Medical Specialty: Orthopedic
Sample Name: Knee Arthroplasty - Revision

PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS:  ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: ,  Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes.  Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used.  A NexGen femoral component with a distal femoral augmented block, size 5 mm.  A NexGen tibial component, size 3 mm was used.  A size 14 mm constrained polyethylene surface was used as well.  Original patellar component that the patient had was maintained.,COMPLICATIONS:  ,None.,BRIEF HISTORY:,  The patient is a 68-year-old female with a history of knee pain for 13 years.  She had previous total knee arthroplasty and revision at an outside facility.  She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:,  The patient was taken to the operative suite and placed on the operating table.  Department of Anesthesia administered the spinal anesthetic.  Once adequately anesthetized, the patient was placed in a supine position.  Care was ensured and she was adequately secured and well padded in position.  Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was inflated to approximately 325 mmHg on the right thigh.  At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum.  A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface.  There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well.  At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed.  This was done without difficulty.  Attention was then directed removing the femoral component.  Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed.  After this was performed, attention was then directed to the tibial component.  An osteotome was again inserted around the surface and this was easily pried loose.  There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation.  This was evaluated.  The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component.  The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component.  At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut.  We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut.  We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12.  At this point, the distal femoral cutting guide based on the intramedullary head was then placed.  Care was ensured that this was aligned in proper rotation with the external epicondylar axis.  Once this was pinned in position, approximately a six degree valgus cut was then made.  This allowed a portion of the medial condyle to be removed distally.  The anterior cut was checked next using the intramedullary guide.  The anterior surface cutting block was then placed.  This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis.  Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made.  It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface.  _______ was then removed and the chamfer cutting guide was then placed on.  This allowed us to make a box cut and recut some of the angled cuts of the distal femur.  Once this was placed and pinned in position.  Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut.  It was noted that the anterior chamfers did not need to be cut, take off no bone.  The posterior chamfers did remove some bony aspects.  This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component.  After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed.  This appeared to have an adequate fit and then packed in position.  It appeared to be satisfactory.  At this point, this was removed and attention was then directed to the tibia.  The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained.  At this point, the intramedullary guide was used to evaluate a tibial cut.  This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface.  The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component.  At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone.  This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component.  This was placed in a proper position.  A 10 mm articular surface was placed in the knee and this was taken through range of motion.  This was found to have better alignment and satisfactory position.  We elected to take an intraoperative x-ray at this point, to evaluate our cut.  The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis.  At this point, all trials were removed.  The patella was then examined.  The rongeur was used to remove the surrounding synovium.  The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone.  It was elected at this time to maintain this anatomic patella that was previously placed.  At this point, the joint again was reevaluated and any bone loose fragments removed.  There was noted to be some posterior tightness and mild osteophytes.  These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes.  Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried.  The tourniquet was then reinflated.  The canals were prepped for cementing.  They were suction-dried and cleaned.  The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial.  Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component.  The stemmed femoral component was then impacted in position and cemented.  Again care was ensured that it was in adequate position and proper rotation.  A size 14 mm poly was then inserted in between to provide compression.  This was then taken through extension and held until cement cured.  This was then removed and the components were evaluated.  All excess cement was removed and they were well fixed.  Size 14 mm trial Poly was then placed and this was taken through range of motion.  This was found to have excellent range of motion and good stability.  It was elected at this time that we would go with the size 14 mm Poly.  This gave us extra Poly for ware and then provide excellent contact throughout the range of motion.  The final articular surface was then placed and tightened into position to allow to _______ secured.  The knee was then reduced and the knee was taken through range of motion.  The patella was tracking with no-touch technique and adequately positioned.  At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry.  All bleeding was cauterized using a Bovie cautery.  The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion.  This was reinforced with a running #2-0 Vicryl.  The knee was then flexed and noted that the patella was tracking with good alignment.  The wound was again copiously irrigated and suctioned dry.  A drain was placed prior to retinaculum repair deep to this to provide adequate drainage.  At this point, the subcutaneous tissue was closed with #2-0 Vicryl.  Skin was approximated with skin clips.  Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed.  A large Dupre dressing was then placed up the entire lower extremity.  The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition.
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DESCRIPTION: Revision right total knee arthroplasty.  Right failed total knee arthroplasty.

orthopedic, knee arthroplasty, revision, zimmer nexgen, distal femoral, intramedullary guide, femoral component, femoral, knee, arthroplasty, intramedullary, patellar, medial, tibial,

Revision knee arthroplasty is a significant surgical procedure due to its complexity and the potential for complications. The patient had a failed total knee arthroplasty with continuous symptoms, requiring a revision, which indicates a serious level of intervention needed to restore functionality and alleviate pain. The surgery involves substantial planning and precision, as indicated by the need for proper alignment, assessment of bone conditions, and the requirement to correct any pre-existing issues such as malalignment. The use of specialized components and techniques, along with the detailed observation of the procedure, signifies a high level of stakes involved both in the success of the surgery and the patient's recovery. Additionally, the mention of specific measures to prevent complications (such as monitoring for infection and managing blood loss) contributes to the high-stakes nature of this procedure. Therefore, this situation overall involves significant risks and requires acute attention to ensure a successful outcome.


