Medical Specialty: Cardiovascular / Pulmonary
Sample Name: DDDR Permanent Pacemaker

PROCEDURES PERFORMED:,1.  DDDR permanent pacemaker.,2.  Insertion of a steroid-eluting screw in right atrial lead.,3.  Insertion of a steroid-eluting screw in right ventricular apical lead.,4.  Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length.  They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure.  The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner.  We also scrubbed for approximately eight minutes.  Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized.  Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein.  The Cook needles were removed.  Then the guidewires were secured in place with hemostat.  Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle.  The skin was then undermined making a pocket for the generator.  The guidewires were then tunneled through the performed pocket.  Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively.  Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed.  After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead.  After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture.  The leads were then connected to a pulse generator.  The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket.  The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique.  The area was then cleansed and dry.  Steri-Strips and pressure dressing were applied.  The patient tolerated the procedure well.  There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name:  Sigma.,Model #:  SDR203.,Serial #:  123456.,ATRIAL LEAD,Model #:  4568-45 cm.,Serial #:  123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #:  4068-52 cm.,Serial #:  123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking.  Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking.  The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well.  There were no complications.  The patient went to Recovery in satisfactory condition.  Family was updated.  Orders are all in the chart.  Please see orders.,Again, thank you for allowing to participate in this care.
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DESCRIPTION: DDDR permanent pacemaker, insertion of a steroid-eluting screw in right atrial lead, insertion of a steroid-eluting screw in right ventricular apical lead, pulse generator insertion, model Sigma,

The procedure of inserting a DDDR permanent pacemaker is critical since it addresses symptomatic bradycardia and other heart complications. However, the procedure was executed without complications, the patient tolerated it well, and all relevant consents were obtained, indicating careful preparation and low immediate risk. The stakes, while significant given the patient's condition, are managed well due to the protocol adherence and lack of complications, which slightly lowers the stakes post-procedure.


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

Medical Specialty: Radiology
Sample Name: MRI Knee - 4

EXAM:,MRI OF THE LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain. Twisting injury.,FINDINGS:,The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. Mildly increased bone signal overlying the inferolateral portion of the patella is identified. No significant degenerative changes about the patella can be seen. The quadriceps tendon as well as the infrapatellar ligament both look intact. There is some prepatellar soft tissue edema.,The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. NO significant areas of bone edema are appreciated.,There is soft tissue edema along the lateral aspect of the knee. There is a partial tear of the lateral collateral ligament complex. The medial collateral ligament complex looks intact. A small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,The posterior cruciate ligament looks intact. The anterior cruciate ligament is thickened with significant increased signal. I suspect at least a high grade partial tear.,The posterior horn of the medial meniscus shows some myxoid degenerative changes. The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. I don’t see a definite tear extending to the articular surface.,IMPRESSION:,Sizeable joint effusion which is complex and may contain blood products.,Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,Soft tissue swelling and partial tear of the lateral collateral ligament complex.,At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,The posterior cruciate ligament is intact.,Injury to the patellar cartilage as above.
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DESCRIPTION: MRI left knee without contrast.

MRI left knee without contrast.

radiology, lateral collateral ligament, medial collateral ligament, posterior cruciate ligament, anterior cruciate ligament, collateral ligament complex, myxoid degenerative, partial tear, collateral ligament, ligament complex, cruciate ligament, mri, effusion, cartilage, collateral, cruciate, knee, tear, ligament

This MRI report indicates significant injuries to the knee, including a high grade partial tear of the anterior cruciate ligament (ACL), a partial tear of the lateral collateral ligament (LCL), and injury to the patellar cartilage. These injuries can lead to joint instability, pain, and functional limitations, affecting the patient's mobility and quality of life. Immediate medical evaluation and possibly surgical intervention might be required to prevent further damage and to restore knee function. Therefore, the situation involves significant medical decisions that can impact the patient's health and wellbeing.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracotomy & Pleurectomy

PREOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,POSTOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,PROCEDURE: , Left thoracotomy with total pulmonary decortication and parietal pleurectomy.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube.  A time-out process had been followed and preoperative antibiotics were given.,The patient was positioned with the left side up for a left thoracotomy.  The patient was prepped and draped in the usual fashion.  A posterolateral thoracotomy was performed.  It included the previous incision.  The chest was entered through the fifth intercostal space.  Actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke.  Thanks to Dr. X's ingenuity, we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura.  We aspirated an abundant amount of pus from this cavity.  The sample was taken for culture and sensitivity.,Then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm.  Once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung.  Further samples for culture and sensitivity were sent.,Then, we were left with the trapped lung.  It was trapped by thickened visceral pleura.  This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively.  Finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily.  There was only one area towards the mediastinum that apparently I was not able to fill.  This area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so I restrained from doing that.  Two large chest tubes were placed.  The cavity had been abundantly irrigated with warm saline.  Then, the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.,The chest tubes were affixed to the skin with heavy sutures of silk.  Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.,Estimated blood loss was about 500 mL.  The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition.
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DESCRIPTION: Left thoracotomy with total pulmonary decortication and parietal pleurectomy.  Empyema of the chest, left.

cardiovascular / pulmonary, total pulmonary decortication, pulmonary decortication, parietal pleurectomy, endotracheal tube, chest retractor, chest tubes, parietal pleura, pleurectomy, empyema, endotracheal, thoracotomy, pleura, chest

The situation involves a complex surgical procedure to treat empyema of the chest, which is a serious condition requiring significant surgical intervention. A thoracotomy with decortication and pleurectomy involves risks such as bleeding, infection, and potential damage to the lung, as indicated by the difficulty in removing the parietal pleura without injury. The procedure has potential life-threatening complications if not managed correctly, affecting the respiratory system critical for survival. However, since the patient tolerated the procedure well and was in satisfactory post-operative condition, the acute risk appears to have been well-managed. This indicates high stakes, primarily during the surgical intervention and immediate recovery, but they seem to have been effectively handled by the medical team.


