Medical Specialty: Neurology
Sample Name: TIA & Lumbar Stenosis

CHIEF COMPLAINT: , Transient visual loss lasting five minutes.,HISTORY OF PRESENT ILLNESS: , This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation, possible lumbar stenosis.  He reports he experienced a single episode of his vision decreasing "like it was compressed from the top down with a black sheet coming down".  The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car.  He was able to pull the car over to the side of the road safely.  During the episode, he felt nauseated and possibly lightheaded.  His wife was present and noted that he looked extremely pale and ashen during the episode.  He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable.  It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker.  He has had no further similar events.  He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem.,He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis.  The question has arisen as to whether he should have a CT myelogram to further evaluate this process.  He has no back pain or pain of any type, he denies bowel or bladder incontinence or frank lower extremity weakness.  He is extremely active and plays tennis at least three times a week.  He denies recent episodes of unexpected falls.,REVIEW OF SYSTEMS: , He only endorses hypothyroidism, the episode of visual loss described above and joint pain.  He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative.  A copy is in his clinic chart.,PAST MEDICAL HISTORY:  ,As above.  He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  He is retired from the social security administration x 20 years.  He travels a lot and is extremely active.  He does not smoke.  He consumes alcohol socially only.  He does not use illicit drugs.  He is married.,MEDICATIONS: , The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago.  He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d.,PHYSICAL EXAMINATION:,Vital Signs:  BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds.  He denies any pain.,General:  This is a pleasant white male in no acute distress.,HEENT:  He is normocephalic and atraumatic.  Conjunctivae and sclerae are clear.  There is no sinus tenderness.,Neck:  Supple.,Chest:  Clear to auscultation.,Heart:  There are no bruits present.,Extremities:  Extremities are warm and dry.  Distal pulses are full.  There is no edema.,NEUROLOGIC EXAMINATION:,MENTAL STATUS:  He is alert and oriented to person, place and time with good recent and long-term memory.  His language is fluent.  His attention and concentration are good.,CRANIAL NERVES:  Cranial nerves II through XII are intact.  VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline.,MOTOR:  He has normal bulk and tone throughout.  There is no cogwheeling.  There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5.  Otherwise he is 5/5 throughout including hip adductors and abductors.,SENSORY:  He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration.,COORDINATION:  There is no dysmetria or tremor noted.  His Romberg is negative.  Note that he cannot rise from the chair without using his arms.,GAIT:  Upon arising, he has a normal step, stride, and toe, heel.  He has difficulty with tandem and tends to fall to the left.,REFLEXES:  2 at biceps, triceps, patella and 1 at ankles.,The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection.,He has had full labs for cholesterol and stroke for risk factors although he does not have those available here.,IMPRESSION:,1.  TIA.  The character of his brief episode of visual loss is concerning for compromise of the posterior circulation.  Differential diagnoses include hypoperfusion, stenosis, and dissection.  He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system.  He has recently been started on Paxil by his primary care physician and this should be continued.  Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup.  The patient and his wife assure me that the workup was complete and that nothing was found at that time.,2.  Lumbar stenosis.  His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability.  In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this time.  Therefore we would defer further evaluation with CT myelogram as he does not want surgery.,PLAN:,1.  We will get a CT angiogram of the cerebral vessels.,2.  Continue Plavix.,3.  Obtain copies of the workup done at the outside hospital.,4.  We will follow the lumbar stenosis for the time being.  No further workup is planned.
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DESCRIPTION: Patient experienced a single episode of his vision decreasing.  During the episode, he felt nauseated and possibly lightheaded.  His wife was present and noted that he looked extremely pale.

The patient is experiencing transient visual loss, which can be a symptom of a transient ischemic attack (TIA) and potentially indicative of a more serious cerebrovascular issue. While there are no immediate life-threatening symptoms, the episode of visual loss while driving and its potential implications could lead to more serious outcomes if untreated. The patient's age and medical history add to the concern, necessitating further evaluation such as the CT angiogram. The situation is moderately high-stakes given the risk of future cerebrovascular events.


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

Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 3

PREOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-c4 and C4-C5.,2.  Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1.  Cervical spinal stenosis, C3-C4 and C4-C5.,2.  Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1.  Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2.  Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3.  Anterior cervical fusion, C3-C4 (CPT 22554),4.  Anterior cervical fusion, C4-C5 (CPT 22585).,5.  Utilization of allograft for purposes of spinal fusion (CPT 20931).,6.  Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE INDICATIONS:  ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  We discussed the diagnosis and the treatment options.  Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5.  We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  Furthermore I explained that the fusion may not become solid or that the hardware could break.  We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation.  I explained the rationale for this as well as the options of using his own bone.  Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  He was then positioned supine on the operating table, and all bony prominences were padded.  Pulse oximetry was maintained on both feet throughout the case.  The arms were carefully padded and tucked at his sides.  A roll was placed between the shoulder blades.  The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  Ten pounds of traction was applied.  A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle.  This was then split in line with its fibers.  Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  A needle was placed into a disc and an x-ray was done to determine its location.  The longus colli muscles were then elevated bilaterally with the electrocautery unit.  Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5.  This included complete removal of the anterior annulus, nucleus, and posterior annulus.  The posterior longitudinal ligament was removed as were the posterior osteophytes.  Foraminotomies were then accomplished bilaterally.  Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  Bleeding cancellous bone was exposed.  The disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  Two screws were then placed into each of the vertebral bodies at C3, C4, and C5.  There was excellent purchase.  A final x-ray was done confirming good position of the hardware and grafts.  The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks.  The carotid pulse was strong.  A drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure.  Steri-Strips were placed followed by application of a sterile dressing.  The drain was hooked to bulb suction.  A Philadelphia collar was applied.,The cranial tongs were carefully removed.  The soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.
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DESCRIPTION: Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal.  Anterior cervical fusion.  Utilization of allograft for purposes of spinal fusion.  Application of anterior cervical locking plate.