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

Medical Specialty: General Medicine
Sample Name: Melena - ICU Followup

HISTORY:,  Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.  Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient.  Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value.  He also underwent EGD earlier today with Dr. X.  I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding.  Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future.  The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU.  He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 100/54, heart rate 80 and temperature 98.8.  Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL:  This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough.  Pallor is improved.,EYES:  Conjunctivae are now pink.,ENT:  Oropharynx is clear.,CARDIOVASCULAR:  Reveals distant heart tones with regular rate and rhythm.,LUNGS:  Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN:  Soft and nontender with no organomegaly appreciated.,EXTREMITIES:  Showed no clubbing, cyanosis or edema.  Capillary refill time is now normal in the fingertips.,NEUROLOGICAL:  Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:,  Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000.  This is up from 8.6 and 24.7.  Platelets are stable.  Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive.  EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1.  Melena secondary to ulcerative esophagitis.  We will continue to monitor the patient overnight to ensure there is no further bleeding.  If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2.  Chronic obstructive pulmonary disease exacerbation.  The patient is doing well, taking PO.  We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments.  We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions.  This does appear to be improving.  His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3.  Elevated CEA.  The patient will need colonoscopy on an outpatient basis.  He has refused this today.  We would like to encourage him to do so.  Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion.  Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4.  Anemia, normochromic normocytic with low total iron binding capacity.  This appears to be anemia of chronic disease.  However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding.  Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.
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DESCRIPTION: Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.

general medicine, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding

The situation involves a patient who has been in the ICU due to acute anemia from upper GI bleeding, which required a blood transfusion and endoscopic evaluation. Additionally, the patient has chronic obstructive pulmonary disease (COPD) exacerbation, complicating his condition with respiratory issues. The medical team is actively monitoring for further bleeding and complications, indicating a critical phase of treatment. The context of an elevated CEA level, a marker that could suggest underlying malignancies, adds complexity to the patient's condition. Overall, this scenario involves significant medical risks requiring careful management and coordination between medical teams, making it inherently high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Nephrology
Sample Name: Peritoneal Dialysis Catheter Insertion

PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:,  Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS:  ,This 14-year-old young lady is in the renal failure and in need of dialysis.  She had had a previous PD catheter placed, but it became infected and had to be removed.  She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection.  The fascia was divided and the posterior fascia and peritoneum were identified.  A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity.  The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision.  A PD catheter was then placed into the pelvis over a guidewire.  At this point, the peritoneum and posterior fascia was closed around the catheter.  The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia.  The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site.  The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return.  The skin was closed with 5-0 subcuticular Monocryl.  Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition.
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DESCRIPTION: A 14-year-old young lady is in the renal failure and in need of dialysis.

nephrology, pd catheter, catheter, omentum, peritoneal dialysis catheter, peritoneal dialysis, renal failure, peritoneal, dialysis, renal

The procedure described is the insertion of a peritoneal dialysis catheter, which is a necessary step in establishing dialysis for a patient with renal failure. Since the patient is a 14-year-old with renal failure and previously had complications with an infected catheter, this procedure is critical for her ongoing treatment and management of her condition. Dialysis is a life-sustaining intervention for individuals with renal failure, and without the catheter, the patient cannot receive dialysis, which could lead to serious health consequences. Therefore, the situation is high-stakes due to the patient's dependence on dialysis for survival and the previous complications with catheter placement.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal ROS Template - 4

GENERAL:  Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC:  Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT:  Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC:  Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY:  Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL:  Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY:  Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY:  Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC:  Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC:  Negative for any abnormal bruising, frequent infections or bleeding.
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DESCRIPTION: Negative for any nausea, vomiting, fevers, chills, or weight loss.

consult - history and phy., review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting,

The scenario described is a review of systems template often used in medical consultations to ensure a comprehensive check for any symptoms patient might have. The ROS (Review of Systems) includes multiple medical aspects that are general negative indicators for common illnesses. Though it ensures thoroughness in assessment, reviewing the patient's medical symptoms in a template format typically does not involve high-stakes decision-making because it is part of a routine evaluation process, and no urgent or life-threatening issues are identified by the negative statements listed.


Medical Specialty: Surgery
Sample Name: Colonoscopy Template - 4

A colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve.  This was done without difficulty and the bowel preparation was good.  The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal.  The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed.,COMPLICATIONS: , None.
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DESCRIPTION: Common description of colonoscopy

Common description of colonoscopy

surgery, cecum, colonoscope, bleeding, infection, perforation, allergic reaction, ileocecal valve, informed, allergic, ileocecal, valve, colonoscopyNOTE,: 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 user's situation involves a colonoscopy procedure, which is a routine medical exam. While it is an important medical procedure, the stakes described in the scenario are not particularly high since the result was normal and no complications were noted. Routine medical procedures like this one generally carry low stakes unless complications or abnormalities are detected. Moreover, the provided text describes a normal procedure without any distress or emergency situation.


Medical Specialty: Neurology
Sample Name: MRI Brain: Thalamic Infarct

CC:, Left hemiplegia.,HX: , A 58 y/o RHF awoke at 1:00AM on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable. She was admitted locally. She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour. She was placed on IV Heparin following the 3rd episode and was transferred to UIHC. She had not been taking ASA.,PMH:, 1)HTN. 2) Psoriasis.,SHX:, denied ETOH/Tobacco/illicit drug use.,FHX:, Unknown.,MEDS:, Heparin only.,EXAM:, BP160/90 HR145 (supine). BP105/35 HR128 (light headed, standing) RR12 T37.7C,MS: Dysarthria only. Lucid thought process.,CN: left lower facial weakness only.,Motor: mild left hemiparesis with normal muscle bulk. Mildly increased left sided muscle tone.,Sensory: unremarkable.,Coordination: impaired secondary to weakness on left. Otherwise unremarkable.,Station: left pronator drift. Romberg testing not done.,Gait: not tested.,Reflexes: symmetric; 2+ throughout.,Gen Exam: CV: Tachycardic without murmur.,COURSE:, The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. She was immediately placed in a reverse Trendelenburg position and given IV fluids. Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms. PT/PTT/GS/CBC/ABG were unremarkable. EKG revealed sinus tachycardia with rate dependent junctional changes. CXR unremarkable. MRI Brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images. Over the ensuing days of admission she had significant fluctuations of her BP (200mmHG to 140mmHG systolic). Her symptoms worsened with falls in BP. Her BP was initially controlled with esmolol or labetalol. Renal Ultrasound, abdominal/pelvic CT, renal function scan, serum and urine osmolality, urine catecholamines/metanephrine studies were unremarkable. Carotid doppler study revealed 0-15%BICA stenosis and antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram was unremarkable. Cerebral angiogram was performed to r/o vasculitis. This revealed narrowing of the M1 segment of the right MCA. This was thought secondary to atherosclerosis and not vasculitis. She was discharged on ASA, Procardia XL, and Labetalol.
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DESCRIPTION: MRI Brain: Subacute right thalamic infarct.

