Throughout the procedure, the patient had a history of anticoagulant usage, adding to the complexity as it increases the risk of bleeding, which indeed occurred minimally but was managed successfully. Despite the potential risks, the patient tolerated the procedure well and was stable throughout, with no further hemoptysis. The stakes are moderately high due to the complexities, the serious nature of the symptoms, and the management of anticoagulation, but the fact that the procedure was conducted successfully and the patient's condition was stable afterward indicates that the situation was well-controlled.


Medical Specialty: Radiology
Sample Name: Myoview Perfusion Scan

INDICATIONS:,  Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:,  Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:,  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.
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DESCRIPTION: Resting Myoview perfusion scan and gated myocardial scan.  Findings consistent with an inferior non-transmural scar

radiology, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion

The scenario involves the interpretation of a Myoview Perfusion Scan in a radiology context, with specific findings related to myocardial perfusion and heart function. The scan reveals a moderate size inferoapical perfusion defect and possible scar tissue, which are important in diagnosing and managing cardiac conditions. The assessment indicates an improved heart function compared to a previous study, but some aspects cannot be assessed due to the lack of stress imaging. This situation holds moderate importance, given that it concerns the patient's heart health and potential intervention strategies. However, it is not immediately life-threatening unless severe and immediate intervention is required based on additional patient-specific clinical information, which isn't provided here.


Medical Specialty: Surgery
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.

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

The procedure described involves a routine surgical intervention for a child with a right inguinal hernia. While there are standard risks associated with any surgery and particularly with anesthesia in young children, this is noted to be an elective and quite common procedure with a relatively low risk of severe complications. The surgical team is experienced in both the procedure and in dealing with pediatric cases, which further mitigates the stakes. However, given that the patient is a 4-year-old, the inherent considerations of operating on a child and the use of general anesthesia increase the stakes slightly above routine adult surgery. Thus, it's a reasonably safe surgery but with moderate stakes due to the nature of the patient involved.


Medical Specialty: Surgery
Sample Name: Breast Mass Excision - 1

PREOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,POSTOPERATIVE DIAGNOSES:,1.  Left breast mass.,2.  Hypertrophic scar of the left breast.,PROCEDURE PERFORMED:  ,Excision of left breast mass and revision of scar.,ANESTHESIA:  ,Local with sedation.,SPECIMEN: , Scar with left breast mass.,DISPOSITION:  ,The patient tolerated the procedure well and transferred to the recover room in stable condition.,BRIEF HISTORY:  ,The patient is an 18-year-old female who presented to Dr. X's office.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.  The patient also has a hypertrophic scar.  Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.,INTRAOPERATIVE FINDINGS: , A hypertrophic scar was found and removed.  The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.,PROCEDURE: , After informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion.  Elliptical incision was made over the previous cicatrix.  The total length of the incision was 5.5 cm.  Removing the cicatrix in its entirety with a #15 blade Bard-Parker scalpel after anesthetizing with local solution with 0.25% Marcaine.  Next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro Bovie cautery.  Hemostasis was maintained.  Attention was next made to approximating the deep dermal layers.  An interrupted #4-0 Vicryl suture was used and then a running subcuticular Monocryl suture was used to approximate the skin edges.  Steri-Strips as well as bacitracin and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.
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DESCRIPTION: Left breast mass and hypertrophic scar of the left breast.  Excision of left breast mass and revision of scar.  The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.

surgery, hypertrophic scar, palpable mass, fibrocystic, scar, fibrocystic disease, breast mass, breast, cicatrix, excision, biopsy, hypertrophic, palpable,

The situation involves the surgical excision of a breast mass and the revision of a hypertrophic scar. While the procedure was performed under local anesthesia with sedation and the patient tolerated it well, the stakes are higher than routine because it involves surgical intervention on an 18-year-old patient. Additionally, the presence of a breast mass could have potential implications for breast cancer or other issues, making accurate diagnosis and removal critical. Therefore, this scenario has moderately high stakes in a medical context.


Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 2

GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit.  Height is ?? feet ?? inches.  Weight is ?? pounds.  This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:,  The pupils were equal, round and reactive to light.  Extraocular movements are intact.  Sclera are nonicteric.  Ears, nose, mouth and throat - Externally the ears and nose are normal.  The mucous membranes are moist and midline.,NECK:  ,The neck is supple without masses.  No thyromegaly, no carotid bruits, no adenopathy.,LUNGS:  ,There is a normal respiratory effort.  Bilateral breath sounds are clear.  No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location.  S1 and S2 are normal.  No rubs, murmurs or gallops.  A regular rate and rhythm.  There are no abdominal aortic bruits.  The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS:  ,The breasts show no masses or tenderness.  No axillary adenopathy.,ABDOMEN:,  The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:,  Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact.  Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three.  Judgment and insight are good.  Affect is appropriate.
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DESCRIPTION: Normal physical exam template.  This is a well-developed and well-nourished.  The pupils were equal, round and reactive to light.  Extraocular movements are intact.

The provided text is a template for a normal physical examination. This kind of template is typically used for routine documentation during physical exams and does not contain any specific patient information or present any immediate health concerns. Routine physical exams are standard procedures that do not inherently involve high-stakes decisions unless abnormal or concerning findings are recorded, which is not the case here.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 11

The patient and his wife had the opportunity to ask questions, all of which were answered for them and the patient stated in a clear, competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate.,PROCEDURE NOTE:  ,The patient was brought to the Cardiac Catheterization Lab in a fasting state.  All appropriate labs had been reviewed.  Bilateral groins were prepped and draped in the usual fashion for sterile conditions.  The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.  He received a total of 2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good effect.  Bilateral groins had been prepped and draped in the usual fashion.  Right femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-French vascular sheath was put into place percutaneously via guide-wire exchanger with a finder needle.  All catheters were passed using a J-tipped guide-wire.  Left heart catheterization and left ventriculography performed using a 6-French pigtail catheter.  Left system coronary angiography performed using a 6-French JL4 catheter.  Right system coronary angiography performed using a 6-French CDRC catheter.  Following the procedure, all catheters were removed.  Manual pressure was held with the Neptune pad and the patient was discharged back to his room.  I inspected the femoral arteriotomy site after the procedure was complete and it was benign without evidence of hematoma nor bruit with intact distal pulses.  There were no apparent complications.  A total of 77 cc of Isovue dye and 1.4 minutes of fluoroscopy time were utilized during the case.,FINDINGS:,HEMODYNAMICS: , LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.,LV function is normal, EF 60%, no wall motion abnormalities.,CORONARY ANATOMY:,1.  Left main demonstrates 30-40% distal left main lesion which is tapering, not felt significantly obstructive.,2.  The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion immediately after the take-off of this large diagonal of 99% which is quite severe with TIMI-3 flow throughout the LAD and the left main.,3.  The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.,4.  The right coronary artery was the dominant artery giving rise to right posterior descending artery demonstrates mild luminal irregularity.  There is a moderate distal PDA lesion of 60% seen.,IMPRESSION:,1.  Mild to moderate left main stenosis.,2.  Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and moderate prox-LAD CAD.,We are going to continue the patient's aspirin, beta blocker as heart rate tolerates as he tends to run on the bradycardic side and add statin.  We will check a fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/deciliter or less but in the past the patient's LDL had been higher or high.
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DESCRIPTION: Patient with significant angina with moderate anteroapical ischemia on nuclear perfusion stress imaging only.  He has been referred for cardiac catheterization.

cardiovascular / pulmonary, wall motion abnormalities, cardiac catheterization, mid lad, timi flow, femoral arteriotomy, catheterization, ischemia, angina, distal, stenosis, stress, artery, coronary, lad, cardiac,

The situation involves a complex medical procedure, cardiac catheterization, which is critical for diagnosing and potentially guiding treatment of serious cardiovascular conditions. The findings indicate significant coronary artery disease, including severe lesions that require careful management to prevent adverse cardiac events. The patient's hemodynamics and coronary anatomy findings are crucial for determining the next steps in treatment, such as medication adjustments or possible interventions. As such, the stakes are high given the potential implications for the patient's immediate health and treatment outcomes.