The situation involves a detailed description of an anterior cervical discectomy and fusion procedure performed on a patient with significant cervical spinal stenosis and spondylotic myelopathy. Neurosurgical procedures are inherently high-stakes due to the potential for severe complications such as paralysis, infection, and failure to alleviate symptoms. The patient's neurological symptoms and near-term surgical outcomes could significantly impact their quality of life. Furthermore, the complexity of the surgery, potential risks, and future implications for the patient, including artifact degeneration or the need for additional surgeries, contribute to the high-stakes nature of this scenario.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Pacemaker (Dual Chamber) - 1

PREPROCEDURE DIAGNOSIS: , Complete heart block.,POSTPROCEDURE DIAGNOSIS:  ,Complete heart block.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a dual-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of a dual-chamber pacemaker.,FLUOROSCOPY TIME: , 2.6 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Versed 2.5 mg.,2.  Fentanyl 150 mcg.,3.  Benadryl 50 mg.,CLINICAL HISTORY: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block.  She has been referred for a pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy.  A guide wire was advanced into the vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision.  A pocket was then fashioned in the medial direction.  Using the previously placed wire, a 7-French side-arm sheath was advanced over the wire into the left axillary vein.  The dilator was then removed over the wire.  A second wire was then advanced into the sheath into the left axillary vein.  The sheath was then removed over the top of the two wires.  One wire was then pinned to the drape.  Using the remaining wire, a 7 French side-arm sheath was advanced back into the left axillary vein.  The dilator and wire were removed.  A passive pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical location.  Adequate pacing and sensing functions were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  With the remaining wire, a 7-French side-arm sheath was advanced over the wire into the axillary vein.  The wire and dilating sheaths were removed.  An active pacing lead was then advanced down into the right atrium.  The peel-away sheath was removed.  Preformed J stylet was then advanced into the lead.  The lead was positioned in the appendage location.  Lead body was then turned, and the active fix screw was fixed to the tissue.  Adequate pacing and sensing function were established.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # 12345, serial #1234.,2.  Right atrial lead, manufacturer Guidant, model #12345, serial #1234.,3.  Right ventricular lead, manufacturer Guidant, model #12345, serial #1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 534 ohms.  P waves measured at 1.2 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,2.  Right ventricular lead impedance 900 ohms.  R-waves measured 6.0 millivolts.  Pacing threshold 1.0 volt at 0.5 milliseconds.,DEVICE SETTINGS: , DDD 60 to 130.,CONCLUSIONS,1.  Successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be taken back to her room for continued observation.  She can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Completion of the course of antibiotics.,4.  Home dismissal instructions provided in written format.,5.  Device interrogation in the morning.,6.  Wound check in 7 to 10 days.,7.  Enrollment in device clinic.
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DESCRIPTION: Implantation of a dual-chamber pacemaker and fluoroscopic guidance for implantation of a dual-chamber pacemaker.

The situation involves the surgical procedure of implanting a dual-chamber pacemaker in an 80-year-old patient with complete heart block. This type of medical procedure is critical as it directly addresses a life-threatening condition. A complete heart block can have severe consequences, including heart failure or death if not treated appropriately. The surgery itself carries inherent risks, including potential complications such as lead dislodgement, infection, or failure of the device. However, given the information provided, such as no acute complications and successful implantation, the immediate situation seems stable. Nonetheless, due to the life-saving nature of the procedure and the patient's condition, this scenario should be considered high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Intraocular Lens Implant

TITLE OF OPERATION:  ,1.  Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,INDICATION FOR SURGERY:  ,The patient is a 62-year-old white male who underwent cataract surgery in 09/06.  This was complicated by posterior capsule rupture.  An intraocular lens implant was not attempted.  He developed corneal edema and a preretinal hemorrhage.  He is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,PREOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,POSTOP DIAGNOSIS:  ,1.  Preretinal hemorrhage.,2.  Diabetic retinopathy.,3.  Aphakia.,4.  Corneal edema.,ANESTHESIA: , General.,SPECIMEN:  ,1.  Donor corneal swab sent to Microbiology.,2.  Donor corneal scar rim sent to Eye Pathology.,3.  The patient's cornea sent to Eye Pathology.,PROS DEV IMPLANT:  ,ABC Laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,NARRATIVE: , Informed consent was obtained, and all questions were answered.  The patient was brought to the preoperative holding area, where the operative left eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced.  The left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye.  A lid speculum was placed.  The posterior segment infusion was placed by the vitreoretinal service.  Peritomy was performed at the 3 and 9 o'clock limbal positions.  A large Flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion.  The cornea was then measured and was found to accommodate a 7.5-mm trephine.  The center of the cornea was marked.  The keratoprosthesis was identified.,A 7.5-mm trephine blade was then used to incise the anterior corneal surface.  This was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae.  Once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed.  Corneoscleral scissors were then used to excise completely the central cornea.  The keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures.  This was done without difficulty.  At this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note.  At the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service.  The 9-0 Prolene sutures double armed were then placed on each lens haptic loop.  The keratoprosthesis was removed.  Prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies.  Wet-field cautery also was performed to achieve hemostasis.  The leading hepatic sutures were then passed through the bed of the scleral flap.  These were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic.  The trailing hepatic was then placed into the posterior segment of the eye as well.  The trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn.  These were tied securely into position with the IOL nicely centered.  At this point, the donor cornea punched at 8.25 mm was then brought into the field.  This was secured with four cardinal sutures.  The corneal button was then sutured in place using a 16-bite 10-0 nylon running suture.  The knot was secured and buried after adequate tension was adjusted.  The corneal graft was watertight.  Attention was then turned back to the IOL sutures, which were locked into position.  The ends were trimmed.  The flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried.  At this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure.  The patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well.  No complications were noted.  The attending surgeon, Dr. X, performed the entire procedure.  No complications of the procedure were noted.  The intraocular lens was selected from preoperative calculations.  No qualified resident was available to assist.
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DESCRIPTION: Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.  A concurrent vitrectomy and endolaser was performed by the vitreoretinal team.

ophthalmology, vitrectomy, endolaser, keratoplasty, intraocular lens implant, preretinal hemorrhage, scleral flaps, intraocular, keratoprosthesis, chamber, implant, scleral, vitreoretinal, lens, sutures, eye,

The procedure described involves complex and delicate eye surgery that addresses multiple serious eye conditions such as diabetic retinopathy, preretinal hemorrhage, corneal edema, and aphakia. The concurrent surgeries, including a penetrating keratoplasty and vitrectomy, suggest a high degree of complexity and coordination between different surgical teams. Eye surgeries, particularly those involving the retina or cornea, can carry significant risks such as vision loss, infection, or failure to restore vision, which underscores the high-stakes nature. Moreover, the use of general anesthesia adds to the risks involved.