Medical Specialty: Surgery
Sample Name: SynchroMed Pump Placement

PROCEDURES:,1.  Placement of SynchroMed infusion pump.,2.  Tunneling of SynchroMed infusion pump catheter,3.  Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position.  The patient was prepped and draped in a sterile manner.  The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter.  This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle.  A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle.  The needle was withdrawn.  The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak.  The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure.  The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene.  Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created.  Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery.  A pocket was created that would encompass the SynchroMed fusion pump.  A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device.  The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision.  The intrathecal catheter was trimmed.  A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together.  The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties.  Good CSF was then demonstrated flowing through the SynchroMed pump catheter.  The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie.  Excess catheter was coiled and placed behind the pump.  The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall.  The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed.  The subcutaneous tissues were irrigated with normal saline.  The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl.  The skin of both wounds was closed with staples.  Antibiotic ointment and a sterile dressing were applied.  The patient was awake and taken to the recovery room.  The patient tolerated the procedure well and was stable at the completion of the procedure.  All sponge and lap, needle and instrument counts were correct at the completion of the procedure.
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DESCRIPTION: Placement of SynchroMed infusion pump and tunneling of SynchroMed infusion pump catheter.  Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.

surgery, intrathecal, catheter, paraspinous, cerebrospinal, synchromed infusion pump, synchromed pump catheter, synchromed pump, paraspinous muscle, cerebrospinal fluid, tunneling device, infusion pump, subcutaneous tissue, infusion, synchromed, pump, incision,

The placement of a SynchroMed infusion pump is a surgical procedure that requires precision and skill, highlighting its complexity and potential risks. This procedure involves anesthesia, tunneling, and precise placement of medical devices, so the stakes are significant because any errors could lead to complications such as infection, bleeding, or incorrect drug infusion. However, it is not as high-stakes as life-threatening surgeries such as organ transplants or heart surgeries, but it is still a serious medical procedure. The description indicates that it was performed under stable conditions with the patient tolerating it well, suggesting efficient handling by the surgical team.


Medical Specialty: Radiology
Sample Name: EMG/Nerve Conduction Study - 1

HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand.  She denies any weakness.  No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past.  She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left.  Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES:  ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity.  The left median sensory distal latency is prolonged with an attenuated evoked response amplitude.  The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude.  The right median motor distal latency and evoked response amplitude is normal.  Left ulnar motor and sensory and left radial sensory responses are normal.  Left median F-wave is normal.,NEEDLE EMG:,  Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles.  It revealed spontaneous activity in the left abductor pollicis brevis muscle.  There is increased insertional activity in the right first dorsal interosseous muscle.  Both interosseous muscles showed signs of reinnervation.  Left extensor digitorum communis muscle showed evidence of reduced recruitment.  Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:  A left median neuropathy at the wrist consistent with carpal tunnel syndrome.  Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies.  This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ.  She will follow up with Dr. XYZ with respect to treatment of the above conditions.
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DESCRIPTION: The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.

radiology, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduction, conduction study, median motor, needle emg, distal latency, evoked response, emg/nerve, bilateral, evoked, conduction,

The situation involves a medical assessment that identifies carpal tunnel syndrome and possible C8 radiculopathy in the patient. The findings indicate the presence of nerve issues that require further exploration through an MRI and subsequent follow-up. While such conditions can impact quality of life and functional abilities, they are not typically considered life-threatening or critically urgent. Therefore, the situation is not high-stakes in terms of immediate risk, but it is important for the patient's ongoing health and functionality.


Medical Specialty: General Medicine
Sample Name: Post Thyroidectomy - Discharge Summary

ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS:  ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY:  ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter.  She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,HOSPITAL COURSE:  ,The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period.  On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs.  She required intravenous narcotics for pain control.  She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control.  The wound was clean and dry.  The drain was removed.  She was instructed to follow up in the surgical office within one week after discharge.  She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.
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DESCRIPTION: Symptomatic thyroid goiter.  Total thyroidectomy.

general medicine, nodular, symptomatic thyroid goiter, thyroidectomy, goiter,

The situation involves a post-operative discharge summary for a patient who underwent a total thyroidectomy due to a symptomatic thyroid goiter. While surgical procedures and post-operative care inherently carry some risk, this case appears to be stable. The patient had a successful surgery, stable recovery, and the discharge plan seems routine with standard follow-up care and medication prescribed. There are no immediate or severe complications described. Hence, in the context of general medical operations and patient discharges, this situation is not high-stakes.


Medical Specialty: Surgery
Sample Name: Vasectomy - 2

DIAGNOSIS:,  Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:,  General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic.  No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound.  Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two.  He tolerated the procedure well.  A sterile dressing was applied.  He was awakened and transferred to the recovery room in stable condition.
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DESCRIPTION: Normal vasectomy

Normal vasectomy

surgery, scrotal incision, right vas, bleeding, anesthesia, vasectomy

This situation involves a routine vasectomy procedure, which is considered a low-risk surgical operation. The procedure described went smoothly, with no bleeding and the patient being in stable condition post-operation. Although surgery typically carries some inherent risks, vasectomies are common and have a high success rate. Therefore, the stakes involved in this specific case are relatively low.


Medical Specialty: Surgery
Sample Name: Eyelid Squamous Cell Carcinoma Excision

PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:,  Local with sedation.,INDICATION:,  The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion.  He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids.  The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes.  This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid.  The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact.  Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate.  The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma.  Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid.  The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures.  An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition.
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DESCRIPTION: Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.

surgery, frozen section, full-thickness skin grafting, squamous cell carcinoma, eyelid, orbicularis,

The situation involves the surgical excision of squamous cell carcinoma from the eyelid, a procedure that entails careful removal of the cancer along with a reconstruction step using a skin graft from the opposite eyelid. The surgery is intricate because it deals with the eye, a sensitive and complex area, and requires meticulous technique to ensure functional and aesthetic outcomes. Although the procedure was completed without complications and the patient tolerated it well, surgeries around crucial areas like the eye involve considerable risks related to vision, aesthetics, and overall function, making this a high-stakes situation. However, given the absence of complications and minimal blood loss, it isn't at the absolute highest level of stakes.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 2

PREOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:,  General.,FINDINGS:,  The gallbladder was thickened and showed evidence of chronic cholecystitis.  There was a great deal of inflammatory reaction around the cystic duct.  The cystic duct was slightly larger.  There was a stone impacted in the cystic duct with the gallbladder.  The gallbladder contained numerous stones which were small.  With the stone impacted in the cystic duct, it was felt that probably none were within the common duct.  Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:,  Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully.  Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out.  This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct.  In this manner, the cystic duct and cystic artery were dissected out.  Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct.  The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct.  The gallbladder was then dissected free from the gallbladder bed.  Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction.  The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding.  The gallbladder was extracted through the operating trocar site, and the trocar was reinserted.  Inspection was made of the gallbladder bed.  One or two bleeding areas were fulgurated, and bleeding was well controlled.
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DESCRIPTION: Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis.

surgery, cholelithiasis chronic, inflammatory reaction, cystic artery, laparoscopic cholecystectomy, common duct, chronic cholecystitis, gallbladder bed, cystic duct, cystic, gallbladder, duct, inflammatory

The situation described is a laparoscopic cholecystectomy, which is a common surgical procedure to remove the gallbladder in patients with cholelithiasis (gallstones) and chronic cholecystitis. While this procedure is routine, it still involves risks typically associated with surgery, such as infection, bleeding, and injury to nearby structures like the common bile duct. Furthermore, the presence of complications like a stone impacted in the cystic duct and fibrosis from chronic inflammation increases the complexity. The procedure was successfully carried out without complications, but it still involves high-stakes elements due to the potential for surgical complications and the need for general anesthesia.


Medical Specialty: Consult - History and Phy.
Sample Name: Malignant Meningioma - Consult

REASON FOR VISIT: , This is a new patient evaluation for Mr. A. There is a malignant meningioma.  He is referred by Dr. X.,HISTORY OF PRESENT ILLNESS: , He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07.  He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.  He is unable to stand at the moment.  He is unable to care for himself. ,I reviewed the information that was sent down with him from the nursing home which includes his medical history.,MEDICATIONS:  ,Keppra 1500 twice a day and Decadron 6 mg four times a day.  His other medicines include oxycodone, an aspirin a day, Prilosec, Dilantin 300 a day, and Flagyl.,FINDINGS:,  On examination, he is lying on the stretcher.  He has oxygen on and has periods of spontaneous hyperventilation.  He is unable to lift his right arm or right leg.  He has an expressive dysphasia and confusion.,I reviewed the imaging studies from summer from the beginning of 10/07, end of 10/07 as well as the current MRI he had last week.  This shows that he has had progression of disease with recurrence along the surface of the brain and there is significant brain edema.  This is a malignant meningioma by diagnosis.,ASSESSMENT/PLAN: , In summary, Mr. A has significant disability and is not independent currently.  I believe that because of this that the likelihood of benefit from surgery is small and there is a very good chance that he would not be able to recover from surgery.  I do not think that surgery will help his quality of life and a need to control the tumor would be dependent on another therapy impacting the tumor.  Given that there are not good therapies and chemotherapy would be the option at the moment, and he certainly is not in a condition where chemotherapy would be given, I believe that surgery would not be in his best interest.  I discussed this both with him, although it is not clear to me how much he understood, as well as his family.
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DESCRIPTION: Problems with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently.

consult - history and phy., seizures, hemiparesis, tumor, seizures hemiparesis, malignant meningioma, chemotherapy, malignant, meningioma, aspirin

The situation involves a malignant meningioma with a history of multiple surgeries and radiation. The patient has complex medical history including seizures, hemiparesis, and significant disability, and is not independent. The medical assessment indicates that surgery is unlikely to benefit the patient, and chemotherapy is not a viable option, leaving limited treatment avenues. The decisions here involve weighing the risks and benefits of further medical interventions for a life-threatening condition, making this a high-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 32

