Medical Specialty: Gastroenterology
Sample Name: Upper Endoscopy

PROCEDURE:,  Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years.  She comes in this morning with complaints of inability to swallow anything including her saliva.  This started almost a day earlier.  She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything.  She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient.  The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed.  Daughter was also informed about the procedure and risks.  Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg.  The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus.  There was a meat bolus in the distal esophagus.  This was visualized after clearing the liquid material and small particles of what appeared to be carrots.  The patient, however, was not tolerating the conscious sedation.  Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation.  Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net.  Then, a snare was used to cut the meat bolus into pieces, as it was very soft.  Small pieces were grabbed with the snare and pulled out.  Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully.  The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy.  No active bleeding was seen.  There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach.  As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction.  Treated as described above.,RECOMMENDATIONS:,  IV Protonix 40 mg q.12h.  Clear liquid diet for 24 hours.  If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks.  She should take Prevacid SoluTab 30 mg b.i.d. on discharge.
---
DESCRIPTION: Upper endoscopy with removal of food impaction.

gastroenterology, dysphagia, removal of food impaction, distal esophagus, stomach, distal esophageal, esophageal stricture, upper endoscopy, food impaction, endoscopy, aspiration, sedation, bolus, impaction, esophagus,

The situation involves a 92-year-old patient with a food impaction in the esophagus, which is a significant medical concern due to her age and the use of Coumadin (a blood thinner). The risks involved in the procedure, such as aspiration, bleeding, perforation, and infection, amplify the stakes. The need for careful sedation and potential surgical intervention further elevate the situation. Given the serious potential complications and the patient's vulnerability, this is a high-stakes medical procedure.


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

Medical Specialty: Orthopedic
Sample Name: Wrist Ganglion Excision

PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg.  I made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.  I then excised the ganglion and its stalk.  In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve.  We then identified the scapholunate ligament, which was uninjured.  I irrigated and closed in layers and injected Marcaine with epinephrine.  I dressed and splinted the wound.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
---
DESCRIPTION: Excision of dorsal wrist ganglion.  Made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.

orthopedic, origin of stalk, extensor retinaculum, wrist ganglion, incision, excision, dorsal, tourniquet, wrist, ganglion

The given scenario describes a surgical procedure for excision of a dorsal wrist ganglion. These types of procedures are generally considered routine in orthopedic surgery with relatively low risk. The patient is described as having tolerated the procedure well and was sent to the recovery room in good condition. Therefore, while there is always some level of risk associated with surgery, the stakes are not particularly high in this context.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Chest Closure

PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.
---
DESCRIPTION: Delayed primary chest closure.  Open chest status post modified stage 1 Norwood operation.  The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.

surgery, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation

The procedure described involves a delayed primary chest closure for a newborn who has undergone a modified stage 1 Norwood operation. This type of surgery is complex and high-risk due to the intricate nature of congenital heart defects like hypoplastic left heart syndrome, and the critical condition of the patient being an infant. The success of this procedure is crucial for the patient's recovery and overall survival post-operatively, making it high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 6

SUBJECTIVE:,  The patient is in with several medical problems.  She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain.  She initially describes it as a sharp quality pain, but is unable to characterize it more fully.  She has had it for about a year, but seems to be worsening.  She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot.  They are not worse with walking.  It seems to be worse when she is in bed.  There is some radiation of the pain up her leg.  She also continues to have bilateral shoulder pains without sinus allergies.  She has hypothyroidism.  She has thrombocythemia, insomnia, and hypertension.,PAST MEDICAL HISTORY:,  Surgeries include appendectomy in 1933, bladder obstruction surgery in 1946, gallbladder surgery in 1949, another gallbladder surgery in 1954, C-section in 1951, varicose vein surgery in 1951 and again in 1991, thyroid gland surgery in 1964, hernia surgery in 1967, bilateral mastectomies in 1968 for benign disease, hysterectomy leaving her ovaries behind in 1970, right shoulder surgery x 4 and left shoulder surgery x 2 between 1976 and 1991, and laparoscopic bowel adhesion removal in October 2002.  She had a Port-A-Cath placed in June 2003, left total knee arthroplasty in June 2003, and left hip pinning due to fracture in October 2003, with pins removed in May 2004.  She has had a number of colonoscopies; next one is being scheduled at the end of this month.  She also had a right total knee arthroplasty in 1993.  She was hospitalized for synovitis of the left knee in April 2004, for zoster and infection of the left knee in May 2003, and for labyrinthitis in June 2004.,ALLERGIES: , Sulfa, aspirin, Darvon, codeine, NSAID, amoxicillin, and quinine.,CURRENT MEDICATIONS:,  Hydroxyurea 500 mg daily, Metamucil three teaspoons daily, amitriptyline 50 mg at h.s., Synthroid 0.1 mg daily, Ambien 5 mg at h.s., triamterene/hydrochlorothiazide 75/50 daily, and Lortab 5/500 at h.s. p.r.n.,SOCIAL HISTORY:,  She is a nonsmoker and nondrinker.  She has been widowed for 18 years.  She lives alone at home.  She is retired from running a restaurant.,FAMILY HISTORY:,  Mother died at age 79 of a stroke.  Father died at age 91 of old age.  Her brother had prostate cancer.  She has one brother living.  No family history of heart disease or diabetes.,REVIEW OF SYSTEMS:,General:  Negative.,HEENT:  She does complain of some allergies, sneezing, and sore throat.  She wears glasses.,Pulmonary history:  She has bit of a cough with her allergies.,Cardiovascular history:  Negative for chest pain or palpitations.  She does have hypertension.,GI history:  Negative for abdominal pain or blood in the stool.,GU history:  Negative for dysuria or frequency.  She empties okay.,Neurologic history:  Positive for paresthesias to the toes of both feet, worse on the right.,Musculoskeletal history:  Positive for shoulder pain.,Psychiatric history:  Positive for insomnia.,Dermatologic history:  Positive for a spot on her right cheek, which she was afraid was a precancerous condition.,Metabolic history:  She has hypothyroidism.,Hematologic history:  Positive for essential thrombocythemia and anemia.,OBJECTIVE:,General:  She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs:  Her age is 81.  Temperature:  98.0.  Blood pressure:  140/70.  Pulse:  72.  Weight:  127.,HEENT:  Head was normocephalic.  Pupils equal, round, and reactive to light.  Extraocular movements are intact.  Fundi are benign.  TMs, nares, and throat were clear.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur, click, or rub.  No carotid bruits are heard.,Abdomen:  Normal bowel sounds.  It is soft and nontender without hepatosplenomegaly or mass.,Breasts:  Surgically absent.  No chest wall mass was noted, except for the Port-A-Cath in the left chest.  No axillary adenopathy is noted.,Extremities:  Examination of the extremities reveals no ankle edema or calf tenderness x 2 in lower extremities.  There is a cyst on the anterior portion of the right ankle.  Pedal pulses were present.,Neurologic:  Cranial nerves II-XII grossly intact and symmetric.  Deep tendon reflexes were 1 to 2+ bilaterally at the knees.  No focal neurologic deficits were observed.,Pelvic:  BUS and external genitalia were atrophic.  Vaginal rugae were atrophic.  Cervix was surgically absent.  Bimanual exam confirmed the absence of uterus and cervix and I could not palpate any ovaries.,Rectal:  Exam confirmed there is brown stool present in the rectal vault.,Skin:  Clear other than actinic keratosis on the right cheek.,Psychiatric:  Affect is normal.,ASSESSMENT:,1.  Peripheral neuropathy primarily of the right foot.,2.  Hypertension.,3.  Hypothyroidism.,4.  Essential thrombocythemia.,5.  Allergic rhinitis.,6.  Insomnia.,PLAN:
---
DESCRIPTION: Patient with several medical problems - numbness, tingling, and a pain in the toes.