Medical Specialty: Neurology
Sample Name: Acute Intracerebral Hemorrhage

CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died.
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DESCRIPTION: MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).

This case involves a 72-year-old patient who presented with concerning neurological symptoms, eventually leading to the discovery of a large intracerebral hemorrhage. The patient exhibited symptoms like lethargy and stupor, and ultimately died after the MRI revealed a significant hematoma. Intracerebral hemorrhage is a serious and potentially life-threatening condition that requires immediate medical attention. The fact that the patient died underscores the high-stakes nature of this medical situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Stress Test Thallium

INDICATIONS:  ,Chest pain.,STRESS TECHNIQUE:,
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DESCRIPTION: Thallium stress test for chest pain.

Thallium stress test for chest pain.

cardiovascular / pulmonary, chest pain, ecg stress, thallium stress test, aerobic capacity, ejection fraction, gated tomographic spect system, myocardial perfusion, thallous chloride, ventricle, wall motion, stress test, stress

The situation involves a medical stress test (Thallium stress test), which is used to evaluate heart function and blood flow. This test is an essential diagnostic tool for conditions like coronary artery disease. The indication for the test is chest pain, which can be a symptom of serious underlying cardiovascular issues. If a serious condition is present and not addressed, it can lead to severe health consequences including heart attack. Therefore, accurate testing and interpretation are crucial.


Medical Specialty: Surgery
Sample Name: Fiberoptic Bronchoscopy with Lavage

PREOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1.  Status post multiple trauma/motor vehicle accident.,2.  Acute respiratory failure.,3.  Acute respiratory distress/ventilator asynchrony.,4.  Hypoxemia.,5.  Complete atelectasis of left lung.,6.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE:  ,ICU.  Room #164.,ANESTHESIA/SEDATION:,  Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,:  The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance.  The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation.  Chest x-ray as noted above revealed complete atelectasis of the left lung.  The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,:  A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots.  These were lavaged with several aliquots of normal saline until cleared.  The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope.  The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina.  The endotracheal tube was noted to be in good position.  The bronchoscope was advanced through the distal trachea.  There was a white tissue completely obstructing the left main stem at the carina.  The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned.  Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen.  The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes.  There was diffuse mucus impactions/tissue as well as intermittent clots.  There was no evidence of any active bleeding noted.  Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted.  Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system.  There is no plugging or obstruction of the right bronchial system.  The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina.  The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure.  Throughout the procedure, pulse oximetry was greater than 95% throughout.  There is no hemodynamic instability or variability noted during the procedure.  Postprocedure chest x-ray is pending at this time.
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DESCRIPTION: Emergent fiberoptic bronchoscopy with lavage.   Status post multiple trauma/motor vehicle accident.  Acute respiratory failure.  Acute respiratory distress/ventilator asynchrony.  Hypoxemia.  Complete atelectasis of left lung.  Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.

surgery, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, respiratory,

The procedure described involves an emergent medical situation where a patient with multiple traumatic injuries and acute respiratory issues requires immediate intervention to clear obstructions in the airway. Failure to successfully perform this procedure could result in severe respiratory distress or even fatality, highlighting the high-stakes nature of the situation. The patient's condition is critical due to acute respiratory failure and atelectasis, and timely medical intervention is crucial for the patient’s survival and recovery.


Medical Specialty: Surgery
Sample Name: Achilles Tendon Repair

PREOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,POSTOPERATIVE DIAGNOSIS: , Achilles tendon rupture, left lower extremity.,PROCEDURE PERFORMED:,  Primary repair left Achilles tendon.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:  ,40 minutes at 325 mmHg.,POSITION:,  Prone.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 26-year-old African-American male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.,PROCEDURE:,  After all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, the operative surgeon, Department Of Anesthesia, and nursing staff.  While in this hospital, the Department Of Anesthesia administered general anesthetic to the patient.  The patient was then transferred to the operative table and placed in the prone position.  All bony prominences were well padded at this time.,A nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time.  Left lower extremity was sterilely prepped and draped in the usual sterile fashion.  Once this was done, the left lower extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes.  After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal.  Careful dissection was then taken down to the level of the peritenon.  Once this was reached, full thickness flaps were performed medially and laterally.  Next, retractor was placed.  All neurovascular structures were protected.  A longitudinal incision was then made in the peritenon and opened up exposing the tendon.  There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point.  The plantar tendon was noted to be intact.  The tendon was debrided at this time of hematoma as well as frayed tendon.  Wound was copiously irrigated and dried.  Most of the ankle appeared that there was sufficient tendon links in order to do a primary repair.  Next #0 PDS on a taper needle was selected and a Krackow stitch was then performed.  Two sutures were then used and tied individually ________ from the tendon.  The tendon came together very well and with a tight connection.  Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon.  The wound was once again copiously irrigated and dried.  A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin.  Steri-Strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, Kerlix roll, sterile Kerlix and a short length fiberglass cast in a plantar position.  At this time, the Department of anesthesia reversed the anesthetic.  The patient was transferred back to hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure well.  There were no complications.
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DESCRIPTION: Achilles tendon rupture, left lower extremity.  Primary repair left Achilles tendon.  The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg.  The patient was placed in posterior splint and followed up at ABC orthopedics for further care.

surgery, repair, achilles tendon rupture, longitudinal incision, tendon rupture, achilles tendon, tendon, achilles, rupture, extremity

The repair of a ruptured Achilles tendon through primary surgical intervention is generally not considered an extremely high-risk procedure, particularly since there were no complications and the patient tolerated the procedure well under general anesthesia. These factors, along with minimal blood loss, indicate a routine surgical intervention. However, surgery in general involves significant stakes due to the inherent risks of anesthesia, infection, and the need for a successful outcome to restore function. Thus, while not extremely high-stakes like life-threatening surgeries, it demands careful attention and skill.