neurology, mri brain, ct brain, heparin, dysarthria, hemiplegia, infarct, neurological exam, thalamic, thalamic infarct, mri, brain,

The situation involves a patient with a history of neurological symptoms indicative of an ischemic event (thalamic infarct), which requires urgent evaluation and management due to the risk of significant functional impairment. The symptoms and acute changes in the patient's condition, like dysarthria and hemiplegia, suggest a stroke-like event, which is indeed a high-stakes medical situation needing immediate and careful intervention to prevent worsening outcomes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Foot Lesions

S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes.  She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot.  She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter.  There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter.  These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening.  The first and fifth metatarsal heads are plantarflexed.  Vibratory sensation appears to be absent.  Dorsal pedal pulses are nonpalpable.  Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent.  The medial aspect of the left great toenail has dried blood under the nail.  The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic.  All of the patient's toenails are elongated and discolored and opaque as well.  There is dried blood under the medial aspect of the left great toenail.,A - ,1.  Painful feet.,
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DESCRIPTION: Patient with complaint of a very painful left foot because of the lesions on the bottom of the foot.

soap / chart / progress notes, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful

The situation involves an elderly diabetic patient experiencing painful foot lesions and additional nail problems. Considering the patient's age, diabetes, and hypertension, complications such as infection or ulceration are high risks. This can potentially lead to amputation if left untreated, but it is likely to be managed effectively with prompt treatment. Given the potential for serious complications affecting mobility and quality of life, this situation is high-stakes but not immediately life-threatening.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Interbody Fusion

PREOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  Cervical spondylosis with herniated nucleus pulposus, C5-C6.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Arthrodesis with anterior interbody fusion, C5-C6.,3.  Spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS:  ,1200 cc of crystalloids.,URINE OUTPUT: , No Foley catheter.,SPECIMENS: , None.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,INDICATIONS FOR THE OPERATION:,  This is a case of a very pleasant 38-year-old Caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist.  The patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants.  The patient's symptoms continued to persist and subsequently, an MRI of the C-spine was done, which showed disc desiccation, spondylosis and herniated disk at C5-C6, an EMG and CV revealed a presence of mild-to-moderate carpal tunnel syndrome.  The patient is now being recommended to undergo decompression and spinal instrumentation and fusion at C5-C6.  The patient understood the risks and benefits of the surgery.  Risks include but not exclusive of bleeding and infection.  Bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function.  This could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele.  Should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the CSF leak and evacuation of the pseudomeningocele.  There is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level.  There is also the possibility of nonimprovement of her symptoms in about 10% of cases.  The patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery.  There is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation.  The patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  She understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut.  A marker was placed.  This verified the level to be at the C5-C6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle.  The area was then prepped with DuraPrep after the head was turned 45 degrees to the left.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion.  Dissection was then carried underneath the platysma superiorly inferiorly.  The anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle.  The prevertebral fascia was noted to be taken her case with a lot of fat deposition.  Bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with Hemoclips x4.  After this was completed, a localizing x-ray verified the marker to be at the C6-C7 level.  We proceeded to strip the longus colli muscles off the vertebral body of the C5 and C6.  Self-retaining retractor was then laid down.  An anterior osteophyte was carefully drilled using a Midas 5-mm bur and the disk together with the inferior endplate of C5 and the superior endplate of C6 was also drilled down with the Midas 5-mm bur.  This was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using Kerrison's ranging from 1 to 4 mm.  The herniation was noted on the right.  However, there was significant neuroforaminal stenosis on the left.  Decompression on both sides was done and after this was completed, a Valsalva maneuver showed no evidence of any CSF leakage.  The area was then irrigated with saline with bacitracin solution.  A 7 mm implant with its inferior packed with Vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium.  X-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution.  A round French 10 JP drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly.  The catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl subcuticular 4-0 Stitch for the dermis, and the wound was reinforced with Dermabond.  Dressing was placed only at the exit site of the catheter.  C-collar was placed.  The patient was extubated and transferred to recovery.
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DESCRIPTION: Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.

The situation involves discussing a surgical procedure, specifically an Anterior Cervical Discectomy and Fusion, which carries significant risks and potential complications. The pre-operative and post-operative diagnoses involve complex spinal issues, and the procedure itself is detailed with critical steps that, if not performed correctly, could lead to severe outcomes such as paralysis or failure to relieve symptoms. The risks of the procedure include potential nerve damage, infection, bleeding, and other complications that can have serious long-term effects on the patient's health. However, it is somewhat routine in spinal surgery, and while the stakes are high due to the proximity to critical neural structures, it is a standard and well-understood procedure, indicating lower risk than some emergent or more complex surgeries.