This medical consult describes an elderly patient with several health issues, including peripheral neuropathy, hypertension, hypothyroidism, essential thrombocythemia, allergic rhinitis, and insomnia. The patient's symptoms and history suggest complexity, especially due to the multiple simultaneous conditions and the chronic nature of some, like the peripheral neuropathy and thrombocythemia. While these are serious and require careful management, they are not immediately life-threatening or acute emergencies. The stakes involve managing potential complications from these chronic conditions to maintain quality of life and prevent deterioration.


Medical Specialty: Radiology
Sample Name: Exercise Myocardial Perfusion Study

CLINICAL INDICATION:,  Chest pain.,INTERPRETATION: , The patient received 14.9 mCi of Cardiolite for the rest portion of the study and 11.5 mCi of Cardiolite for the stress portion of the study.,The patient's baseline EKG was normal sinus rhythm.  The patient was stressed according to Bruce protocol by Dr. X.  Exercise test was supervised and interpreted by Dr. X.  Please see the separate report for stress portion of the study.,The myocardial perfusion SPECT study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact.  There is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.,The gated SPECT study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.,CONCLUSION:,1.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.,2.  Normal LV systolic function with LV ejection fraction of 59%.
---
DESCRIPTION: Exercise myocardial perfusion study.  The exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall and normal LV systolic function with LV ejection fraction of 59%

radiology, chest pain, cardiolite, ekg, spect, lv systolic function, lv ejection fraction, myocardial perfusion study, spect study, ejection fraction, myocardial, perfusion, ischemia,

The exercise myocardial perfusion study identifies a potential mild ischemia in the inferolateral wall and normal left ventricular systolic function. Ischemia detection is significant as it can indicate underlying coronary artery disease, but the report suggests it is mild and partially reversible, indicating a less acute situation. The stakes are moderate as further evaluation or monitoring may be needed to prevent future complications, but there is no immediate life-threatening condition described in the report.


Medical Specialty: Consult - History and Phy.
Sample Name: Paroxysmal Atrial Fibrillation

INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 55-year-old white female with multiple myeloma.  She is status post chemotherapy and autologous stem cell transplant.  Latter occurred on 02/05/2007.  At that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,As part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007.  This demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute.  She was subsequently transferred to telemetry for observation.  Cardiology consultation was requested.  Prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (LV) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures.  Overall, essentially normal heart.,At the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,PAST MEDICAL HISTORY:,  Multiple myeloma, diagnosed in June of 2006, status post treatment with thalidomide and Coumadin.  Subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,PAST SURGICAL HISTORY: , Cosmetic surgery of the nose and forehead.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,CURRENT MEDICATIONS,1.  Acyclovir 400 mg p.o. b.i.d.,2.  Filgrastim 300 mcg subcutaneous daily.,3.  Fluconazole 200 mg daily.,4.  Levofloxacin 250 mg p.o. daily.,5.  Pantoprazole 40 mg daily.,6.  Ursodiol 300 mg p.o. b.i.d.,7.  Investigational drug is directed ondansetron 24 mg p.r.n.,FAMILY HISTORY: , Unremarkable.  Father and mother both alive in their mid 70s.  Father has an unspecified heart problem and diabetes.  Mother has no significant medical problems.  She has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,SOCIAL HISTORY: , The patient is married.  Has four adult children.  Good health.  She is a lifetime nonsmoker, social alcohol drinker.,REVIEW OF SYSTEMS: , Prior to treatment for her multiple myeloma, she was able to walk four miles nonstop.  Currently, she has dyspnea on exertion on the order of one block.  She denies any orthopnea or paroxysmal nocturnal dyspnea.  She denies any lower extremity edema.  She has no symptomatic palpitations or tachycardia.  She has never had presyncope or syncope.  She denies any chest pain whatsoever.  She denies any history of coagulopathy or bleeding diathesis.  Her oncologic disorder is multiple myeloma.  Pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis.  Gastrointestinal (GI) review of systems is negative for known gastroesophageal reflux disease, GI bleed, and hepatobiliary disease.  Genitourinary review of systems is negative for nephrolithiasis or hematuria.  Musculoskeletal review of systems is negative for significant arthralgias or myalgias.  Central nervous system (CNS) review of systems is negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.  Psychiatric review of systems is negative for known affective or cognitive disorders.,PHYSICAL EXAMINATION,GENERAL:  This is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,VITAL SIGNS:  She is afebrile at 97.4 degrees Fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular.  Respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmHg.  Oxygen saturation on room air is 94%.,HEENT:  Benign being normocephalic and atraumatic.  Extraocular motions are intact.  Her sclerae are anicteric and conjunctivae are noninjected.  Oral mucosa is pink and moist.,NECK:  Jugular venous pulsations are normal.  Carotid upstrokes are palpable bilaterally.  There is no audible bruit.  There is no lymphadenopathy or thyromegaly at the base of the neck.,CHEST:  Cardiothoracic contour is normal.  Lungs, clear to auscultation in all lung fields.,CARDIAC:  Irregularly irregular rhythm and rate.  S1, S2 without a significant murmur, rub, or gallop appreciated.  Point of maximal impulse is normal, no right ventricular heave.,ABDOMEN:  Soft with active bowel sounds.  No organomegaly.  No audible bruit.  Nontender.,LOWER EXTREMITIES:  Nonedematous.  Femoral pulses were deferred.,LABORATORY DATA: , EKG, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute.  Nonspecific ST-T wave abnormality is seen in the inferior leads only.,White blood cell count is 9.8, hematocrit of 30 and platelets 395.  INR is 0.9.  Sodium 136, potassium 4.2, BUN 43 with a creatinine of 2.0, and magnesium 2.9.  AST and ALT 60 and 50.  Lipase 343 and amylase 109.  BNP 908.  Troponin was less than 0.02.,IMPRESSION: , A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,Currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,RECOMMENDATIONS,1.  Atrial fibrillation.  The patient is currently hemodynamically stable, tolerating her dysrhythmia.  However, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible.  Given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours.  We will initiate therapy with amiodarone 150 mg intravenous (IV) bolus followed by mg/minute at this juncture.  If she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,As part of amiodarone protocol, please check TSH.  Given her preexisting mild elevation of transaminases, we will follow LFTs closely, while on amiodarone.,2.  Thromboembolic risk prophylaxis, as discussed above.  No immediate indication for anticoagulation.  If however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy.  This was discussed with Dr. X.  Preference would be to run intravenous heparin with PTT of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3.  Congestive heart failure.  The patient is clinically euvolemic.  Elevated BNP possibly secondary to infarct or renal insufficiency.  Follow volume status closely.  Follow serial BNPs.,4.  Followup.  The patient will be followed while in-house, recommendations made as clinically appropriate.
---
DESCRIPTION: A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.