Medical Specialty: Pain Management
Sample Name: Costochondral Cartilage Injection

COSTOCHONDRAL CARTILAGE INJECTION,PROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form.  The patient was placed in the supine position.,Intravenous access was established.  The patient was given mild narcotics for sedation.  For further details, please refer to anesthesia note.,DESCRIPTION OF PROCEDURE:,  The area of discomfort was palpated under fluoroscopy and the costochondral cartilages that were symptomatic were marked out.  After careful asepsis, local anesthesia was given subcutaneously and a 0.25-gauge hypodermic needle was inserted into the costochondral cartilage junction, taking care not to stray from the rib.  Fluoroscopy in AP and lateral positions confirmed good position of the needle in the * costochondral junction and subsequently after aspiration, 0.5 mL of Depo-Medrol 80 and 0.5 mL of 0.5% Marcaine was injected.  The same procedure was carried out at the * costochondral junction.,POSTPROCEDURE INSTRUCTIONS:,1.  After a period of 30 minutes of observation, during which there was no distress and good relief of symptoms was noted, the patient was discharged home.,2.  The patient has been given instructions on watching for possible pneumothorax and any respiratory distress.  The patient will call us if any inflammation, swelling, or other associated discomfort arises.  We will call the patient in 48 hours.
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DESCRIPTION: Costochondral Cartilage Injection

Costochondral Cartilage Injection

pain management, costochondral cartilage injection, 0.5% marcaine, ap and lateral, costochondral, depo-medrol, costochondral junction, fluoroscopy, hypodermic needle, pneumothorax, subcutaneously, supine position, cartilage injection, costochondral cartilage, needle, distress, cartilage, injection,

The described procedure involves injecting medication into the costochondral cartilage junction under fluoroscopic guidance, which can be technically demanding and carries some risks, including potential pneumothorax. However, the procedure is relatively routine in pain management and does not inherently require immediate critical decisions or actions that could lead to significant immediate life-threatening consequences. Therefore, while there are risks involved, they are managed with standard precautions such as post-procedure monitoring and patient instructions.


Medical Specialty: Orthopedic
Sample Name: Tissue Expander Insertion

PREOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,POSTOPERATIVE DIAGNOSES: , History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,OPERATIONS:,1.  Wound debridement x2, including skin, subcutaneous, and muscle.,2.  Insertion of tissue expander to the medial wound.,3.  Insertion of tissue expander to the lateral wound.,COMPLICATIONS: , None.,TOURNIQUET: , None.,ANESTHESIA:  ,General.,INDICATIONS: , This patient developed a compartment syndrome.  She underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg.  She was doing very well and was obviously improving.,The swelling was reduced.  A compartment pressure had obviously improved based on examination.  She was therefore indicated for placement of tissue expander for ventral wound closure.  The risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well.  Risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  She understood them well.  All questions were answered, and she signed the consent for the procedure as described.,DESCRIPTION OF THE PROCEDURE:,  The patient was placed on the operating table and general anesthesia was achieved.  The medial wound was noted to be approximately 10.5 cm in length x 4 cm.  The lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width.  Both wounds were then thoroughly debrided.  The debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion.  This involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides.  At this point adequate debridement was performed and healthy tissue did appear to be present.  Initially on the medial wound I did place the DermaClose RC continuous external tissue expander.  On the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately.  I then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor.  I then did place adequate tension on the sutures.  Continued tension will be noted after engaging the tension controller.  At this point I performed the similar procedure to the lateral wound.  The skin anchors were placed separately and appropriately on either side of the skin margin.  The line loop from the tension controller was placed in lace like manner through the skin anchors.  The tension controller was then attached to the mid anchor and appropriate tension was applied.,It must be noted I did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained.  Adequate tension was placed in this region.  A non thick dressing was then applied to the open-wound region and sterile dressing was then applied.  No complications were encountered throughout the procedure and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.
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DESCRIPTION: History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle.  Insertion of tissue expander to the medial and lateral wound.

orthopedic, fasciotomy, subcutaneous, muscle, wound debridement, insertion of tissue expander, compartment syndrome, compartment fasciotomy, lateral wound, medial wound, tension controller, tissue expander, wound, tissue, compartment,

The situation involves a postoperative procedure following a serious condition (compartment syndrome), which could lead to severe complications if not treated properly. Although the surgery was performed without complications, the potential risks discussed with the patient (including bleeding, infection, and more) indicate significant medical stakes. The successful placement of tissue expanders is critical for proper healing and wound closure, making this a reasonably high-stakes situation in the context of patient outcomes and potential complications.


Medical Specialty: Surgery
Sample Name: Cleft Repair - Soft Palate

PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1.  Repair of cleft soft palate, CPT 42200.,2.  Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table.  After anesthesia was administered, time out was taken to ensure correct patient, procedure, and site.  The face was prepped and draped in a sterile fashion.  The right ear tag was examined first.  This was a small piece of skin and cartilaginous material protruding just from the tragus.  The lesion was excised and injected with 0.25% bupivacaine with epinephrine and then excised using an elliptical-style incision.  Dissection was carried down the subcutaneous tissue to remove any cartilaginous attachment to the tragus.  After this was done, the wound was cauterized and then closed using interrupted 5-0 Monocryl.  Attention was then turned towards the palate.  The Dingman mouthgag was inserted and the palate was injected with 0.25% bupivacaine with epinephrine.  After giving this 5 minutes to take effect, the palate was incised along its margins.  The anterior oral mucosa was lifted off and held demonstrating the underlying levator muscle.  Muscle was freed up from its attachments at the junction of the hard palate and swept down so that it will be approximated across the midline.  The Z-plasties were then designed, so there would be opposing Z-plasties from the nasal mucosa compared to the oral mucosa.  The nasal mucosa was sutured first using interrupted 4-0 Vicryl.  Next, the muscle was reapproximated using interrupted 4-0 Vicryl with an attempt to overlap the muscle in the midline.  In addition, the remnant of the uvula tissue was found and was sutured in such a place that it would add some extra bulk to the nasal surface of the palate.  Following this, the oral layer of mucosa was repaired using an opposing Z-plasty compared to the nasal layer.  This was also sutured in place using interrupted 4-0 Vicryl.  The anterior and posterior open edges of the palatal were sewn together.  The patient tolerated the procedure well.  Suction of blood and mucus performed at the end of the case.  The patient tolerated the procedure well.,IMMEDIATE COMPLICATIONS: , None.,DISPOSITION:,  In satisfactory condition to recovery.
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DESCRIPTION: Cleft soft palate.  Repair of cleft soft palate and excise accessory ear tag, right ear.

surgery, repair, tragus, oral mucosa, nasal mucosa, ear tag, soft palate, palate, cleft, soft

The situation involves a surgical procedure to repair a cleft soft palate, which is a significant medical intervention. The process requires precision, skill, and appropriate care to avoid complications that could impact the patient's quality of life. Furthermore, as it involves general anesthesia and surgical intervention on a vulnerable area, there is inherent risk involved, although the procedure described did not have immediate complications. This makes the stakes higher than routine medical check-ups but not at the level of emergency surgeries. Thus, it is moderately high-stakes.