Medical Specialty: Surgery
Sample Name: Needle-Localized Excisional Biopsy - Breast - 1

PREOPERATIVE DIAGNOSIS: ,Left breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:,  Left breast mass with abnormal mammogram.,PROCEDURE PERFORMED:,  Needle-localized excisional biopsy of the left breast.,ANESTHESIA:,  Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Breast mass.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,INTRAOPERATIVE FINDINGS: , The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.,BRIEF HISTORY:,  The patient is a 62-year-old female who presented to Dr. X's office with an abnormal mammogram showing a suspicious area on the left breast with microcalcifications and a nonpalpable mass.  So the patient was scheduled for a needle-localized left breast biopsy.,PROCEDURE:,  After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought to the operating suite.  After IV sedation was given, the patient was prepped and draped in normal sterile fashion.  Next, a curvilinear incision was made.,After anesthetizing the skin with 0.25% Marcaine and 1% lidocaine mixture, an incision was made with a #10 blade scalpel.  The lesion with needle was then grasped with an Allis clamp.  Using #10 blade scalpel, the specimen was colonized out and sent to Radiology for confirmation.  Next, hemostasis was obtained using electrobovie cautery.  The skin was then closed with #4-0 Monocryl suture in running subcuticular fashion.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was sent to Recovery in stable condition.
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DESCRIPTION: Needle-localized excisional biopsy of the left breast.  Left breast mass with abnormal mammogram.  The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.

surgery, needle localized excisional biopsy, excisional biopsy, abnormal mammogram, breast mass, breast, radiology, biopsy, mammogram, needle

The procedure described is a needle-localized excisional biopsy, which while a fairly routine and minimally invasive surgical procedure, involves removing a suspicious mass possibly indicative of breast cancer. Breast biopsies are crucial for diagnosing breast cancer, which is serious and impacts treatment and long-term health outcomes. However, the procedure itself was performed without complications, and the patient was stable post-op, indicating a lower immediate risk. The stakes are elevated due to the potential implications of the biopsy results rather than the procedure itself.


Medical Specialty: Consult - History and Phy.
Sample Name: Uveitis

PAST MEDICAL HISTORY: , Significant for GERD, history of iron deficiency anemia, and asthma for which she takes an inhaler.,REVIEW OF SYSTEMS:,  Positive for only for left knee arthritis.  She has no exposure to tuberculosis or syphilis, she has no mouth or genital ulcers.  She has no skin rashes.  She has no connective tissue disorders.,PAST OCULAR HISTORY: , Significant for cataract and glaucoma surgery of the right eye.,PHYSICAL EXAMINATION: , On examination, visual acuity measures hand motions on the right and 20/25 in the left.  There is an afferent pupillary defect on the right.  On examination, there is a right hypertropia.  There is dense anterior chamber inflammation on the right eye with a stagnant aqueous.  There is either neovascularization on the iris or reactive iris vessels, it is difficult to discern.  This seems to be complete iris synechia to the anterior lens capsule.  There is a posterior chamber intraocular lens with an inflammatory debris on the anterior surface.  The anterior chamber appears narrow.  On the left, there is also dense inflammation at 4+ cell.  There is 1+ nuclear sclerosis.  Dilated fundus examination cannot be performed on the right secondary to intense inflammation.  On the left, there is no evidence of active posterior uveitis.  There is some inferior vitreous debris.,ASSESSMENT/PLAN:,  Chronic bilateral recurrent nongranulomatous diffuse uveitis.  Currently, there is very severe right eye inflammation and severe left eye.  I discussed at length with the patient that this will likely take an oral steroid to quite her down.  Since she has only one seeing eye, I am anxious to obtain a decreased inflammation as soon as possible.  She has been on oral steroids in the past.  We also discussed, considering the aggressive recurrent nature of this process, it is likely we will have to consider a steroid sparing agent to maintain longer term control of this recurrent process so that we do not use visual acuity in the left.  I anticipate we will likely start methotrexate in the near future.  In this acute phase, I have recommended oral steroids at a dose of 60 mg a day, hourly topical Pred Forte as well as atropine sulfate.  We will watch her closely in clinic.  I am sending a copy of this dictation to her primary care doctor, she said she has had a negative HLA-B27, rheumatoid factor, and ANA in the past.  At this stage, to be thorough I would ask Dr. X to assist us in repeating her chest x-ray, PPD if not current, and an RPR.  Additionally, in anticipation of need for methotrexate, it would be helpful to have a full liver function profile as well as hepatitis B and hepatitis C.
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DESCRIPTION: The patient with recurrent nongranulomatous anterior iritis and most recently, pain in  left eye associated with headache and photophobia.

consult - history and phy., iritis, nongranulomatous, uveitis, eye inflammation, photophobia, recurrent nongranulomatous anterior iritis, headache and photophobia, anterior chamber, anterior, chamber, inflammation,

The situation involves a patient with chronic bilateral recurrent nongranulomatous uveitis, which has resulted in extremely severe inflammation in the right eye and severe inflammation in the left eye. The patient only has one seeing eye, making the condition particularly precarious. The immediate treatment with high-dose steroids and the consideration of long-term treatment with immunosuppressants suggest a potentially serious risk to the patient's vision if not managed properly. The plan to engage more testing and potential methotrexate use highlights the necessity for precise management to prevent long-term damage. Thus, it can be considered a high-stakes medical scenario due to the risk of significant vision loss.