The situation involves a patient with a recent history of multiple myeloma treatment, now experiencing paroxysmal atrial fibrillation. This condition poses a risk for thromboembolic events, which can be life-threatening. The medical team plans to manage the atrial fibrillation to prevent these complications and address her elevated BNP levels, indicating possible heart failure or renal issues. Despite the immediate hemodynamic stability, the potential for rapid deterioration makes this a high-stakes situation, requiring careful monitoring and intervention, such as medication adjustments and potential electrical cardioversion or anticoagulation. Given the risks and comorbidities involved, this is indeed a critical medical scenario.


Medical Specialty: Gastroenterology
Sample Name: Consult - Laparoscopic Cholecystectomy

PAST MEDICAL HISTORY: , Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , Currently employed.  She is married.  She is in sales.  She does not smoke.  She drinks wine a few drinks a month.,CURRENT MEDICATIONS: , She is on Carafate and Prilosec.  She was on metformin, but she stopped it because of her abdominal pains.,ALLERGIES: , She is allergic to PENICILLIN.,REVIEW OF SYSTEMS:,  Negative for heart, lungs, GI, GU, cardiac, or neurologic.  Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,PHYSICAL EXAMINATION: , She is afebrile.  Vital Signs are stable.  HEENT:  EOMI.  PERRLA.  Neck is soft and supple.  Lungs clear to auscultation.  She is mildly tender in the abdomen in the right upper quadrant.  No rebound.  Abdomen is otherwise soft.  Positive bowel sounds.  Extremities are nonedematous.  Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,IMPRESSION/PLAN: , I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP, and possible need for further surgery among other potential complications.  She understands and we will proceed with the surgery in the near future.,
---
DESCRIPTION: Patient with mid-epigastric abdominal pain.  Sonogram revealed gallstones.

gastroenterology, laparoscopic cholecystectomy, mid epigastric, epigastric abdominal, potential complications, laparoscopic, cholecystectomy, epigastric, abdomen, surgery, gallstones, disease, abdominal

The scenario involves a patient being considered for laparoscopic cholecystectomy, a relatively common and minimally invasive procedure to remove the gallbladder. While the surgery is routine and generally safe, it is still a surgical procedure, which carries inherent risks such as bleeding, infection, and potential complications that were explained to the patient. The severity of any surgical procedure typically increases the stakes, particularly because there can be serious complications if something goes wrong. However, the situation involves no immediate life-threatening conditions, and the patient seems informed and prepared for the surgery.


Medical Specialty: Consult - History and Phy.
Sample Name: Neurogenic Bladder - Consult

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day.  However, June 24, 2008, he was seen in the ER, and with fever, weakness, possible urosepsis.  He had a blood culture, which was positive for Staphylococcus epidermidis, as well as urine culture noted for same bacteria.  He was treated on IV antibiotics, Dr. XYZ also saw the patient.  Discharged home.  Not taking any antibiotics.  Today in the office, the patient denies any dysuria, gross hematuria, fever, chills.  He is catheterizing 3 times a day, changing his catheter weekly.  Does have history of renal transplant, which has been followed by Dr. X and is on chronic steroids.  Renal ultrasound, June 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space.  Creatinine, July 7, 2008 was 2.0, BUN 36, and patient tells me this is being followed by Dr. X.  No interval complaints today, no issues with catheterization or any gross hematuria.,IMPRESSION:  ,1.  Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2.  Recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system.  He is asymptomatic today.  No complaints today.,PLAN:,  Following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above.  Based on the recent culture, we will place him on Keflex nighttime prophylaxis, for the next three months or so.  He will call if any concerns.  Follow up as previously scheduled in September for re-assessment.  All questions answered.  The patient is seen and evaluated by myself.
---
DESCRIPTION: Neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week

consult - history and phy., neurogenic bladder, catheterizing, catheter, urinary tract infection, self-catheterization, intermittent self catheterization, renal transplant, catheterization,

This medical case involves a patient with neurogenic bladder and a history of renal transplant, making them susceptible to infections due to immunosuppression from steroid use. The patient has experienced recurrent UTIs and was recently hospitalized with possible urosepsis. This scenario involves chronic health management and infection risk, which, while serious, are being actively managed and monitored, reducing immediate risk. However, the stakes are moderately high due to possible complications from infections and the history of renal transplant.


Medical Specialty: Orthopedic
Sample Name: Bunionectomy - Austin - Akin

PREOPERATIVE DIAGNOSIS:,  Bunion, right foot.,POSTOPERATIVE DIAGNOSIS:,  Bunion, right foot.,PROCEDURE PERFORMED:,  Austin/akin bunionectomy, right foot.,HISTORY: , This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.  The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,PROCEDURE DETAILS:,  An IV was instituted by Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap.  Copious amounts of Webril were placed around the right ankle followed by blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected in a Mayo block type fashion.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated to the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg.  The foot was lowered to the operating field and the stockinet was reflected.  The foot was cleansed with wet and dry sponge.,Attention was directed to the bunion deformity on the right foot.  An approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated with hemostasis.  The skin and subcutaneous tissue were then undermined off of the capsule medially.  A dorsal linear capsular incision was then created over the first metatarsophalangeal joint.  The periosteum and capsule were then reflected off of the first metatarsal.  There was noted to be a prominent medial eminence.  The articular cartilage was healthy for patient's age and race.  Attention was then directed to the first interspace where a lateral release was performed..  A combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified.  The adductor tendons were transected as well as a lateral capsulotomy was performed.  The extensor digitorum brevis tendon was identified and transected.  Care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum.  Extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon.  Attention was then directed to medial eminence, which was resected with a sagittal saw.  Sagittal was then used to create a long dorsal arm outside the Austin type osteotomy and the first metatarsal.  The head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted.  The head was intact.  A 0.45 K-wire was inserted through subcutaneously from proximal medial to distal lateral.  A second K-wire was then inserted from distal lateral to proximal plantar medial.  Adequate fixation was noted at the osteotomy site.  The K-wires were bent, cut, and pin caps were placed.  Attention was then directed to the proximal phalanx of the hallux.  The capsular periostem was reflected off of the base of the proximal phalanx.  A sagittal was then used to create an akin osteotomy closing wedge.  The apex was lateral and the base of the wedge was medial.  The wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression.  Two 0.45 K-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site.  Adequate fixation was noted at the osteotomy site and the osteotomy was closed.  The toe was noted to be in a markedly more rectus position.  Sagittal saw was then used to resect the remaining prominent medial eminence.  The area was then smoothed with a reciprocating rasp.  There was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp.  The area was then inspected for any remaining short bony edges, none were noted.,Copious amounts of sterile saline was then used to flush the surgical site.  The capsule was closed with #3-0 Vicryl.  Subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular #5-0 Vicryl.  Steri-Strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,Dressings consisted of #0-1 silk, copious Betadine, 4 x 4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot.  A _______ cast was then applied postoperatively.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported from the operating room to the PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain.  The patient is to follow up with Dr. X in his office as directed.
---
DESCRIPTION: Austin/akin bunionectomy, right foot.  Bunion, right foot.  The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.

orthopedic, austin/akin bunionectomy, hallucis brevis, bunion deformity, extensor hallucis, osteotomy site, foot, austin, bunionectomy

The procedure described is an Austin/Akin bunionectomy, which is a surgical operation to correct a bunion deformity. While any surgery carries inherent risks, this type of procedure is a routine orthopedic surgery typically performed to alleviate pain and improve foot function for the patient. The patient is elderly, which can add complexity, but the operation is not considered high-stakes in the context of surgical procedures. The operation has been detailed thoroughly without complications, and the patient's vital signs were stable post-operation. Therefore, the stakes are moderate but not extremely high.