Medical Specialty: Radiology
Sample Name: MRI Knee - 3

EXAM:,MRI LEFT KNEE,CLINICAL:,This is a 41 -year-old-male with knee pain, mobility loss and swelling. The patient had a twisting injury one week ago on 8/5/05. The examination was performed on 8/10/05,FINDINGS:,There is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear.,There is intrasubstance degeneration within the lateral meniscus, and there is a probable small tear in the anterior horn along the undersurface at the meniscal root.,There is an interstitial sprain/partial tear of the anterior cruciate ligament. There is no complete tear or discontinuity, and the ligament has a celery stick appearance.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a sprain of the femoral attachment of the fibular collateral ligament, without complete tear or discontinuity. The fibular attachment is intact.,Normal biceps femoris tendon, popliteus tendon and iliotibial band.,Normal quadriceps and patellar tendons.,There are no fractures.,There is arthrosis, with high-grade changes in the patellofemoral compartment, particularly along the midline patellar ridge and lateral facet. There are milder changes within the medial femorotibial compartments. There are subcortical cystic changes subjacent to the tibial spine, which appear chronic.,There is a joint effusion. There is synovial thickening.,IMPRESSION:,Probable small tear in the anterior horn of the lateral meniscus at the meniscal root.,Interstitial sprain/partial tear of the anterior cruciate ligament.,Arthrosis, joint effusion and synovial hypertrophy.,There are several areas of focal prominent medullary fat within the medial and lateral femoral condyles.
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DESCRIPTION: MRI left knee.

MRI left knee.

radiology, mri left knee, interstitial sprain/partial tear, anterior cruciate ligament, lateral meniscus, cruciate ligament, synovial, mri, meniscus, sprain/partial, cruciate, knee, ligament

The situation involves interpreting MRI findings to diagnose a knee injury. Although the findings such as ligament sprain, meniscus tears, and arthrosis are significant for patient treatment and recovery, they are not typically life-threatening on their own. The situation, while clinically important, does not involve immediate life-or-death decisions, but may affect the patient's mobility and lifestyle if not properly managed.


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

CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great.  Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain:  Localized to the bilateral knees right worse than left.,Quality:  There is no swelling, no redness, or warmth.  The pain is described as aching occasionally.  There is no burning. ,Duration:  Months.,Associated symptoms:  Includes stiffness and weakness.  There is no sleep loss and no instability.  ,Hip Pain:  None. ,Back pain: None. ,Radicular type pain:  None. ,Modifying factors: Includes weight bearing pain and pain with ambulation.  There is no sitting, and no night pain.  There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:,  No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living.  ,REVIEW OF SYSTEMS:,  No change.,Constitutional:  Good appetite and energy.  No fever.  No general complaints.,HEENT:  No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP:  No shortness of breath at rest or with exertion.  No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum.  No chest pain on exertion.,GI:
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DESCRIPTION: Orthopedic progress note for follow up of osteoarthritis, knees.

The progress note details a follow-up for a common condition, osteoarthritis, and describes the patient's condition as stable. There is no indication of immediate life-threatening symptoms or urgent medical interventions required. While the pain levels assessed are high (VAS pain score of 10), osteoarthritis is typically a chronic condition managed over time. Therefore, the stakes are primarily related to ongoing management rather than immediate medical crisis.


Medical Specialty: Surgery
Sample Name: Retrograde Pyelogram & Cystourethroscopy

PREOPERATIVE DIAGNOSIS: , Right ureteral calculus.,POSTOPERATIVE DIAGNOSIS: , Right ureteropelvic junction calculus.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right double-J stent placement 22 x 4.5 mm.,FIRST SECOND ANESTHESIA: , General.,SPECIMEN:,  Urine for culture and sensitivity.,DRAINS: , 22 x 4.5 mm right double-J ureteral stent.,PROCEDURE: , After consent was obtained, the patient was brought to operating room and placed in the supine position.  She was given general anesthesia and then placed in the dorsal lithotomy position.  A #21 French cystoscope was then passed through the urethra into the bladder.  There was noted to be some tightness of the urethra on passage.  On visualization of the bladder, there were no stones or any other debris within the bladder.  There were no abnormalities seen.  No masses, diverticuli, or other abnormal findings.  Attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter, however, the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter.  The cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis.  An open-end ureteral catheter was then passed ________ into the distal right ureter.  Retrograde pyelogram was then performed.,There was noted to be an UPJ calculus with no noted hydronephrosis.  The wire was then passed back through the ureteral catheter.  The catheter was removed and a 22 x 4.5 mm double-J ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance.  The stent was clear within the kidney as well as within the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  She will be discharged home.  She is to follow up with Dr. X for ESWL procedure.  She will be given prescription for Darvocet and will be asked to have a KUB x-ray done prior to her followup and to bring them with her to her appointment.
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DESCRIPTION: Cystourethroscopy, right retrograde pyelogram, and right double-J stent placement 22 x 4.5 mm.  Right ureteropelvic junction calculus.

surgery, ureteropelvic junction, calculus, cystourethroscopy, retrograde pyelogram, double-j stent placement, double j stent, cone tip catheter, ureteral stent, ureteral orifice, ureteral catheter, retrograde, pyelogram, catheter, ureteral

The situation involves a surgical procedure that, while routine in the field of urology, still carries inherent risks such as complications from anesthesia, potential for infection, or complications from stent placement. However, it appears the procedure went smoothly and the patient is expected to recover well and be discharged. The need for a follow-up ESWL indicates a planned continuation of care for the patient's condition. This is a mid-range stakes situation due to successful surgery and clear plans for follow-up care.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Chest Pain