Medical Specialty: Nephrology
Sample Name: Nephrectomy - Radical (Laparoscopic)

PREOPERATIVE DIAGNOSIS:,  Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:,  Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:,  100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA:  ,General endotracheal.,DRAINS:,  16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass.  This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma.  I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy.  All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:,  After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia.  After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest.  All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure.  Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage.  The abdomen was insufflated in the right outer quadrant.  Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy.  The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident.  We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus.  Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed.  Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar.  There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt.  This exposed the retroperitoneum on the right side.  The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only.  We then identified the ureter and gonadal vein in the retroperitoneum.  The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum.  Sequential packets of tissue were taken using primarily the LigaSure Atlas device.  Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins.  We proceeded then and skeletonized the structures into four individual packets.  We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland.  The adrenal was spared during this procedure.  There was no contiguous connection between the renal mass and a right adrenal gland.  This plane of dissection was taken down primarily using the LigaSure device.  We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring.  Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments.  The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected.  The kidney was then freed within the retroperitoneum.  A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction.  We extended the lower most trocar site approximately 6 cm to facilitate extraction.  The kidney was removed and passed off the table as a specimen for pathology.  This was bivalved by pathology, and we reviewed the specimen.
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DESCRIPTION: Laparoscopic right radical nephrectomy due to right renal mass.

nephrology, renal mass, carter-thomason, endocatch bag, foley catheter, gi stapler, laparoscopic, ligasure, toldt, laparoscopic scissors, nephrectomy, radical nephrectomy, screw-type trocar, umbilicus, upper pole, urethra, carter thomason closure device, laparoscopic right radical nephrectomy, carter thomason closure, carter thomason, renal hilum, kidney, abdomen, endotracheal, radical, oncocytoma, renal,

The procedure described is a laparoscopic right radical nephrectomy, which is a surgical operation to remove a kidney due to the presence of a renal mass. It is highly relevant to patient health, given the suspicion of renal cell carcinoma, a potentially life-threatening condition. Although the post-operative status shows no complications and estimated blood loss was low, the procedure itself is critical because it involves major organ removal due to cancer. Nephrectomies carry potential risks and implications for future patient health, thus representing a high-stakes situation. Additionally, the detailed surgical steps and the patient's age (71) add complexity, further supporting the high-stakes nature of the situation.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 37

Chief Complaint:, Dark urine and generalized weakness.,History of Present Illness:,40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed.,He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.,Past Medical History:, DM II-HbA1c unknown,Past Surgical History:, Cholecystectomy without complication,Family History:, Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).,Social History:, He was unemployed and denied any alcohol or drug use. He was a prior “mild” smoker, but quit 10 years previous.,Medications:, Insulin (unknown dosage),Allergies:, No known drug allergies.,Physical Exam:,Temperature: 98.2,Blood pressure:118/80,Heart rate: 95,Respiratory rate: 18,GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time.,HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx.,NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits.,CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs,PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes,ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable.,RECTAL: Guaiac negative,EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm,NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis,SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata.,Hospital Course:,The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved.,Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis.,By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma.,By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection.,STUDIES (HISTORICAL):,CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal.,CT neck: No abnormalities noted,CT head: No intracranial abnormalities,RUQ US (for biopsy): Heterogenous liver with lymphadenopathy.,ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam.
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DESCRIPTION: Patient with complaint of dark urine and generalized weakness.

The patient's case involves symptoms indicative of liver failure, notably dark urine and jaundice, which could signify serious underlying conditions such as liver disease, autoimmune disorders, or potentially even malignancies. The extensive diagnostic process, including multiple biopsies and imaging studies, reflects the complexity and seriousness of the medical issue. The prolonged hospital stay and the progression of symptoms, despite intervention, further underscore the gravity. Liver failure is a medical emergency requiring careful management to prevent life-threatening complications, thus making it a high-stakes scenario.


Medical Specialty: Psychiatry / Psychology
Sample Name: Neuropsychological Evaluation - 2

REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved "honors in school" and "looked smart."  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently "bang her head against the wall" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and "thrown two and a half city blocks."  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and "tunnel vision" (vision goes smaller to a pinpoint), and she was "spazzing out" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test
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DESCRIPTION: A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.

This neuropsychological evaluation is being conducted to assess and understand various cognitive and neurological functions due to the patient's extensive history of syncope and possible neurological concerns, including a history of head injury and alcohol exposure in utero. While it involves the assessment of a complex medical history and aims to direct future therapeutic planning, it does not seem to pose an immediate life-or-death situation. The stakes are more about understanding and managing the patient's long-term neurological health and syncopal episodes, rather than addressing a critical emergency. However, there is concern over potential undiagnosed and untreated issues, indicating a moderately high-stakes situation in terms of ensuring the patient's psychological and cognitive well-being.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy - 2

ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:,  This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs.  She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted.  Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery.  She was interested in participating in the artificial disk replacement study and was entered into that study.  She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007.  She has done well postoperatively with a sensation of right arm pain and numbness in her fingers.  She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well.  She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment.  She will contact our office prior to her appointment if she has problems.  Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n.  #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n.  #60 with 1 refill.
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DESCRIPTION: Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.  Right C5-C6 herniated nucleus pulposus.

surgery, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE

The situation involves a surgical procedure, specifically an anterior cervical discectomy with artificial disc replacement, which inherently carries significant risks such as potential complications from anesthesia, surgical errors, or postoperative issues like infection. The patient is also participating in a study, which adds another layer of complexity and responsibility to the surgical team. Although the surgery appears to have gone well and the patient is recovering, the stakes remain high due to the potential for serious complications or adverse outcomes. Therefore, the decision-making and execution of the surgery are crucial and can impact the patient's quality of life significantly, which characterizes this as a high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: MRI Shoulder - 1

EXAM:,MRI-UP EXT JOINT LEFT SHOULDER,CLINICAL:,Left shoulder pain. Evaluate for rotator cuff tear.,FINDINGS:,  Multiple T1 and gradient echo axial images were obtained, as well as T1 and fat suppressed T2-weighted coronal images.,The rotator cuff appears intact and unremarkable. There is no significant effusion seen. Osseous structures are unremarkable. There is no significant downward spurring at the acromioclavicular joint. The glenoid labrum is intact and unremarkable.,IMPRESSION:,  Unremarkable MRI of the left shoulder.,
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DESCRIPTION: Left shoulder pain. Evaluate for rotator cuff tear.

orthopedic, rotator cuff tear, cuff tear, rotator cuff, joint, mri, rotator, cuff, shoulder, tear,

The scenario involves reviewing an MRI to evaluate a patient's rotator cuff for potential tear, which is important for clinical decision-making but does not present immediate life-threatening risks. The MRI results are unremarkable, indicating no significant condition has been found. Thus, while it affects treatment planning, it is not an emergency or critical diagnosis.