Medical Specialty: Radiology
Sample Name: CT Head

TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes.  The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are within normal limits.  ,IMPRESSION: , No acute abnormalities.
---
DESCRIPTION: Common CT Head template.

Common CT Head template.

radiology, decreased attenuation, skull base, sequential axial ct images, bony calvarium, extra-axial fluid, ct head, attenuationNOTE

The findings indicate mild generalized atrophy and chronic small vessel ischemic changes, but no acute abnormalities were noted. While these are important findings that require monitoring, they are not immediately life-threatening. The scan did not reveal acute issues like hemorrhage or infarction, lowering the stakes from an urgent clinical perspective.


Medical Specialty: Surgery
Sample Name: Debridement Necrotic Tissue

PREOPERATIVE DIAGNOSIS: , Necrotizing infection of the left lower abdomen and left peritoneal area.,POSTOPERATIVE DIAGNOSIS:,  Necrotizing infection of the left lower abdomen and left peritoneal area.,PROCEDURE PERFORMED:,  Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.,ANESTHESIA:,  General.,FLUIDS:,  800 cc given.,ESTIMATED BLOOD LOSS:  ,350 cc.,SPECIMEN,:  Pannus and left peritoneal specimen sent to Pathology.,REASON FOR PROCEDURE:,  This is a 53-year-old white male who presented to ABCD General Hospital on 09/05/03 with a chief complaint of drainage from his left groin.  The patient is a diabetic who requires insulin, but has been noncompliant and states that his blood sugars have been out of control.  He has had a groin abdominal wound drained for about four days.  The patient states that there has been pus that has saturated his sheath.  He has had a possible fever at home that he did not chart with a thermometer.  He has had the same groin infection twice in the past with tunneling lesions.  The patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day.  Bowel habits and eating were essentially normal.,Urinary habits were normal.  The patient is morbidly obese and is approximately 450 lb.  He has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications.,PAST MEDICAL HISTORY:,  Diabetes, morbid obesity, and nephrolithiasis.,PAST SURGICAL HISTORY:,  Appendectomy and stone extraction.,PROCEDURE: , The patient was examined in the Emergency Room by Dr. X and was found to have multiple areas of erythematous tissue, which could potentially be consistent with a necrotizing fascitis texture.  The patient had a white count of 11.4 and a hemoglobin of 13.4.  Please note that the patient is a Jehovah's Witness and has adamantly refused receiving any blood products.  The risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted.  In the operative suite, he was prepped and draped in the usual sterile fashion.  The patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen.  Copious amounts of Betadine solution were used to cleanse the area and the wound was visualized.  Approximately, 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis.  Necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated.  The abdomen appeared to have a large erythematous border, however, the true indurated tissue was approximately the size of a deck of cards.  The area was incised using a #10 blade scalpel and then Bovie cauterization was used to achieve good hemostasis.  The tissue was removed using an Allis forceps as well as a Bovie to double the incision down to the fascia.  The necrotic tissue was lifted out of the abdomen.  All bleeding was cauterized using the Bovie.  A solution of gentamicin and sterile saline was placed into a high-powered water pump device and the wound was copiously irrigated and suctioned.  A wet Kerlix dressing was passed into the wound and it will be left opened with wet-to-dry dressing.  The left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm.  The tissue was incised to the muscle layer of the muscle.  There was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well.  There was a mild amount of pus that drained from the wound.  Cultures were taken from the groin wound and were sent to pathology.  The specimen was excised using traction with the Allis clamps as well as Bovie set on coag.  Once the tissue was excised from the ________, the area was fully irrigated using the gentamicin sterile saline solution in the high-powered water irrigation unit.  After the irrigation, the wound was packed using a wet Kerlix dressing and will be left open to heal.,It was determined at this time that both wounds will be left open to heal with the wet-to-dry dressings in place and we will come back and close the wounds at a later date.  The skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology.  The patient tolerated the procedure well and was taken to recovery in good condition.
---
DESCRIPTION: Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.  Pannus and left peritoneal specimen sent to Pathology.

surgery, debridement, abdomen, peritoneal, pannus, pathology, necrotizing infection, necrotic tissue, tissue, infection, necrotizing, groin, wound,

The situation involves a surgical procedure for a patient with a necrotizing infection, which is a rapidly progressing and potentially life-threatening condition. The patient is also a diabetic, non-compliant with insulin, and has other risk factors such as morbid obesity. These factors increase the complexity and risk associated with the procedure. Furthermore, the patient's refusal of blood products as a Jehovah's Witness adds an additional layer of critical decision-making during surgery. These elements together make this a high-stakes medical situation.


Medical Specialty: Surgery
Sample Name: Nasal Septoplasty

PREOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,POSTOPERATIVE DIAGNOSES: , Nasal fracture and deviated nasal septum with obstruction.,OPERATION:,  Open reduction, nasal fracture with nasal septoplasty.,ANESTHESIA: , General.,HISTORY: , This 16-year-old male fractured his nose playing basketball.  He has a left nasal obstruction and depressed left nasal bone.,DESCRIPTION OF PROCEDURE: , The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.,The face was prepped with Betadine soap and solution and draped in a sterile fashion.  Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve.  Further up, the cartilaginous septum was displaced to the left of the maxillary crest.  There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,A left hemitransfixion incision was made.  Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate.  Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut.  The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.,The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,This area was freed from the perichondrium on both sides.  The maxillary crest was removed with a gouge.  Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,Thus, the deviated septum was corrected.  Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures.  The septum was also filtered with #4-0 plain catgut sutures.,By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,Next, the nasal bone suture deviated to the left side were corrected.  The right nasal bone was depressed and left nasal bone was wide.  Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities.  The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment.  Approximate blood loss was 10 to 20 mL.
---
DESCRIPTION: Open reduction, nasal fracture with nasal septoplasty.

surgery, nasal fracture, deviated nasal septum, nasal septoplasty, nasal bones, ethmoid plate, cartilaginous septum, nasal bone, maxillary crest, septum, nasal, fracture, maxillary, cartilaginous, crest,

This scenario involves a surgical procedure on a 16-year-old patient for the correction of a nasal fracture and deviated nasal septum, both of which are causing obstruction. The procedure includes general anesthesia and requires skilled surgical intervention to correct structural anomalies in the nose. The stakes are reasonably high due to the use of general anesthesia, the age of the patient, and the intricate nature of the surgery involving precise manipulation of nasal structures. However, it is generally a standard surgical procedure and not an emergency situation. Therefore, while there are inherent risks, the surgery is relatively common and typically has a good prognosis.


Medical Specialty: Orthopedic
Sample Name: Back & Leg Pain - Discharge Summary

ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:,  Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation.  This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain.  He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability.  He was admitted and underwent an uncomplicated surgical procedure as noted above.  In the postoperative period, he was up and ambulatory.  He was taking p.o. fluids and diet well.  He was afebrile.  His wounds were healing well.  Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP:  ,At this time, the patient will follow up with me in the office in six weeks' time.  The patient understands discharge plans and is in agreement with the discharge plan.  He will follow up as noted
---
DESCRIPTION: Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.  Chronic pain syndrome.

orthopedic, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg

The situation described is a discharge summary for a patient who underwent orthopedic surgery for a condition involving the spine. While this is a significant medical procedure, the context indicates that the surgery was uncomplicated, and the patient is recovering well with a clear discharge plan and follow-up appointment. The nature of the surgery and the condition can be serious, but post-surgery, there are no immediate high-risk issues mentioned. Therefore, the stakes are moderate.