PROBLEM LIST:,1.  Generalized osteoarthritis and osteoporosis with very limited mobility.,2.  Adult failure to thrive with history of multiple falls, none recent.,3.  Degenerative arthritis of the knees with chronic bilateral knee pain.,4.  Chronic depression.,5.  Hypertension.,6.  Hyperthyroidism.,7.  Aortic stenosis with history of CHF and bilateral pleural effusions.,8.  Right breast mass, slowly enlarging.  Patient refusing workup.,9.  Status post ORIF of the right wrist, now healed.,10.  Anemia of chronic disease.,11.  Hypoalbuminemia.,12.  Chronic renal insufficiency.,CURRENT MEDICATIONS:,  Acetaminophen 325 mg 2 tablets twice daily, Coreg 6.25 mg twice daily, Docusate sodium 100 mg 1 cap twice daily, ibuprofen 600 mg twice daily with food, Lidoderm patch 5% to apply 1 patch to both knees every morning and off in the evening, one vitamin daily, ferrous sulfate 325 mg daily, furosemide 20 mg q.a.m., Tapazole 5 mg daily, potassium chloride 10 mEq daily, Zoloft 50 mg daily, Ensure t.i.d., and p.r.n. medications.,ALLERGIES:,  NKDA.,CODE STATUS:,  DNR, healthcare proxy, durable power of attorney.,DIET:,  Regular with regular consistency with thin liquids and ground meat.,RESTRAINTS: , None.  She does have a palm protector in her right hand.,INTERVAL HISTORY:,  No significant change over the past month has occurred.  The patient mainly complains about pain in her back.  On a scale from 1 to 10, it is 8 to 10, worse at night before she goes to bed.  She is requesting something more for the pain.  Other than that, she complains about her generalized pain.  There has been no significant change in her weight.  No fever or chills.  No complaint of headaches or visual changes, chest pain, shortness of breath, dyspnea on exertion, orthopnea, or PND.  No hemoptysis or night sweats.  No change in her bowels, abdominal pain, bright red rectal bleeding, or melena.  No nausea or vomiting.  Her appetite is fair.  She is a picky eater but definitely likes her candy.  There has been no change in her depression.  It seems to be stable on the Zoloft 50 mg daily, which she has been on since October 17, 2006.  She denies feeling depressed to me but complains of being bored, stating she just sits and watches TV or sometimes may go to activities but not very seldom due to her back pain.  No history of seizures.  She denies any tremors.  She is hyperthyroid and is on replacement.,PHYSICAL EXAMINATION: , An elderly female, sitting in a wheelchair, in no acute distress, very kyphotic.  She is very pleasant and alert.  Vital signs per chart.  Skin is normal in texture and turgor for her age.  She does have dry lips, which she picks at and was picking at her lips while I was talking with her.  HEENT:  Normocephalic, atraumatic.  She has nevi above her left eye, which she states she has had since birth and has not changed.  Pupils are equal, round and reactive to light and accommodation.  No exophthalmos or lid lag.  Anicteric sclerae.  Conjunctivae pink, nasal passages clear.  She is edentulous but does have her upper dentures in.  No mucosal ulcerations.  External ears normal.  Neck is supple.  No increased JVD, cervical or supraclavicular adenopathy.  No thyromegaly or masses.  Trachea is midline.  Her chest is very kyphotic, clear to A&P.  Heart:  Regular rate and rhythm with a 2-3/6 systolic murmur heard best at the left sternal border.  Abdomen:  Soft.  Good bowel sounds.  Nontender.  Unable to appreciate any organomegaly or masses as she is sitting in a wheelchair.  Extremities are without edema, cyanosis, clubbing, or tremor.  She does have Lidoderm patches over both of her knees and is wearing a brace in her right hand.,LABORATORY TESTS: , Albumin was 3.2 on 12/06/06.  Dietary is aware.  Electrolytes done 11/28/06, her sodium was 144, potassium 4.4, chloride 109, bicarbonate 26, anion gap 9, BUN 28, creatinine 1.2, GFR 44.  Digoxin was done and was less than 0.9, but she is not on digoxin.  CBC showed a white count of 7400, hemoglobin 11.1, hematocrit 35.9, MCV of 95.2, and platelet count of 252,000.  Her TSH was 1.52.  No changes were made in her Tapazole.,ASSESSMENT AND PLAN:,  We will continue present therapy except we will add Tylenol No.  3 to take 1 tablet before bed as needed for her back pain.  If she does develop drowsiness from this, then the CNS side effects will help her sleep.  During the day, her daughter likes the patient to remain alert and will use the ibuprofen at that time as long as she does not develop any GI symptoms.  We will make sure that she is taking the ibuprofen with food.  No further laboratory tests will be done at this time.
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DESCRIPTION: Patient with osteoarthritis and osteoporosis with very limited mobility, depression, hypertension, hyperthyroidism, right breast mass, and chronic renal insufficiency

The situation involves managing a complex array of chronic conditions in an elderly patient, including osteoporosis, osteoarthritis, depression, hypertension, hyperthyroidism, a right breast mass, and chronic renal insufficiency, some of which can be life-threatening or significantly reduce quality of life if not well managed. The patient's pain management is also challenging, given her request for additional pain relief and the need to balance alertness during the day. The presence of a right breast mass that the patient is refusing to get checked adds an additional layer of risk. Moreover, the patient's DNR status implies that her health situation is serious. However, since there is no immediate life-threatening condition or acute distress reported in the current state, the stakes are not at the highest level. The assessment and plan suggest a stable management approach without the need for immediate interventions, making it a high-stakes but not critical situation.


Medical Specialty: Surgery
Sample Name: Thrombectomy AV Shunt

PREOPERATIVE DIAGNOSIS: , Thrombosed arteriovenous shunt left forearm.,POSTOPERATIVE DIAGNOSIS:  ,Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,PROCEDURE:  ,Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.,ANESTHESIA: , Local.,SKIN PREP: , Betadine.,DRAINS: , None.,PROCEDURE TECHNIQUE:  ,The left arm was prepped and draped.  Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop.  The runoff vein was dissected out and encircled with the vessel loop as well.  A longitudinal incision was made over the venous anastomosis.  There was a narrowing in the area and slightly the incision was extended more proximally.  There was good back bleeding from the vein as well as bleeding from the more distal vein.  These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously.  A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established.  There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator.  The Fogarty catheter was then passed up the vein, but no clot was obtained.  A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture.  Clamps were removed and flow established.  A thrill was easily palpable.  Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin.  A sterile dressing was applied.  The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well.  Sponge, instrument and needle counts were reported as correct.
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DESCRIPTION: Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.  Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.

surgery, angioplasty, venous, anastomosis, patch angioplasty, av shunt, venous anastomosis, av, thrombectomy, thrombosed, arteriovenous, vein, forearm, shunt,

The situation described involves a surgical procedure to address a thrombosed arteriovenous shunt in the left forearm, which is significant as it is related to a patient's circulatory system and their ability to receive effective dialysis. The surgical process, including the thrombectomy and patch angioplasty, must be performed with precision; however, the procedure is typically routine for a vascular surgeon. Local anesthesia and the satisfactory condition of the patient post-surgery suggest it was not the most critical scenario but still holds substantial importance for the patient's health management.


Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis - 6

REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant.  Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction.  The urinary bladder is normal.  The uterus appears unremarkable.  Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen.  The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.
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DESCRIPTION: Right-sided abdominal pain with nausea and fever.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.

gastroenterology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct

The scenario describes a CT scan revealing acute appendicitis, a common and treatable condition but one that usually requires urgent surgical intervention to prevent complications like rupture or infection. Given the symptoms and CT findings, it is a medically significant situation that needs prompt attention, making it moderately high-stakes.