Medical Specialty: Orthopedic
Sample Name: Long-Arm Cast

PREOPERATIVE DIAGNOSIS:,  Left distal radius fracture displaced.,POSTOPERATIVE DIAGNOSIS: , Left distal radius fracture displaced.,SURGERY:  ,Closed reduction and placement of long-arm cast, CPT code 25605.,ANESTHESIA:  ,General LMA.,FINDINGS:  ,The patient was found to have a displaced fracture.  She was found to be in perfect alignment after closed reduction and placement of cast.  The radial deviation was well corrected.,INDICATIONS: , The patient is 5 years old.  She was seen in our office today 1 week after being placed into a cast for a displaced fracture.  She was noted to have significant loss of alignment especially on the lateral view.  She was indicated for closed reduction and placed of the long-arm cast.  Risks and benefits were discussed at length with the family.  They wished to proceed.,PROCEDURE:  ,The patient was brought to the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  Previous cast was previously removed.  An arm was approached and a closed reduction was performed.  This was checked under AP and lateral projection and was found to be in adequate alignment.  There was very mild residual dorsiflexion deformity noted.,A long-arm cast was then placed with plaster and molding.  Repeat x-rays demonstrated adequate alignment on both views.,The cast was then reinforced with fiberglass.  The patient was awakened from anesthesia and taken to recovery room in good condition.  There were no complications.  All instruments, sponge, and needle counts were correct at the end of case.,PLAN:  ,The patient will be discharged home.  She will return in 3 weeks for cast removal and clinical examination.  She would likely be placed into a wrist-guard at that time.  She has a prescription for Tylenol with codeine elixir.,
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DESCRIPTION: Closed reduction and placement of long-arm cast.

orthopedic, long-arm cast, closed reduction, displaced fracture, radial deviation, distal radius fracture, arm cast

The situation involves a 5-year-old patient who underwent a closed reduction and placement of a long-arm cast for a displaced distal radius fracture. Although it is a surgical procedure and involves general anesthesia, it is generally considered a routine procedure in orthopedic practice, particularly in pediatric cases. The patient was in good condition post-operation, with no complications reported. The stakes are lower compared to more invasive surgeries or cases with potential life-threatening conditions. The procedure is necessary and the situation is managed well medically, suggesting a low to moderate level of stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Fifth Disease - SOAP

SUBJECTIVE:,  Grandfather brings the patient in today because of headaches, mostly in her face.  She is feeling pressure there with a lot of sniffles.  Last night, she complained of sore throat and a loose cough.  Over the last three days, she has had a rash on her face, back and arms.  A lot of fifth disease at school.  She says it itches and they have been doing some Benadryl for this.  She has not had any wheezing lately and is not taking any ongoing medications for her asthma.,PAST MEDICAL HISTORY:,  Asthma and allergies.,FAMILY HISTORY:  ,Sister is dizzy but no other acute illnesses.,OBJECTIVE:,General:  The patient is an 11-year-old female.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color and good light reflex.  Oropharynx is pink and moist.  No erythema or exudates.  She has postnasal discharge.  Nares are swollen and red.  Purulent discharge in the posterior turbinates.  Both maxillary sinuses are tender.  She has some mild tenderness in the left frontal sinus.  Eyes are puffy and she has dark circles.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink.  Moist mucous membranes.  Red, lacey rash from the wrists to the elbows, both sides.  It is very faint on the lower back and she has reddened cheeks, as well.,ASSESSMENT:,  Fifth disease with sinusitis.,PLAN:,  Omnicef 300 mg daily for 10 days.  May use some Zyrtec for the itching.  Samples are given.
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DESCRIPTION: Fifth disease with sinusitis

Fifth disease with sinusitis

soap / chart / progress notes, fifth disease, soap, asthma, headaches, sinusitis, sore throat, oropharynx,

The situation describes a medical consultation regarding an 11-year-old patient with symptoms consistent with fifth disease and sinusitis. While it involves medical assessment and treatment planning, it doesn't imply immediate life-threatening conditions. Fifth disease typically has mild symptoms, and sinusitis can usually be managed with prescribed medication. Thus, it's relatively low-stakes in terms of immediate medical urgency and critical impact.