Medical Specialty: Hematology - Oncology
Sample Name: Posttransplant Lymphoproliferative Disorder

CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1.  Posttransplant lymphoproliferative disorder.,2.  Chronic renal insufficiency.,3.  Squamous cell carcinoma of the skin.,4.  Anemia secondary to chronic renal insufficiency and chemotherapy.,5.  Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007.  He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia.  He did not seek medical attention immediately.  He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma.  He was discussed at the hematopathology conference.  Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started.  First cycle of chemotherapy was complicated by sepsis despite growth factor support.  He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date.  He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well.  His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy.  He states he feels well.  He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue.  He denies any tingling or numbness in his fingers.  Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit.  There is mild pallor noted.  There is no icterus, adenopathy or petechiae noted.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  Systolic flow murmur is best heard in the pulmonary area.  ABDOMEN:  Soft and nontender with no organomegaly.  Renal transplant is noted in the right lower quadrant with a scar present.  EXTREMITIES:  Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1.  Diffuse large B-cell lymphoma following transplantation.  The patient is to receive his sixth and final cycle of chemotherapy today.  PET scan has been ordered to be done within 2 weeks.  He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2.  Chronic renal insufficiency.,3.  Anemia secondary to chronic renal failure and chemotherapy.  He is to continue on his regimen of growth factor support.,4.  Hypertension.  This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled.  His CMP is pending from today.,5.  Squamous cell carcinoma of the skin.  The scalp is well healed.  He still has an open wound on the right posterior aspect of his trunk.  This has no active drainage, but it is yet to heal.  This probably will heal by secondary intention once chemotherapy is finished.  Prescription for prednisone as part of his chemotherapy has been given to him.
---
DESCRIPTION: Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension.  The patient is here for followup visit and chemotherapy.

hematology - oncology, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative,

The situation described involves a patient with multiple serious health conditions, including posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma, anemia, and hypertension. The patient is currently undergoing the final cycle of chemotherapy which is a critical phase of treatment. These conditions, especially in combination with the recent history of chemotherapy complications like sepsis, make this a high-stakes medical situation. The outcome of the final chemotherapy cycle, as well as pending diagnostic tests like the PET scan, are crucial for the patient’s prognosis. Failure to manage these conditions or complications effectively could significantly impact the patient's overall health or survival.


Medical Specialty: Psychiatry / Psychology
Sample Name: Neurobehavioral Assessment

BENDER-GESTALT TEST: , Not organic.,BECK TESTING:,Depression: 37,Anxiety: 41,Hopelessness: 10,Suicide Ideation:  18,SUMMARY:,  The patient was cooperative and appeared to follow the test instructions. There is no evidence of organicity on the Bender. He endorsed symptoms of depression and anxiety. He has moderately negative expectancies regarding his future and is expressing suicidal ideation. Great care should be taken to confirm the accuracy of the results as the patients seems over-medicated and/or drunk.
---
DESCRIPTION: Bender-Gestalt Neurological Battery and Beck testing.

psychiatry / psychology, bender-gestalt neurological battery, beck anxiety inventory, beck depression inventory, beck hopelessness scale, beck scale, suicide ideation, bender-gestalt test, beck testing, bender gestalt, beck,

This situation is high-stakes because the patient has reported a significant level of suicidal ideation, as indicated by the score of 18 on the Suicide Ideation section of the Beck Testing. The presence of suicidal thoughts, particularly when coupled with depression and anxiety, requires immediate and careful attention due to the potential risk to the patient’s safety. Additionally, the note about the patient appearing over-medicated or intoxicated adds complexity to the situation, indicating the need for careful cross-evaluation and possibly urgent intervention to ensure the patient's safety.


Medical Specialty: Podiatry
Sample Name: Dystrophic Nails

S: , The patient presents for evaluation at the request of his primary physician for treatment for nails.  He has last seen the primary physician in December 2006.,PRIMARY MEDICAL HISTORY:,  Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, and atrial fibrillation.,MEDICATIONS:,  Refer to chart.,O: , The patient presents in wheelchair, verbal and alert.  Vascular:  He has absent pedal pulses bilaterally.  Trophic changes include absent hair growth and dystrophic nails.  Skin texture is dry and shiny.  Skin color is rubor.  Classic findings include temperature change and edema +2.  Nails:  Thickened and hypertrophic, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1.  Dystrophic nails.,2.  Peripheral vascular disease as per classic findings.,3.  Pain on palpation.,4.  Diabetes.,P:  ,Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided.  The patient will be seen at the request of the nursing staff for therapeutic treatment of dystrophic nails.
---
DESCRIPTION: The patient presents for evaluation at the request of his primary physician for treatment for dystrophic nails.

podiatry, debrided, nails, dystrophic nails, dystrophic

The medical situation involves the evaluation and treatment of dystrophic nails, which are often a cosmetic or minor medical issue but can become more significant in the presence of other health conditions. The patient has a complex medical history that includes diabetes, COPD, CAD, and PVD, which are serious conditions. This adds complexity as these underlying conditions can impact healing and increase the risk of complications. However, the immediate focus is on nail treatment rather than a life-threatening condition. Although the patient is monitoring and managing multiple serious conditions, the primary focus of this evaluation itself does not involve life-threatening factors.


Medical Specialty: Emergency Room Reports
Sample Name: Closed Head Injury

CHIEF COMPLAINT:,  Status post motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle.  He denies loss of consciousness, although the EMT people report that he did have loss of consciousness.  The patient was stable en route.  Upon arrival, he complained of headache.,PAST MEDICAL HISTORY:,  Medical:  None.  Surgical:  None.,REVIEW OF SYSTEMS: , CARDIAC:  No history.  PULMONARY:  Some morning cough.  (Patient is a smoker.),MEDICATIONS:,  None.,ALLERGIES:,  ALLERGIC TO PENICILLIN, CAUSES SKIN RASH.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 120/80, pulse 82, respirations 20, temperature 36.8°.,HEENT:  Contusion over right occipital area.  Tympanic membranes benign.,NECK:  Nontender.,CHEST:  Atraumatic, nontender.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Flat, soft, and nontender.,BACK:  Atraumatic, nontender.,PELVIS:  Stable,EXTREMITIES:  Contusion over right forearm.  No bone deformity or crepitus.,RECTAL:  Normal sphincter tone; guaiac negative.,NEUROLOGIC:  Glasgow coma scale 15.  Pupils equal, round, reactive to light.  Patient moves all 4 extremities without focal deficit.,LABORATORY DATA: , Serial hematocrits 42.4, and 40.4.  White blood count 6.3.  Ethanol:  None.  Amylase 66.  Urinalysis normal.  PT 12.6, PTT 29.  Chem-7 panel within normal limits.,X-rays of cervical spine and lumbosacral spine within normal limits.  X-rays of pelvis and chest within normal limits.,ASSESSMENT:,1.  Closed head injury.,2.  Rule out intra-abdominal injury.,PLAN:,  The patient will be admitted to the trauma surgery service for continued evaluation and treatment for closed head injury as well as possible intra-abdominal injury.
---
DESCRIPTION: Status post a high-speed motor vehicle accident in which patient was ejected from the vehicle.