Medical Specialty: Urology
Sample Name: Flank Pain - Consult

CHIEF COMPLAINT: , Left flank pain and unable to urinate.,HISTORY: , The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating.  Details are in the history and physical.  She does have a vague history of a bruised left kidney in a motor vehicle accident.  She feels much better today.  I was consulted by Dr. X.,MEDICATIONS:,  Ritalin 50 a day.,ALLERGIES: , To penicillin.,PAST MEDICAL HISTORY: , ADHD.,SOCIAL HISTORY:,  No smoking, alcohol, or drug abuse.,PHYSICAL EXAMINATION: , She is awake, alert, and quite comfortable.  Abdomen is benign.  She points to her left flank, where she was feeling the pain.,DIAGNOSTIC DATA: , Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.,LABORATORY WORK: , Showed white count 6200, hematocrit 44.7.  Liver function tests and amylase were normal.  Urinalysis 3+ bacteria.,IMPRESSION:,1.  Left flank pain, question etiology.,2.  No evidence of surgical pathology.,3.  Rule out urinary tract infection.,PLAN:,1.  No further intervention from my point of view.,2.  Agree with discharge and followup as an outpatient.  Further intervention will depend on how she does clinically.  She fully understood and agreed.
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DESCRIPTION: Left flank pain and unable to urinate.

Left flank pain and unable to urinate.

urology, flank pain, unable to urinate, urinary tract infection, flank,

The situation involves a patient presenting with left flank pain and difficulty urinating, raising concerns about potential urinary tract infection or other urological issues. However, the patient's CAT scan shows no evidence of surgical pathology, and they are comfortable and agreed to outpatient follow-up. While there is a need for further monitoring, it does not appear to be an emergency or life-threatening situation currently, especially with a good immediate response to initial findings.


Medical Specialty: Dermatology
Sample Name: I&D - Buttock Abscess

PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:,  Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE:  ,Under general anesthesia, skin was prepped and draped in usual fashion.  Two incisions were made along the right buttock approximately 5 mm diameter.  Purulent material was drained and irrigated with copious amounts of saline flush.  A Penrose drain was placed.  Penrose drain was ultimately sutured forming a circular drain.  The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis.  Anesthesia, general endotracheal anesthesia.  Estimated blood loss approximately 5 mL.  Intravenous fluids 100 mL.  Tissue collected.  Purulent material from buttock abscess sent for usual cultures and chemistries.  Culture and sensitivity Gram stain.  A single Penrose drain was placed and left in the patient.  Dr. X attending surgeon was present throughout the entire procedure.
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DESCRIPTION: Incision and drainage (I&D) of buttock abscess.

dermatology, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage

An incision and drainage (I&D) of a buttock abscess is a routine dermatological procedure used to treat localized infections. While it is important for patient comfort and health to treat abscesses, the procedure itself is commonly performed with low risk under controlled conditions. General anesthesia does add a level of risk, but the overall stakes remain moderate due to the straightforward nature of the procedure and the expectation of outpatient follow-up.


Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Depression - 2

REASON FOR CONSULT:,  Depression.,HPI:,  The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006.  The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty.  Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture.  This was also treated with vertebroplasty.  The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  Her pain is in her upper back around her shoulder blades.  The patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  Does not see any future for herself.  Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  Admits to decreased appetite, feeling depressed, and always wanting to be alone.  Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace.  Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  Denies auditory and visual hallucinations.  No paranoid, delusions, or other abnormalities of thought content.  Denies panic attacks, flashbacks, and other feelings of anxiety.  Does admit to feeling restless at times.  Is concerned with her physical appearance while in the hospital, i.e., her hair looking "awful.",PAST MEDICAL HISTORY:,  Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes.  No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:,  Unknown.,ALLERGIES:,  CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:,  Unremarkable.,PAST PSYCHIATRIC HISTORY:,  Unremarkable.  Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:,  Unremarkable childhood.  Married for 40 plus years, widowed in 1981.  Worked as administrative assistant in UTMB Hospitals VP's office.  Two children.  Before admission, lived in the Terrace Independent Living Center.  Was happy and very active while living there.  Had friends in the Terrace and would not mind going back there after discharge.  Occasional glass of wine at dinner.  Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:,  The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  Slight decrease in motor activity.  Normal eye contact.  Speech, low volume and rate.  Good articulation and inflexion.  Normal concentration.  Mood, labile, tearful at times, depressed, then euthymic.  Affect, mood congruent, full range.  Thought process, logical and goal directed.  Thought content, no delusions, suicidal or homicidal ideations.  Perception, no auditory or visual hallucinations.  Sensorium, alert, and oriented x3.  Memory, fair.  Information and intelligence, average.  Judgment and insight, fair.,MINI MENTAL STATUS EXAM,:  A 28/30.  Could not remember two out of the three recalled words.,ASSESSMENT:,  The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I:  Major depression disorder.,Axis II:  Deferred.,Axis III:  Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV:  Lives independently at Terrace, difficulty walking, hospitalization.,Axis V:  45.,PLAN:,  Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms.  Discussed about possible inpatient psychiatric care.,Thank you for the consultation.
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DESCRIPTION: Psychiatric Consultation of patient with major depression disorder.

The consultation involves an elderly patient with major depressive disorder, recent multiple fractures, and other comorbid conditions. The patient's mental health and its interaction with her physical health are central concerns, alongside her desire for independence and quality of life. Complicating the case is her risk of deterioration if depression symptoms worsen, and the impact on her capability to manage other health issues. While there are no immediate life-threatening conditions described, the situation involves significant health and quality of life challenges, requiring careful management to avoid critical outcomes. The suggestion of possible inpatient psychiatric care indicates the seriousness of managing her mental health, although there is no mention of acute risks like suicidal ideation. These factors make it a moderately high-stakes medical situation.