Medical Specialty: Surgery
Sample Name: Arthroscopy Shoulder/Knee

PREOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, posterior horn of left knee.,2.  Carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3.  Impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,POSTOPERATIVE DIAGNOSES:,1.  Carpal tunnel syndrome, right hand, severe.,2.  Bursitis, tendonitis, impingement, and AC arthritis, right shoulder.,3.  Medial and lateral meniscal tears, posterior horn old, left knee.,PROCEDURE:,1.  Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection.,2.  Right carpal tunnel release.,3.  Left knee arthroscopy and partial medial and lateral meniscectomy.,ANESTHESIA: , General with regional.,COMPLICATIONS:  ,None.,DISPOSITION: , To recovery room in awake, alert, and in stable condition.,OPERATIVE INDICATIONS: , A very active 50-year-old gentleman who had the above problems and workup revealed the above problems.  He failed nonoperative management.  We discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and he gave his fully informed consent to the following procedure.,OPERATIVE REPORT IN DETAIL: , The patient was brought to the operating room and placed in the supine position on the operating room table.  After adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  All bony prominences were padded.  The right shoulder was prepped and draped in the usual sterile manner using standard Betadine prep, entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar.,Serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments, articular surfaces, and labrum.  Subacromial space was entered.  Visualization was poor due to the hemorrhagic bursitis, and this was resected back.  It was essentially a type-3 acromion, which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur.  Rotator cuff was little bit fray, but otherwise intact.  Thus, the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed.  The burr was then introduced to the anterior portal and the distal clavicle excision carried out.  The width of burr about 6 mm being careful to preserve the ligaments in the capsule, but removing the spurs and the denuded arthritic joint.,The patient tolerated the procedure very well.  The shoulder was then copiously irrigated, drained free of any residual debris.  The wound was closed with 3-0 Prolene.  Sterile compressive dressing applied.,The patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard Betadine prep.,The attention was first turned to the right hand where it was elevated, exsanguinated using an Esmarch bandage, and the tourniquet was inflated to 250 mmHg for about 25 minutes.  Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis.  Tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures.,Cautery was used for hemostasis.  The never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament, and so a small amount of Celestone was dripped onto the nerve to help quite it down.  The patient tolerated this portion of the procedure very well.  The hand was then irrigated, closed with Monocryl and Prolene, and sterile compressive dressing was applied and the tourniquet deflated.,Attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars.  After entering the knee through inferomedial and inferolateral standard arthroscopic portals, examination of the knee showed a displaced bucket-handle tear in the medial meniscus and a radial tear at the lateral meniscus.  These were resected back to the stable surface using a basket forceps and full-radius shaver.  There was no evidence of any other significant arthritis in the knee.  There was a lot of synovitis, and so after the knee was irrigated out and free of any residual debris, the knee was injected with Celestone and Marcaine with epinephrine.,The patient tolerated the procedure very well, and the wounds were closed with 3-0 Prolene and sterile compressive dressing was applied, and then the patient was taken to the recovery room, extubated, awake, alert, and in stable condition.
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DESCRIPTION: Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.

The situation involves a detailed operative report for multiple orthopedic surgical procedures, including shoulder arthroscopy, carpal tunnel release, and knee arthroscopy with meniscectomy. While surgery inherently carries risks, this instance is described as being well-tolerated by the patient with no complications and stable post-operative condition. The patient gave fully informed consent and the procedures are routine in orthopedic practice. The patient's condition post-surgery being stable and the absence of complications suggest that, while serious, it is not an extreme high-stakes scenario, as it likely follows standard procedural outcomes.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 3

DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF PRESENT ILLNESS:, Details are present in the dictated report.,BRIEF HOSPITAL COURSE:, The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy.,DISCHARGE MEDICATIONS:, Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily.,TRANSFER INSTRUCTIONS:, The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required.
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DESCRIPTION: Patient with increased shortness of breath of one day duration.

discharge summary, chronic obstructive pulmonary disease, hypercapnic respiratory failure, atrial fibrillation, chronic atrial fibrillation, increased shortness of breath, shortness of breath, increased shortness, coumadin, atrial,

The discharge summary indicates a complex medical case, as it involves management of multiple serious conditions including COPD with acute hypercapnic respiratory failure, atrial fibrillation, and a history of lung cancer. The patient required mechanical ventilation, which highlights the severity of the situation during hospitalization. Proper continuation of care through medications and specific respiratory support instructions (e.g., BI-PAP settings) is crucial to avoid further complications. While not emergent, the stakes are high in ensuring patient stability post-discharge and avoiding readmission.