CHIEF COMPLAINT:,  Multiple problems, main one is chest pain at night.,HISTORY OF PRESENT ILLNESS:,  This is a 60-year-old female with multiple problems as numbered below:,1.  She reports that she has chest pain at night.  This happened last year exactly the same.  She went to see Dr. Murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month.  She wakes in the middle of the night and reports that she has a pressure.  It is mild-to-moderate in the middle of her chest and will stay there as long she lies down.  If she gets up, it goes away within 15 minutes.  It is currently been gone on for the last week.  She denies any fast heartbeats or irregular heartbeats at this time.,2.  She has been having stomach pains that started about a month ago.  This occurs during the daytime.  It has no relationship to foods.  It is mild in nature, located in the mid epigastric area.  It has been better for one week as well.,3.  She continues to have reflux, has noticed that if she stops taking Aciphex, then she has symptoms.  If she takes her Aciphex, she seems that she has the reflux belching, burping, and heartburn under control.,4.  She has right flank pain when she lies down.  She has had this off and on for four months.  It is a dull achy pain.  It is mild in nature.,5.  She has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past.  It is not painful.,6.  She has had spots in her armpits initially on the right side and then going to the left side.  They are not itchy.,7.  She is having problems with urgency of urine.  When she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking.  She is wearing a pad now.,8.  She is requesting a colonoscopy for screening as well.  She is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer.,9.  She has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months.  There has been no swelling or redness or trauma to these areas.,REVIEW OF SYSTEMS:,  She has recently been to the eye doctor.  She has noticed some hearing loss gradually.  She denies any problems with swallowing.  She denies episodes of shortness of breath, although she has had a little bit of chronic cough.  She has had normal bowel movements.  Denies any black or bloody stools, diarrhea, or constipation.  Denies seeing blood in her urine and has had no urinary problems other than what is stated above.  She has had no problems with edema or lower extremity numbness or tingling.,SOCIAL HISTORY:,  She works at nursing home.  She is a nonsmoker.  She is currently trying to lose weight.  She is on the diet and has lost several pounds in the last several months.  She quit smoking in 1972.,FAMILY HISTORY: , Her father has type I diabetes and heart disease.  She has a brother who had heart attack at the age of 52.  He is a smoker.,PAST MEDICAL HISTORY:,  Episodic leukopenia and mild irritable bowel syndrome.,CURRENT MEDICATIONS:,  Aciphex 20 mg q.d. and aspirin 81 mg q.d.,ALLERGIES:,  No known medical allergies.,OBJECTIVE:,Vital Signs:  Weight:  142 pounds.  Blood pressure:  132/78.  Pulse:  72.,General:  This is a well-developed adult female who is awake, alert, and in no acute distress.,HEENT:  Her pupils are equally round and reactive to light.  Conjunctivae are white.  TMs look normal bilaterally.  Oropharynx appears to be normal.  Dentition is excellent.,Neck:  Supple without lymphadenopathy or thyromegaly.,Lungs:  Clear with normal respiratory effort.,Heart:  Regular rhythm and rate without murmur.  Radial pulses are normal bilaterally.,Abdomen:  Soft, nontender, and nondistended without organomegaly.,Extremities:  Examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the PIP joint and DIP joint.  Her armpits are examined.  She has what appears to be a tinea versicolor rash present in the armpits bilaterally.  She has a lesion on her left shoulder, which is 6 mm in diameter.  It has diffuse borders and is slightly red.  It has two brown spots in it.  In her lower extremities, there is no cyanosis or edema.  Pulses at the radial and posterior tibial pulses are normal bilaterally.  Her gait is normal.,Psychiatric:  Her affect is pleasant and positive.,Neurological:  She is grossly intact.  Her speech seems to be clear.  Her coordination of upper and lower extremities is normal.,ASSESSMENT/PLAN:,1.  Chest pain.  At this point, because of Dr. Murphy’s evaluation last year and the symptoms exactly the same, I think this is noncardiac.  My intonation is that this is reflux.  I am going have her double her Aciphex or increase it to b.i.d., and I am going to have her see Dr. XYZ for possible EGD if he thinks that would be appropriate.  She is to let me know if her symptoms are getting worse or if she is having any severe episodes.,2.  Stomach pain, uncertain at this point, but I feel like this is probably related as well to chest pain.,3.  Suspicious lesions on the left shoulder.  We will do a punch biopsy and set her up for an appointment for that.,4.  Tinea versicolor in the axillary area.  I have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days.,5.  Cystocele.  We will have her see Dr. XYZ for further discussion of repair due to her urinary incontinence.,6.  History of leukopenia.  We will check a CBC.,7.  Pain in the thumbs, probably arthritic in nature, observe for now.,8.  Screening.  We will have her see Dr. XYZ for discussion of colon cancer screening.,9.  Gastroesophageal reflux disease.  I have increased Aciphex to b.i.d. for now.
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DESCRIPTION: Patient with multiple problems, main one is chest pain at night.

The patient's main complaint of chest pain has been assessed by a previous doctor with no cardiovascular disease found, and symptoms were previously resolved. The doctor suspects the pain is related to reflux rather than a cardiac issue. Other issues include potential arthritic pain, epidermal lesions requiring biopsy, and incontinence due to suspected cystocele. None of these individual issues currently present as emergencies or highly critical cases. While some follow-up actions are needed, such as biopsy and referral for possible surgery, there are no immediate, life-threatening conditions reported. The presence of multiple symptoms and issues does increase complexity but does not equate to high stakes as each issue appears manageable at present.


Medical Specialty: Orthopedic
Sample Name: Anterior Cruciate Ligament Reconstruction

PREOPERATIVE DIAGNOSIS: , Anterior cruciate ligament rupture.,POSTOPERATIVE DIAGNOSES:,1.  Anterior cruciate ligament rupture.,2.  Medial meniscal tear.,3.  Medial femoral chondromalacia.,4.  Intraarticular loose bodies.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2.  Removal of loose bodies.,3.  Medial femoral chondroplasty.,4.  Medial meniscoplasty.,OPERATIVE PROCEDURE:  ,The patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the Department of Anesthesia.  Following this, the knee was sterilely prepped and draped as discussed for this procedure.  The inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region.  After the notch was identified, then ACL was confirmed and ruptured.  There was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface.  The snare was smoothed out.  Entire area was thoroughly irrigated.  Following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage.  The areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing.  There were multiple loose bodies noted in the knee and these were then __________ and then removed.  The tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed.  The knee was taken through a full range of motion without any impingement.  An Endobutton was used for proximal fixation.  Distal fixation was obtained with an independent screw and a staple.  The patient was then taken to Postanesthesia Care Unit at the conclusion of the procedure.,
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DESCRIPTION: Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.  Removal of loose bodies.  Medial femoral chondroplasty and meniscoplasty.

orthopedic, femoral chondroplasty, intraarticular loose bodies, anterior cruciate ligament reconstruction, anterior, arthroscopy, meniscoplasty, fixation, reconstruction, chondroplasty, ligament, femoral, intraarticular, medial

The scenario involves a surgical procedure for anterior cruciate ligament (ACL) reconstruction, which is a common orthopedic surgery aimed at restoring knee stability. Despite it being a routine procedure, surgery always carries some inherent risks such as infection, bleeding, or complications from anesthesia. However, it is not typically life-threatening unless there is an unexpected complication. Therefore, while the stakes are significant in terms of potential impact on the patient's mobility and quality of life, it does not represent the highest level of stakes relative to other medical procedures like cardiac or neurological surgeries.