Medical Specialty: Hematology - Oncology
Sample Name: Hematology Consult

REASON FOR CONSULTATION:,  Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS:  ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital.  A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism.  A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis.  A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct.  Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today.  He has been on intravenous heparin and hemodialysis is being planned for tomorrow.  Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication.  He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY:  ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son.  He has a brother who is healthy.  There is no history of tobacco use or alcohol use.,FAMILY HISTORY:,  No family history of hypercoagulable condition.,MEDICATIONS:  ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope.  He denied any hemoptysis.  He denied any calf swelling or pain.  Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL:  He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Oropharynx normal.,NECK:  No adenopathy or thyromegaly.  No jugular venous distention.,HEART:  Regular.,LUNGS:  Bilateral air entry.,ABDOMEN:  Obese and benign.,EXTREMITIES:  No calf swelling or calf tenderness appreciated.,SKIN:  No petechiae or ecchymosis.,NEUROLOGIC:  Nonfocal.,LABORATORY FINDINGS:,  Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000.  Liver profile normal.  Thyroid study revealed a TSH of 1.3.  Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds.  Renal function, BUN 44 and creatinine 5.7.  Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1.  Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2.  Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3.  Acute renal failure secondary to embolic right renal infarction.,4.  Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play.  For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin.  In view of worsening renal function, may need temporary hemodialysis until renal function improves.  I discussed at length with the patient's wife at the bedside.
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DESCRIPTION: Leukocytosis, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.

The patient's condition involves multiple critical complications: acute deep venous thrombosis, bilateral pulmonary embolism, and acute renal failure. The situation is life-threatening due to the presence of pulmonary embolism and compromised kidney function, necessitating immediate treatment with anticoagulation and potentially hemodialysis. The patient's condition requires close monitoring and rapid intervention to prevent further complications or deterioration. There is also uncertainty regarding the hereditary component of the hypercoagulable state. These factors make the stakes very high, as they impact the patient's survival and long-term health.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fiberoptic Bronchoscopy

PREOPERATIVE DIAGNOSIS:,  Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral upper lobe cavitary lung masses.,2.  Final pending pathology.,3.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite.  After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis.  Topical lidocaine was utilized for anesthesia.  Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent.  This may be normal anatomic variant.  The scope was advanced into the trachea.  The main carina was sharp in appearance.  Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized.  Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left.  No specific intrinsic masses were noted.  Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe.  Also cytologic brushings and protected bacteriologic brushing specimens were obtained.  Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe.  During lavage, some caseous appearing debris appeared intermittently.  The specimens were collected and sent to the lab.  Procedure was terminated with hemostasis having been verified.  The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.
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DESCRIPTION: Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.   Bilateral upper lobe cavitary lung masses.  Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left.  There are also changes of inflammation throughout.

cardiovascular / pulmonary, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe,

The procedure described is a diagnostic fiberoptic bronchoscopy, which is instrumental in diagnosing potential serious conditions such as infections, malignancies, or other pulmonary disorders related to the cavitary lung masses. The situation involves obtaining biopsies and lavage to determine the nature of these lung masses. While the bronchoscopy procedure itself carries risks and is critical for diagnostic purposes, the provided details indicate that the patient tolerated the procedure well, and vital signs remained stable. However, the potential findings and the nature of the lung masses could have significant implications for the patient's treatment and prognosis, marking this as reasonably high-stakes from a medical diagnostic and treatment-planning perspective.


Medical Specialty: General Medicine
Sample Name: Air Under Diaphragm - Consult

REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia.
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DESCRIPTION: Possible free air under the diaphragm.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.  No intra-abdominal pathology.

The situation involves a 77-year-old patient who was found obtunded in the emergency room with possible free air under the diaphragm. This can be a sign of a perforated abdominal organ, which is a serious condition requiring urgent evaluation. The patient is unable to communicate due to sedation and obtundation, complicating the assessment. Additionally, she has significant electrolyte imbalances (severe hyponatremia and hypokalemia), which can pose immediate health risks if not treated promptly. These elements make the situation critical as it involves potential life-threatening conditions if not appropriately managed.


Medical Specialty: Letters
Sample Name: Reflex Sympathetic Dystrophy - Letter

Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008.  As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities.  His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg.  He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this.  He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain.  He was seen by Dr. Y at Orthopedic Associates for review of this.  However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation.  Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds.  As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain.  He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain.  He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain.  He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation.  Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion.  He has been evaluated by Dr. X for rehab concerns to determine.  He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation.  If you have any questions regarding his care please feel free to call me at my office.  Otherwise, I look forward to hearing back from you shortly after your evaluation.  Please feel free to call me if it is possible or if you have any questions about anything.
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DESCRIPTION: Reflex sympathetic dystrophy of both lower extremities.

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

The situation described in the letter involves complex medical management for a serious condition (Reflex Sympathetic Dystrophy) with significant complications, like a non-healing wound and severe pain requiring high doses of multiple medications. The consideration of treatment options such as hyperbaric oxygen therapy and potential amputation, along with the coordination between multiple specialists, suggest that the outcome will significantly impact the patient's quality of life and health. These factors contribute to a high-stakes scenario as decisions made could severely affect the patient's future well-being.


Medical Specialty: Surgery
Sample Name: Epidural Hematoma Evacuation

PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.
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DESCRIPTION: Evacuation of epidural hematoma and insertion of epidural drain.   Epidural hematoma, cervical spine.  Status post cervical laminectomy, C3 through C7 postop day #10.  Central cord syndrome and acute quadriplegia.

surgery, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia,

The situation involves a patient with severe neurological compromise (quadriplegia) following a cervical spine surgery, necessitating an emergency surgical intervention to evacuate an epidural hematoma. The stakes are high because the patient's potential for recovery of neurologic function is uncertain, and there is a risk of permanent quadriplegia if the hematoma is not relieved. The surgical procedure is critical to prevent further deterioration of neurological function and possibly improve the current condition, given the already severe impairments. Additionally, there are significant considerations including a prior history of major cardiac events, which could complicate surgery and recovery. Hence, the decision to proceed with surgery involves weighing the potential benefits against the risk of maintaining or worsening the current neurological status.