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

Medical Specialty: Emergency Room Reports
Sample Name: Intracranial aneurysm - ER Visit

CHIEF COMPLAINT:,  Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan.  He was discharged home with a follow up to neurosurgery on the 14th.  Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  He has had headaches since the 13th and complains now of some worsening of his pain.  He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:,  Vicodin.,ALLERGIES:,  None.,PHYSICAL EXAM:  ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT:  Pupils equal, round, reactive to light, oropharynx moist, sclera clear.  ,Neck:  Supple, no meningismus.,Lungs:  Clear.,Heart:  Regular rate and rhythm, no murmur, gallop, or rub.  ,Abdomen:  Benign.,Neuro:  Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal.  Cranial nerves normal.  ,COURSE IN THE ED:  ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  I recommended an LP but he prefers not to have this done.  He received morphine for pain and his headache improved.  I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  He left the ED against my advice.  ,IMPRESSION: , Headache, improved.  Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.
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DESCRIPTION: Headache, improved.  Intracranial aneurysm.

emergency room reports, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial,

The situation involves a patient with a diagnosed intracranial aneurysm, which is a serious medical condition that can lead to life-threatening complications if it ruptures. The patient's decision to leave the emergency department against medical advice increases the stakes due to the risk of an adverse event occurring before the scheduled angiogram. While the patient is currently stable, the medical implications are significant, making it a high-stakes situation.


Medical Specialty: Discharge Summary
Sample Name: D&C - Discharge Summary

ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Fibroid uterus.,OPERATIONS PERFORMED:,1.  Hysteroscopy.,2.  Dilatation and curettage (D&C).,3.  Myomectomy.,COMPLICATIONS: , Large endometrial cavity fibroid requiring careful dissection and excision.,BLOOD TRANSFUSIONS: , Two units of packed red blood cells.,INFECTION: , None.,SIGNIFICANT LAB AND X-RAY: , Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.,HOSPITAL COURSE AND TREATMENT: , The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed.  Hysteroscopy revealed a large endometrial cavity fibroid.  Careful shaving and excision of this fibroid was performed with removal of the fibroid.  Hemostasis was noted completely at the end of this procedure.  Postoperatively, the patient has done well.  The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss.  The patient is now ambulating without difficulty and tolerating her diet.  The patient desires to go home.  The patient is discharged to home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:  ,Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks.  Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate  tablets 1 tablet p.o. daily.  Ambulate with assistance at home only.  The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care.  The patient was given full and complete postop and discharge instructions.  All her questions were answered.
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DESCRIPTION: Hysteroscopy, dilatation and curettage (D&C), and myomectomy.  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and fibroid uterus.

discharge summary, (d&c), fibroid uterus, myomectomy, dilatation, curettage, menometrorrhagia, uterus, hysteroscopy, fibroid,

The situation involves a standard discharge summary for a patient who underwent surgical procedures (hysteroscopy, D&C, and myomectomy) and had complications of severe anemia requiring blood transfusion. While there are stakes involved due to the patient's medical condition and the need for proper postoperative care, it reflects a typical post-surgical recovery process managed in a clinical setting. The summary indicates that the patient is stable, making the immediate stakes moderate but not critical. Hence, the scenario is not extremely high-stakes, but it requires careful follow-up and adherence to discharge instructions to ensure proper recovery.


Medical Specialty: Radiology
Sample Name: CT C-Spine

TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.
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DESCRIPTION: Common CT C-Spine template

Common CT C-Spine template

radiology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE

The situation involves the interpretation and reporting of a CT scan of the cervical spine, used to identify potential injuries or abnormalities. While the findings are normal with no acute abnormalities, the stakes relate to ensuring accurate and reliable interpretation to avoid missing any significant conditions. However, given the report indicates normal findings, the immediate stakes are relatively low, as no urgent medical intervention is required.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification - Kelman

PREOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:,  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:,  Topical.,COMPLICATIONS:,  None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision.  They were found to have a visually significant cataract.  The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was taken to the operating room.  A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion.  A paracentesis was created at ** o'clock.  The anterior chamber was filled with Viscoat.  A clear corneal incision was made at ** o'clock with the 3-mm diamond blade.  A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps.  The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag.  The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion.  The residual cortex was removed with the irrigation/aspiration handpiece.  The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well.  The residual Provisc was removed with the irrigation/aspiration handpiece.  The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution.  The wounds were found to be free from leak.  Zymar and Pred Forte were instilled postoperatively.  The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications.  He will follow up with us in one day.
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DESCRIPTION: Nuclear sclerotic cataract, right eye.  Kelman phacoemulsification with posterior chamber intraocular lens, right eye.

ophthalmology, nuclear sclerotic cataract, intraocular lens, cataract, kelman phacoemulsification, sclerotic cataract, posterior chamber, capsular bag, eye, anesthesia, phacoemulsification

This situation involves a routine cataract surgery known as phacoemulsification, which is a standard and common procedure in ophthalmology. The key details provided include no complications, the patient tolerating the procedure well, and routine postoperative follow-up being planned. While all surgeries have inherent risks, this is not particularly high-stakes as cataract surgery is generally safe and the procedure went without complications. The stakes would be higher if there were complications or if the patient had other significant risk factors.


Medical Specialty: Surgery
Sample Name: Craniotomy - Occipital

PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:,  Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:,  Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:,  The patient was placed in the prone position after general endotracheal anesthesia was administered.  The scalp was prepped and draped in the usual fashion.  The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  The bone flap was elevated.  The ultrasound was then used.  The ultrasound showed the tumors directly I believe are in the interhemispheric fissure.  We noticed that the dura was quite tense despite that the patient had slight hyperventilation.  We gave 4 ounce of mannitol, the brain became more pulsatile.  We then used the stealth to perform a ventriculostomy.  Once this was done, the brain began to pulsate nicely.  We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus.  After having done this we then used operating microscope and slight self-retaining retraction was used.  We obtained access to the tumor.  We biopsied this and submitted it.  This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total.  After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates.  The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  The next step was to close the wound after reapproximating the bone flap.  The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  The sterile dressings were applied to the scalp.  The patient returned to the recovery room in satisfactory condition.  Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.
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DESCRIPTION: Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.

surgery, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain,

The case involves a complex surgical procedure known as a craniotomy for the removal of multiple brain tumors. This is inherently high-stakes due to several factors: the critical location of the tumors in the brain, the use of advanced surgical techniques and equipment, the involvement of metastasis indicating cancer has spread, and the need for subsequent operations. Brain surgeries are typically high-stakes due to the potential for significant complications, impacts on critical functions, and the serious underlying conditions they address. Furthermore, the potential for worsening or complications intraoperatively or postoperatively increases the stakes.