Medical Specialty: General Medicine
Sample Name: Nausea - ER Visit

CHIEF COMPLAINT: , Nausea and feeling faint.,HPI:  ,The patient is a 74-year-old white female brought in by husband.  The patient is a vague historian at times.  She reports her appetite has been fair over the last several days.  Today, she complains of some nausea.  She feels weak.  No other specific complaints.,REVIEW OF SYSTEMS:  ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS:  ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY:  ,COPD and hypertension.,HABITS:  ,Tobacco use, averages two cigarettes per day.  Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY:  ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2, pulse is 105, respirations 20, and BP 137/80.  GENERAL:  A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated.  SKIN:  Warm, dry, and good color.  EYES:  EOMI.  PERRL.  MOUTH:  Clear.  Mucous membranes moist.  NECK:  Supple.  No JVD.  LUNGS:  Reveal faint expiratory wheeze heard in the posterior lung fields.  HEART:  Slightly tachycardic without murmur.  ABDOMEN:  Soft, positive bowel sounds, and nontender.  No rebound or guarding is appreciated.  BACK:  No CVA tenderness.  EXTREMITIES:  Moves all four extremities.  No pretibial edema.  NEURO:  Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils.  Hemoglobin 10.7 and hematocrit 31.2 both are decreased.  Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2.  Amylase and lipase both normal.  Clean catch urinalysis is unremarkable.  Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7.  It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD.  Monitor indicates sinus tachycardia at rate 103.  No ectopy.,ED COURSE:  ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse.  The patient was given albuterol unit dose small volume nebulizer treatment.  Repeat lung exam reveals resolution of expiratory wheezing.  The patient later had normal saline lock started by the nurse.  She was given IV fluids of normal saline 1L wide open over approximately one hour.  She was able to void urine indicating that she is well hydrated.  Rectal examination was performed with female nurse in attendance.  Good sphincter tone.  No masses.  The rectal secretions were heme negative.  The patient was reassessed.  She feels slightly better.  Monitor now shows normal sinus rhythm, rate 81, no ectopy.  Blood pressure is 136/66.  The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history.  Laboratory evaluation today indicates the following problems, anemia and hyponatremia.  This could contribute the patient's feelings of tiredness and not feeling well.  There is no evidence of rectal bleeding at this time.  The patient was advised that she needs to follow up with Dr. X to further investigate these problems.  The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1.  Acute tiredness.,2.  Anemia of unknown etiology.,3.  Acute hyponatremia.,PLAN:  ,The patient is advised to put salt on her food for the next week.  Should be given discharge instruction sheet for anemia.  Recommend follow up with personal physician, Dr. X in two to three days for recheck.  Return to ED sooner if condition changes or worsen anyway.  Discharged in stable condition.
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DESCRIPTION: Nausea and feeling faint.  She complains of some nausea.  She feels weak.  The patient is advised to put salt on her food for the next week.

The situation involves a 74-year-old patient presenting in the ER with nausea, feeling faint, and general weakness. The stakes are moderate due to the patient's age and underlying conditions such as COPD and hypertension, which require careful monitoring. The lab results indicate anemia and hyponatremia, which are not life-threatening in their current state but require further investigation and follow-up. The patient is stable enough to be discharged with follow-up care instructions. The elements of uncertainty and the potential for more serious underlying conditions slightly increase the stakes, but given the current findings and the stabilization in the ER, it is not an extremely high-stakes situation at this moment.