The situation involves a 17-year-old patient who has been in a high-speed motor vehicle accident, was ejected from the vehicle, and experienced a loss of consciousness. These factors indicate high potential for severe injuries, particularly to the head and possibly the abdomen, which are critical concerns in trauma medicine. The patient is being admitted for further evaluation and treatment for a closed head injury and potential intra-abdominal injuries. These considerations make it a high-stakes medical emergency due to the potential for life-threatening outcomes if injuries are undetected or not treated promptly.


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

Medical Specialty: Letters
Sample Name: Cardiology - Letter

Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD,
---
DESCRIPTION: Follow up update on patient with left carotid angioplasty and stent placement.

letters, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: 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 scenario describes a standard follow-up letter concerning a patient who underwent cardiac procedures. The patient shows no significant recurrence and the procedure remains successful, indicating low immediate medical risk. Moreover, there is no urgent threat to the patient's health or life from this update. This is routine in medical practice, hence, it involves low-stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Blood in Urine - ER Visit

CHIEF COMPLAINT: , Blood in urine.,HISTORY OF PRESENT ILLNESS:  ,This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder.  The patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine.  The patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool.  The patient has not had any fever.  There is no abdominal pain and the patient is still able to pass urine.  The patient has not had any melena or hematochezia.  There is no nausea or vomiting.  The patient has already completed chemotherapy and is beyond treatment for his cancer at this time.  The patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer.  The patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  The patient does report generalized fatigue and weakness over the past several days.  HEENT:  No headache, no neck pain, no rhinorrhea, no sore throat.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough, although the patient does get easily winded with exertion over these past few days.  GASTROINTESTINAL:  The patient denies any abdominal pain.  No nausea or vomiting.  No changes in the bowel movement.  No melena or hematochezia.  GENITOURINARY:  A gross hematuria since yesterday as previously described.  The patient is still able to pass urine without difficulty.  The patient denies any groin pain.  The patient denies any other changes to the genital region.  MUSCULOSKELETAL:  The chronic lower back pain which has not changed over these past few days.  The patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.  SKIN:  No rashes or lesions.  No easy bruising.  NEUROLOGIC:  No focal weakness or numbness.  No incontinence of urine or stool.  No saddle paresthesia.  No dizziness, syncope or near-syncope.  ENDOCRINE:  No polyuria or polydipsia.  No heat or cold intolerance.  HEMATOLOGIC/LYMPHATIC:  The patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,PAST MEDICAL HISTORY: , Prostate cancer with metastatic disease as previously described.,PAST SURGICAL HISTORY: , TURP.,CURRENT MEDICATIONS:,  Morphine, Darvocet, Flomax, Avodart and ibuprofen.,ALLERGIES: , VICODIN.,SOCIAL HISTORY: , The patient is a nonsmoker.  Denies any alcohol or illicit drug use.  The patient does live with his family.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be pale, but otherwise looks well.  The patient is calm, comfortable.  The patient is pleasant and cooperative.  HEENT:  Eyes normal with clear conjunctivae and corneas.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple.  Full range of motion.  No JVD.  CARDIOVASCULAR:  Heart is mildly tachycardic with regular rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruit.  No masses or pulsatile masses.  GENITOURINARY:  The patient has normal male genitalia, uncircumcised.  There is no active bleeding from the penis at this time.  There is no swelling of the testicles.  There are no masses palpated to the testicles, scrotum or the penis.  There are no lesions or rashes noted.  There is no inguinal lymphadenopathy.  Normal male exam.  MUSCULOSKELETAL:  Back is normal and nontender.  There are no abnormalities noted to the arms or legs.  The patient has normal use of the extremities.  SKIN:  The patient appears to be pale, but otherwise the skin is normal.  There are no rashes or lesions.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal speech.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  There is no evidence of bruising noted to the body.  No lymphadenitis is palpated.,EMERGENCY DEPARTMENT TESTING:,  CBC was done, which had a hemoglobin of 7.7 and hematocrit of 22.6.  Neutrophils were 81%.  The RDW was 18.5, and the rest of the values were all within normal limits and unremarkable.  Chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable.  Alkaline phosphatase was 770 and albumin was 2.4.  Rest of the values all are within normal limits of the LFTs.  Urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.  The patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen.  Coagulation profile study had a PT of 15.9, PTT of 43 and INR of 1.3.,EMERGENCY DEPARTMENT COURSE: , The patient was given normal saline 2 liters over 1 hour without any adverse effect.  The patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect.  The patient was given Levaquin 500 mg by mouth as well as 2 doses of Phenergan over the course of his stay here in the emergency department.  The patient did not have an adverse reaction to these medicines either.  Phenergan resolved his nausea and morphine did relieve his pain and make him pain free.  I spoke with Dr. X, the patient's urologist, about most appropriate step for the patient, and Dr. X said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion.  It was all a matter of what the patient wished to do given the advanced stage of his cancer.  Dr. X was willing to assist in any way the patient wished him to.  I spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion.  The patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight.  The patient's son felt comfortable with his father's choice.  This was done.  The patient was transfused 2 units of packed red blood cells after appropriately typed and match.  The patient did not have any adverse reaction at any point with his transfusion.  There was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength.  Over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction.  Foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder.  The patient was given a leg bag and the Foley catheter was left in place.,DIAGNOSES,1.  HEMATURIA.,2.  PROSTATE CANCER WITH BONE AND BLADDER METASTATIC DISEASE.,3.  SIGNIFICANT ANEMIA.,4.  URINARY OBSTRUCTION.,CONDITION ON DISPOSITION:  ,Fair, but improved.,DISPOSITION: , To home with his son.,PLAN: , We will have the patient follow up with Dr. X in his office in 2 days for reevaluation.  The patient was given a prescription for Levaquin and Phenergan tablets to take home with him tonight.  The patient was encouraged to drink extra water.  The patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.
---
DESCRIPTION: Patient has prostate cancer with metastatic disease to his bladder.  The patient has had problems with hematuria in the past.  The patient was encouraged to drink extra water and was given discharge instructions on hematuria.

This situation involves a 78-year-old male patient with prostate cancer that has metastasized to the bones and bladder, leading to hematuria and significant anemia. Although the patient's cancer is beyond curative treatment, he is experiencing acute medical issues such as hematuria and urinary obstruction, which warrant emergency care. This patient was admitted to the ER, received a blood transfusion, and was treated for pain and other symptoms before being discharged with a care plan. The patient's decision to receive home care instead of hospitalization signifies a life-limiting decision, adding to the complexity and gravity of the case. Hence, this is a high-stakes medical situation concerning the optimization of quality of life and symptom management for a terminally ill patient.


Medical Specialty: Hematology - Oncology
Sample Name: Breast Mass Excision

PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:,  Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:,  Excision of right breast mass.,PROCEDURE:,  With the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  Hemostasis was obtained using electrocautery.  Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  The breast tissues were approximated using 4-0 Vicryl.  The skin was closed using 5-0 Vicryl running subcuticular stitches.  A sterile bandage was applied.  The patient tolerated the procedure well.,
---
DESCRIPTION: Excision of right breast mass.  Right breast mass with atypical proliferative cells on fine-needle aspiration.

hematology - oncology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass,

The situation involves a surgical procedure to remove a breast mass that was initially diagnosed with atypical proliferative cells, which could suggest a risk of breast cancer. However, the postoperative diagnosis revealed it to be a benign breast mass. Surgical procedures inherently carry some risk, and the initial concern for cancer increases the stakes, but since the mass was ultimately benign and the patient tolerated the procedure well, the stakes are not extremely high. The stakes are moderate due to the potential implications of the initial diagnosis and the surgical aspect, but they are not life-threatening or urgent given the outcome.


Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template - 4

VITAL SIGNS:,  Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:,  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  No papilledema, glaucoma, or cataracts.  Ears:  Normal set and shape with normal hearing and normal TMs. Nose and Sinus:  Unremarkable.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy.  Trachea is midline without stridor, shift, or subcutaneous emphysema.  Thyroid is palpable, nontender, not enlarged, and free of nodularity.,CHEST: , Lungs bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI is nondisplaced.  Chest wall is unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS: , Normal male breast tissue.,ABDOMEN:,  No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and intraabdominal bruit on auscultation.,EXTERNAL GENITALIA: , Normal for age.  Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,RECTAL:,  Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness.  No rectal masses palpated.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK: , Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC: , Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN:  ,Unremarkable for any premalignant or malignant condition with normal changes for age.
---
DESCRIPTION: An example/template for a routine normal male physical exam.

general medicine, digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue,

The text provided is a template for a routine normal male physical exam and does not indicate any specific medical emergency or high-risk situation. It outlines standard observations expected during a general examination in a male patient, confirming that there are no abnormal findings. This template serves as a baseline for comparison in general practice rather than an urgent health situation.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Epidermal Autograft

PREOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,POSTOPERATIVE DIAGNOSIS:,  A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,PROCEDURES PERFORMED:,1.  Epidermal autograft on Integra to the back (3520 cm2).,2.  Application of allograft to areas of the lost Integra, not grafted on the back (970 cm2).,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Approximately 50 cc.,BLOOD PRODUCTS RECEIVED:,  One unit of packed red blood cells.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities.  He has previously undergone total burn excision with placement of Integra and an initial round of epidermal autografting to the bilateral upper extremities and hands.  His donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the Integra on his back utilizing the buttock donor sites, the extent they will provide coverage.,OPERATIVE FINDINGS:,1.  Variable take of Integra, particularly centrally and inferiorly on the back.  A fair amount of lost Integra over the upper back and shoulders.,2.  No evidence of infection.,3.  Healthy viable wound beds prior to grafting.,PROCEDURE IN DETAIL:,  The patient was brought to the operating room and positioned supine.  General endotracheal anesthesia was uneventfully induced and an appropriate time out was performed.  He was then repositioned prone and perioperative IV antibiotics were administered.  He was prepped and draped in the usual sterile manner.  All staples were removed from the Integra and the adherent areas of Silastic were removed.  The entire wound bed was further prepped with scrub brushes and more Betadine followed by a sulfamylon solution.  Hemostasis of the wound bed was ensured using epinephrine-soaked Telfa pads.  Following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air Zimmer dermatome.  These grafts were passed to the back table where they were meshed 3:1.  The donor sites were hemostased using epinephrine-soaked Telfa and lap pads.  Once all the  grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of Integra engraftment.  We were happy with the lie of the grafts and they were stapled into place.  The grafts were then overlaid with Conformant 2, which was also stapled into place.  Utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor Integra engraftment.  Allograft was thawed and meshed 1:1.  It was then brought up onto the field, trimmed to fit and stapled into place over the wound.  Once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied.  Donor sites on his buttocks were dressed in Acticoat and secured with staples.  He was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications.  He was transported to PACU in stable condition.
---
DESCRIPTION: A 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.  Epidermal autograft on Integra to the back and application of allograft to areas of the lost Integra, not grafted on the back.

cosmetic / plastic surgery, flame burns, body surface area, epidermal autograft, autograft, integra, integra engraftment, wound, grafts, epidermal, allograft,

The situation involves a 26-year-old male who has sustained extensive injuries with 60% total body surface area flame burns. The patient has already undergone multiple surgeries and continues to require complex procedures including skin grafting. The stakes are high due to the extensive nature of the burns, the risk associated with large surgical procedures, the importance of preventing infection, and ensuring successful graft take to avoid complications. However, given the patient's stability and absence of immediate complications, it's not an emergency but remains a critical medical scenario.


Medical Specialty: Pain Management
Sample Name: Cervical Epidural Steroid Injection - 2

PROCEDURE PERFORMED:,  Cervical epidural steroid injection, C5-6.,ASSISTANT:,  None.,ANESTHESIA:,  Local.,DETAILS OF PROCEDURE: , The patient was brought to the operating theater and placed prone onto the radiolucent table.  Subsequent monitored anesthesia care was administered.  The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level.  The neck area was then prepped with Betadine solution and draped sterile.  A metallic marker was placed over the C5-6 lamina and a skin wheal was raised in the skin.  A #20-gauge Tuohy needle was then advanced into the spinal canal using 1% Xylocaine anesthetic and the depth of penetration to the C5 lamina was determined.  The needle was redirected into the interlaminar space and advanced to the previously determined level.  A 10 cc syringe was then placed onto the end of the needle and, using an air-negative technique, the needle was advanced into the epidural space.  When a free flow of air was produced, a solution of 80 mg Depo-Medrol, 2 cc of 1% Xylocaine injectable, and 5 cc of normal saline was then injected into the epidural space.  The Tuohy needle was removed.  Betadine was cleansed from the skin.  A bandage was placed over the needle entrance point.  The patient was turned supine onto a regular hospital bed and subsequently allowed to be awakened from anesthesia.  The patient was taken to the recovery room in stable condition.
---
DESCRIPTION: Cervical epidural steroid injection, C5-6.  The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level.

pain management, c-arm, cervical epidural steroid injection, ap view, lumbar spine, tuohy needle, epidural steroid, steroid injection

The procedure described is a cervical epidural steroid injection performed at spinal level C5-6, which is commonly used to manage pain in patients with cervical spine conditions. These injections can provide significant relief but come with risks, such as infection, bleeding, and potential nerve damage. The stakes are moderate, as the procedure, while generally safe when performed by knowledgeable practitioners, is invasive and could lead to complications if not done correctly. Therefore, it requires skill and care, impacting the patient's safety and outcome. Despite these risks, it is a routine procedure in pain management settings.


Medical Specialty: ENT - Otolaryngology
Sample Name: Stapedectomy - Argon Lasor Assisted

PREOPERATIVE DIAGNOSIS: , Bilateral progressive conductive hearing losses with probable otosclerosis.,POSTOPERATIVE DIAGNOSIS: , Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,OPERATION PERFORMED: , Right argon laser assisted stapedectomy.,DESCRIPTION OF OPERATION:  ,The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The patient's right ear was carefully prepped and then draped in the usual sterile fashion.  Slow infiltration of the external canal accomplished with 1% Xylocaine with epinephrine.  The earlobe was also infiltrated with the same solution.  A limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5-0 nylon.  This could later be removed in bishop.  A reinspection of the ear canal was accomplished.  A 65 Beaver blade was used to make incision both at 12 o'clock and at 6 o'clock.  Jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation.  Elevation was carried down to the fibrous annulus.  An annulus elevator was used to complete the elevation beneath the annular ligament.  The tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain.  Palpation of the malleus revealed good mobility of both it and incus, but no movement of the stapes was identified.  Palpation with a fine curved needle on the stapes itself revealed no movement.  A house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani.  The nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well.  The self-retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse.  The stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured.  The fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation.  A small bit of additional footplate was removed with a right angle hook to accommodate the 0.6 mm piston.  The measuring device was used and a 4.25 mm slim shaft wire Teflon piston chosen.  It was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate.  The hook was placed over the incus and measurement appeared to be appropriate.  A downbiting crimper was then used to complete the attachment of the prosthesis to the incus.  Prosthesis is once again checked for location and centering and appeared to be in ideal position.  Small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph.  A small pledget of fat was also placed on the top of the incudo-prosthesis junction.  The mobility appeared excellent.  The flap was placed back in its normal anatomic position.  The external canal packed with small pledgets of Gelfoam and antibiotic ointment.  She was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to Bishop.  Sutures will be out in a week and a recheck in Reno in four to five weeks from now.
---
DESCRIPTION: Right argon laser assisted stapedectomy.  Bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.