Medical Specialty: Surgery
Sample Name: Vitrectomy - General Anesthesia

DESCRIPTION OF PROCEDURE: , After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.
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DESCRIPTION: Vitrectomy under general anesthesia

Vitrectomy under general anesthesia

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

The situation describes a surgical procedure involving a vitrectomy conducted under general anesthesia. Surgery, especially involving the eye, is typically a high-stakes situation due to the complexity and potential for serious complications. General anesthesia adds another layer of risk, requiring careful monitoring and management. The success of the procedure can significantly impact the patient's vision and overall health.


Medical Specialty: Surgery
Sample Name: Ear Examination

PREOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation.,POSTOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation along with chronic otitis media.,PROCEDURE: , Right ear examination under anesthesia.,INDICATIONS: , The patient is a 15-year-old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss.  Exam in the office revealed a posterior superior right marginal tympanic perforation.  Risks and benefits of surgery including risk of bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed with the mother.  The mother wished to proceed with surgery.,FINDINGS:,  The patient was brought to the room, placed in supine position, given general endotracheal anesthesia.  The postauricular crease was then injected with 1% Xylocaine with 1:200,000 epinephrine along with external meatus.  An area of the scalp was shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected, a total of 4 mL local anesthetic was used.  The ear was then prepped and draped in the usual sterile fashion.  The microscope was then brought into view and examining the marginal perforation, the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum.  The granulation tissue was debrided as much as possible.  Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible.  The middle ear space was filled with Floxin drops.  The patient woke up anesthesia, extubated, and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge was correct.  Estimated blood loss minimal.
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DESCRIPTION: Right ear examination under anesthesia.  Right tympanic membrane perforation along with chronic otitis media.

surgery, chronic otitis media, middle ear space, tympanic membrane perforation, otitis media, hearing loss, middle ear, ear space, ear examination, membrane perforation, tympanic membrane, anesthesia, membrane, tympanic, ear, perforation,

The situation involves a surgical procedure for a child involving general anesthesia, which carries inherent risks such as bleeding, hearing loss, and issues related to anesthesia itself. However, the operation is about examining the ear and debriding tissue, not a major surgery with life-threatening risks at stake like open-heart surgery. The procedure was completed without complications, and the patient was stable post-procedure, also ensuring that the immediate high-stakes risks were managed well. Thus, while important, it is not an extremely high-stakes scenario compared to other surgical contexts.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 1

PROCEDURE:,  Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.,DETAILS OF THE PROCEDURE: , The risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed.  The patient received topical lidocaine by nebulization.  The flexible fiberoptic bronchoscope was introduced orally.  The patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions.  I proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe.  I proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies.  Followup fluoroscopy was negative for pneumothorax.  I wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes.,I then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions.  I performed a bronchial washing after the biopsies in the right upper lobe.  I then performed two transbronchial needle aspirations with a Wang needle biopsy in the precarinal area.  All of these samples were sent for histology and cytology respectively.  Estimated blood loss was approximately 5 cc.  Good hemostasis was achieved.  The patient received a total of 12.5 mg of Demerol and 3 mg of Versed and tolerated the procedure well.  Her ASA score was 2.
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DESCRIPTION: Bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration.

cardiovascular / pulmonary, bronchoscopy, wang needle, biopsy, bronchial washing, bronchoscope, bronchus, fiberoptic, hemostasis, lidocaine, nebulization, right upper lobe, transbronchial, transbronchial needle aspiration, needle aspiration, transbronchial needle, upper lobe, bronchial, precarinal, biopsies, needle, lobeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

This procedure description outlines a bronchoscopy performed for diagnostic purposes. While the procedure has potential risks, including bleeding and pneumothorax (collapsed lung), these are standard procedures that experienced medical professionals routinely perform. The use of sedation, careful monitoring, and fluoroscopic guidance helps to mitigate these risks. The fact that the patient tolerated the procedure well and no complications such as pneumothorax were observed indicates that the situation is controlled and lower risk than emergency or critical interventions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracentesis

PREOPERATIVE DIAGNOSIS:,  Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:,  After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department.  His left back was prepped and draped in the usual fashion.  Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood.  This blood was nonclotting and it was tested twice.  Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s.  Therefore, we laid him off his right side while keeping the chest catheter in place.  At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.
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DESCRIPTION: Thoracentesis.  Left pleural effusion.  Left hemothorax.

cardiovascular / pulmonary, pleural effusion, hemothorax, thoracentesis, chest,

Thoracentesis is a procedure to remove fluid from the pleural space for diagnostic or therapeutic reasons. The situation involves management of a left hemothorax, which can be serious if not addressed properly. The patient experienced dizziness and a drop in blood pressure, indicating potential complications. These symptoms necessitated immediate adjustments during the procedure, including repositioning the patient to stabilize blood pressure, which suggests that the situation was managed effectively. Monitoring and potential further interventions (e.g., CT scan, pigtail catheter) indicate careful attention to a potentially serious condition. Thus, while the procedure was routine, the patient's reaction and the underlying diagnosis elevate the stakes.