Medical Specialty: Podiatry
Sample Name: Foot Pain

CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team.  He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet.  He was barefoot at that time.  He had been in the pool practicing an hour prior to this injury.  Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care.  He is able to bear weight; however, complains of pain in his toes.  The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot.  According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY:  ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,He does not use alcohol, tobacco or illicit drugs.  He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION:,GENERAL:  This is a pleasant white male in no acute distress.,VITAL SIGNS:  He is afebrile.  Vitals are stable and within normal limits.,HEENT:  Negative for acute evidence of trauma, injury or infection.,LUNGS:  Clear.,HEART:  Regular rate and rhythm with S1 and S2.,ABDOMEN:  Soft.,EXTREMITIES:  There are some abrasions across the dorsum of the right foot including the second, third and fourth toes.  There is some mild tenderness to palpation.  However, there are no clinical fractures.  Distal pulses are intact.  The left foot notes superficial avulsion lacerations to the third and fourth digit.  There are no subungual hematomas.  Range of motion is decreased secondary to pain.  No obvious fractures identified.,BACK EXAM:  Nontender.,NEUROLOGIC EXAM:  He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably.  He was informed of the x-ray findings.  The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable.  All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge.  The patient/family understood the instructions and was discharged without further incident.
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DESCRIPTION: Patient dropped a weight on the dorsal aspects of his feet.

The situation involves a teenage athlete who has sustained a non-life-threatening injury to his feet. The patient is stable, without fractures, and was discharged with minor treatment needed. The condition is painful and may impact his sports participation temporarily, but it is not considered a high-stakes medical emergency. The primary focus is on pain management and healing of the superficial wounds.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Sleep Study Followup

REASON FOR VISIT:,  This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,HISTORY OF PRESENT ILLNESS: , The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion.  At that time, she was evaluated and found to have evidence for sleep disruption and daytime fatigue.  She also complained of nocturnal choking episodes that have since abated over the past several months.  In the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea, returns today to review her study results.,The patient's sleep patterns consist of going to bed between 9.00 and 10.00 p.m. and awakening in the morning between 5.00 and 6.00 a.m.  She reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night.  She reports tossing and turning throughout the night and awakening with the sheets in disarray.  She reports that her sleep was much better quality in the sleep laboratory as compared to home.  When she awakens, she might have a dull headache and feels tired in the morning.  Her daughter reports that she has heard the patient talking during sleep and snoring.  There are no apneic episodes.  The patient reports that she used to cough a lot in the middle of the night, but has no longer been doing so in recent weeks.,During the daytime, the patient reports spending a lot of sedentary time reading and watching TV.  She routinely dozes off during these sedentary activities.  She also might nap between 2.00 and 3.00 p.m., and nods off in the evening hours.,The patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner.,She reports that her weight has fluctuated and peaked at 260 pounds approximately 1 year ago.  Since that time, her weight is down by approximately 30 pounds.,The patient is managed in Outpatient Psychiatry and at her Maintenance Clinic.  She takes methadone, trazodone, and Seroquel.,PAST MEDICAL HISTORY:,1.  Depression.,2.  Hepatitis C.,3.  Hypertension.,4.  Inhaled and intravenous drug abuse history.,The patient has a history of smoking two packs per day of cigarettes for approximately 25 pounds.  She also has a history of recurrent atypical chest pain for which she has been evaluated.,FAMILY HISTORY: , As previously documented.,SOCIAL HISTORY:  ,The patient has a history of inhalation on intravenous drug abuse.  She is currently on methadone maintenance.  She is being followed in Psychiatry for depression and substance abuse issues.  She lives with a room-mate.,REVIEW OF SYSTEMS:,  Not contributory.,MEDICATIONS: , Current medications include the following:,1.  Methadone 110 mg by mouth every day.,2.  Paxil 60 mg by mouth every day.,3.  Trazodone 30 mg by mouth nightly.,4.  Seroquel 20 mg by mouth nightly.,5.  Avalide (irbesartan) and hydrochlorothiazide.,6.  Albuterol and Flovent inhalers two puffs by mouth twice a day.,7.  Atrovent as needed.,FINDINGS: , Vital Signs:  Blood pressure 126/84, pulse 67, respiratory rate 18, weight 232 pounds, height 5 feet 8 inches, temperature 97.4 degrees, SaO2 is 99 percent on room air at rest.  HEENT:  Sclerae anicteric.  Conjunctivae pink.  Extraocular movements are intact.  Pupils are equal, round, and reactive to light.  The nasal passages show deviation in the nasal septum to the right.  There is a slight bloody exudate at the right naris.  Some nasal mucosal edema was noted with serous exudate bilaterally.  The jaw is not foreshortened.  The tongue is not large.  Mallampati airway score was 3.  The oropharynx was not shallow.  There is no pharyngeal mucosa hypertrophy.  No tonsillar tissue noted.  The tongue is not large.  Neck is supple.  Thyroid without nodules or masses.  Carotid upstrokes normal.  No bruits.  No jugular venous distention.  Chest is clear to auscultation and percussion.  No wheezing, rales, rhonchi or adventitious sounds.  No prolongation of the expiratory phase.  Cardiac:  PMI not palpable.  Regular rate and rhythm.  S1 and S2 normal.  No murmurs or gallops.  Abdomen:  Nontender.  Bowel sounds normal.  No liver or spleen palpable.  Extremities:  No clubbing or cyanosis.  There is 1+ pretibial edema.  Pulses are 2+ in upper and lower extremities.  Neurologic:  Grossly nonfocal.,LABORATORIES:,  Pulmonary function studies reportedly show a mild restrictive ventilatory defect without obstruction.  Diffusing capacity is well preserved.,An overnight sleep study was performed on this patient at the end of 02/07.  At that time, she reported that her sleep was better in the laboratories compared to home.  She slept for a total sleep time of 398 minutes out of 432 minutes in bed (sleep proficiency 92 percent).  She fell asleep in the middle of latency of less than 1 minute.  She woke up after sleep onset of 34 minutes.  She had stage I sleep that was some elevated at 28 percent of total sleep time, and stage I sleep is predominantly evident in the lateral portion of the night.  The remainders were stage II at 69 percent, stage III and IV at 3 percent of total sleep time.,The patient had no REM sleep.,The patient had no periodic limb movements during sleep.,The patient had no significant sleep-disordered breathing during non-REM sleep with less than one episode per hour.  Oxyhemoglobin saturation remained in the low to mid 90s throughout the night.,Intermittent inspiratory flow limitation compatible with snoring was observed during non-REM sleep.,ASSESSMENT AND PLAN: , This patient presents with history of sleep disruption and daytime sleepiness with fatigue.  Her symptoms are multifactorial.,Regarding the etiology of difficulty in initiating and maintaining sleep, the patient has a component of psychophysiologic insomnia, based on reports of better sleep in the laboratory as compared to home.  In addition, nontrivial smoking in the home setting may be contributing significantly to sleep disruption.,Regarding her daytime sleepiness, the patient is taking a number of long-acting central nervous system acting medications to sedate her and can produce a lasting sedation throughout the daytime.  These include trazodone, Seroquel, and methadone.  Of these medications, the methadone is clearly indicative, given the history of substance abuse.  It would be desirable to reduce or discontinue trazodone and then perhaps consider doing the same with Seroquel.  I brought this possibility up with the patient, and I asked her to discuss this further with her psychiatrist.,Finally, to help mitigate sleep disruption at night, I have provided her with tips for sleep hygiene.  These include bedtime rituals, stimulus control therapy, and sleep restriction as well as avoidance of nicotine in the evening hours.
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DESCRIPTION: Followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.  This patient presents with history of sleep disruption and daytime sleepiness with fatigue.  Her symptoms are multifactorial.