ent - otolaryngology, bilateral progressive conductive hearing loss, argon laser assisted, conductive hearing losses, intubation, argon, stapedectomy, otosclerosis, canal, earlobe, prosthesis, pledgets, laser

The procedure described is a stapedectomy, which is a surgical intervention to address conductive hearing loss due to otosclerosis. This type of surgery, while routinely performed and generally considered safe, still involves the use of general anesthesia and intricate work on the delicate structures of the middle ear. The stakes are higher because the outcome of the surgery can significantly impact the patient's hearing ability and quality of life. While it is not a life-threatening situation, it requires careful execution and carries some risks, such as hearing loss or damage to nearby structures like the chorda tympani nerve. Therefore, the stakes are moderate to high given the context.


Medical Specialty: Surgery
Sample Name: Vitrectomy - 2

PREOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye.  CME, right eye.,POSTOPERATIVE DIAGNOSES: , Epiretinal membrane, right eye.  CME, right eye.,PROCEDURES: , Pars plana vitrectomy, membrane peel, 23-gauge, right eye.,PREOPERATIVE FINDINGS:,  The patient had epiretinal membrane causing cystoid macular edema.  Options were discussed with the patient stressing that the visual outcome was guarded.  Especially since this membrane was of chronic duration there is no guarantee of visual outcome.,DESCRIPTION OF PROCEDURE: , The patient was wheeled to the OR table.  Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified.  Preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified.  The fluid was run.  Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock.  Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ILM forceps, the membrane was peeled off in its entirety.  There were no complications.  DVT precautions were in place.  I, as attending, was present in the entire case.
---
DESCRIPTION: Pars plana vitrectomy, membrane peel, 23-gauge, right eye.

surgery, epiretinal membrane, pars plana vitrectomy, membrane peel, macular edema, cystoid, eye, retrobulbar, epiretinal, vitrectomy, membrane,

The described procedure is a vitrectomy with membrane peel, which is a significant surgical intervention but is commonly performed and generally considered low to moderate in risk when conducted by experienced practitioners. The primary concerns would be the postoperative visual outcome, especially given the chronic nature of the epiretinal membrane and existing cystoid macular edema. However, the immediate procedural risks are well-managed with standard precautions, such as local anesthesia and sclerotomy procedure. The stakes are considered moderate due to the potential impact on the patient's vision and the meticulous nature of ocular surgery.


Medical Specialty: General Medicine
Sample Name: Perioperative Elevated Blood Pressure

REASON FOR CONSULTATION:,  Perioperative elevated blood pressure.,PAST MEDICAL HISTORY:,1.  Graves disease.,2.  Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.,3.  Diverticulosis.,4.  GERD.,5.  High blood pressure.,6.  Prostatic hypertrophy, status post transurethral resection of the prostate.,PAST SURGICAL HISTORY: , Bilateral inguinal hernia repair, right shoulder surgery with reconstruction, both shoulders rotator cuff repair, left knee arthroplasty, and transurethral resection of prostate.,HISTORY OF PRESENTING COMPLAINT:  ,This 71-year-old gentleman with the above history, underwent laser surgery for the prostate earlier today.  Before surgery, the patient's blood pressure was 181/107.  The patient received IV labetalol.  Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.  Currently, blood pressure is 158/100, goes up to 155 systolic when he is talking.  On further questioning, the patient denies shortness of breath, chest pain, palpitations, or dizziness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No recent fever or general malaise.,ENT:  Unremarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  No chest pain.,GASTROINTESTINAL:  No nausea or vomiting.,GENITOURINARY:  The patient has prostatic hypertrophy, had laser surgery earlier today.,ENDOCRINE:  Negative for diabetes, but positive for Graves disease.,MEDICATIONS:  ,The patient takes Synthroid and aspirin.  Aspirin had been discontinued about 1 week ago.  He used to be on atenolol, lisinopril, and terazosin, both of which have been discontinued by his cardiologist, Dr. X several months ago.,PHYSICAL EXAMINATION:,GENERAL:  A 71-year-old gentleman, not in acute distress.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGICAL:  The patient is alert and oriented x3.  Examination is nonfocal.,ASSESSMENT AND PLAN:,1.  Perioperative hypertension.  We will restart lisinopril at half the previous dose.  He will be on 20 mg p.o. daily.  If blood pressure remains above systolic of 150 within 3 days, the patient should increase lisinopril to 40 mg p.o. daily.  The patient should see his primary physician, Dr. Y in 2 weeks' time.  If blood pressure, however, remains above 150 systolic despite 40 mg of lisinopril, the patient should make an appointment to see his primary physician in a week's time.,2.  Prostatic hypertrophy, status post laser surgery.  The patient tolerated the procedure well.,3.  History of Graves disease.,4.  History of atrial fibrillation.  The patient is in normal sinus rhythm.,DISPOSITION:  ,The patient is stable to be discharged to home.  Nurse should observe for 1 hour after lisinopril to make sure the blood pressure does not go too low.
---
DESCRIPTION: Before surgery, the patient's blood pressure was 181/107.  The patient received IV labetalol.  Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100.

The situation involves managing a patient's hypertension perioperatively, which can lead to serious complications if not controlled. The patient has a history of multiple medical conditions, including Graves disease and atrial fibrillation, that add complexity to his treatment. While the current situation does not involve immediate life-threatening danger, it requires careful monitoring to avoid potential complications such as stroke or cardiac events.


Medical Specialty: Radiology
Sample Name: MRI Head - 1

EXAM:,  MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:,  Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla.  Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction.  There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease.  There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size.  There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy.  There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan.  This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution.  No abnormal mass effect is identified.  There are no findings to suggest active hydrocephalus.  No abnormal extra-axial collection is identified.  There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation.  The region of the pituitary/optic chiasm grossly appears normal.  The mastoids and paranasal sinuses are clear.,IMPRESSION:,1.  No definite acute findings identified involving the brain.,2.  There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes.  There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3.  Moderate to moderately advanced atrophy.
---
DESCRIPTION: MRI head without contrast.

MRI head without contrast.

radiology, severe headaches, chiari malformation, cerebral ischemic change, mri head without contrast, cerebellar hemisphere, superior portion, mri head, cerebellar, infarction, ischemic

This MRI report indicates findings of chronic ischemic changes, moderate atrophy, and an old infarct, but no acute or life-threatening issues are identified. The presence of these chronic conditions suggests ongoing health concerns that need monitoring, yet there is no immediate risk necessitating urgent intervention. Therefore, while important for long-term health management, the situation doesn't represent a high-stakes emergency.