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

Medical Specialty: Surgery
Sample Name: Bunionectomy & Flexor Tenotomy

PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1.  Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4.  Flexor tenotomy, bilateral third toes.,HISTORY:,  This is a 36-year-old female who presented to ABCD preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet.  The patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation.  She has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief.  At this time, she desires attempted surgical correction.  The risks versus benefits of the procedure have been discussed in detail by Dr. Kaczander with the patient and the consent is available on the chart.,PROCEDURE IN DETAIL:,  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,Copious amounts of Webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the Webril.  After adequate IV sedation was administered, a total of 18 cc of a 0.5% Marcaine plain was used to anesthetize the right foot, performing a Mayo block and a bilateral third, fourth, and fifth digital block.  Next, the foot was prepped and draped in the usual aseptic fashion bilaterally.  The foot was elevated off the table and an Esmarch bandage was used to exsanguinate the right foot.  The pneumatic ankle tourniquet was elevated on the right foot to 200 mmHg.  The foot was lowered into operative field and the sterile stockinet was reflected proximally.  Attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux.  There was decreased range of motion of the first metatarsophalangeal joint.  A dorsolinear incision was made with a #10 blade, approximately 4 cm in length.  The incision was deepened to the subcutaneous layer with a #15 blade.  Any small veins traversing the subcutaneous layer were ligated with electrocautery.  Next, the medial and lateral wound margins were undermined sharply.  Care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Next, the first metatarsal joint capsule was identified.  A #15 blade was used to make a linear capsular incision down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  The PASA was found to be within normal limits.  There was a hypertrophic medial eminence noted.  A sagittal saw was used to remove the hypertrophic medial eminence.  A 0.045 inch Kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide.  A standard lateral release was performed.  The fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly.  Next, a sagittal saw was used to perform a long arm Austin osteotomy.  The K-wire was removed.  The capital fragment was shifted laterally and impacted into the head.  A 0.045 inch Kirschner wire was used to temporarily fixate the osteotomy.  A 2.7 x 16 mm Synthes, fully threaded cortical screw was throne using standard AO technique.  A second screw was throne, which was a 2.0 x 12 mm Synthes cortical screw.  Excellent fixation was achieved and the screws tightly perched the bone.  Next, the medial overhanging wedge was removed with a sagittal saw.  A reciprocating rasp was used to smooth all bony prominences.  The 0.045 inch Kirschner wire was removed.  The screws were checked again for tightness and found to be very tight.  The joint was flushed with copious amounts of sterile saline.  A #3-0 Vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique.  A #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted technique.  A #5-0 Monocryl was used to close the skin in a running subcuticular fashion.,Attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint.  A #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint.  The incision was deepened with a #15 blade.  The wedge of skin was removed in full thickness.  The long extensor tendon was identified and the distal and proximal borders of the wound were undermined.  The #15 blade was used to transect the long extensor tendon, which was reflected proximally.  The distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released.  Crown and collar scissors were used to release the planar attachment to the head of the middle phalanx.  Next, a double action bone cutter was used to resect the head of the middle phalanx.  The toe was dorsiflexed and was found to have an excellent rectus position.  A hand rasp was used to smooth all bony surfaces.  The joint was flushed with copious amounts of sterile saline.  The flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision.  Next, #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,Attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated.  An oblique skin incision with two converging semi-elliptical incisions was created using #15 blade.  The rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot.  All the same suture materials were used.  However, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,Attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint.  A linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint.  Next, a #15 blade was used to deepen the incision to the subcutaneous layer.  The medial and lateral margins were undermined sharply to the level of the long extensor tendon.  The proximal interphalangeal joint was identified and the tendon was transected with the #15 blade.  The tendon was reflected proximally, off the head of the proximal phalanx.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  A double action bone nibbler was used to remove the head of the proximal phalanx.  A hand rasp was used to smooth residual bone.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to close the long extensor tendon with two simple interrupted sutures.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,A standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, Kerlix, Kling, and Coban were applied.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,Attention was directed to the left foot.  The foot was elevated off the table and exsanguinated with an Esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmHg.  Attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint.  The exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,Attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated.  The exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle.  The same suture material were used to close the incision.,Attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint.  The same procedure performed on the right third digit was also performed.  The same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit.  A standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot.  The pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the foot.  She was given postoperative shoes and will be partial weighbearing with crutches.  She was admitted short-stay to Dr. Kaczander for pain control.  She was placed on Demerol 50 and Vistaril 25 mg IM q3-4h. p.r.n. for pain.  She will have Vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain.  She was placed on Subq. heparin and given incentive spirometry 10 times an hour.  She will be discharged tomorrow.  She is to ice and elevate both feet today and rest as much as possible.,Physical Therapy will teach her crutch training today.  X-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.
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DESCRIPTION: Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.  Proximal interphalangeal joint arthroplasty, bilateral fifth toes.  Distal interphalangeal joint arthroplasty, bilateral third and fourth toes.   Flexor tenotomy, bilateral third toes.

surgery, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, blade, proximal, foot, joint, toes, tendon,

The scenario describes a surgical procedure involving multiple corrections on both feet, including bunionectomy and tenotomy. Surgical procedures inherently carry significant risks such as complications from anesthesia, infection, and post-operative complications like improper healing or vascular issues. The detailed procedure notes in the sample indicate it is being conducted in a medical setting with proper monitoring, which is standard for surgical operations and helps mitigate risks. There is informed consent, and the patient is managed for pain and monitored afterward, adding to the complexity and stakes of the situation. Although the procedure itself is fairly routine in nature, the stakes remain high due to the potential for complications during and after surgery, patient recovery, and the quality of the surgical outcome affecting patient's mobility and quality of life. However, it's not among the most critical or life-threatening types of surgery, thereby not reaching the top of the scale.


Medical Specialty: Hematology - Oncology
Sample Name: Nuclear Medicine Lymphatic Scan

EXAM:,  Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,FINDINGS:  ,There are two small foci of increased activity in the left axilla.  This is consistent with the sentinel lymph node.  No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,IMPRESSION:  ,Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.
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DESCRIPTION: Left breast cancer.  Nuclear medicine lymphatic scan.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.

hematology - oncology, technetium-99m, mci, biopsy, breast cancer, nuclear medicine, lymphatic scan, lymph node, nuclear, breast,

The lymphatic scan results indicate that the tracer used in the procedure has localized two small foci of increased activity in the axilla, which are consistent with the sentinel lymph nodes. This finding is crucial in the staging and treatment plan for breast cancer. Identifying and analyzing the sentinel lymph nodes is a critical step in evaluating the spread of cancer and determining the appropriate course of action. Therefore, this scenario involves significant medical implications and decisions regarding the patient's treatment strategy, making it a high-stakes situation.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Reactive Airway Disease

CHIEF COMPLAINT AND IDENTIFICATION:,  A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough.  She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom.  She has been taking 1 teaspoon every 6 hours.  She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis.  She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness.  All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots.  She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:,  Her maternal uncles have asthma.  There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts.  The family lives in Delano.  She lives with her mom and sister.  The dad is involved, but the parents are separated.  There is no smoking exposure.,PHYSICAL EXAMINATION:,  ,GENERAL:  The child was in no acute distress.,VITAL SIGNS:  Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28.  Oxygen saturations 98% on continuous.  Off of oxygen shows 85% laying down on room air.  The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN:  Clear.,HEENT:  Pupils were equal, round, react to light.  No conjunctival injection or discharge.  Tympanic membranes were clear.  No nasal discharge.  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly, or masses.,CHEST:  Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds are present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY:  No inguinal lymphadenopathy.  Tanner stage I female.,EXTREMITIES:  Symmetric in length.  No joint effusions.  She moves all extremities well.,BACK:  Straight.  No spinous defects.,NEUROLOGIC:  The patient has a normal neurologic exam.  She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive.  She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate.  Metabolic panel:  Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3.  White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000.  Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress.  I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment.  She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage.  She is being admitted for hypoxemia.  I hope that this will resolve overnight, and she will be discharged in the morning.  I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course.
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DESCRIPTION: A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.

The situation involves a 23-month-old girl with a history of reactive airway disease, now diagnosed with bacterial pneumonia and presenting with significant symptoms such as respiratory distress and hypoxemia, which resulted in a necessary hospital admission. The high-stakes nature is due to the young age of the patient, the seriousness of the symptoms (notably, the respiratory distress and hypoxemia), and the fact that she was previously receiving treatment on an outpatient basis that failed. However, she's currently stable under hospital care. Therefore, while the situation is serious, it is being actively managed in a controlled environment.