This situation involves a follow-up medical visit for a patient experiencing significant sleep issues, which impact the patient's overall health and well-being. The stakes are moderate because, while the symptoms are impacting the patient's daily life, they do not appear immediately life-threatening given the assessment details. Key concerns such as potential sleep apnea were ruled out, and management strategies focus on smoking cessation, medication adjustments, and sleep hygiene. However, given her complex medical history including substance abuse and current medications, ongoing management and follow-up are crucial to prevent escalation of health issues.


Medical Specialty: Surgery
Sample Name: Carpal Ligament Reconstruction

PROCEDURE:,  Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially for 2-3 mm, and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with a scissor.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Carpal tunnel release with transverse carpal ligament reconstruction.  A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.

surgery, carpal tunnel, carpal ligament reconstruction, transverse carpal ligament, ulnar, hemostat, transverse, superficial, ligament, carpal

Carpal tunnel release with transverse carpal ligament reconstruction is a surgical procedure that involves precise movements around delicate structures like the median nerve. While it is a common and generally low-risk surgery, there can be significant consequences if mistakes occur, such as nerve damage. However, it's not life-threatening, and complications are rare with experienced surgeons. The stakes are moderate as it involves surgical skill and has implications for the patient's functionality and comfort but does not carry immediate life-threatening risks.


Medical Specialty: Ophthalmology
Sample Name: Cataract Extraction

PROCEDURE PERFORMED:,  Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room.  The patient was identified and the correct operative site was also identified.  A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding.  The patient was prepped and draped in the usual fashion.  A lid speculum was applied.,A groove incision at the 12 o'clock position was made with a 5700 blade.  This was beveled anteriorly in a lamellar fashion using the crescent knife.  Then the anterior chamber was entered with a slit knife.  The chamber was deepened with Viscoat.  Then a paracentesis at the 3 o'clock position was created using a super sharp blade.  A cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps.  Hydrodissection was employed using BSS on a blunt 27-gauge needle.,The phaco tip was then introduced into the eye, and the eye was divided into 4 grooves.  Then a second instrument was used, a Sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified.  I/A proceeded without difficulty using the irrigation/aspiration cannula.  The capsule was felt to be clear and intact.  The capsular bag was then expanded with ProVisc.,The internal corneal wound was increased using the slit knife.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.  A corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture.  Then the Viscoat was removed using I/A, and the suture drawn up and tied.,The 0.2 ml of gentamicin was injected subconjunctivally.  Maxitrol ointment was instilled into the conjunctival sac.  The eye was covered with a double patch and shield, and the patient was discharged.
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DESCRIPTION: Cataract extraction with lens implantation, right eye.  The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.

ophthalmology, lens implantation, anterior chamber, lid speculum, eye, sinskey hook, cataract extraction, capsular bag, cataract, capsular, knife, lens

The procedure described is a cataract extraction with lens implantation, a common but critical ophthalmologic surgery. While it is a routine operation, it carries risks such as infection, bleeding, inflammation, or complications affecting the patient's vision. However, it is generally considered low-risk with a high success rate when performed by experienced professionals. The stakes are important in terms of patient outcomes, but not typically life-threatening.


Medical Specialty: Surgery
Sample Name: Cystopyelogram

PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:,  LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones.  The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A 0.035 glidewire was placed in the left system.  Using graspers, left-sided stent was removed.  A semirigid ureteroscopy was done.  A stone was visualized in the mid to upper ureter.  Using laser, the stone was broken into 5 to 6 small pieces.  Using basket extraction, all the pieces were removed.  Ureteroscopy all the way up to the UPJ was done, which was negative.  There were no further stones.  Using pyelograms, the rest of the system appeared normal.  The entire ureter on the left side was open and patent.  There were no further stones.  Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  Over the 0.035 glidewire, a 26 double-J stent was placed.  There was a nice curl in the kidney and one in the bladder.  The patient tolerated the procedure well.  Please note that the string was kept in place and the patient was to remove the stent the next day.  The patient's family was instructed how to do so.  The patient had antibiotics and pain medications at home.  The patient was brought to recovery room in a stable condition.
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DESCRIPTION: Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.

surgery, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,

The scenario involves a patient undergoing a surgical procedure to address a ureteral stone, including laser lithotripsy and stent placement. While the procedure itself is not uncommon and seems to have been routine with minimal complications, it is still a surgical procedure requiring anesthesia and careful postoperative instructions. This context implies moderate stakes, primarily because it addresses a recurrent medical issue that had previously led to sepsis, indicating potential serious health implications if not managed properly. Additionally, there are risks associated with the procedure such as bleeding, infection, and anesthesia, which are standard in surgical interventions. However, since the procedure was completed without complications and the patient was stable post-operation, it is not at the highest level of stakes.